|Year : 2014 | Volume
| Issue : 4 | Page : 419-424
Physiotherapy: Key to the kinetics of orofacial musculature
Amandeep Sodhi, Priya K Nair, Sushmini Hegde
Department of Oral Medicine and Radiology, The Oxford Dental College and Hospital, Bangalore, Karnataka, India
|Date of Submission||04-Aug-2014|
|Date of Acceptance||23-Mar-2015|
|Date of Web Publication||22-Apr-2015|
Priya K Nair
Department of Oral Medicine and Radiology, The Oxford Dental College and Hospital, Bangalore - 560 068, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Orofacial pain disorders involve a variety of postural and functional disorders of the oral and craniofacial system. These disorders are multifactorial with muscular pain being the most common manifestation. Orofacial pain can interfere with the emotional, psychological and social well-being of the patient which in turn can affect the quality of life. Physiotherapy is a primary health care profession aimed at enhancing mobility, physical independence and quality of life. The purpose of this review is to provide an insight in to the role of physiotherapy in managing orofacial pain conditions. Using the phrase 'physiotherapy in orofacial conditions' a literature search was conducted via Pubmed, Copernicus, Scopus database and Google scholar. The first reported article in Pubmed was published in 1990 and the recently reported article was in 2014. For this systematic review, seven articles from Pubmed, two from Copernicus, two from Google Scholar, and one from Scopus database were included.
Keywords: Orofacial conditions, physiotherapy, therapeutic applications
|How to cite this article:|
Sodhi A, Nair PK, Hegde S. Physiotherapy: Key to the kinetics of orofacial musculature. J Indian Acad Oral Med Radiol 2014;26:419-24
|How to cite this URL:|
Sodhi A, Nair PK, Hegde S. Physiotherapy: Key to the kinetics of orofacial musculature. J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2020 Mar 29];26:419-24. Available from: http://www.jiaomr.in/text.asp?2014/26/4/419/155690
| Introduction|| |
Orofacial pain conditions are complex, chronic disorders of multifactorial origin, the diagnosis and management of which is a real challenge to the dental profession. Orofacial pain is one of the most common conditions encountered. This unpleasant sensation is usually associated with emotional, psychological and social disturbance which can affect the physical quality of life and well-being of an individual. The primary therapeutic treatment objective for patients and clinicians is the relief from pain and well-being of the patient. Physical therapy is a non-pharmacological treatment that is based on the traditions established in the field of orthopedics, concerned with the care, management and rehabilitation of patients. It encompasses a range of interventions including manual techniques, clinician-assisted techniques, home exercises, etc., that are designed to reduce pain and improve physical function. We as oral physicians, within our sphere of practice, in association with physical therapists, should have expertise in delivering a wide choice of physical modalities that can be used to relieve orofacial pain. This review focuses on the various physiotherapeutic modalities in the management of orofacial conditions.
| Methodology|| |
Using the phrase 'physiotherapy in orofacial conditions' a literature search was conducted via Pubmed, Copernicus, Scopus database and Google scholar. The first reported article in Pubmed was published in 1990 and the recently reported article was in 2014. For this systematic review, seven articles from Pubmed, two from Copernicus, two from Google Scholar, and one from Scopus database were included.
| Discussion|| |
Physiotherapy is often chosen for the management of orofacial conditions because it is simple, non-invasive and cost-effective as compared to the other treatments. The actual evidence for the efficacy of physical exercises is weak because of limited number of randomized control trials available in literature. Physiotherapy helps to restore normal function by altering sensory input, reducing inflammation, co-ordinating and strengthening the muscle activity and thus helps in repair and regeneration of the tissues. Treatment modalities in physiotherapy is broadly classified into three categories [Table 1]. ,
| Physical Therapies|| |
With massage the pain is reduced and proper length and flexibility of the muscles is restored. It stimulates parasympathetic activity which in turn reduces stress and anxiety. Deep massage can assist in mobilizing tissues, increasing blood flow to the area and eliminating trigger points. It is most effective when it follows 10-15 minutes of preparation of the tissues with deep moist heat which tends to relax the muscle tissue, decreasing pain and enhancing the effectiveness of the deep massage. 
Spray and stretch technique
This technique utilizes a mixture of flurocarbons as a vapocoolant. It is thought that the vapocoolant modulates the pain so that more manipulation is possible without discomfort.
