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Embouchure overuse syndrome: Information about lip swelling, lip pain, and other debilitating embouchure problems.                       

 

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Lip Swelling

While every brass player experiences lip swelling from time to time, for the chronic sufferer, swelling almost always appears very shortly after he begins to play and prevents him from feeling his lips or mouthpiece normally. Understandably, someone plagued by this sort of relentless, inexplicable swelling looks for a physical explanation, such as an allergy to the metal of his mouthpiece rim. 

Tissue swelling can result from either physical trauma or a physical disorder. Obviously, a severe trauma like a blow to the lips would cause them to swell. Any physical disorder which causes edema (fluid in the tissues) can cause the extremities, including the lips, to swell. Certain medications can cause fluid retention and general swelling. Allergic reactions to ingested substances like foods, herbs, or vitamins, or to environmental or chemical exposure can also cause the extremities, and not just the lips, to swell. Although allergies to metal do exist, such as in the form of contact dermatitis, the reaction usually presents itself as a crusty, painful or blistered rash or irritation on the skin and not as localized swelling.  Any player suspecting a metal allergy should consult a dermatologist.

In general, swelling  in areas of the body besides the lips (ankles, hands, wrists, face, eyelids, etc.) would indicate the presence of a physical disorder. If swelling is only noticeable in the lips and occurs only during playing, more than likely, it is the result of
embouchure overuse syndrome

Peripheral Neuropathy in the Embouchure Itchy--Tingly, Pin-prick pain

This is a unique kind of lip discomfort which is described by sufferers as a sharp pin-prick pain, usually on the upper lip under the mouthpiece rim, and noticeable when playing. The cause is an entrapment neuropathy that often results from a front incisor pressing the lip against the rim of the mouthpiece.

Certainly, any kind of chronic lip discomfort can eventually have a negative impact on a player
's ability to play and lead him into developing embouchure overuse syndrome
. Filing down the offending tooth may correct the problem. Speak with your doctor or dentist.

Acid Reflux Disease (GERD), Excessive (hyper)Salivation (water brash), and Mouth Discomfort

One of many factors contributing to hypersalivation and mouth burning is acid reflux disease, also known as Gastroesophageal Reflux Disease (GERD). When the lower esophageal sphincter (LES) is functioning correctly, it prevents stomach digestive acids from moving up the esophagus.  If the LES has become weak or ineffective, the result is GERD.  Reflux of gastric contents irritates the lining of the esophagus and causes heartburn or discomfort in the middle of the chest. Once reflux occurs, esophageal peristalsis, which is the wavelike muscular contractions of the alimentary canal, may not be adequate to clear the gastric acid quickly. This has the effect of stimulating esophagosalivary reflex (ESR) and leads to episodic sialorrhea (hypersalivation or water brash). Saliva has a natural therapeutic quality to it.  Swallowing therefore neutralizes the residual gastric acids, albeit temporarily so.  Excessive salivation can also be caused by certain medications, such as those for seizure and affective disorders.

Embouchure problems are bad enough, but when a player has to deal with mouth discomfort and too much saliva excreted in the mouth during playing, playing can become a real challenge. The remedy for this problem begins with a visit to a specialist in gastric disorders. The American over-the-counter drugs Prilosec and Previcid are quite effective in treating acid reflux and reducing water brash. If none of the medications for GERD improves your mouth burning and hypersalivation, obviously, you need to speak with your doctor.

Allergies 

Allergic reactions, also referred to as hyper-sensitivity reactions, are reactions of the immune system.  When any part of the body encounters antigens (allergens such as dust, pollen, vitamins, minerals herbal remedies, or certain foods or food additives), it stimulates an immune response, and chemicals are released to protect the exposed area.  Unfortunately, these chemicals also injure the surrounding tissue, thus the "allergic reaction." An allergic reaction can be mild or severe and life threatening.  Only a medical evaluation can determine the source of the sensitivity or allergy.

 Food Allergies

 A food allergy is an allergic reaction to a particular food.  Food intolerance, characterized by gas, nausea, diarrhea, or other gastric symptoms, is far more common but is not an allergic reaction.  While food allergies in some begin in childhood, certain people develop severe allergic reactions to specific allergens in foods, especially shellfish or nuts.  The allergic reaction might be as simple as a rash or so severe as to cause the throat to swell and close.  Skin tests may be helpful in diagnosing food allergies, but the only sure treatment is to stop eating the foods that trigger them. 

Skin Allergies (Contact Dermatitis) 

Contact dermatitis is inflammation of the skin which is caused by contact with a particular substance.  There are two kinds of contact dermatitis, irritant contact dermatitis or allergic contact dermatitis. Allergic contact dermatitis may develop with repeated exposure to such things as soaps, perfumes, or metals. Irritant contact dermatitis can appear quickly after exposure to highly irritating agents, such as chemical solvents. 

In allergic contact dermatitis, a person may suddenly develop an allergic reaction to a particular substance, even though he has regularly been exposed to that substance with no previous problem. One of the most common metal allergies is to nickel. Symptoms of allergic contact dermatitis range from a mild redness of the skin to severe swelling and a rash with itchy blisters.  The rash will first be confined to the original contact site, but it can spread to other areas. Patch tests can help determine the cause of dermatitis. 

