Physiotherapy in dentistry - Dr Sanjana ravindra

Physiotherapy: Key to the kinetics
of 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
PAIN : an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described in
terms of such damage IAHS
KINEMATICS: The phase of mechanics that deals with possible
motion of a material body
Myofascial trigger points : hyperirritable spots, usually within a
taut band of skeletal muscle or in the muscle fascia, that are
painful on compression and that can give rise to characteristic
referred pain, tenderness and autonomic response

Physical medicine and
rehabilitation specialty that
remediates impairments and
promotes mobility, function, and
quality of life through
examination, diagnosis,
prognosis, and physical
intervention using mechanical
force and movements.
Oxford Textbook of Palliative Medicine
DEFINITION
World Confederation for Physical Therapy (WCPT) defines Physical Therapy

History
Physicians like Hippocrates & Hector believed to be the first
practitioners of a primitive physical therapy( 460 B.C)
First school of Physiotherapy - the University of Otago in
New Zealand in 1913.
Treatment in 1940s primarily consisted of exercise,
massage, and traction.
In1980s, the explosion of technology and computers led to
advances in rehabilitation-ultrasound, electric stimulators, &
iontophoresis with the advances in therapeutic cold laser.
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.

•CARDIOPULMONARY DISEASES
•NEUROLOGICAL DISORDRES
•MUSCULOSKETAL INJURIES
•ORTHOPAEDIC
THERAPEUTIC APPLICATIONS
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.

THERAPEUTIC APPLICATIONS IN
OROFACIAL CONDITIONS
▪ TMDs
▪ Intracapsular joint
disorders (clicking and
clicking-related jaw
incoordination as a result
of disc displacement)
disorders (acute trauma-
induced joint pain)
disorders (chronic closed
lock and painful
capsulitis)
disorders (arthritic
changes in TMJ)
▪ Masticatory muscle pain
▪ Mandibular mobility
disorders (Hypermobility)
▪ Mandibular mobility
disorders (Hypomobility)
▪ Post-orthognathic
surgery
▪ Post-TMJ surgery
▪ Oral submucous fibrosis
▪ Bell’s palsy
Sodhi A, Nair PK, Hegde S. Physiotherapy: Key to the kinetics of orofacial musculature. J Indian Acad Oral Med Radiol 2014;26:419-24.

TREATMENT MODALITIES IN
PHYSIOTHERAPY

PHYSICAL THERAPY
▪ Massage
oDeep tissue massage
oTrigger point therapy
oMyofascial release massage
▪ Spray and stretch
▪ Physical activity

▪ Massage
oDeep tissue massage
oTrigger point therapy
oMyofascial release massage
▪ Spray and stretch
▪ Physical activity
PHYSICAL THERAPY

Mechanical manipulation
of body tissues with
rhythmical pressure and
stroking for the purpose
of promoting health and
well-being.
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
Techniques which stretch a muscle, elongate fascia
or mobilize soft tissue adhesions or restrictions
Always accompanied by some reflex effects
• As mechanical stimulus becomes more effective, reflex stimulus
becomes less effective
Directed at deeper tissues, such as adhesions or
restrictions in muscle, tendons, and fascia.
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

EFFECTS ON
MUSCLE
• Mechanical stretching of intramuscular connective
tissue
• To relieve pain and discomfort associated with
myofascial trigger points
• Increase blood flow to skeletal muscle
• To retard muscle atrophy following injury
• To increase range of motion
• Does not increase strength or muscle tone

EFFECTS
ON SKIN
• Increase in skin temperature
• Increases sweating
• Decreases skin resistance to galvanic current
• Mechanically loosens adhesions and softens scar
• Stretches and breaks down fibrous scar tissue
• Breaks down adhesions between skin and subcutaneous tissue

PHYSIOLOGIC EFFECTS
Mechanical
stimulation of tissues
by rhythmically
applied pressure and
stretching
Increase Decrease
Muscle blood flow
Relaxation hormone
Stress hormone
Changes in tissue or organ
Physiological effect

Psychologic Effects
Psychological
effects
Increased
relationship
between body and
mind
Increasing
relaxation
Decreasing anxiety
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
decrease pain
decrease neuromuscular excitibility
stimulate circulation
facilitate healing
restore joint mobility
alleviate muscle cramps
increase blood flow
increase venous return

Indications
muscle spasm
Myositis
revascularizationheadaches
migraines
Contraindications
Cellulitis
Synovitis
Abscesses
Skin
infections
Cancers
Acute
inflammatory
conditions

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.

