Oral and perioral changes in professional morsing players: a descriptive exploratory pilot study

Abstract

Background

The morsing, a traditional South Indian jaw harp, is played by holding two metal forks against the anterior teeth. Prolonged playing of mouth-contact musical instruments may be accompanied by structural and functional changes in the oral and perioral regions. The effects of morsing playing on oral health have not been well studied, despite its cultural significance.

Aim

The purpose of this study was to assess oral and paraoral alterations, such as tooth wear and temporomandibular joint (TMJ) symptoms, among professional morsing players.

Methods

This exploratory study was conducted over three months among 62 professional morsing players in Tamil Nadu with at least three years of active practice, recruited through purposive and snowball sampling. Clinical examinations assessed occlusion, TMJ function, facial muscle activity, oral mucosa, anterior tooth wear (Smith and Knight Tooth Wear Index), oral hygiene (Oral Hygiene Index - Simplified), dental caries (Decay Missing Filled teeth) and periodontal health (Community Periodontal Index). Data were analysed using descriptive statistics and simple bivariate tests. Significance was set at p < 0.05.

Results

Moderate-to-severe anterior tooth wear was present in 58.1% of players. Facial muscle fatigue was present in 72.6% of the morsing players. The mean DMFT was 2.45 ± 0.80, and mild-to-moderate periodontal involvement (mean CPI 1.63 ± 0.66). Age and years of playing were strongly correlated with each other (ρ = 0.74) and with tooth wear score (ρ = 0.78 and 0.74, respectively).

Conclusion

Professional morsing players showed a high prevalence of anterior tooth wear and facial muscle fatigue, together with appreciable TMJ symptoms, that tended to be more common in older and longer-practising players.

Introduction

Oral health has a particular importance for musicians who play mouth-contact instruments, in whom the instrument interacts directly with the teeth, lips, tongue and jaw during sound production [1]. These demands can make oral hygiene more difficult to maintain and have been linked to problems such as altered dental positioning, mucosal changes, periodontal inflammation and temporomandibular disorders (TMD) [1, 2].

Most published work in this area concerns are about western wind instruments. Systematic reviews and observational studies report that wind-instrument players show altered dentofacial morphology, higher rates of dental abrasion and lip erosion, and an increased burden of TMD and orofacial pain compared with the general population [2–4]. A systematic review and meta-analysis of TMD in musicians found a high pooled prevalence, underlining that music performance can act as an occupational risk factor for orofacial complaints [5, 6].

Among mouth-contact instruments, the morsing — a traditional South Indian jaw harp used in Carnatic music — has received virtually no dental research attention. The morsing is played by positioning two parallel metal forks between the upper and lower anterior teeth, holding them firmly with one hand while the index finger of the other hand strikes a metal trigger; vibrations are transmitted through the teeth and resonate within the oral cavity, with tonal variation achieved by altering oral space, nasal airflow and tongue position. Because the instrument requires sustained anterior tooth contact and repetitive jaw and facial-muscle activity, prolonged practice might plausibly be accompanied by tooth wear, TMJ discomfort and muscle fatigue. The oral and perioral status of morsing players has not been documented in any study to the best of our knowledge.

Due to the absence of prior data, this descriptive study was conducted among morsing players of Tamil Nadu to characterise oral and perioral findings in professional morsing players and to obtain preliminary prevalence estimates.

Methods

Study design and setting

This was a descriptive exploratory pilot study conducted over three months (May–July 2024) across locations in Tamil Nadu, India, where morsing music is traditionally practised. Professional morsing artists were contacted through music academies, cultural organisations and personal networks.

Study population and sampling

The study population comprised professional morsing artists aged 18–60 years who had been performing actively for at least three consecutive years. Because professional morsing players form a small, geographically dispersed group for which no sampling frame exists, recruitment used a combination of purposive and network-based (snowball) sampling. A total of 62 eligible participants consented and were enrolled. Given the rarity of this occupational group, this number represented the feasible sample that could be recruited within the available study period.

Inclusion criteria

(1) Age 18–60 years; (2) active professional morsing players with ≥ 3 years of playing experience; (3) willingness to participate and to provide written informed consent.

Exclusion criteria

(1) Unwilling or unable to provide consent; (2) non-morsing players; (3) deleterious oral habits (nail biting, object biting, bruxism); (4) missing anterior teeth or anterior dental prostheses; (5) systemic conditions affecting oral health (e.g., diabetes, medication-induced xerostomia). Individuals with bruxism and relevant systemic conditions were excluded to reduce well-established competing causes of tooth wear and oral disease.

