Temporomandibular dysfunction and the developing singer.

SEVERAL YEARS AGO A YOUNG, INTELLIGENT student walked into my studio for voice lessons. We started by discussing repertoire, goals, and technique; however, Susan (name changed) was very eager to begin vocalizing. As we began, I noticed jaw tension, and she described pain when she tried to open her jaw very wide. Since the pain happened both in and out of the studio and in a fairly predictable pattern, I set up a consultation for her with my husband, Dr. R. Russell Burt, a dentist who is familiar with temporomandibular dysfunction (TMD). Her TMD dental history is used in this article with her permission. (1) Unfortunately, Susan was judged by other vocal teachers to be incapable, and at times, the TMD symptoms she described were regarded by others as made-up excuses to perform less than her best. I believed in Susan's potential and did not listen to such accusations. This resulting article discusses temporomandibular joint function and dysfunction with recommendations for teachers of singing to help students during the recovery process.

AGE OF TMD SUFFERERS

That the usual or typical classical singing student is a young female in college or high school is significant, (2) because the majority of people who suffer from TMD are also female and young. (3) In fact, Okeson reports that the typical patient with this affliction falls into two demographics: the young active female and the middle-aged active female, although he does point out the majority of male TMD patients are in the middle-age demographic. (4) It would, therefore, be wise for the singing teacher to be educated in the recognition of the dysfunction, at least at a level that he or she would be able to encourage the student to seek professional help.

THE JAW AND THE TEMPOROMANDIBULAR JOINTS

A basic understanding of the jaw is helpful for the singing teacher and student. The upper jaw is known as the maxilla; the lower jaw is the mandible (Figure l). (5) Grant's Anatomy depicts the bones that make up this structure, showing that the projection of the bone extending up the back of the mandible (the bone that holds the lower teeth) toward the ear is the condyle, and the actual socket-like depression that receives the condyle is the glenoid fossa found in the temporal bone just in front of the ear. (6) The temporal bone is connected to the maxilla, the bone that holds the upper teeth.

The temporomandibular joints (TMJ) are the joints of the mandible that attach it to the skull on either side of the head. The two joints have the ability to work together as well as to act independently. They are often inaccurately described as ball and socket joints. A ball and socket joint is a joint with a ball-shaped insert that ts into a cup-shaped joint capsule in which it can rotate and pivot freely. The TMJ, however, is perhaps best described as a sliding T-bar hinge. (7) It has very little lateral mobility and no ability to swing backward beyond about forty to sixty degrees. (8) It can swing forward very well and slip forward along a track on both sides. Additionally, each side can move somewhat independently from the other. The roughly T-shaped bar is the articular extension of the lower jaw forming the top of the condyle; it is called the head of the condyle. The front slope of the glenoid fossa is the articular eminence. The head of the condyle does not articulate and slide bone-against-bone; rather, it has a small, tough disc that has indentations on the top, where the articular eminence slides, as well as on the bottom into which the head of the condyle rests. This is termed the articular disc, or simply "disc," and is attached to the neck of the condyle just below the head by ligaments that secure it loosely. It must be loose so that it can adjust position on the top of the condyle as the condyle slides forward and down along the track of the articular eminence. (9) The joint is a synovial joint, which means that it secretes its own lubricant. (10)

NORMAL FUNCTION OF THE TMJ

An understanding of the normal function of the TMJ is useful. In the rest position, the lips of a singer should be touching or slightly open and the teeth should not be touching. They should be about two millimeters apart. When the singer begins to open her mouth, she parts her lips and opens her teeth. When talking or functioning throughout the day, and when not involved in singing or eating, her teeth rarely open more than five to fifteen millimeters. The TMJ in this capacity is simply working as a hinge, rotating in place within a few degrees. It is when the singer opens wider than this that the joint stops functioning as a simple hinge and becomes a slip-joint. (11) The head of the condyle, resting on the center of the disc, tries to move forward (Figure 2). (12) It runs into the sloped surface of the articular eminence and is directed downward and forward, which allows the mouth to open wide. As the condyle travels along the articular eminence and the slope changes, the disc stays centered on the head of the condyle and adjusts itself forward, backward, and laterally. It remains on the head of the condyle, thereby keeping the condyle from actually touching the articular eminence and acting as a cushion and lubricant. When the mouth is fully open the head of the condyle has translated so far forward that it no longer is in the glenoid fossa. (13) At that point it is on the bone just ahead of the articular eminence. When the mouth closes the condyle retraces its path and the disc remains centered on top of its head. (14)

SOME CAUSES OF TMD

In a young singer, one or more parts of the face, neck, or back structure can malfunction, causing temporo mandibular dysfunction. The TMJ and the supporting structures around it are intricate, and when they are not functioning properly can produce pain. There are many reasons that a young, developing singer may suffer from TMD. One frequent cause is the body structure of the patient, (15) but the anatomic cause of TMD for each patient is different.

