Oro Facial PT

Physiotherapy:
Physiotherapy: Key
Key to
to
the
the kinetics
kinetics of
of
orofacial
musculature
orofacial musculature
Sodhi A, Nair PK, Hegde S
J Indian Acad Oral Med Radiol
2014;26:419-24.
Dr Sanjana Ravindra
Oral medicine and radiology
Rajarajeswari dental college
DEFINITION
DEFINITION
World Confederation for Physical Therapy (WCPT) defines Physical Therapy
Oxford Textbook of Palliative Medicine
History
Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care
THERAPEUTIC APPLICATIONS
CARDIOPULMONARY DISEASES
NEUROLOGICAL DISORDRES
MUSCULOSKETAL INJURIES
ORTHOPAEDIC
Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care
THERAPEUTIC APPLICATIONS
IN OROFACIAL CONDITIONS
TMDs
Intracapsular joint disorders
(clicking and clicking-related
jaw incoordination as a
result of disc displacement)

(acute trauma-induced joint
pain)

(chronic closed lock and
painful capsulitis)

(arthritic changes in TMJ)
Masticatory muscle pain

Mandibular mobility
disorders (Hypermobility)
Mandibular mobility
disorders (Hypomobility)
Post-orthognathic surgery
Post-TMJ surgery
Oral submucous fibrosis
Bells palsy
Sodhi A, Nair PK, Hegde S. Physiotherapy: Key to the kinetics of orofacial musculature. J Indian Acad Oral Med Radiol
TREATMENT MODALITIES IN
PHYSIOTHERAPY
PHYSICAL THERAPY
Massage
oDeep tissue massage
oTrigger point therapy
oMyofascial release massage
Spray and stretch

Physical activity
PHYSICAL THERAPY
Massage
Spray and stretch

Physical activity
MASSAGE
Clark GT, Adachi NY, Dornan MR. Physical medicine procedures affect temporomandibular disorders: A review. J Am Dent Assoc
1990;121:151-62
BIOMECHANICAL
EFFECTS
Eisensmith L. (2007). Massage therapy decreases frequency and intensity of symptoms related to temporomandibular joint syndrome in patients one
case study. Journal of bodywork and movement therapies. 11: 223-230
BIOMECHANICAL EFFECTS
BIOMECHANICAL EFFECTS
PHYSIOLOGIC EFFECTS
Psychologic Effects
It stimulates
parasympathetic
activity which in turn
reduces stress and
anxiety.
Treatment Techniques
Clinician hands should be warm
Pressure regulation determined by the type and amount of tissue

present and patient's condition
Rhythm must be steady and even
Duration depends on the pathology, size of the area being treated,

speed of motion, age, size, and condition
Massage should never be painful
Direction of forces should parallel muscle fibers
Make sure patient is warm and in a comfortable, relaxed position
Sufficient lubricant should be used
Begin with superficial stroking to spread lubricant
Stroke should overlap
Pressure should be in line with venous flow followed by a return stroke
All strokes should be rhythmic
Outcome of Massage
1990;121:151-62
Indications
Contraindications
1990;121:151-62
PHYSICAL THERAPY
Massage
Spray and stretch

Physical activity
SPRAY AND STRETCH

TECHNIQUE
This technique utilizes a

vapocoolant.
It is thought that the

vapocoolant modulates the
pain so that more
manipulation is possible
without discomfort.
SPRAY AND STRETCH

TECHNIQUE
SPRAY AND STRETCH

TECHNIQUE
SPRAY AND STRETCH

TECHNIQUE
Simons
and
Mense
(2003)
Indication
PHYSICAL THERAPY
Massage
Spray and stretch

Physical activity
Physical activity
Soft tissue mobilization

Soft tissue therapy(STT) is theassessment,treatmentand
management ofsoft tissueinjury, pain and dysfunction primarily of
the neuromusculoskeletal system
Also known as - Myofascial
Release
Group of stretching techniques
used to relieve soft tissue from
abnormal grip of tight fascia
Myofascial restrictions are
unpredictable and may occur in
many different planes and
directions
Treatment is on localizing
restriction and moving into the
direction of the restriction
Joint mobilization
MUSCLE CONDITIONING
Muscle conditioning is a term that relates to

a group of exercises that are performed in
order to strengthen the muscles in the body
and improve endurance.
LIP EXERCISES
BLOW AIR
AND HOLD
OPEN
CLOSE LIPS
TIGTHLY
SMILE
PUCKER
PUCKER
AND MOVE
SIDEWAYS
TONGUE EXERCISES
MOVE TO THE
RIGHT
MAKE A
CIRCLE
STRETCH AND
HOLD
TOUCH
UPPER LIP
PUSH CHEEK
WITH TONGUE
MOVE TO THE
LEFT
TREATMENT MODALITIES IN
PHYSIOTHERAPY
ELECTRODE PLACEMENT
Electrodes may be placed:
On or around the painful area
Over sites where peripheral nerves that innervate the painful area
becomes superficial and can be easily stimulated
Over superficial vascular structures
Over trigger point locations
Bellis E, Bazin S, Kitchen S, (2009) .Electrotherapy evidence based practice. Publisher: Churchill Livingstone
11 ed: 259-281
Indications for Electrical

