Oral Health-Related Quality of Life and Maxillary Function in Wind Instrument Musicians: A Cross-Sectional Survey

Response to Reviewer 1 Comments

1. Summary

Thank you very much for taking the time to review this manuscript.

Please find the detailed responses below and the corresponding revisions highlighted the changes in the re-submitted file.

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Is the work a significant contribution to the field?

Thanks for your opinion

Is the work well organized and comprehensively described?

We are now presenting the improvements made thanks to the reviewer’s helpful comments

Is the work scientifically sound and not misleading?

Thank you for the reviewer’s encouraging comment

Are there appropriate and adequate references to related and previous work?             

Six new, recently published references have been added, as they were found to be of value to the review of the text. We are, however, open to examining any other references that the reviewer has identified but which are not included, in order to assess whether they are relevant for inclusion in this work.

Is the English used correct and readable?             

Minor grammatical adjustments have been made, and we have consulted our university’s department regarding any queries that arose in this regard

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: The abstract should avoid over interpretation and incorporate key numerical findings to strengthen clarity and transparency.

Thank you for your pertinent comment. The summary has been revised to remove any over-interpretation. The principal data was reported, as: sample size, gender, mean age, and the mean length of playing experience. We have also detailed the numerical results, such as the average daily practice duration and prevalence found in jaw pain, temple or ear.

Comments 2: Keywords to be arranged alphabetically

Response 2: Thank you for bringing this to our attention; we have reorganised the keywords

Keywords: dentistry; musician’s dystonia; oral health; quality of life; temporomandibular joint disorders

Comments 3: The study design and terminology need clarification, as the current description-“experimental, cross-sectional, and observational” is conceptually inconsistent. It is suggested to revise this to “cross-sectional observational study” to improve accuracy and methodological coherence.

Response 3: The reviewer is quite right, and we thank them for spotting this inaccuracy in Section 2.1. We have removed the word ‘experimental’ from the description, as no variables were manipulated.

The text has been amended to ‘cross-sectional observational study’, bringing the terminology into line with that already correctly used in the Abstract.

On page 3, in the sixth paragraph, line 122, the sentence now reads: ‘A cross-sectional, observational study was conducted.’

Comments 4: The manuscript would benefit from enhanced methodological rigor, including a clear justification of the sample size through a power calculation and consideration of potential sampling bias arising from convenience sampling.

Response 4: A primary methodological limitation of this study involves the utilization of a non-probability convenience sampling method paired with a relatively small sample size (n = 71), which inherently compromises the generalization of the data to the broader population of wind instrumentalists. Furthermore, due to the absence of an a priori statistical power calculation, potential sampling biases inherent to convenience sampling must be explicitly acknowledged, warranting caution when interpreting the scope of these findings.

The text has been reorganized, with the opening paragraph split into two separate paragraphs, and a sentence has been added to the section on limitations to include this clarification; we agree with the reviewer that this should be made more explicit as a way of improving the proposed article.

A new initial paragraph has been included in Limitations and Future Directions sub-section on page 11, between lines 357-363: “A primary methodological limitation of this study involves the utilization of a non-probability convenience sampling method paired with a relatively small sample size (n = 71), which inherently compromises the generalization of the data to the broader population of wind instrumentalists. Furthermore, due to the absence of an a priori statistical power calculation, potential sampling biases inherent to convenience sampling must be explicitly acknowledged, warranting caution when interpreting the scope of these findings.”

Comments 5: Greater detail should be provided regarding recruitment settings (type of bands, geographic spread), inclusion and exclusion criteria (prior TMDs/ systemic diseases), and the use of validated cut-offs for the assessment tools.

Response 5: Thank you for bringing this to our attention, the manuscript has been updated in Section 2.2 to specify that the musicians were recruited from various schools and bands (community and philharmonic) in the Douro Litoral region of Portugal.

The sentence in page 3, 6^th paragraph, lines n. 128-129 was changed to: “The study population consisted of wind instrument players recruited from various musical bands in the Douro Litoral region of Portugal.”

Also, for the exclusion criteria, these have now been clarified.

See new sentence in page 3 and 4, lines 131-133.

We have clarified in Section 2.3 that we adopted the validated Portuguese version of the OHIP-14 and the specific criteria of the RDC/TMD (Axis 1-C1 and Axis 1-C1/R1) for the screening of the temporomandibular joint, with no cut-off points being used on these scales for statistical analysis

Comments 6: The interpretation of findings should avoid causal language (should avoid terms such as ‘impact’ as it is a cross-sectional study) and instead focus on associations, with additional clarification of counter intuitive results and possible confounding factors.

Response 6: Thank you for bringing this to our attention; as this is a cross-sectional observational study, we have carried out a cross-sectional review of the entire manuscript.

