BRIEF REPORT
Temporomandibular Disorders in Association With
Scuba Diving
Andreas Koob, Dr Med Dent,* Brigitte Ohlmann, Dr Med Dent,* Olaf Gabbert, Dent,*
Christoph Klingmann, Dr Med,† Peter Rammelsberg, Prof Dr Med Dent,*
and Marc Schmitter, Dr Med Dent*
Objective: To determine the prevalence of temporomandibular
disorders (TMD) in scuba divers and to identify the risk factors for
the development of pain in the stomatognathic system before and
after diving by the use of a questionnaire.
Design: Retrospective cohort study based on questionnaires.
Participants: A total of 296 active divers, aged 18 to 65 years,
participating in scuba diving meetings in Heidelberg, Germany.
Interventions: Each diver answered a questionnaire containing
29 questions, predominantly on symptoms of TMD.
Main Outcome Measures: The data collected from the divers
were calculated by the use of logistic regression tests. Risk factors for
the development of TMD were evaluated.
Results: Clenching seemed to be the greatest risk factor for pain
while holding the mouthpiece and for pain in the masticatory muscle
system after diving. Limited mouth opening and clenching were
responsible for the development of pain in the temporomandibular
joint after the dive. The prevalence of TMD-related symptoms was
higher in women before, during, and after the dive.
Conclusions: Individuals exhibiting TMD-related symptoms seem
to be at the greatest risk of developing pain in the masticatory muscle
system and/or the temporomandibular joint during or after the dive.
Key Words: scuba diving, temporomandibular disorders, risk factors,
logistic regression tests
(Clin J Sport Med 2005;15:359–363)
D iving has been one of the most rapidly growing adventure
sports during the last 10 years.1
However, diving may trigger problems in all parts of
the body, but especially in some cranial regions. Mostly
the problems with the masticatory muscles and/or the
Received for publication November 2004; accepted July 2005.
From the *Department of Prosthodontics, University of Heidelberg,
Heidelberg, Germany; and †Department of Otorhinolaryngology,
University of Heidelberg, Heidelberg, Germany.
Reprints: Marc Schmitter, Dr Med Dent, University of Heidelberg, Germany,
Poliklinik für Zahnärztliche Prothetik Im Neuenheimer Feld 400 69120
Heidelberg, Germany (e-mail: marc_schmitter@med.uni-heidelberg.de).
Copyright Ó 2005 by Lippincott Williams & Wilkins
Clin J Sport Med  Volume 15, Number 5, September 2005
temporomandibular joints (TMJs) during or after the dive can
be covered by the diagnosis temporomandibular disorders
(TMD).2 This diagnosis includes both masticatory and
arthrogenous findings.3 Hobson4 and Aldridge and Fenlon5
concluded that the development of functional disorders in the
TMJ and the masticatory muscles during the dive was caused
by holding the regulator mouthpiece. Furthermore, Balestra
et al6 could not reject the hypothesis that the altered position of
the TMJ during scuba diving may induce pain as the result of
stress on the retrodiscal portion of the joint, which is near
neurovascular elements.
If there are muscular findings, the customary treatments
for TMD include, first of all, self-directed home physical ther-
apy and muscle relaxation. In addition, physiotherapy, suitable
medication, behavioral cognitive treatment, and occlusal
splints should be considered as possible interventions7
(Table 1).
Patients with TMD of arthrogenous origin should mainly
be treated with occlusal appliances that change the condylar
position, combined with a physical medicine program7
(Table 2).
The aims of the present pilot study were to determine the
prevalence of TMD in scuba divers and to identify the risk
factors for the development of pain in the stomatognathic
system before and after diving.
MATERIALS AND METHODS
Study Population
Within this pilot study, 400 questionnaires were issued
to active divers attending 2 scuba diving meetings. A total of
296 (74%) questionnaires were answered.
Questionnaire
The questionnaire contained 29 questions, of which 23
were dichotomous (yes/no). It was not validated (Fig. 1).
Statistical Analyses
Before the divers were questioned, a sample size
calculation for logistic regression analyses8 was performed.
Within the study, 2 statistical models were applied:
1. Descriptive statistical analysis was used to calculate
cumulative percentages and mean values.
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TABLE 1. Muscular Findings and Their Therapy Based on the Research of Clark et al7
Diagnosis Therapy
Acute myalgia/myositis Physical medicine methods, rest and ice applications, nonsteroidal anti-inflammatory medication, soft tissue massage,
gradual remobilization exercises
Chronic myalgia Combination of a dental appliance, anti-inflammatory medication, stress–and tension-reduction patient education
(occasionally, analgesic blocking of the tender areas in the involved muscle), adjunctive physical medicine procedures
(postural exercises, soft tissue mobilization, deep tissue massage, acupressure, biofeedback, ice and heat packs,
ultrasound, electrical stimulation)
Trismus, splinting Ice or vapocoolant spray application, gentle stretching of the involved muscles (consultation by a psychologist),
other physical therapeutic approaches (electrical stimulation of the muscles, ultrasound applications)
Dyskinesia Exercises (proprioceptive neuromuscular feedback)

