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Wind Instrument Performance and Oral Health: A Performing Arts Medicine Perspective
Int J Clin Prev Dent 2024;20(4):117-122
Published online December 31, 2024;  https://doi.org/10.15236/ijcpd.2024.20.4.117
© 2024 International Journal of Clinical Preventive Dentistry.

Hojin Moon

Department of Conservative Dentistry, Dankook University College of Dentistry, Cheonan, Korea
Received December 9, 2024; Revised December 27, 2024; Accepted December 27, 2024.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Wind instrument performance requires complex coordination of oral structures and significantly impacts oral health. This narrative review examines the relationship between wind instrument performance and oral health through the lens of performing arts medicine, focusing on three critical aspects: dental and craniofacial changes, temporomandibular disorders, and embouchure-related neuromuscular conditions. First, the influence of wind instrument performance on dental position and craniofacial morphology is analyzed, examining how different embouchure types affect oral structures. Second, the relationship between performance and musculoskeletal disorders, particularly temporomandibular dysfunction, is explored with emphasis on biomechanical demands. Third, the development and progression of embouchure-related disorders, especially embouchure dystonia, is investigated from a neuromuscular perspective. Current evidence suggests that while wind instrument playing generates significant forces on oral structures, its effects vary based on instrument type, playing technique, and individual factors. This review provides clinically relevant insights for dental practitioners in performing arts medicine, highlighting the need for specialized approaches in the diagnosis and treatment of oral health issues in wind musicians.
Keywords : music, occupational diseases, oral health
Introduction

Wind instrument performance requires complex coordination of oral structures and can significantly impact oral health [1]. Recent studies have highlighted increasing attention to oral health issues among wind instrument performers in dental practice [2]. The embouchure, which refers to how musicians position their mouth on the instrument’s mouthpiece, creates unique mechanical stresses on oral structures that persist throughout a musician’s career [3].

This complex orchestration of lips, teeth, tongue, and masticatory muscles during performance, combined with its prolonged and repetitive nature, can lead to various oral health challenges including dental problems, soft tissue injuries, and musculoskeletal disorders. Additionally, the intimate contact between the instrument and oral cavity raises concerns about microbial contamination and associated health risks [4].

Each of the four distinct embouchure types creates different biomechanical demands (Figure 1). Single-reed instruments (clarinet, saxophone) require direct contact between the upper teeth and mouthpiece, with the lower lip cushioning the reed. Double-reed instruments (oboe, bassoon) demand a rounded lip formation without direct dental contact. Brass instruments use cup-shaped mouthpieces that require specific lip tension and jaw positioning. The flute’s aperture-type embouchure involves lateral positioning and precise perioral muscle control.

Figure 1. Types of embouchures in wind instruments. This figure illustrates the four main types of embouchures used by wind instrument players. (A) Single-reed Embouchure: involves the lower lip cushioning the reed while the upper teeth contact the mouthpiece at varying angles, depending on the instrument (e.g., clarinet vs. saxophone). (B) Double-reed Embouchure: the lips form a rounded shape around the double reed, with the teeth apart to allow the reeds to vibrate freely, as seen in oboe and bassoon players. (C) Cup-shaped Embouchure: used in brass instruments, where the lips contact a cup-shaped mouthpiece, with lip tension maintained by the perioral muscles, and varying mouthpiece sizes for different brass instruments. (D) Aperture-type Embouchure: involves positioning the lower lip against the blowing edge of the flute’s headjoint, directing the air stream across the aperture, requiring precise control of the perioral muscles.

Despite these concerns, there is limited comprehensive literature reviewing the spectrum of oral health issues specific to wind instrument musicians. Many dental practitioners may be unfamiliar with the unique oral health challenges these patients face, potentially leading to delayed diagnosis or suboptimal treatment approaches. This raises three critical questions in dental practice [3]:

1. How does wind instrument performance influence dental position and craniofacial morphology?

2. What are the relationships between wind performance and musculoskeletal disorders, including temporomandibular dysfunction?

3. What are the pathophysiological mechanisms and neural changes that lead to embouchure dystonia in musicians?

This narrative review examines current evidence addressing these questions, aiming to provide clinically relevant insights for dental practitioners treating wind musicians. By understanding the structural changes, functional disorders, and neuromuscular control disorders associated with wind instrument playing, dental practitioners can provide more targeted care for wind musicians while helping preserve their performance capabilities.

Dental Position and Craniofacial Changes in Wind Musicians

The influence of wind instrument playing on dental position and craniofacial morphology has long been of interest to both dentists and musicians. This relationship becomes particularly significant when orthodontic patients play wind instruments or when wind instrumentalists undergo orthodontic treatment [5,6].

Tooth movement requires forces exceeding a minimum threshold and appropriate duration of application. According to Engelman’s measurements from a study of 20 subjects aged between 10 and 17 years, the forces exerted during wind instrument playing were found to be approximately 500 g for brass instruments, 270 g for double/single-reed woodwind instruments, and 211 g for aperture-type instruments (flutes), which are significantly higher than the 35-60 g typically used in orthodontic treatment [7].