Ethical considerations

Ethical approval was obtained from the Institutional Ethics Committee of Sree Balaji Dental College and Hospital, Bharath Institute of Higher Education and Research (IEC/SBDCH/2024/045). All procedures complied with the Declaration of Helsinki and its amendments. Written informed consent was obtained from all participants, and data were anonymised and handled confidentially.

Clinical examination and data collection

A structured proforma captured demographic data (age, years of playing, practice frequency) and playing-related symptoms (jaw pain, facial muscle fatigue, neck/shoulder discomfort). All clinical examinations were conducted under standardised conditions using natural light supplemented by a portable dental light, a mouth mirror and a Community Periodontal Index (CPI) probe, by two examiners who were trained and calibrated against a reference examiner before data collection. Calibration was performed on ten volunteers not included in the study; inter-examiner agreement was high (Cohen’s kappa = 0.87) and intra-examiner reliability on repeat examination of a subset was satisfactory (kappa ≥ 0.85).

Oral and perioral parameters

The following were recorded: occlusal pattern (Angle’s classification); TMJ status (tenderness, clicking, deviation and pain on mandibular movement, graded 0–4); facial muscles (buccinator and circumoral muscles palpated for hypertrophy, soreness or fatigue); oral mucosa (traumatic changes, keratotic patches or instrument-related impressions); anterior tooth wear (Smith and Knight Tooth Wear Index, 0–4 per surface) [7]; oral hygiene ( Oral Hygiene Index-Simplified, OHI-S) [8]; dental caries (DMFT index) [9]; and periodontal health (Community Periodontal Index, CPI) [10]. Moderate-to-severe anterior tooth wear was defined as a Smith and Knight score ≥ 2 on any anterior surface.

Statistical analysis

Data were entered in Microsoft Excel and analysed using standard statistical software. Descriptive statistics (mean ± standard deviation, frequency, percentage) summarised participant characteristics and outcomes. For the principal binary outcomes, prevalence estimates are reported with 95% confidence intervals (Wilson score method). Bivariate associations between categorical exposures (age group, years-of-practice category, practice frequency) and binary outcomes (jaw pain, tooth wear ≥ 2, facial fatigue, TMJ symptoms) were assessed using the chi-square test, with Fisher’s exact test where expected cell counts were small. Dose–response across ordered playing-duration categories was assessed using the Cochran–Armitage test for trend. Spearman rank correlation coefficients (ρ) were used to describe monotonic relationships between continuous and ordinal variables (age, years of playing, practice frequency, tooth wear score, TMJ severity score and DMFT). All tests were two-tailed with significance set at p < 0.05.

Results

Participant characteristics

Sixty-two professional morsing players participated. The mean age of morsing players was 39.1 ± 11.5 years (range 22–59), distributed fairly evenly across age groups. Mean playing experience was 14.8 ± 9.7 years (range 3–37). Nearly half (48.4%) practised daily, 16.1% practised 3–4 times/week and 35.5% practised 1–2 times/week. All participants used the right hand for playing. Demographic and clinical characteristics are summarised in Table 1.

Table 1.

Demographic and clinical characteristics of morsing players (n = 62)

Characteristic	Value
Age (years), mean ± SD	39.1 ± 11.5
Age group, n (%)
• 18–30 years	18 (29.0)
• 31–45 years	22 (35.5)
• > 45 years	22 (35.5)
Years of playing, mean ± SD	14.8 ± 9.7
Practice frequency, n (%)
• Daily	30 (48.4)
• 3–4 times/week	10 (16.1)
• 1–2 times/week	22 (35.5)
Tooth wear (anterior, score ≥ 2), n (%) [95% CI]	36 (58.1) [45.7–69.5]
Facial muscle fatigue while playing, n (%) [95% CI]	45 (72.6) [60.4–82.1]
TMJ symptoms present, n (%) [95% CI]	33 (53.2) [41.0–65.1]
Jaw pain while playing, n (%) [95% CI]	23 (37.1) [26.2–49.5]
DMFT (total), mean ± SD	2.45 ± 0.80
• Decayed (D), mean ± SD	1.76 ± 0.80
• Missing (M), mean ± SD	0.08 ± 0.33
• Filled (F), mean ± SD	0.61 ± 1.23
OHI-S score, mean ± SD	1.44 ± 0.69
CPI score, mean ± SD	1.63 ± 0.66