2. Logistic regression test was used to assess the influence of
different covariables on the dependent variables.
The statistical analyses were performed using SPSS 11.5
(SPSS Inc., Chicago, IL) for Windows.
RESULTS
The questionnaires were answered by 82 female and 213
male divers (response rate, 74%). One person forgot to provide
the gender. The number of dives generally lay between 2 and
5151 and the period of diving (diving experience) between
1 month and 50 years (Table 3).
Table 4 shows the prevalence of TMD-related symptoms
independent of diving. Alltogether, women were more affected
by symptoms of TMD than men.
During the dive, there was a distinct increase in pain in
the TMJ and an apparent increase in pain while holding the
mouthpiece, especially in female divers. In contrast, the inci-
dence of general muscle pain and arthralgia was significantly
reduced (Table 5).
The prevalence of TMD-related findings after the dive is
given in Table 6. Pain in the masticatory muscle system clearly
increased relative to the situation during the dive. Again, more
female than male divers were affected.
Logistic Regression
Dependent Variable: Pain in the Masticatory Muscle
System After the Dive
The logistic regression test showed an influence of the
covariables—clenching, age, and gender—on the dependent
variable. Other covariables did not show any effect (Table 7).
Dependent Variable: Pain in the TMJ After the Dive
The logistic regression test demonstrated a connection
between limited mouth opening and the dependent variable. In
addition, clenching seemed to be a risk factor (table 8).
Dependent Variable: Pain While Holding
the Mouthpiece
Another logistic regression analysis presented clenching
to be responsible for pain while holding the mouthpiece. The
covariable age did also influence the dependent variable
significantly (Table 9).
DISCUSSION
Considering the sample size calculation for logistic
regression of Hsieh et al,8 the sample sample size in the present
study seemed to be satisfactory. The study population was not
distributed equally with respect to gender; this demonstrates

TABLE 2. Arthrogenous Findings and Their Therapy Based on the Research of Clark et al7
Diagnosis Therapy
TMJ clicking (a) Exercise-avoidance regime
(b) Dental appliance that stops the click while worn by repositioning the mandible (only if the problem cannot be managed
with a simple exercise avoiding approach)
(c) TMJ surgery (only if the problem is progressive, if it causes substantial disability, and if it cannot be managed
with a simple exercise avoiding approach)
TMJ locking (a) Manual manipulation (if successful: a dental repositioning appliance)
(b) Physical medicine program (if pain and limitation is minimal)
(c) If (a) and (b) are not successful: arthroscopic surgery with a presurgical and postsurgical physical medicine program
Trauma-induced joint pain
(macrotrauma) Ice and anti-inflammatory medication
Trauma-induced joint pain Physical medicine program, occlusal appliance, gentle mobilization techniques, active range-of-motion exercises,
(microtrauma) self-directed home physical therapy
Polyarthritic disease Physical medicine procedures, pain relief methods, range-of-motion exercises, exercise to keep the joint mobile

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FIGURE 1. Questionnaire designed for TMD-related symptoms at scuba divers.

(continued on next page)

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Koob et al Clin J Sport Med  Volume 15, Number 5, September 2005

FIGURE 1. (continued) Questionnaire designed for TMD-related symptoms at scuba divers.