We have replaced causal verbs and nouns (such as ‘impacts’ or ‘causes’) with associative language, using expressions such as ‘is associated with’, ‘is related to’ or ‘correlates with’.

Less obvious associations, such as the lack of a statistical relationship between anxiety and quality of life, have also been reframed from this perspective of non-causal association.

Page 8 line 241-244: reporting: “…and anxiety levels showed no statistically significant association …” and adding the sentence “Performing warm-up exercises was not found to be associated with the reported outcomes”

Comments 7: Data presentation could be improved by simplifying tables, emphasizing key findings, and ensuring overall clarity and consistency.

Response 7:

We appreciate the reviewer’s comments, but we would like to await the editor’s own opinion before even considering this decision, as we fear that by aggregating or reducing the data presented in the tables, we may be limiting the full interpretation of data that is important to readers and other researchers.

Comments 8: Please incorporate more recent literature (2023–2025) on musicians’ occupational health and temporomandibular disorders in performers, along with more in-depth mechanistic insights, particularly regarding embouchure biomechanics and muscle fatigue, and a clearer presentation of clinical implications such as screening and preventive dental care.

Response 8: We accepted the reviewer’s challenge to delve even deeper into the recent available literature and have included four articles, drawing on them to revise certain paragraphs in the introduction and subsequently in the discussion section:

(Wolff, AL, 2021), (Z'Graggen S et al, 2025), (Rodríguez-Gude C et al, 2025), (de Sá JSN, 2025), (Akkor HÖ et al, 2026) and (Rodríguez-Gude C et al, 2026).

A paragraph has been added to the Introduction section: on page 3, between lines 97 and 101, and to the Discussion section on page 10, between lines 294 and 303; page 11, lines: 350-355 and 369-374.

Comments 9: The gender analysis also needs refinement, avoiding over generalization by accounting for potential confounders like instrument type and practice patterns, and by more critically exploring biological versus sociocultural influences. Furthermore, clinical relevance can be strengthened by incorporating practical recommendations, including ergonomic training, scheduled rest protocols, and physiotherapy or jaw exercises, while clearly linking these findings to dental and public health practice.

Comments 10: The gender analysis needs further refinement, as the assertion that females are more affected seems overgeneralized. It is essential to account for potential confounders such as instrument type and practice patterns, and to incorporate a more nuanced discussion differentiating biological influences from sociocultural factors.

Response 9 and 10:

We fully acknowledge that the statement regarding women being more affected required further contextualisation (comments 9 and 10).

We have amended the Discussion section to reflect that the higher incidence of complaints among women (particularly regarding joint noises and jaw locking) is heavily influenced by the choice of instrument. We specified that Classes 4 (Transverse Flute) and 1 (Clarinet and Saxophone) had the lowest Quality of Life scores and that these classes had, respectively, 85% and 63% female predominance.

We clearly distinguished this influence of sociocultural gender stereotypes on instrument choice from purely hormonal or pathological predispositions inherent to female biology (despite the literature presented).

Furthermore, we have enriched the conclusions and discussions with clear clinical and ergonomic recommendations: we recommend longitudinal monitoring of posture by instructors, the mandatory implementation of post-practice muscle relaxation exercises to alleviate tension and stiffness, and the observance of strict scheduled breaks.

With regard to the gender analysis: We would like to express our sincere thanks to the reviewer for this insightful critique. We agree that stating that ‘women are more affected’ without further qualification was an excessive generalisation, particularly given the significant gender imbalance in certain instrument categories (for example, 85% of women in Category 4/Flute).

To address this issue, we have expanded the ‘Discussion’ section to critically distinguish between:

·        Sociocultural/behavioural factors: instrument choices based on gender stereotypes and potential differences in pain reporting behaviours.

·        Biological influences: Hormonal fluctuations (oestrogen), joint laxity and anatomical variations.

·        Confounding variables: We explicitly acknowledge that physical asymmetry and the specific biomechanical demands of Class 4 and Class 1 instruments strongly confound gender-related results.

Regarding Clinical Relevance: Furthermore, we have followed the reviewer’s excellent recommendation to strengthen the practical impact of our study. We have added a dedicated subsection in the Discussion and updated the Conclusions to provide concrete and actionable recommendations. These include:

·        Specific ergonomic and postural training protocols for wind instrument players.

·        Scheduled rest periods (e.g., micro-breaks during long practice sessions).

·        Physiotherapy and specific jaw exercises (such as coordination and relaxation movements for the masticatory muscles).

·        A direct link to how dental health professionals and public health systems can integrate these findings into occupational health programmes for performing artists.

All changes have been highlighted in the revised manuscript.

The paragraphs on page 9, between lines 254 and 271, have been amended to reflect the relevant suggestions made by the reviewer.