In most TMD patients the two condyles and discs on either side of the face do not match in size, position, or functionality. (16) A typical TMD patient has some physical asymmetry of the head; (17) this might be due to congenital malformation, trauma, or environmental stresses resulting in one or both of the articular discs displaced off the center of the head of the condyle. (18) If the disc is off center but is still located on the head of the condyle, it is said to be a displaced disc; if it has been totally pushed or pulled off the top of the condyle, it is said to be dislocated. (19) In both situations the student is experiencing disc derangement. A joint is said to be reduced if it is in normal functioning position. If the derangement happens when the student opens, but goes back to normal when she closes, it is called disc displacement (or dislocation, if appropriate) with reduction. If the disc has become deranged in either position and, upon closing, does not go back into normal position, it is said to be displaced (or dislocated) without reduction. (20) The student demonstrating a popping sound while opening, and then again while closing, is typically experiencing disc displacement with reduction; in other words, the disc is resetting itself on the head of the condyle upon closure. The popping sound is produced when the disc is forcefully ejected from its normal position between the condyle and the articular eminence and when it returns to its normal position.

Many cases of TMD each year are diagnosed because of the need for orthodontic treatment. The orthodontist can correct problems such as an open bite (an area in the arrangement of the teeth in which the upper teeth do not meet the lower teeth) or a cross bite (an area where the lower teeth are shifted out from under the upper teeth so that the upper teeth are partially displaced toward the tongue more than the lower teeth). Interceptive orthodontic appliances are often prescribed at a very young age to pr event jaw problems. This can either be done with fixed appliances attached directly to the teeth, or with appliances that are removable. Orthodontics initiated when the child is in her teenage years or as a young adult can be fixed or removable as well. If the vocal student has been prescribed removable devices, parents and voice teachers should encourage the student to wear them as prescribed.

The student may have missing teeth, which may cause the bite to be incorrect. even one missing molar can throw off the way the teeth come together (occlusion) and cause a significant discrepancy in the bite. (21) TMDs can be expressed if a student has had orthodontics, new dental work, car accidents, or any other physical stress. Indeed, it appears that TMDs are a result of an accumulation of stresses that eventually reach the point that they overwhelm the body's ability to cope.

Trauma to the joint or the muscles that attach to the joint can be a cause of TMD. Pain, stiffness, and other signs of inflammation can occur. A blow to the head from a baseball, a fight with peers, or whiplash from a car accident all can affect the health of the TMJ. A misaligned spine or neck can cause changes in the TMJ. (22) Clenching or grinding of teeth (bruxing) causes trauma to the masseter (the large muscles in the cheeks) and temporalis muscles (the large muscles attached to the lower jaw and the side of the skull) and can cause joint dysfunction. (23) Leaning on the jaw and chin during lectures can cause straining of the ligament that attaches the articular disc to the head of the condyle. Ligaments are a type of connective tissue that is ridged and cannot stretch. A forceful strain on the ligament can cause it to snap, such as might happen in a car accident. But the force applied when the student habitually rests her chin in her hand during lectures, is a small force applied over an extended period of time. The ligament responds to this type of strain by actually growing longer. After the ligament is elongated, the disc becomes so loose on the head of the condyle that it can easily slip out of place, causing a popping sound. (24)

Chewing gum excessively or chewing on pencils or other objects can also be detrimental. The masseter muscles and the temporalis muscles are very strong; they exist to help the mandible bring the teeth to a closed position to chew food. The average chewing forces expended by these muscles are in the range of about 40 to 100 pounds per square inch. When we chew on anything other than food, we can generate forces in excess of 400 psi. This excess force can cause significant pain and cramping in the chewing muscles and can cause changes in the joints. (25)

MUSCLE SPLINTING AND SPASMS

Very small, seemingly irrelevant actions and habits can cause TMD symptoms. The voice student who leans on one leg during a lesson could be causing un even distribution of weight, which puts strain on the back, neck, and even the jaw. Perhaps the student has one leg shorter than the other and stands with the body out of alignment. (26) In order to protect the body from uneven distributions of weight or forces from strongly contracting muscles, other muscles that oppose the original muscles contract. This is a response called protective cocontraction or muscle splinting, and is a very important reflex. (27) If this did not happen reflexively, for example, a gardener bending over to pull weeds would bend over and fall into the weeds.