Any allergy which has an effect on the contour or comfort of the playing surface of the lips can create playing problems and even throw a monkey wrench into the normal function of a player's embouchure and lead to embouchure overuse syndrome.  A plastic rim or a different plating might help. 

Dry Mouth
 

Many things can contribute to the mouth feeling dry and gummy.  Lack of hydration, performance anxiety, a cold or fever, antihistamine allergy medications, radiation treatment for cancer, and antidepressants can all cause mouth dryness.  Diseases which affect the salivary glands and calcium deposits which block the salivary ducts will impair normal salivation. Saliva has a protective quality which heals mouth injuries and protects the teeth from decay. Therefore, a loss of saliva can have a serious impact on dental hygiene.

Since saliva lubricates the mouth, tongue, and lips in playing, it is quite important.  Performance anxiety is the most common cause of transient dry mouth in brass players.  A beta blocker may be helpful in relieving performance anxiety.   Speak with your doctor for more information.


Embouchure Dystonia (Focal Dystonia)

Dystonia is a disorder of motor control and produces involuntary contraction of a muscle. There are different kinds of dystonia, but the occupational version that strikes musicians is focal dystonia.   

An embouchure dystonia is initially perceived or felt as a loss of playing control or that the affected lip is weak. A player may find himself having to use more effort to play the most routine passages and, therefore, interpret the early onset symptoms as an embouchure problem.  It is typically only felt when playing and may not really appear visually as much as its affects show up in sound, articulation, late attacks, etc.  One of the more common embouchure dystonias appears in one corner of a player's mouth, causing it to pull up uncontrollably in playing.  Embouchure dystonia is usually isolated to a particular part of a player's range, or articulation.  All other aspects of range and technique are not affected. 

Since dystonias are classified as movement disorders (along with Parkinson's disease), a musician experiencing symptoms or suspecting the presence of a dystonia should seek treatment from a neurologist specializing in movement disorders. There is no cure for dystonia, although there are some treatments for its symptoms. There are a few drugs which may be mildly effective. Injections of botulinum toxin (Botox), which weakens the overactive muscle, can help improve the condition but usually does not allow a player to return to normal playing.

Dr. Steven Frucht, (sf216@columbia.edu) who conducted a study on brass players' embouchure dystonias at New York's Columbia Presbyterian Hospital, says that it is unknown what triggers a dystonia in musicians, but any musician can develop one. Musicians who do will usually begin to experience symptoms in their late 20s to early 40s--although younger and older players have also developed dystonias. 

Another aim of Dr. Frucht's project has been to assist musicians, first by making documentation and information available to musicians who are seeking workers' compensation or disability benefits for dystonia. He has also created a foundation to assist musicians suffering with dystonia and especially those who can't afford treatment.   For more information on where to seek help and treatment for dystonia, please visit http://www.dystonia_foundation.org.

Although they are not life threatening, dystonias are often career ending.   Since dystonias are a neurological disorder, retraining the brain may be the only means of reversing the problem.  As of yet, however, no one has devised a consistently successful retraining system for dystonia, although there are new and interesting approaches some players have devised which have helped some.  Please visit http://www.embouchuredystonia.com for more information.

Dental Bonding, Porcelain Veneers, and Caps

Dental bonding, veneers, and caps are used to cover teeth.  Bonding is semi-permanent.  Veneers and caps are fixed permanently to the teeth.  Caps are generally used to cover a tooth after root canal or to cover a tooth which is cracked.  Bonding is often used for cosmetic dentistry to close small gaps or chips in teeth.  Veneers are also used for cosmetic dentistry and to repair cracks. 

Bonding, veneers, or caps may have no negative effect on playing, depending on their location.  Players who try to make their dental surfaces more comfortable with bonding usually find that the change in the feel of the bonded surface makes playing different and more difficult.  Overlays and caps can have the same effect.

Gum Disease (periodontal disease)

Periodontal diseases, ranging from simple gingivitis to pericoronitis, is caused by an accumulation of bacteria and can erode the gums, bone, and the roots of teeth.

Teeth are as important to a brass player as his musical equipment.  A strong dental surface, upon which to rest a mouthpiece, is essential for comfortable and secure playing.  If a player's gums are inflamed and his teeth have become loose in the sockets from periodontal disease, his dental surface will change, and he will gradually lose control of his playing.   Good oral hygiene and regular dental screening is the only way to prevent periodontal disease.  Preventive dentistry in general will increase your playing life.

More extensive information on medical and dental problems which affect brass players can be found in Broken Embouchures.

If you would like to locate a physician in your area who treats musicians in, please contact artsmed@comcast.net. If you need medical assistance and cannot afford it, please visit www.actorsfund.org/ahirc. Actorsfund.org has compiled a list of free clinics and medical services available for performing artists. It also has information on low-cost health insurance.  See more medical links by clicking the links icon  in the left column.

 

 
Send mail to cinlewis@embouchures.com with questions or comments.
Copyright 2005 Embouchures.com, Inc.
Last modified: July 24, 2010