CI Confidence interval (Wilson score method), DMFT Decayed–missing–filled teeth, OHI-S Simplified Oral Hygiene Index, CPI Community Periodontal Index, TMJ Temporomandibular joint

Prevalence of oral and perioral findings

Moderate-to-severe anterior tooth wear (Smith and Knight score ≥ 2) was the most prominent structural finding, present in 58.1% of players (36/62; 95% CI 45.7–69.5%). Facial muscle fatigue while playing was the most common symptom overall, reported by 72.6% (45/62; 95% CI 60.4–82.1%). TMJ symptoms (clicking, deviation or tenderness) were present in 53.2% (33/62; 95% CI 41.0–65.1%) and jaw pain while playing in 37.1% (23/62; 95% CI 26.2–49.5%). Caries experience was modest (mean DMFT 2.45 ± 0.80; decayed 1.76 ± 0.80, missing 0.08 ± 0.33, filled 0.61 ± 1.23). Oral hygiene was generally fair (mean OHI-S 1.44 ± 0.69) and periodontal involvement mild-to-moderate (mean CPI 1.63 ± 0.66) (Table 1).

Bivariate associations with age and playing exposure

The prevalence of all four key outcomes increased with age (Table 2). Jaw pain rose from 5.6% in the 18–30 years group to 77.3% in those aged > 45 years; moderate-to-severe tooth wear was absent in the youngest group but present in 63.6% of the 31– 45 years group and in all players aged > 45 years; facial fatigue increased from 66.7% to 95.5%; and TMJ symptoms were most frequent in the middle and older age groups.

Table 2.

Bivariate associations of age group and playing duration with key outcomes

Exposure/outcome	Test	p value
Age group vs. jaw pain	χ² = 24.84, df = 2 #	< 0.001
Age group vs. tooth wear ≥ 2	χ² = 41.09, df = 2 *	< 0.001
Age group vs. facial fatigue	χ² = 9.70, df = 2 #	0.008
Age group vs. TMJ symptoms	χ² = 24.57, df = 2 #	< 0.001
Playing duration vs. tooth wear ≥ 2	Cochran–Armitage trend	< 0.001
Playing duration vs. jaw pain	Cochran–Armitage trend	< 0.001
Playing duration vs. facial fatigue	Cochran–Armitage trend	0.006

*Fischer exact test, # Chi square test

A similar pattern was seen across playing-duration categories. The prevalence of tooth wear ≥ 2 and of jaw pain increased steadily from the shortest to the longest playing-duration groups, and Cochran–Armitage tests indicated significant increasing trends for tooth wear (p < 0.001), jaw pain (p < 0.001) and facial fatigue (p = 0.006).

Correlation analysis

Spearman rank correlations were used to describe relationships between age, playing exposure and the graded clinical measures (Table 3). Age and years of playing were strongly correlated with each other (ρ = 0.74, p < 0.001), so they cannot be regarded as independent exposures in this dataset. Both correlated strongly with tooth wear score (age ρ = 0.78; years of playing ρ = 0.74; both p < 0.001), while practice frequency showed a weak correlation with tooth wear (ρ = 0.26, p = 0.039). An incidental moderate negative correlation was observed between age and DMFT (ρ = −0.43, p < 0.001).

Table 3.

Spearman rank correlations between exposure variables and graded oral measures

Variable 1	Variable 2	ρ	p value
Age	Years of playing	0.74	< 0.001
Age	Tooth wear score	0.78	< 0.001
Years of playing	Tooth wear score	0.74	< 0.001
Practice frequency	Tooth wear score	0.26	0.039
Years of playing	TMJ severity score	−0.17	0.177
Age	DMFT	−0.43	< 0.001

ρ Spearman rank correlation coefficient, DMFT Decayed–missing–filled teeth, TMJ Temporomandibular joint

Discussion

This study provides, to our knowledge, the first documentation of oral and perioral findings in professional morsing players — a traditional South Indian musician population absent from the oral-health literature. The main observations were a high prevalence of anterior tooth wear and facial muscle fatigue, appreciable TMJ symptoms and jaw pain, and a modest caries burden. All of these findings tended to be more frequent in older and longer-practising players.