Protective cocontraction is the simultaneous contraction of agonist and antagonist muscles around a joint to hold a position. (28) even this normal muscular reflex can cause problems in TMD patients. For example, a patient with a tight levator scapulae that originates in the neck on the cervical spine and inserts on the top of the scapula (in the shoulder) may have muscle spasms. (29) When this happens, the nerves leading from this area to the medulla oblongata of the brain stem are continually firing. This stimulates areas in the midbrain where the neurons meet to send information into the cortex and to complete reflex arcs that will allow the body to react to threats by contracting muscles, or releasing hormones and neurotransmitters. These pathways become hyperexcited, which often exites other neurons close by that would normally not respond if the area did not stay excited. So, not only do the appropriate neurons send responses back to the appropriate muscles and nerves, but the inappropriate neurons send responses back to other muscles and nerves causing muscles to contract and nerves to hurt in inappropriate places. Therefore, the rhomboideus major and minor, trapezius, and latisimus dorsi muscles of the upper back may contract to keep the head from falling too far forward, combatting gravitation that pulls the neck forward, but the muscles of the forehead and the scalp may contract, causing severe headaches. (30) The student may habitually lean forward when this happens, which places the mandible too far forward. The pterygoid, temporalis, and the masseter muscles are agonists; this means they will draw the mandible up and clench the teeth together. The antagonistic response from the digastric muscles pulls the jaw apart. If all of these muscles stay in contraction for very long, muscle spasms and pain in the cheeks and the jaws occur. This would then feel like a problem in the TMJ, even though the problem originated in the back.

Muscles that do not relax are said to be in spasm, a condition that may result from overuse. When this happens the muscle becomes tense and sore. A singer with a demanding schedule often becomes tired. When the student makes a habit of sacrificing sleep in order to get practicing and homework done and to participate in a college night life, she may find herself yawning. She may then begin to notice TMD symptoms as her tired, over-used muscles become spasmodic. If she also has a habit of chewing gum, she can find herself in sudden and constant pain as muscle spasms develop, which may take weeks or months to resolve. If this continues for a long time, the muscle will eventually shorten and begin to scar down, resulting in a permanent disabling of that muscle. When this occurs to muscles of mastication, the singer will not be able to open her jaw very wide. (31)

A muscle may develop areas within its body called trigger points. (32) These are extra sensitive spots that are sore all the time. A trigger point has a constant stimulus to contract. When a muscle is in spasm, therapy is directed to relaxing the muscle by passive stretching and relaxation massage. When a trigger point develops, massage and manipulation may also be helpful, but the stretching of the muscle must be done with extreme care by a licensed health care professional. If it is attempted without the direction of a healthcare provider trained to provide this type of therapy, the problem can become irreversible. If pain is stimulated during the stretching phase, it must be stopped in order to prevent more cocontraction in that muscle or related muscle groups. (33) Many of these spasm problems can be avoided with proper fluid intake, eating, sleeping, and exercise.

Emotional stress can contribute to muscles that do not relax. David Magee states, "Stress can play a significant role in TMDs; it can either initiate problems or aggravate an existing dysfunction." (34) Whether the stress is emotional or physical, often a psychologist can be a powerful tool for healing. Because students often have preconceived resistance to the idea of going to a psychologist, Magee also suggests that a patient is much more willing to accept a referral to a clinical psychologist who is experienced in stress management techniques if this is brought up as a possibility before any therapy is initiated.