However, studies have reported conflicting results regarding the influence of wind instrument playing on dental position. Grammatopoulos et al. [8] reported that wind instrument playing has little effect on tooth position. However, other studies have observed significant changes, particularly in young players. Brass instrumentalists showed a reduction in overjet (‒0.67 mm) over 6 months to 3 years, which was statistically significant compared to controls [6]. Single-reed instrumentalists tended to show larger overjet in adults [5].

A recent longitudinal study by Hernández et al. [9] examined dental and orofacial changes in wind instrument players over a two-year period. While they found significant differences in overjet, dental crowding, and dental abrasion between musicians and non-musicians, the relatively short observation period limits definitive conclusions about long-term effects [9]. Considering the significant craniofacial changes that occur throughout life, as demonstrated by Al-Taai et al. [10] in their 50-year follow-up study from age 13 to 62, there is a clear need for extended longitudinal research examining wind musicians across their professional careers. Such long-term studies would be particularly valuable for understanding the cumulative effects of wind instrument playing on craniofacial development and aging patterns.

In a recent craniofacial morphology study by Clemente et al. [11], wind instrument playing was found to have minimal impact on craniofacial morphology. The analysis showed that measurable differences emerged only in the positioning of the lower central incisor in reference to the skeletal base, with wind instrumentalists showing a more orthopositioned tendency. The authors suggested this might be due to the hyperfunction of the lower lip during the embouchure mechanism in wind instrumentalists.

Clinical evidence demonstrates that a Class I occlusal relationship appears appropriate for all wind instruments, and mild malocclusions do not necessarily impede professional performance [12]. However, severe malocclusions may cause greater difficulties in playing. Therefore, regular dental monitoring is recommended for professional players, and early orthodontic intervention may be necessary, particularly for young musicians.

Musculoskeletal Disorders and Temporomandibular Dysfunction in Wind Musicians

Recent investigations into temporomandibular disorders (TMDs) among musicians have revealed significant variations in prevalence rates, ranging from 29% to 89% [13]. This wide range primarily reflects the duration of daily instrument use, which explains over 80% of the variation in TMD prevalence. The relationship between wind instrument performance and temporomandibular joint (TMJ) function appears particularly influenced by the extended hours of practice and performance.

These findings have emerged from systematic reviews examining both wind and string musicians [14]. Each instrument category creates distinct biomechanical loads on the orofacial system. String instruments, particularly violins, require stabilization forces between jaw and shoulder that generate pressures of 200 g to 2,200 g transmitted to the TMJ region. Wind instruments present different biomechanical challenges through their specific embouchure formations and sustained mandibular positions. These distinctive mechanical loading patterns, combined with extended practice durations, suggest instrument-specific pathways in TMD development.

Different instrument categories show distinctive patterns of TMD manifestation. Clinical studies demonstrate that upper string players experience significantly increased TMJ pain risk, while both woodwind and brass players show heightened susceptibility to joint sounds and pain [15]. These patterns correspond to the unique biomechanical demands of each instrument: violinists and violists must stabilize their instruments between jaw and shoulder, while wind instrumentalists employ specific embouchure formations and jaw movements. Postural factors also play a crucial role, particularly arm position during performance. Musicians playing with elevated arms show notably higher rates of muscle pain compared to those maintaining neutral positions. Moreover, extended practice duration appears to exacerbate these risks, particularly for myofascial pain development. This evidence suggests that TMD risk in musicians varies systematically with both instrument type and specific performance techniques.

While these biomechanical factors are crucial, recent research has expanded our understanding to include psychosocial aspects of TMD in musicians. Recent investigations have highlighted the significant interaction between physical and psychological factors. Performance anxiety emerges as a critical factor - highly anxious musicians show significantly higher rates of TMD symptoms [16]. Electromyographic studies reveal that facial muscles involved in wind instrument performance demonstrate distinct activity patterns, with emission control and articulation muscles showing higher activity than mouthpiece-stabilizing muscles [17]. The relationship appears moderated by factors including playing technique, experience level, and psychological state.

Current evidence indicates that wind instrument performance affects TMJ function through multiple interactive pathways. Direct mechanical stress from embouchure formation combines with altered muscle activity patterns, particularly evident in less experienced players. These physical factors interact with psychological elements such as performance anxiety and stress, while being further modulated by individual variations in playing technique and practice patterns [18,19].

The impact is not uniformly detrimental - some musicians develop adaptive responses through experience, while others benefit from preventive measures such as pre-performance conditioning exercises and stress management techniques [19]. This suggests a dynamic and individualized relationship between wind instrument performance and TMJ function, rather than a simple causative one.