Passively stretching the target muscle.
Ethyl chloride spray topically.
Sudden drop in skin temperature.
Temporary anesthesia.
Blocking the spinal stretch reflex and the
sensation of pain at a higher center.
Activate trigger points relieves muscle
spasm and reduce referred pain.

They support that the sudden cold and
the tactile stimulation provided by the
vapocoolant spray, inhibit the pain and the
reflex motor, and autonomic responses in
the central nervous system.
When the pain stimuli subside or
suppress, an effective relaxation takes
place that allows the gently stretching and
lengthening of the muscle
Simons
and
Mense
(2003)

myofascial pain
due to active
trigger points
musculoskeletal
dysfunction
to increase
range of motion
(ROM) of
various joints
Indication

Physical activity
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.
Soft tissue therapy (STT) is the assessment, treatment and management
of soft tissue injury, 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
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.

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.
MUSCLE CONDITIONING

LIP EXERCISES
OPEN PUCKER
PUCKER
AND MOVE
SIDEWAYS
SMILE
CLOSE LIPS
TIGTHLY
BLOW AIR
AND HOLD

TONGUE EXERCISES
STRETCH AND
HOLD
MOVE TO THE
LEFT
MOVE TO THE
RIGHT
PUSH CHEEK
WITH TONGUE
MAKE A
CIRCLE
TOUCH
UPPER LIP

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

–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 skin
Indications for Electrical Stimulation
281

Contraindications for Electrical Stimulation
▪ Pregnancy
▪ Infection
▪ Malignancy
▪ Pacemaker
281

With this theory, pain depends on the
relative amount of traffic in two different
sensory pathways which carry information
from the sense organs to the brain.
Slow/Small fibers
No myelin sheaths, so
messages delivered more
slowly. Very intense
stimuli (like that caused by
a tissue injury) send strong
signals on these slow
fibers.
Slow/small fibers open the
gate = you feel pain
Fast/Large fibers
Deliver most sensory
information to the brain.
Covered by fatty myelin
sheaths so delivery is
faster.
Fast/large fibers close the
gate = block pain signals
Gate Control Theory
Implies a non-painful
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
gate Conditions that open the
gate
Conditions that close 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
Intense concentration or
distraction
Boredom
Involvement and interest
in life activities

The SG (substantia gelatinosa)
acts as a modulating gate or a
control system between the
peripheral nerve fibers and central
cells that permits only one type of
nerve impulse (pain or no pain) to
pass through.
Opening and closing the
gate to allow the
appropriate information to
be passed along to the T
cell.
Impulses traveling on
the fast, non-pain fibers
↑ activity in the SG.
Impulses on the slower
pain fibers exert an
inhibitory influence
When the SG is active, the
gate is in its “closed”
position and a non-painful
stimulus is allowed to pass
on to the T cell.

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.

▪ Low-intensity direct current (microampere)-
Bioelectric current follow path of least
resistance
▪ Injured site increasing ATP production, assist
in tissue growth and healing
Microcurrent Electrical Nerve Stimulation

ELECTROACUPUNCTURE
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).

Diathermy
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.

Contraindications
Over wet dressings & tape
Moderate to excessive edema
Areas of skeletal growth
Malignancies
Ischemic areas
Metallic implants
Pacemakers
Indications
Disorders of musculoskeletal system
Superficial inflammatory/Infective
conditions
Degenerative joint disease
Muscle and tendon tears
Synovitis
Joint stiffness
Carbuncles
281

ULTRASOUND
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.