“Regarding instrument type, participants in Class 1 (Clarinet and Saxophone) and Class 4 (Transverse Flute) reported the lowest QoL. These groups presented a marked female predominance (85% in Class 4 and 63% in Class 1). This convergence requires a nuanced interpretation, as biological sex and instrument mechanics act as major con-founding variables.

From a sociocultural perspective, gender stereotypes heavily influence instrument choice [23], clustering female musicians into specific classes like the flute. Biomechanically, Class 4 involves a highly asymmetric playing posture and sustained activation of the craniomandibular muscles, which may inherently trigger more symptoms, regardless of gender.

Concurrently, distinct biological factors cannot be ruled out; literature suggests that females exhibit higher rates of temporomandibular disorders due to estrogen receptor influences on joint tissues, greater generalized joint laxity, and central pain modulation differences [26]. Furthermore, sociocultural conditioning may lead to higher rates of self-reported symptoms and health-seeking behavior’s in women compared to men [24,25]. Given our sample size (n=71), we cannot statistically decouple biological sex from the intrinsic mechanical demands of the chosen instrument class, which constitutes a limitation that future larger-scale studies must address using multivariable regression models.”

Also, add 2 paragraphs in pages 10 and 11, between lines: 314-337.

All the conclusion was also rewritten to incorporate these perspectives suggested by the reviewer at page 12, lines: 380-389.

4. Response to Comments on the Quality of English Language

Point 1:

Response 1: Minor grammatical adjustments have been made, and we have consulted our university’s department regarding any queries that arose in this regard

5. Additional clarifications

Before changing the table settings, we would like to raise the question of whether this is necessary with the editor of BioMed journal (MDPI)

Response to Reviewer 2 Comments

1. Summary

We would like to thank the reviewers in advance for their comments.

We have clarified and incorporated their suggestions and feedback in order to make this submission more engaging and to better reflect the original research carried out.

2. Questions for General Evaluation

Reviewer’s Evaluation

Response and Revisions

Does the introduction provide sufficient background and include all relevant references?

Yes/Can be improved/Must be improved/Not applicable

Two publications have been added which indicate a higher prevalence of herpes lesions among wind instrument players

Are all the cited references relevant to the research?

Yes/Can be improved/Must be improved/Not applicable

The numbering in the bibliography has simply been rearranged, following the addition of two references

Is the research design appropriate?

Yes/Can be improved/Must be improved/Not applicable

no changes

Are the methods adequately described?

Yes/Can be improved/Must be improved/Not applicable

We have added further details to the methods section to make it clearer when the study took place

Are the results clearly presented?

Yes/Can be improved/Must be improved/Not applicable

no changes

Are the conclusions supported by the results?

Yes/Can be improved/Must be improved/Not applicable

no changes

3. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Introduction

line 45 –

It is not entirely clear why musicians are more likely to be affected by herpes labialis, since it is a viral infection and no specific link to musical instruments can be assumed. If this is documented in the literature, relevant evidence would be helpful.

Response 1: Thank you for bringing this point to our attention. We agree with this comment and, in this regard, have identified two further publications that report a higher prevalence of herpetic lesions among wind instrument players. The main trigger is constant trauma and friction. The continuous pressure of the instrument’s mouthpiece against the lips (the embouchure) causes micro-injuries and stress to the tissues. Physical trauma to the lip area is one of the strongest factors in ‘reactivating’ the virus from its dormant state within nerve cells.

Consequently, two publications have been added (No. 5 – Barkvoll, P. et al., 1987; and No. 6 – Gambichler T et al., 2004) which indicate a higher prevalence of herpetic lesions among wind instrument players – page 2, line 46.]

“Such practice may lead to various soft tissue injuries, including mucosal ulcerations, focal dystonia of the facial muscles, prosthetic instability, herpes labialis, or xerostomia [3,5,6].”

Comments 2: line 51-54 as well as 2.2 line 113-118 -

Please specify the special instruments related to the different groups as they are also mentioned in the discussion (line 237ff).

Response 2: We appreciate your comments and agree to identify and clarify, in two separate sections of the text (pages 2 and 3), examples of different instruments in accordance with the general classifications of musical instruments and, specifically, wind instruments based on the type of mouthpiece.

These changes can be found:

Page number 2, 2^nd paragraph, lines 49-56

“The systematic classification of musical instruments, based on the Hornbostel-Sachs system and adapted by Henrique [8], identifies four primary categories according to the mechanism of sound production: (i) aerophones, where sound is generated by air vibration (for example: flute, saxophone, or bassoon); (ii) chordophones, involving the vibration of tensioned strings (for example: violin or harp); (iii) idiophones, where the instrument's body itself produces sound without external tension (for example: triangle or cymbal); and (iv) membranophones, which rely on a stretched membrane for sound generation (for ex-ample: snare drum and timpani)”

and in

page number 3, 7^th paragraph, and lines 125-126.