Anterior tooth wear

Moderate-to-severe anterior tooth wear was the dominant structural finding (58.1%), and was universal among players with the longest playing experience. This is directionally consistent with the wider musician literature. Czech and Alt, in a review of wind musicians, describe tooth wear and abrasion concentrated at sites of instrument contact [1], and Laparra Hernández et al., comparing wind players with matched non-players, found significantly higher dental abrasion and lower-lip erosion in musicians [3]. A systematic review and meta-analysis by van der Weijden et al. likewise concluded that playing a wind instrument can influence tooth position and morphology [4]. The morsing differs from these instruments in that the metal forks contact the anterior teeth directly, which could plausibly concentrate mechanical stress on the incisors. Importantly, in the present study age and years of playing were strongly correlated (ρ = 0.74), so the observed increase in wear with playing duration cannot be separated from ordinary age-related wear in the absence of a comparison group.

Temporomandibular joint symptoms and jaw pain

TMJ symptoms (53.2%) and jaw pain while playing (37.1%) were common and increased with age. These figures sit within the broad range reported for musicians. Van Selms et al., in a large questionnaire study, documented a substantial burden of TMD and related pain among instrumentalists [5], and a systematic review and meta-analysis by Campos et al. reported a high pooled prevalence of TMD in musicians and cautioned clinicians not to underestimate these signs and symptoms [6]. The current study findings are compatible with the possibility that sustained jaw positioning and repetitive striking forces transmitted through the anterior teeth contribute to TMJ-related symptoms in morsing players.

Facial muscle fatigue

Facial muscle fatigue was the most prevalent symptom (72.6%) and, like the other outcomes, was more common with longer and more frequent practice. Morsing technique requires sustained contraction of the buccinator, orbicularis oris and masseter muscles, and prolonged practice without adequate recovery could contribute to fatigue, analogous to the embouchure-related muscular demands described for wind players [1, 2].

Dental caries and periodontal health

Caries experience was modest (mean DMFT 2.45), and oral hygiene (OHI-S 1.44) and periodontal status (CPI 1.63) were generally fair, suggesting that poor hygiene alone does not account for the observed tooth-wear findings. This mirrors the wider literature, in which the principal oral concerns for musicians relate to mechanical and functional changes rather than to a distinctly elevated caries burden [1].

Strengths and limitations

The main strengths of this descriptive study are its focus on a previously unstudied population, a comprehensive clinical examination performed by trained and calibrated examiners, and the use of validated indices. There are a few limitations for this descriptive study, such as the cross-sectional design, which cannot establish causation, and the small, non-probability sample (n = 62) limits how broadly the results apply. Without a comparison group, we can’t fully tease apart age-related from playing-related effects, especially since age and years of playing were closely linked. Given all this, the findings are best seen as an early, hypothesis-generating step rather than a definitive conclusion.

Implications and future directions

Even as preliminary data, these observations have practical value. They indicate that anterior tooth wear, TMJ symptoms and facial-muscle fatigue are common enough among morsing players to warrant clinical attention, and they provide the prevalence estimates needed to size a definitive study. We suggest, pending confirmation, that professional morsing players receive periodic dental review focused on anterior tooth wear and TMJ function, together with ergonomic advice on playing posture and rest. Future work should include adequately powered, longitudinal studies with appropriate comparison groups; objective measures of muscle activity and occlusal load; and comparative studies across jaw-harp traditions to clarify whether the direct metal–tooth interface of the morsing carries a distinctive risk.

Conclusion

In this exploratory study, professional morsing players showed a high prevalence of anterior tooth wear and facial muscle fatigue, with appreciable TMJ symptoms and jaw pain, all of which tended to be more common in older and longer-practising players. Their principal contribution is to document, for the first time, the oral and perioral status of this culturally important but previously unstudied musician population, and to provide preliminary prevalence estimates for future adequately powered, controlled research. In the interim, regular dental monitoring and ergonomic education are reasonable precautions.

Author contributions

S conceptualised the study and conducted primary data collection. KGS performed statistical analysis and contributed to manuscript drafting. DK contributed to study design and clinical examinations. AM supervised the study, provided critical revision, and finalised the manuscript. YT, CS, SP, and CD participated in data collection, clinical examinations, and critical revision of the manuscript. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Data availability

The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request **.**.

Declarations

Ethics approval and consent to participate

This study received approval from the Institutional Ethics Committee of Sree Balaji Dental College and Hospital, Bharath Institute of Higher Education and Research (IEC/SBDCH/2024/045). All procedures complied with the ethical standards of the institutional research committee and the 1964 Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all participants before inclusion.

Competing interests

The authors declare no competing interests.