ADVANCES IN TMD CLASSIFICATIONS

Many advances have been made in the diagnosis and treatment of TMD. One of these advances is the imaging of soft and hard tissues that can be stored in digital form and, if necessary, sent to another specialist. It is very important that only qualified clinicians diagnose TMD patients, such as dentists, medical doctors, osteopathic specialists, otolaryngologists, and chiropractors. It is important that the potential patient know the clinician's qualifications prior to initiating therapy. The chosen clinician should have specialized TMD training. Because the disorder is multifactorial and presents in many ways, no one method of diagnosis or treatment modality is the answer to all forms of TMD.The majority of practitioners are dentists, but they do not by any means have a monopoly on the training, nor is their perspective always the best in all situations. A qualified clinician will find unique dysfunctions and manifestations for each patient. Many TMD doctors use the TMJ Scale[R] to classify TMD, the only commercially available classification scale recognized by the American Dental Association. (35) In the diagnostic process, the TMJ Scale[R] performs several functions: (1) predicts the presence or absence of TMD; (2) differentially detects the presence of clinical symptoms, thus helping the clinician to arrive at a specific diagnosis; (3) predicts the presence of a non-TM disorder; (4) screens for emotional problems and stress; and (5) helps determine whether the patient is likely to develop a chronic TM related illness. Other dentists utilize a process based on professionally developed algorithms to sort through the myriad presentations of myofascial pain and TMD.

WHEN TO SEE A HEALTH CARE PROVIDER

Anyone with pain lasting longer than two weeks should be referred to a health care provider. Seeking the help of a dentist who is trained in TMD is the best starting point, especially since a chiropractor or physical therapist might not be able to distinguish between TMD pain and dental problems. For example, a patient presenting with pain in the TMJ and masseter muscle could be seen by a chiropractor as a TMD, but a dentist would check to be sure the patient's teeth were not abscessed before diagnosing a TMD. Much effort, money, and time can be saved with a correct diagnosis. If the patient is first seen by a chiropractor or a physical therapist, the patient might be given manipulative therapies or range of motion stretches or massage. is is not to say that a chiropractor is not a good practitioner to see for TMD symptoms. Indeed, the chiropractor may help to align the cervical spine or to relieve trigger points. Some chiropractors are making great strides developing methods that seem to cause facial form changes thereby permanently correcting some TMDs. (36) Dentists can give instructions for physical therapy or chiropractic care as part of treatment. In addition to cranial and skeletal manipulation, chiropractors also study vitamins and other nutritional supplements that may be helpful. The idea of treating TMDs with a team approach, therefore, has considerable merit.

General dentists can make or prescribe orthotic devices to help with the various problems that are a result of occlusion or jaw position. Their purposes are to relieve the stresses and strains that are causative of the symptoms manifested in the various patients. One particular splint that dentists utilize is a Nociceptive Trigeminal Inhibition (NTI[R]) device. (37) A form of an anterior positioning appliance, it is used to get muscles out of pain and to correct joint derangements. Students should not buy an over-the-counter splint or use a nonprescription mouth guard which does little to correct the bite and can accentuate the problem. For example, if the student has a high filling, the nonprescription mouth guard might sit on top of it and make it higher, creating an unbalanced occlusion. A dental orthotic is made to a personal prescription. If cost of treatment is a concern, many dental schools offer treatment at reduced cost. Most dental schools now require students to have some experience with TMD and work is supervised by faculty members. Regardless of the treatment modalities or the practitioners sought, it is very important for the student suffering symptoms to seek treatment. Current research suggests that disc derangements left untreated have a strong probability of progressing. This may lead to joint deterioration and facial symmetry changes. (38)

Sometimes a patient will go to a dentist for treatment but will not follow the outlined treatment plan. Perhaps the splint is uncomfortable or health guidelines seem too difficult to adopt. A very unhealthy patient is sometimes untreatable. For example, some patients drink an average of ninety ounces of sugary carbonated beverages per day and eat very few fruits or vegetables; they often have missing teeth and are grossly overweight because of poor diet and a sedentary lifestyle. A patient who is in and out of the hospital for diabetes because of poor health choices can hardly find time or money to treat a TMD. Generally, good health and stress reduction will improve the prognosis of TMD treatment. (39)

GENERAL HEALTH GUIDELINES FOR TMD RELIEF

General relaxation of the body and mind accompanied by enough sleep and proper diet can do much to relieve stress. (40) There are also behavior modification techniques that can be used for singers. Most singers must be taught to relax as they open their mouths, and those with TMD symptoms must be taught not to open too far while therapy progresses. (41) If a voice student seems stressed week after week and does not respond to pedagogic support, a referral to a clinical psychologist might be necessary. (42)