that diving is still a male-dominated sport.5 The average age, after diving. Bruxism is related more to muscular than to
the mean annual number, and the overall number of dives were arthrogenic phenomenona,9 and patients with TMD have an
high compared with former studies, but the questionnaires increase in muscular activities in electromyography in experi-
were mostly completed by experienced divers. Whereas the mental stress situations.
age of the divers seemed to be a significant factor, the expe- In contrast, our results also showed a relation between
rience and the number of dives did not show any influence on clenching and pain in the TMJ after the dive.
the dependent variables. Moreover, the composition of occlusal appliances
Female divers reported more pain in the TMJ, in the influences the masticatory muscle system. Hard splints lead
masticatory muscle system, and while holding the mouthpiece. to a decrease in electromyography activity, whereas soft splints
This may be evidence for specific hormonal but also physical
and psychologic differences in gender on the risk of devel-
oping TMD. However, in the present study, more data from
male divers were evaluated. TABLE 4. Prevalence of TMD-Related Symptoms in the Study
Population (Independent of Diving)
Clenching had a major effect on developing pain while
holding the mouthpiece and in the masticatory muscle system Study Females Males
Finding Population (%) (%) (%)
Arthrosis 9.1 13.4 7.5
Clenching, grinding 29.1 47.6 21.6
TABLE 3. Study Population Splint therapy 7.1 15.9 3.8
Mean Crepitus in the TMJ 5.4 11.0 3.3
Study Population Minimum Maximum Value SD Clicking in the TMJ 22.0 35.4 16.9
Age (y) 18 65 40.02 9.688 Pain in the TMJ 8.8 20.7 4.2
Age/females (y) 18 65 36.93 8.609 Limited mouth opening 10.1 15.9 8.0
Age/males (y) 18 65 41.22 9.835 Orthodontic therapy 29.4 40.2 25.4
Diving experience (mo) 1 600 171.26 104.591 Facial pain 7.4 13.4 5.2
Number of dives 2 5151 796.88 808.797 Removeable dentures 2.4 1.2 2.8
Number of dives/y 2 300 53.66 39.683 Accident in the head-face area 8.1 7.3 8.5

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TABLE 5. Prevalence of TMD-Related Findings and General TABLE 9. Logistic Regression, Dependent Variable: Pain
Muscle/Joint-Related Findings During Diving While Holding the Mouthpiece
Study Population Females Males 95%
Finding (%) (%) (%) Confidence
Interval
TMJ pain 13.2 25.6 8.5
Pain in other joints 9.5 8.5 9.9 Variable Odds Ratio P Lower Upper
Masticatory muscle pain 16.6 28.0 12.2 Clenching, grinding 1.885 0.022 1.096 3.241
Other muscle pain 6.4 1.2 8.5 Age 1.051 0.015 1.010 1.094
Pain during the fixation of Gender 0.877 0.678 0.471 1.630
the mouthpiece 29.7 40.2 25.8 Whiplash 1.617 0.196 0.780 3.351
Limited mouth opening 1.805 0.170 0.777 4.195
Orthodontic therapy 1.075 0.820 0.578 1.999
Accident in the head-face area 2.504 0.064 0.948 6.619
Diving experience 1.000 0.985 0.997 1.004
TABLE 6. Prevalence of TMD Symptoms After the Dive
Number of dives 1.002 0.584 0.994 1.011
Study Population Females Males
Finding (%) (%) (%)
TMJ pain 18.2 29.3 14.1 produce a slight increase.10 Diving and snorkeling mouth-
Masticatory muscle pain 25.3 42.7 18.8 pieces are made of a chewy rubber. This may also have an
Clicking in the TMJ 8.4 11.0 7.5 effect on masticatory muscle activity.
A relation was demonstrated between the covariables
limited mouth opening and the risk of pain in the TMJ after
the dive in the present study. As limited mouth opening is
frequently associated with TMJ pathology, the TMJ may be
TABLE 7. Logistic Regression, Dependent Variable: overloaded during the dive, resulting in TMJ pain.
Masticatory Muscle Pain After Diving On the basis of the present study, it could be
95% demonstrated that divers exhibiting TMD symptoms should
Confidence be examined regularly not only by a general practitioner but
Interval
also by a specialist for TMD. The questionnaire used may
Variable Odds Ratio P Lower Upper become a tool to identify risk factors and to identify those
Clenching, grinding 2.416 0.003 1.350 4.325 needing a specialist’s treatment.
Age 1.094 0.000 1.044 1.146 Further research seems to be necessary to validate the
Gender 0.516 0.046 0.269 0.989 questionnaire and to investigate the effects of different devices
Whiplash 1.388 0.418 0.627 0.307 in reducing the risk of developing TMD-related pain.
Limited mouth opening 2.203 0.082 0.905 5.359
Orthodontic therapy 0.865 0.676 0.440 1.703
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