Stimulation
Creating muscle contraction through
nerve or muscle stimulation
Stimulating sensory nerves to help in
treating pain
Creating an electrical field in biologic
tissues to stimulate or alter the
healing process
Creating an electrical field on the skin
surface to drive ions beneficial to the
healing process into or through the
11 ed: 259-281
Contraindications for
Electrical Stimulation
Pregnancy
Infection
Malignancy
Pacemaker
11 ed: 259-281
Gate Control Theory
Implies a nonpainful stimulus

can block the
transmission of a
noxious stimulus.
Is based on the
premise that the
gate, located in
the dorsal horn of
the spinal cord,
modulates the
afferent nerve
impulses.
S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011.
Conditions that open or close

the gateConditions that open Conditions that close
the gate
the gate
Physical
conditions
Extent of the injury
Medication
Inappropriate activity
level
Counterstimulation,
eg massage
Emotional
Conditions
Anxiety or worry
Positive emotions
Tension
Relaxation
Depression
Rest
Mental
conditions
Focusing on the pain
Boredom
Intense concentration
or distraction
Involvement and
interest in life
activities
TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION
Transcutaneous electrical nerve stimulation
(TENS) utilizes a high frequency, but very low

intensity electric current.
Used to stimulate the nociceptive A-beta
cutaneous afferents that activate the

descending pain-inhibitory mechanism without
involving the opioid peptides.
Useful in acute pain, chronic intractable pain,
trigeminal neuralgia, peripheral nerve injuries,

myofascial pain dysfunction syndrome and
causalgia
Analgesic effect ranges from 50-70%.
ELECTROGALVANIC STIMULATION
THERAPY
Electrogalvanic Stimulation Therapy (EGS)
uses a high-voltage, low-amperage
mesomorphic current of varied frequency.
A rhythmic electrical impulse is applied to
the muscle, creating repeated involuntary

contractions and relaxations.
This causes a break-up of the myospasm as

well as increases the blood flow to the
muscles.
Microcurrent Electrical Nerve Stimulation

Low-intensity direct current
(microampere)-Bioelectric current
follow path of least resistance
Injured site increasing ATP

production, assist in tissue growth
and healing
ELECTROACUPUNCTUR
E
Diathermy
Indications
Contraindications
11 ed: 259-281
ULTRASOUN
D
Therapeutic Ultrasound Generators
High frequency
electrical
generator
connected
through an
oscillator circuit
and a transformer
via a coaxial
cable to a
transducer
housed within an
11 ed: 259-281
Therapeutic Ultrasound Generators
Frequency
range of therapeutic ultrasound is 0.75
to 3.3 MHz
Frequency
is the number of wave cycles per
second
Most
generators produce either 1.0 or 3.0 MHz
Depth
of penetration is frequency dependent not

intensity dependent
1 MHz transmitted through superficial layer

and absorbed at 3-5 cm
3 MHz absorbed superficially at 1-2 cm
11 ed: 259-281
Thermal Effects of Ultrasound
Non-Thermal Effects of
Ultrasound
collagen
extensibility
Increased
Increased
Increased
Increased
blood flow
Decreased
Reduction
of muscle spasm
Decreased
Reduction
pain
joint stiffness
of chronic
inflammation
fibroblastic
activity
Tissue
regeneration
Reduction
Bone
Pain
protein synthesis
of edema
healing
modulation
11 ed: 259-281
indications
Contraindications
of decreased
temperature sensation
Pregnancy
Vascular
Malignancy
Areas
Eyes
insufficiency
Pacemaker
Infection
11 ed: 259-281
Laser
Light Amplification by the Stimulated
Emission of Radiation
Principle - photonic energy
delivered into tissue, modulate

the biologic process in tissue.
Cold
laser
He
Neon
stimulation at acupoints is as
effective as EA and has the
advantage of being practically
painless
Bellis E, Bazin S, Kitchen S, (2009) .Electrotherapy evidence based practice. Publisher: Churchill Livingstone 11 ed: 259-281
IONTOPHORESI
S
TREATMENT MODALITIES
IN PHYSIOTHERAPY
HOT
APPLICATION
Hot application is the application of a hot agent, warmer