General health and relaxation also serve to relieve muscle strain and tension. Sometimes a student will just hurt all over. Unusual stress or illness should be discussed with the voice teacher and referred to a professional health care provider. The teacher may first ask the student if he or she is getting adequate rest. Briefly discuss the benefits of whole grains, protein, fruits, and vegetables; ask if the diet is adequate and if serving sizes are appropriate. Students may share personal stress such as the loss of a relationship or moving away from home or even not having enough money to purchase food. Encourage the student to adopt healthy sleeping and eating habits. Educate the student about harmful substances such as tobacco, alcohol, and overuse of caffeine. (43) Teachers may provide water in the studio and encourage students to drink it. Adequate calcium, vitamin D, and potassium in the diet can significantly improve the relaxation of muscles that otherwise might slip into spasm. (44)

THE STORY OF SUSAN

Susan was a university freshman and a voice major at the time she became my student. She had just moved away from home and was feeling overwhelmed at the changes in her life. She had a very pleasant voice but lacked technique. Initially, it was very difficult for me to decide if Susan had poor vocal technique, a lack of training, or a physical problem that pr evented her from developing good vocal technique. When her technique did not improve with practice, she became discouraged. Her weekly emails to me contained descriptions of chronic pain in her jaw, so I referred her to my husband, coauthor Russell Burt. About this time, her family of origin moved to her college town and she moved back in with her parents. Additionally, her mother was diagnosed with cancer, which greatly added to Susan's stress.

I asked Susan about her diet and sleep habits. She did eat enough whole grains, proteins, fruits, and vegetables; however, she did not sleep long enough and she had trouble going to sleep. I noticed that her water intake was good; I kept bottles of water in my studio and she would often stop by to get one. Because of my referral, Susan had TMD treatment from a dentist, met with a campus psychologist, and received chiropractic care.

Susan at the Dentist

Dr. Burt diagnosed a TMD based on facial asymmetry complicated by inadequate orthodontic treatment. She had an open bite, which means her front teeth did not come completely together. Her lower jaw protruded two or three millimeters forward of where it should be forcing a misalignment of the mandibular teeth with the maxillary teeth. She was also in the habit of clenching her teeth at night and in times of stress during waking hours. She had a limited range of motion (she was unable to open very wide), and her muscles of mastication were in chronic spasm and had shortened. She had an articular disc displacement on the left side. The right side muscles of mastication were longer than the left, causing unequal movement of the mandible up and down, forward and back. As she opened her mouth, her mandible dried to the left, suggesting discal displacement.

Treatment included three goals: the first objective was to reduce or eliminate muscle spasms; the next was to bring the disc back onto the head of the condyle; and the final goal was to eliminate pain so Susan could make vocal progress. Dr. Burt fabricated an occlusal orthotic that was designed to bring her bite into a balanced occlusion (a balanced pattern defined by the upper and lower teeth meeting in a proper relationship that balanced biting forces). The orthotic was made to fit her lower teeth and guide the movement of the lower jaw as it interacted with the upper canine teeth when she closed. She was asked to wear the splint all of the time. It was projected that this therapy would allow the displaced disc to slip back onto the head of the condyle since the stress of occlusion would be directed more anteriorly onto the front teeth. This would reduce the ability of the major muscles of mastication (masseter and temporalis muscles) to contract and give them a chance to rest. When these stresses were reduced it was expected that the long discal ligaments that had allowed the disc to slip off the condyle would shorten naturally, decompressing the joint and allowing the disc to follow a more passive path back onto the head of the condyle. Once the disc was back onto the condylar head, the ligaments that secure it would then be able to reduce in size and the reduced joint would be healed.

Susan Visited a Psychologist

Susan naturally continued to be concerned for her mother. She also became physically ill with respiratory problems, resulting in laryngitis, when it seemed she had too much schoolwork. I referred Susan to a qualified campus counselor, which was a benefit of tuition and did not cost Susan money directly. After a few visits, Susan reported that she was able to sleep better at night, her personal stress level seemed to be less, and she was better able to cope with the demands of school. Susan did not experience a complete lack of motivation, which was unusual compared to other freshman students with health and family problems. I kept a notebook of her emails and began to notice progress. Susan was positive as we worked through the very basics of vocal technique and general relaxation of the mind and body. The psychologist visits were then effective in two ways: Susan received help with her family problems, and a she developed a positive outlook for her voice.