“Data were collected using a multi-part questionnaire designed to assess the impact of wind instrument practice on oral health, and in accordance with the classification pro-posed by Strayer [9] for the type of mouthpiece used in wind instruments:”

Comments 3: Materials and Methods

Please also give information about the time slot when the study was performed.

As it is mentioned in the discussion, data selection had been performed during COVID-19 times, so that it is not totally clear, if the stress level and QoL had been also been influenced by COVID-19 lock down or specifically due to instrument performance (line 279/280).

Response 3: We would like to clarify that the study was conducted between June and December 2020 and that, during this period, there were periods in Portugal when artistic activities (rehearsals and performances) were restricted; for this reason, we have identified this as a possible limitation on the number of participants who had the opportunity to be included in the study.

We have added the period during which data collection took place to the text on page 10, lines 292–293.

With this change in wording, the text now reads: ‘...during a period (June and December 2020) of restricted musical activity due to external circumstances (e.g., the reduction of philharmonic band ...’

Comments 4: 2.3 Data collection

1.           Please give some more information about the selection of participitants. Had there been a special randominsation? What had been the inclusion and exclusion citeria oft he study?

2.           The average age is relativly low. Is there a special correlation between the level of experience with the instrument and stress level during pracicing it?

3.           Had there been a clinical evaluation too? It would be interesting, if the participitans had contacted a dentist or specialist to reduce pain, buxism or physical aids.

4.           If possible please add these information.

Response 4: We would like to thank the reviewer for their comments and clarify that:

1.      The sampling was convenience-based and non-probabilistic, meaning that there was no specific randomisation. No randomisation took place, as schools, music academies and philharmonic societies were contacted, with participants responding anonymously, as stated in line 117: ‘Recruitment was performed through a non-probability convenience sampling method’

The inclusion criteria were: (1) active playing of a wind instrument and (2) voluntary agreement to participate as reported in line 116-119, And volunteers who played any type of wind instrument were admitted. Conversely, candidates who were not active players and individuals who did not complete the multi-part questionnaire in full were excluded from the study.

A sentence has been added to identify the criteria for excluding participants in page 3, paragraph 6, Line 119-121: “Conversely, candidates who were not active players and individuals who did not complete the multi-part questionnaire in full were excluded from the study.”

2.      With regard to stress, the study measured anxiety levels but found no statistically significant association between anxiety and quality of life (QoL) in this specific sample. As many participants were not professionals and were affiliated with music academies, this may account for the lower average age. As for stress levels, these may be related to the learning phase of a musical instrument and, on the other hand, to some technical difficulty in producing sound whilst practising.

A paragraph was add trying explain that question in page 9, 3^rd paragraph, lines 253-260:

"The relatively low average age of our cohort (24.16 years) reflects the demographic reality of many local community bands, which typically integrate young musicians. Although performance and assessment anxiety were highly prevalent among participants (81.7%), our analysis did not identify a statistically significant correlation between stress levels, musical experience, and overall QoL. However, the weak negative correlation observed between years of practice and chronic pain intensity suggests that experienced musicians may develop technical adaptation and psychological habituation to practice-related stress, even though the biomechanical impact remains."

3.      Yes, a clinical assessment was carried out. The Modified Gingival Index and the DMFT Index were used to assess gum health and the history of dental caries, respectively. Lines [136-138]

Participants who were identified as having serious or urgent oral health problems were advised to consult their regular dentist for a medical assessment in addition to this study and to discuss with them the need for any treatment proposed by their regular dentist

Comments 5: Discussion

There is a contradiction between the statements in lines 179–180 and 286–288, as the years of experience are supposed to have a negative correlation with pain perception and HRQoL.

Please clarify.

Response 5:

We appreciate your pointing out this potential contradiction but although the perceived intensity of pain may decrease with experience (perhaps due to adaptation or technique), the cumulative impact over the years may result in more profound functional changes or musculoskeletal sequelae, which would explain the association with greater long-term physical consequences, despite a lower score on the acute pain scale.

To clarify this point, a paragraph has been added in Discussion (page 10, 4^th paragraph, lines 296-303):

“Although a negative correlation has been observed between years of practice and the intensity of chronic pain (GCPS), this phenomenon may be attributed to technical adaptation and psychological habituation in more experienced musicians. Nevertheless, all evidence suggests that it is essential to distinguish between the perception of pain and functional integrity, as the biomechanical impact accumulated over years of practice can result in functional changes and musculoskeletal sequelae (such as temporomandibular joint dysfunction or occlusal changes), which manifest even when reported pain levels are lower.”