than skin either in a moist or dry from on the surface of
the body
McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys
Ther 2006;86:710-25.
Cold application
Cold application is the application of a cold agent cooler than skin either in
a moist or dry form, on the surface of the skin. Cold encourages relaxation
of muscles that are in spasm and thus relieves associated pain
Ther 2006;86:710-25.
Temperature for hot and cold applications
Descriptio Temperatur
n
e
Very cold
Cold
Cool
Tepid
Warm
Hot
Below 15C
C 15-18
C 27 18
C 37 27
C 40 37
C 46 40
Very Hot
Above 46 C
Application
Ice bag
Cold packs
Cold compresses
Alcohol sponge bath
Warm bath
Hot soak, hot
compresses
Hot water bag for
adult
PHYSIOLOGICAL EFFECTS
HOT APPLICATION
COLD APPLICATION
Peripheral Vasodilatation
Peripheral Vasoconstriction
Increased capillary permeability
Decreased capillary
permeability
Increased oxygen consumption
Decreased oxygen consumption
Increased local metabolism
Decreased local metabolism
Decreased blood viscosity
Increased blood viscosity
Decreased muscle tone
Decreased muscle tone
Increased blood flow
Decreased blood flow
Increased lymph flow
Decreased lymph flow
Increased motility of leucocytes
Decreased motility of
leucocytes
Ther 2006;86:710-25.
CONTRAINDICATION
S
HOT APPLICATIONS
Malignancies
Acutely inflammed areas
With paralysis
Open wounds
Edema associated with
venous or lymphatic
diseases
Headache
With very high temperature
Cold APPLICATIONS
State of shock &
collapse
Edema
impaired circulation
Muscle spasm
Decreased sensation
With very low
temperature
Cold hypersensitivity
or intolerance
Raynauds Disease
Regenerating Nerves
Ther 2006;86:710-25.
COMPLICATIONS
HOT APPLICATIONS
Pain
Burns
Redness of the
skin
Edema
Hyperthermia
COLD APPLICATIONS
Pain
Blisters and skin
breakdown
Grey or bluish
discoloration
Thrombus
formation
Redness
Hypothermia
Ther 2006;86:710-25.
HOT PACKS
Ther 2006;86:710-25.
PARAFFIN wax
Ther 2006;86:710-25.
Ice PACKS
Ther 2006;86:710-25.
ICE CUBE
MASSAGE
Ther 2006;86:710-25.
COLD/ ICE SPRAYS
fomentation
Definition: The alternate application of hot and cold fomentation to a
local area.
Heat Induces vasodilation:

drawing blood into the target
tissues. Increased blood flow
delivers needed oxygen and
nutrients, and removes cell
wastes.
The warmth decreases muscle
spasm, relaxes tense muscles,
relieves pain, and can increase
range of motion.
Cold therapy produces

vasoconstriction, which
slows circulation reducing
inflammation, muscle
spasm, and pain.
Ther 2006;86:710-25.
Hot- cold fomentation

Effects:
Relieves pain through acceleration of local circulation.
Stimulates healing in local injuries with contusions.
Relieves muscle stiffness and pain due to trauma and
strain.
Stimulates healing in wound infections.

Indications:
Infected wound.
Local injuries due to trauma and muscular contusions.
Muscle stiffness.
Ther 2006;86:710-25.
Indications
Ther 2006;86:710-25.
Contraindications
Ther 2006;86:710-25.
Conclusion
Physiotherapy has cured various diseases without
inflicting mental trauma and the pain of undergoing
surgery in medical field.
This novel way of medicine has been brought into

practice in dentistry as an adjuvant therapy.
References
1. Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J
Palliat Care 2010;16:138-46.
2. Rosted P. Introduction to acupuncture in dentistry. Br Dent J 2000;189:136-40.

3. Allen RJ. Physical agents used in the management of chronic pain by physical therapists. Phys Med Rehabil Clin N Am
2006;17:315-45.
4. Clark GT, Adachi NY, Dornan MR. Physical medicine procedures affect temporomandibular disorders: A review. J Am
Dent Assoc 1990;121:151-62.
5. Dostalov T, Hlinakova P, Kasparova M, Rehacek A, Vavrickova L, Navrtil L. Effectiveness of physiotherapy and Gas
laser in the management of temporomandibular joint disorders. Photomed Laser Surg 2012;30:275-80.
6. Bush FM, Dolwick MF. Conservative treatment. In: Bush FM, Dolwick MF. The Temporomandibular Joint and Related
Orofacial Disorders. 1st ed. Philadelphia: JB Lippincott Company; 1995. p. 303-56
7. Fulton CL (1994).Physiotherapists in cancer care: A framework for rehabilitation of patients. Physiotherapy 80 (12):
830-34.
8. Fulton CL, Else R (1997) Rehabilitation in palliative care: physiotherapy. in Oxford Textbook of Palliative Medicine.
Doyle D, Hanks GWC, McDonald ed Oxford; Oxford University Press
9. S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011.