Susan at the Chiropractor

Susan also visited a chiropractor who found considerable muscle shortening on the left side of her face. He also determined that her head was habitually held too far forward and that her neck was out of alignment. He worked with her to lengen and relax shortened muscles through passive and active muscle stretching and he aligned her cervical spine and used deep tissue massage to further relax her tightened neck and back. He showed her how to massage her own muscles deep inside her mouth to relax the insertion of the temporalis muscles on the coronoid processes, which is in the cheek beside the upper second or third molars when palpated from the inside of one's mouth. He asked her to use a calcium supplement with vitamin D to enhance her nutrition. Vitamin D enhances calcium metabolism in the muscles and is necessary for bone and ligament health. He also asked her to take a supplement of vitamin B12 and manganese to enhance synaptic nerve impulse transmission and further assist the metabolism of the calcium. Finally, she was asked to take a combination of glucosamine and chondroitin sulfate for ligament and cartilage tone, and to increase her intake of vitamin C.

SEVERAL STUDENTS TAKE A TRIP

At the end of spring semester, five students and I took a trip to New York City to work with well known voice teacher and author, Shirlee Emmons. Shirlee was famous for her vowel modification techniques developed from Berton Coffin, her relaxation techniques, and her breathing techniques. We met with Shirlee five different times before her death in 2010, and she always went back to basics. It was rewarding to see Susan blossom in front of Shirlee with the literature that seemed so difficult nine months before. Shirlee suggested that five or six breaths can return focus and control. "While breathing, think positive thoughts: I am in control. I feel good. I can take my time." (45) Shirley also commented that young singers often use digastric muscles and a tense jaw to support the tone incorrectly. The digastric muscles are strap muscles with two constricting bellies that start just medial to and inferior to the TMJ on the stylohyoid process. Each muscle then extends forward to its first belly and onward to loop under the greater horn of the hyoid bone. From there it extends to its next belly and on to attach to the genial tubercle of the inside of the mandible at the symphasis (below the lower front teeth and behind the chin). This is why it is important to warm the neck, tongue, lips, and in general, the whole body with passive stretching and motion before singing. Tense muscles inhibit correct vocal technique. Tense muscles will pr event the appoggio breath (leaning on the sternum). It was wonderful to hear Shirlee Emmons congratulate us for getting through such a difficult situation. Since I admired Shirlee's teaching, I prepared Susan with appoggio technique as I saw Shirlee do it. Susan was finally doing it right in front of Shirlee and it felt wonderful. Shirlee later wrote:

The most efficient way to make the diaphragm do what is needed is...the
appoggio. The appoggio will deliver the long breath, stability, and
evenness of tone. Asking your singers to push the abdomen in or out
will not. The appoggio position will actually dictate that the
diaphragm and abdominal muscles do the right thing voluntarily. Defined
in basic terms an appoggio consists of a raised sternum and expanded
ribs (shoulders remaining low), maintained from beginning to end of the
phrase. While the breath is being replenished for the next phrase,
nothing should change--shoulders should stay relaxed and down, sternum
should maintain easy height, and ribs stay the extended. This
maintenance is perhaps the most difficult part of the skill to learn.
Yet, unlike other vocal skills, an appoggio is visible to the director,
which makes the training easier. (46)

A VOICE TEACHER CAN RECOGNIZE TENSION

Goals set by student and teacher can include breathing relaxation exercises and relaxation of the jaw and supporting muscles. If the student is unable to do this in and out of the studio because of jaw pain or limitations in jaw motion and if tension persists, advise the student to see a dentist or TMD pain specialist. (47) In terms of tension, what should the voice teacher recognize? James C. McKinney wrote, "Tension probably is the greatest enemy of the public performer. Proper thought patterns and postural habits can do much to keep it under control ... The body cannot operate without tension; the excessive tension is what must be recognized and avoided." (48) A student may have poor posture or twitching of the tensely held muscles. McKinney also suggested that the voice teacher keep a notebook on each student. (49) If the student looks tense, do some general relaxation routines and as well as any that are specific for her individual problems.

CONCLUSION

Susan and I still refer to her notebook with fond memories. After the TMD treatment relieved symptoms, she still had trouble projecting her vocal tone because of physical limitations and confidence level. I provided her with a series of costumes so that she could pretend to be a large animal or person with a big voice. The sounds she produced became better and our laughter provided a positive reward for our efforts. She wrote several sincere thank you letters and is still wearing her dental splint and caring for her own health with diet, sleep, and the xercise.