High frequency
electrical generator
connected through
an oscillator circuit
and a transformer
via a coaxial cable
to a transducer
housed within an
applicator
Therapeutic Ultrasound Generators
281

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
Therapeutic Ultrasound Generators
281

Thermal Effects of Ultrasound
Increased collagen extensibility
Increased blood flow
Decreased pain
Reduction of muscle spasm
Decreased joint stiffness
Reduction of chronic
inflammation
Non-Thermal Effects of Ultrasound
Increased fibroblastic activity
Increased protein synthesis
Tissue regeneration
Reduction of edema
Bone healing
Pain modulation
281

indications
Scar tissue and joint contracture
Soft tissue healing
Pain
reduction
In neuralgia
Chronic inflammation
Stretching of
connective
tissue
Bone
healing

Areas of decreased
temperature sensation
Vascular insufficiency
Eyes
Pregnancy
Pacemaker
Malignancy
Infection
Contraindications
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

IONTOPHORESIS
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.

HOT APPLICATION
To relive pain and congestion
To provide warmth
To promote healing
To decrease muscle tone
To soften the exudates
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
To reduce pain and body temperature
To anaesthetize an area
To control hemorrhage
To control the growth of bacteria
To prevent gangrene
To prevent edema
To reduce inflammation
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
25.

Temperature for hot and cold applications
Description Temperature Application
Very cold Below 15C Ice bag
Cold 15-18 C Cold packs
Cool 18 – 27 C Cold compresses
Tepid 27 – 37 C Alcohol sponge bath
Warm 37 – 40 C Warm bath
Hot 40 – 46 C Hot soak, hot
compresses
Very Hot Above 46 C 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
25.

CONTRAINDICATIONS
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
 Raynaud’s Disease
 Regenerating Nerves
25.

COMPLICATIONS
 Pain
 Burns
 Redness of the
skin
 Edema
 Hyperthermia
HOT APPLICATIONS
 Pain
 Blisters and skin
breakdown
 Grey or bluish
discoloration
 Thrombus
formation
 Redness
 Hypothermia
COLD APPLICATIONS
25.

HOT PACKS
Commercially prepared, disposable hot packs
supply warm dry heat to an injured area.
Striking or squeezing the pack will release
chemicals that create the heat.
These packs are designed to maintain a
constant temperature between 40.6º C & 46º C
for 30 min to 1 hour.
25.

PARAFFIN wax
A mixture of 15 to 30 ml of mineral oil to 1
pound of paraffin wax
Temperature of 118º F to 126 ºF for upper
extremity tx.
Temperatures of 113 º F to 121 º F for lower
extremity (circulation is less efficient)
Paraffin can provide approx. 6x the amount
of heat as water due to low specific heat.
25.

Ice PACKS
Commercially prepared single-use ice
packs provide cold for designated
period of time.
When the pack is squeezed or
kneaded, an alcohol-based solution is
released, creating the cold
temperature.
COMMERCIALLL AVAILABLE
Silica or mix of saline/gel Stored in
freezer at 23º C Moldable to patient’s
body Should be cooled at least 30
minutes between treatments or 2 hrs.
prior to initial use.
25.

ICE CUBE MASSAGE
Slow circular motion for 5-10 min. During
this time the patient will feel cold, burning
And then aching sensation before the part
become numb.
Short strokes should be given.
25.

COLD/ ICE SPRAYS
Fluorimethane is used
The liquid is sprayed on to the area to be
cooled in series of stroke of about 5s
each with a few seconds interval
between each.
The nozzle is held at the angle of 45 or
right angle from the skin surface.
Applied in parallel strokes along skin of
muscle immediately prior to stretching

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.
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.
25.

Indications
Pain from muscle tears
Ligament strains or sprains
Muscle or tendon tightness
Joint stiffness (arthritis)
Post operative healing of wound
Inflammation & oedema
Contracture of tissue
25.

Contraindications
Atrial or venous thrombosis
Confused or disoriented pt
Non-diagnosed pain
Insensitive skin
Open wounds
Acute injury
Cancer
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
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Palliat Care 2010;16:138-46.
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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. Dostalová T, Hlinakova P, Kasparova M, Rehacek A, Vavrickova L, Navrátil 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
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Doyle D, Hanks GWC, McDonald ed Oxford; Oxford University Press
9. S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011.
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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
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temporomandibular disorders. Phys Ther 2006;86:710-25.
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References

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