Physical activity can be achieved by:
- Soft tissue mobilization
- Joint mobilization
- Muscle conditioning
Soft tissue mobilization
It is useful for muscle pain conditions and is accomplished by superficial and deep massage. It helps in mobilizing the tissues, increase blood flow to the area and eliminate trigger points.
Distraction is accomplished by placing the thumb in the patient's mouth over the lower second molar area on the side to be distracted. With the cranium stabilized with the other hand, a downward force is applied on the molar with the thumb as the rest of the same hand pulls up on the anterior portion of the mandible. It is not indicated in inflammatory joint disorders.
There are exercises that can help restore normal function and range of movement of the orofacial musculature. Four types of exercises can be instituted:
- Passive muscle stretching: The patient is instructed to slowly and deliberately open the mouth until pain is felt. The patient is encouraged to open on a straight opening pathway by observing in a mirror.
- Assisted muscle stretching: It is used when there is a need to regain muscle length. The patient is instructed to apply stretching force gently and intermittently to the elevator muscle with the fingers. If pain is elicited, then the force should be decreased or the exercises stopped completely.
- Resistance exercises: The patient is instructed to place the fist under the chin and open the mouth gently against the resistance. These exercises are repeated 10 times each session, six sessions a day. If they elicit pain, they should be discontinued.
- Postural training: In temporomandibular disorder (TMD) patients with muscle pain who also have a forward head posture, training the patient to keep the head in a more normal relationship with the shoulders may be helpful in reducing the TMD symptoms.
Further, exercises for the facial musculature and the tongue can be advised to the patient:
- Facial-strengthening exercises: Puckering of the lips and moving from one side to the other, smiling by showing the teeth and gums, puffing of cheeks, 'O' exercise (by opening the jaw wide and hiding the teeth under the lips and pursing the lips in an 'O' shape), lower lip lifting (by lifting the lower lip as high as it will go, as if someone is pouting), lip holding (by putting a small stick or tongue blade between the lips and holding it with the lips only) are a few facial muscle-strengthening exercises. 
- Tongue exercises: Straight tongue stretch (by opening the mouth and stretching it out as far as possible), side tongue stretch (by stretching the tongue toward the right and left sides and touching the corner of the mouth), up and down stretch (by stretching the tongue upwards toward the nose and downwards toward the chin), tongue sweep (by sliding the tongue along the outside of the teeth and gums, making circles in the mouth), pushing the tongue against the inside of the cheek, etc. 
| Electrotherapy|| |
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation (TENS) utilizes a high frequency (50-100 Hz), but very low-intensity electric current. It is used to stimulate the nociceptive A-beta cutaneous afferents that activate the descending pain-inhibitory mechanism without involving the opioid peptides. It is useful in acute pain, chronic intractable pain, trigeminal neuralgia, peripheral nerve injuries, myofascial pain dysfunction syndrome and causalgia. 
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.
Acupuncture involves insertion of small, solid needles, usually made of stainless steel in to various parts of the body with the intention of curing disease. It uses the body's own antinociceptive system to decrease the levels of pain felt. Stimulation of acupuncture points appears to cause the release of endorphins, which reduces painful sensation by flooding the afferent interneurons with sub-threshold stimuli. These effectively block the transmission of noxious impulses and thus reduce the sensation of pain.  Electroacupuncture requires a current of sufficient intensity to cause pain and phasic muscle contraction, but at a very low frequency (2 Hz). It is applied at specific cutaneous sites, the so called acupoints.
Diathermy is the use of shortwave (wavelength 3-30 m, frequency 10-100 MHz) or microwave (wavelength 0.001-1 m, frequency 300 MHz-300 GHz) electromagnetic radiation to produce heat within body tissue through conversion. 
Ultrasound increases the blood flow in deep tissues and increases the flexibility and extensibility of connective tissue. Diathermy and ultrasound are used for physiotherapy in the form of penetrating heat. Phonophoresis is the process by which drugs can be administered through the skin with the help of ultrasound. For example, 10% hydrocortisone cream is applied to an involved area and the ultrasound transducer is then directed at the temporomandibular joint (TMJ). Salicylates and topical anaesthetics can also be used in this manner. Phonophoresis enhances the effect of corticosteroids, salicylates and other topical anesthetics.