Voice teachers should avoid accusing students of making up the symptoms of TMD. Because of the multifactorial causes and the effects seen in a highly complicated neuromuscular syndrome, the physical and emotional implications are unique for each student. A voice teacher should be familiar with the anatomy of the TMJ to the point of being able to recognize that popping sounds and pain in the area are abnormal. Teachers could document pain or symptoms described by the student at each lesson in a notebook. A very basic knowledge of the TMJ area includes understanding the functions of the mandible, maxilla, condyle, and articular disc. A teacher can encourage a student to see a qualified dentist when popping sounds and pain occur or when the student is not able to open the mouth correctly to sing. A teacher can ask about accidents that involve face and neck. Adequate water intake, diet, and proper sleep should be encouraged by the teacher as a way to decrease the tension in the muscles and improve the body for singing. Teachers can explain that over-the-counter splints do not help and may cause further damage to the singer. In short, the voice teacher can watch for and document signs of tension or pain in a singer. Voice teachers should not try to diagnose TMD; it is not appropriate for one who has not been trained in medicine or dentistry to tell a student that there is TMD. Descriptions of what the teacher sees in the student over time are helpful to give to parents and health care practitioners (with the student's permission if over eighteen years of age). A well trained dentist may diagnose a TMD and is uniquely qualified to treat or to refer the student to appropriate specialists. The success of a young vocal student depends on the leadership of caring, informed adults.

NOTES

(1.) Diane Burt, personal interview of Richard Russell Burt, DDS (September 13, 2011).

(2.) C. R. Pedroni, A. S. De Oliveira, and M. I. Guaratini, "Prevalence Study of Signs and Symptoms of Temporomandibular Disorders in University Students," Journal of Oral Rehabilitation 30, no. 3 (2003): 283-289.

(3.) Sivarama Prasad Vinjamury, MD (Ayurveda), MAOM, Betsy B. Singh, PhD, Raheleh Khorsan, MA, Rocky Comberiati, DC, Melany Meier, DC, and Susan Holm, MS, DC, "Chiropractic Treatment of Temporomandibular Disorders," Alternative Therapies 14, no. 4 (July/August 2008): 60-63.

(4.) Jeffery P. Okeson, Management of Temporomandibular Dis orders and Occlusion, 6th ed. (St. Louis: Mosby Elssevier, 2008).

(5.) Figure drawn by R. Russell Burt, DDS.

(6.) James E. Anderson, MD, Grant's Atlas of Anatomy, 8th ed. (Baltimore, MD: Williams and Wilkins, 1983).

(7.) Burt.

(8.) Okeson, 85.

(9.) Ibid., 21.

(10.) Ibid., 9.

(11.) Burt.

(12.) Figure drawn by R. Russell Burt, DDS.

(13.) Okeson, 22.

(14.) Samuel J. Higdon, Illustrated Anatomy of the Temporomandibular Joint in Function/Dysfunction: An Educational Aide for Patients with Temporomandibular Dysfunction (Portland, OR: 2010).

(15.) Okeson, 237.

(16.) Pamela Steed, "Facial Asymmetry: Recognition of TMD," The Functional Orthodontist 14, no. 5 (November/December 1997): 5-6.

(17.) Ibid., 6.

(18.) Okeson, 237.

(19.) Ibid., 312-315.

(20.) Ibid.

(21.) Ibid., 141.

(22.) Ibid., 187.

(23.) Ibid., 144-146.

(24.) Ibid., 130-156.

(25.) Burt.

(26.) Angela Caine, "Voice Loss in Performers: A Pilot Treatment Programme to Show the Effect on the Voice of Correcting Structural Misalignment," The Voice Workshop, Southampton, UK, as published in Logopedics Phoniatrics Vocology 23, supplement 1 (1998): 32-37.

(27.) Okeson, 54.

(28.) Ibid.

(29.) W. Henry Hollingshead and Cornelius Rosse, Textbook of Anatomy (Philadelphia: Harper and Rowe, 1985), 202.

(30.) Okeson, 307-309.

(31.) Ibid., 384-385.

(32.) Alissa Deeter, "Tennis Ball Massage to Alleviate Trigger Point Pain," Journal of Singing 70, no. 2 (November/December 2013): 157-163.

(33.) Okeson, 384.