10.How physiotherapy works - the mechanisms of physiotherapy. 2008.
11.Karren F. (2002) Oral motor exercises in treatment of phonological disorders. Semin Speech Lang .23(1): 015-026.
12.Khokhar V. (2000) Textbook of Helpline Electrotherapy for Physiotherapists Publisher: Bharat Bharati Prakashan & Co. 1 ed: 627. 2539.
References
13. Wright EF, North SL. Management and treatment of temporomandibular disorders: A clinical perspective. J Man Manip
Ther 2009;17:247-54.
14. von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and
features of temporomandibular dysfunction: A randomized controlled trial. Man Ther 2013;18:345-50.
15. McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for
temporomandibular disorders. Phys Ther 2006;86:710-25.
16. Okeson JP. General considerations in managing orofacial pains. In: Okeson JP. Bells Orofacial Pains: The Clinical
Management of Orofacial Pain. 6th ed. Chicago: Quintessence Publishing Co Inc.; 2005. p. 197-242.
17. Kostopoulos, D., Rizopoulos, K., Effect of topical aerosol skin refrigerant (Spray and Stretch technique) on passive and
active stretching. Journal of Bodywork and Movement Therapy (2008), doi:10.1016/j.jbmt.2007.11.005
18. Bellis E, Bazin S, Kitchen S, (2009) .Electrotherapy evidence based practice. Publisher: Churchill Livingstone 11 ed: 259281
19. Carolyn K, Lynn A, (2002) Therapeutic Exercise: Foundations and Techniques Publisher: F. A. Davis Company 4 ed: 55-99.
20. Charted society of physiotherapy.The effectiveness of physiotherapy in the palliative care of older people. may 2010.
21. Cole RP, Lucien B, Scialla SJ (2000). Functional recovery in cancer rehabilitation. Archives of Physical Medicine &
Rehabilitation. 81: 623-627.
22. Eisensmith L. (2007). Massage therapy decreases frequency and intensity of symptoms related to temporomandibular
joint syndrome in patients one case study. Journal of bodywork and movement therapies. 11: 223-230
23. McDonnell ME, Shea B.D. (1993) the role of physical therapy in intensity in patients with metastatic disease to bone.
Back and Musculoskeletal Rehabilitation. 3(2): 78-84
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Physiotherapy:

Oxford Textbook of Palliative Medicine

Intracapsular joint disorders

Intracapsular joint disorders

Intracapsular joint disorders

Masticatory muscle pain

Spray and stretch

Spray and stretch

Clinician hands should be warm

Pressure regulation determined by the type and amount of tissue

Rhythm must be steady and even

Duration depends on the pathology, size of the area being treated,

Massage should never be painful

Direction of forces should parallel muscle fibers

Make sure patient is warm and in a comfortable, relaxed position

Sufficient lubricant should be used

Begin with superficial stroking to spread lubricant

Stroke should overlap

Pressure should be in line with venous flow followed by a return stroke

All strokes should be rhythmic

Spray and stretch

SPRAY AND STRETCH

This technique utilizes a

It is thought that the

SPRAY AND STRETCH

SPRAY AND STRETCH

SPRAY AND STRETCH

Spray and stretch

Soft tissue mobilization

Muscle conditioning is a term that relates to

Indications for Electrical

Gate Control Theory

Implies a nonpainful stimulus

S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011.

Conditions that open or close

Extent of the injury

Focusing on the pain

TRANSCUTANEOUS ELECTRICAL NERVE

Transcutaneous electrical nerve stimulation

(TENS) utilizes a high frequency, but very low

Used to stimulate the nociceptive A-beta

cutaneous afferents that activate the

Useful in acute pain, chronic intractable pain,

trigeminal neuralgia, peripheral nerve injuries,

Analgesic effect ranges from 50-70%.

A rhythmic electrical impulse is applied to

the muscle, creating repeated involuntary

This causes a break-up of the myospasm as

Microcurrent Electrical Nerve Stimulation

Injured site increasing ATP

Therapeutic Ultrasound Generators

Therapeutic Ultrasound Generators

range of therapeutic ultrasound is 0.75

is the number of wave cycles per

generators produce either 1.0 or 3.0 MHz

of penetration is frequency dependent not

1 MHz transmitted through superficial layer

3 MHz absorbed superficially at 1-2 cm

Thermal Effects of Ultrasound

Principle - photonic energy

delivered into tissue, modulate

Hot application is the application of a hot agent, warmer

Temperature for hot and cold applications