Monochromatic, coherent and highly directional light is used in laser therapy. Most studies on the cold laser report on its use in chronic musculoskeletal, rheumatic and neurologic pain conditions and it is thought that cold laser accelerates collagen synthesis, increases vascularity of healing tissues, decreases the number of micro-organisms, and decreases pain. More studies are needed to better understand the effectiveness of cold laser. ,
The medication is placed in a pad and the pad is placed on the desired tissue area. Then a low electrical current is passed through the pad, driving the medication in to the tissue. Local anesthetics and anti-inflammatory agents are common medications used.
| Thermal Therapy|| |
Superficial mild heat is used in thermotherapy to increase circulation and soft tissue extensibility, enhance healing, and control pain. The mode of delivery of heat to the superficial tissues may be through conduction (using hot packs, paraffin dips, microwavable rice-filled cloth bags and electric heating pads), convection (using hydrotherapy and fluidotherapy), or radiation (using infrared lamps for treating dermal ulcers and psoriasis). Superficial heat has its effects on the metabolic, neuromuscular, and hemodynamic activity. The oxygen-hemoglobin dissociation curve shifts to the right with mild increases in tissue temperature, making more oxygen available for tissue repair. Healing is enhanced by increased oxygen uptake by the cell due to increased enzymatic activity. 
A hot, moist towel is applied over the symptomatic area for 20 minutes, two to three times a day at tolerant temperature. Heat causes vasodilation, increased circulation to the area and reduces symptoms. In a study by Bush, moist heat delivered by a heating pad for 6 weeks reduced painful jaw symptoms by about 35% in 19 of 27 TMD patients, where as 4% reduction in symptoms occurred in the remaining eight untreated patients during this period. Mouth opening increased up to 9 mm after 12 days of treatment in 55 patients with progressive degeneration of TMJ. At the final evaluation, 31% required no further treatment. 
Ice is directly applied to the affected area and is moved in a circular motion without pressure on the tissues for a period of 5-7 minutes. When numbness begins, ice should be removed. After a period of warming, a second application is desirable. Another technique is the application of vapocoolant spray to the desired area from a distance of 1 or 2 feet for approximately 5 seconds. Spraying followed by passive stretching of the muscle can be done when myofascial (trigger point) pain is present. This causes relaxation of muscles in spasm and thus, relieves the associated pain. During warming period in between applications, it increases the blood flow. Stimulation of cutaneous nerve fibres occurs which in turn shuts down the smaller pain (C) fibers. In a study by Bush, cold water packs coupled with stretching of the jaw and the neck proved effective as a short-term intervention for relief in 10 TMD patients. Comparison of pre- and post-treatment ratings showed that the self-report of pain was significantly reduced after 2 weeks of treatment. 
| Indications for Physiotherapy|| |
Following are the situations when it is recommended that dental practitioners should consider referring TMD patients for physiotherapy: ,
Cervical pain: In situations where the patient complains of neck pain which needs treatment and has cervicogenic headaches (produced by neck palpation).
Postural causes of TMD: In situations where the patient has moderate to severe forward head posture and increased TMD symptoms with abnormal postural activities.
Outcome-oriented indications: In situations where the patient does not obtain relief from initial therapies (excluding physical therapy) and post-TMJ surgery.
| Therapeutic Applications in Orofacial Conditions|| |
McNeely et al. conducted a systematic review on the efficacy of physical therapy interventions for TMD patients. Four of the 12 articles which met their selection criteria were dedicated to exercise and manual interventions. Jadad score of 2 was obtained for the four studies. One study did not demonstrate significant benefit from the chosen treatment strategy which was an oral exerciser device. The remaining three studies evaluated postural training, manual therapy and exercise, which demonstrated significant benefit. They concluded that active and passive oral exercises, and exercises to improve posture can reduce symptoms associated with TMD. To firmly establish the role of physical therapy in orofacial disorders, more evidence-based research is needed.  [Table 2] shows the various physical therapies which can be employed for orofacial conditions.
|Table 2: The various physical therapies which can be employed for orofacial conditions|
Click here to view
| Conclusion|| |
Although since many years various orofacial disorders have been treated with physical therapy, there is limited evidence supporting this. It has been suggested that, with severity of the symptoms, anticipated compliance, and impact on the patient's lifestyle and cost, the physical therapies should be appropriately modulated. A multidisciplinary approach using a combination of pharmacotherapy and physiotherapy may be the best form of management in various orofacial pain disorders. Recent studies have favored the use of physical therapy for TMD patients.
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[Table 1], [Table 2]