This complex interaction indicates that managing TMD in wind instrumentalists requires a holistic therapeutic approach that targets both physiological and psychological factors. Prevention strategies should incorporate technical training optimization and stress management, while treatment approaches may need to combine physical therapy with psychological support [16,19].

Development and Progression of Embouchure Dystonia in Wind Musicians

Embouchure dystonia (ED) manifests as a performance-specific motor control impairment affecting wind and brass musicians, characterized by involuntary movements and loss of control of facial, oral, and perioral muscles during instrument playing [20]. Initially affecting specific ranges or styles of playing, ED symptoms typically appear during their fourth decade of life and worsen without remission, significantly impacting musicians’ careers [20]. This condition affects approximately 1% of professional musicians and often leads to career termination [21].

The pathophysiology of ED involves complex interactions across multiple neural systems. Functional neuroimaging studies have shown intensified neural activity in primary motor, premotor, and somatosensory cortices during both dystonia-triggering tasks and neutral activities [22]. Contemporary studies demonstrate modified neural connections within the cerebellar-basal ganglia-thalamo-cortical circuit, with increased functional connectivity between the globus pallidus, cerebellum, supplementary motor area, and prefrontal cortices [23].

Professional musicians typically develop heightened cortical responses paired with decreased inhibitory control relative to non-musicians. However, in ED patients, these normally beneficial adaptations appear to progress abnormally, leading to maladaptive changes in motor control [24]. This manifests in three main areas: reduced inhibition in the sensorimotor system, altered sensory perception, and impaired sensorimotor integration [21].

Research consistently demonstrates decreased inhibition across multiple levels of motor control circuitry. Electromyo-graphic recordings indicate sustained muscle discharge patterns with co-contraction of antagonistic muscles and dispersed activation to non-target muscles [21]. ED patients also demonstrate impaired processing of sensory information with disorganization of somatosensory representations in the facial area [25]. This manifests as abnormalities in temporal and spatial discrimination, with decreased activation of sensorimotor cortex during vibration stimulation correlating with symptom severity [24].

The precise interplay between these various neural mechanisms creates a complex pathophysiological picture that helps explain the task-specific nature of ED symptoms. Current evidence suggests ED stems from the interplay between inherited susceptibility and external influences, particularly in the context of prolonged practice under conditions demanding high temporal-spatial precision [21]. This understanding has important implications for treatment approaches, which may need to target multiple aspects of the pathophysiology simultaneously. Future research employing state-of-the-art brain imaging and neural assessment approaches will be crucial for further elucidating these mechanisms and developing more effective therapeutic strategies.

Clinical Implications for Wind Musicians’ Oral Health

The complex relationship between wind instrument performance and oral health represents a significant area of concern in performing arts medicine. The evidence presented through various studies suggests that wind instrument playing impacts oral health through multiple mechanisms. The nature and severity of these impacts depend on instrument-specific factors (such as mouthpiece type and required embouchure force), performance-related variables (including practice duration and technique), and individual characteristics (like age, anatomical structure, and playing experience).

Dental practitioners treating wind musicians must consider the unique demands placed on the orofacial structures during performance. The forces generated during wind instrument playing, while potentially significant enough to influence dental position, particularly in developing musicians, do not necessarily lead to detrimental effects when proper technique and preventive measures are employed [2]. The interplay between embouchure formation and dental position becomes especially critical when considering orthodontic treatment or dental rehabilitation for these musicians.

The management of musculoskeletal disorders, particularly temporomandibular dysfunction, requires a comprehensive understanding of both the mechanical and physiological demands of specific instruments. While the direct causal relationship between wind instrument playing and TMD remains debatable, the evidence suggests that proper technique and preventive measures can help minimize potential adverse effects [3]. Additionally, the recognition and early intervention of embouchure dystonia have become increasingly important in maintaining musicians’ long-term performance capabilities [1].

Recent research has highlighted the significance of microbial contamination in wind instruments, emphasizing the need for proper instrument hygiene and maintenance protocols [4]. This aspect of wind instrument performance, previously underappreciated, raises crucial health and safety concerns at both individual and group levels, particularly in educational settings where instruments may be shared.

From a clinical perspective, the successful treatment of wind musicians requires collaboration between dental practitioners and performing arts medicine specialists. Understanding the specific demands of different wind instruments and their potential impacts on oral structures allows for more targeted and effective interventions [26]. Prevention strategies, including regular dental monitoring, proper instrument maintenance, and early intervention when problems arise, are crucial for maintaining both oral health and performance capability.

Looking to the future, the field of performing arts medicine continues to evolve, with new research providing deeper insights into the complex relationships between wind instrument performance and oral health. While wind instruments can influence oral health, proper technique, preventive measures, and appropriate dental care can help musicians maintain both their oral health and performance capabilities throughout their careers.

Acknowledgements

This work was supported by the National Research Foun-dation of Korea (NRF) grant funded by Priority Research Center Program 2019R1A6A1A11034536.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

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