(34.) David J. Magee, James E. Zachazewski, and William S. Quillen, Pathology and Intervention in Musculoskeletal Rehabilitation (St. Louis: Saunders Elsevier, 2009).

(35.) Pamela A. Steed, "Clinical Application of Psycometric Analysis for Temporomandibular Dysfunction," The Functional Orthodontist (August/September/October 1996): 33.

(36.) Amir Kamburov, "More Detail on the Jaw," Voice Council Magazine (November 2009):1-10: http:voicecouncil.com/amirs-extra/... (Accessed, November 19, 2012).

(37.) Okeson, 487.

(38.) Steed, "Facial Assymetry."

(39.) Burt.

(40.) James C. McKinney, The Diagnosis and Correction of Vocal Faults: A Manual for Teachers of Singing and for Choir Directors, rev. ed. (Nashville, TN: Genevox Music Group, 1994).

(41.) Burt.

(42.) Magee, 79.

(43.) Kishar Bhavsar, "An Essay on the Evidence Base of Vocal Hygiene," Journal of Singing 65, no. 3 (January/February 2009): 289.

(44.) Burt.

(45.) Shirlee Emmons and Constance Chase, Prescriptions for Choral Excellence (New York: Oxford University Press, 2006), 272-273.

(46.) Ibid., 19.

(47.) Burt.

(48.) McKinney, 35.

(49.) Ibid., 14-15.

Diane Burt is currently a doctoral candidate at Ball State University, studying voice with Dr. Mei Zhong. Previously she studied with Kristine Ciesinski and Shirlee Emmons and has participated in coachings with John Wustman. She taught private voice, opera workshop, and music education classes for thirteen years at Brigham Young University and Idaho State University. Her international presentations include: "Temporomandibular Dysfunction and the Developing Singer" and "The Use of the International Phonetic Alphabet in the Choral Rehearsal" at the eighth International Congress of Voice Teachers, Brisbane, Australia (2013). National presentations include: poster presentation of "Temporomandibular Dysfunction and the Developing Singer" at the 52nd National Conference of National Association of Teachers of Singing in Orlando, Florida (2012), and a poster presentation on "Vocal Health" at the 51st National Conference of National Association of Teachers of Singing in Salt Lake City, Utah (2010). She has performed over 25 faculty and guest recitals, and 32 benefit recitals, teaches master classes, and adjudicates frequently. Her operatic roles include Lucy in the Telephone by Menotti; Violetta in La traviata by Verdi; Antonia in The Tales of Hoffmann by Offenbach (English); Marcellina in The Marriage of Figaro by Mozart (English); and Lola in Gallantry by Douglas Moore. Oratorio experience includes: soloist for German Requiem by Brahms, Gloria by Vivaldi, Christmas Oratorio by Saint Saens, Messiah by Handel, and Messe in G by Schubert. Previously she taught for nine years in the public schools. She is a member of NATS, and holds degrees from Brigham Young University, Idaho State University, and Antioch University. She was the Idaho State winner of the American Mothers vocal contest in 1998. She is married to Dr. Richard Russell Burt (dentist).

Richard Russell Burt, DDS, is a private practice dentist. Dr. Burt owned a general practice in Blackfoot, Idaho for 18 years. Prior to that, he served four years in the United States Army immediately after graduation from dental school. His first year in the Army was a general practice residency (AEPGD--1yr). As a practicing dentist he has continued his education with training in oral surgery, temporomandibular dysfunction, implantology, invisalign orthodontics, cosmetic dentistry, endodontics, leadership development, and practice management. He is a member of the American Dental Association. He received the degree of Doctor of Dental Surgery (DDS) from Creighton University in 1989.

Some keep the Sabbath going
  to church,
I keep it staying at home,
With a bobolink for a
  chorister,
And an orchard for a dome.

Some keep the Sabbath in
  surplice;
I just wear my wings,
And instead of tolling the bell
  for church
Our little sexton sings.

God preaches,--a noted
  clergyman,--
And the sermon is never long;
So instead of getting to heaven
  at last,

I'm going all along!

                "A Service of Song,"
                     Emily Dickinson

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Author:	Burt, Diane; Burt, R. Russell
Publication:	Journal of Singing
Geographic Code:	1USA
Date:	Sep 1, 2014
Words:	6787
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Topics:	Music education Health aspects Music in education Health aspects Temporomandibular joint disorders Educational aspects