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International Journal of Pharmaceutical Science and Health Care Issue 3, Vol 2 April. 2013

Available online on http://www.rspublication.com/ijphc/index.html ISSN 22495738

Page 50

Physiotherapy for improving mouth opening & tongue

protrution in patients with Oral Submucous Fibrosis

(OSMF)Case Series.

Vijayakumar M1, Priya D

2

1. Vijayakumar M, Associate Professor, Padmashree Dr.D.Y.Patil College ofPhysiotherapy, Dr. D.Y.Patil Vidyapeeth, Pune, Maharastra, India -411018.

2. Priya D, Assistant Professor, Padmashree Dr.D.Y.Patil College of Nursing,Dr. D.Y.Patil Vidyapeeth, Pune, Maharastra, India -411018.

______________________________________________________________________________

ABSTRACT:

Oral Submucous fibrosis is a chronic disease featuring the deposition of fibrous tissue in thejuxta epithelial layer of mucous membrane among tobacco chewers. There is progressive

decrease in the mouth opening, associated with difficulty in eating, changed gustatory sensationand dryness of mouth and thus have reduced oral intake . Purpose of the study:-OSMF being a

under-recognised disorder among physiotherapists, an attempt was made to study the role ofphysiotherapy interventions in managing its complications . Methods:-Prospective clinical trial

was adopted. 15 individuals with history of tobacco chewing and complaints of reduced mouthopening, burning sensation in the mouth while eating food with histopathological confirmation

of OSMF volunteered for the study . After a complete history and consent they were assessed formouth opening & tongue protrution with a vernier caliper. Procrdure:They were treated with

Ultrasound therapy, intensity from 0.7 1.5 W/Cm2 (depending upon their thickness of fibrousbands) over the skin of the buccal region of the affected sides with finger and thumb kneading,

consecutively for 6 days/week for 2 weeks. They were advised with a set of home programmeand to avoid spicy foods. The mouth opening and burning sensations were recorded on 1

st, 5

th

10th15thday of treatment and 3 months for follow up and the datas were analysed. Result:- Themean improvement in mouth opening was 6.26mm.(range 2mm-11mm with 75% patients

increased by 9mm) Repeated Measures ANOVA; F = 55.54 and p value = 0.0001. Dunnett testfor multiple comparisons revealed that tenth day onwards there was statistically significant

difference in the mean mouth opening p

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BACK GROUND:

Oral Submucous fibrosis is a chronic disease of insidious onset featuring the deposition

of fibrous tissue in the juxta-epithelial layer of mucous membrane involving the pharynx, palate,

faces, cheek and lips, pharynx and oesophagus.1,2

found among people who chew betel nut

(Areca catechu) with or without tobacco and other ingredients. This condition is characterized byfibrotic changes and severe burning sensation with restricted opening of mouth. Joshi (1953)

3

coined the term Submucous fibrosis of the palate and pillars.

Lal et all (1953)4 postulated that the use of Pan (betel leaf) and Supari (betel nut) may

be important risk factors. Gutka is the predominant form of areca nut (with or without tobacco)

consumption in most parts of India5.Typically, the addiction starts at a very young age. Because

of cheapness, bright pouches, easy availability, sweet taste and forceful misleading

advertisements, it is popular amongst children and adolescents.

Oral submucous fibrosis is a disease mainly confined to the South East Asian countries.

In the early years Joshi (1953)3reported 41 cases of submucous fibrosis in Indian population. Joe

V Desa (1957)6studied 64 cases of submucous fibrosis, all of them were Indians. Pindborg et al

reported the prevalence of Oral submucous fibrosis in India as 0.2- 0.5%.1

In a hospital based

survey conducted in Lucknow, Bombay, Bangalore and Trivandrum the prevalence was recorded

as 0.51 %, 0.5%, 0.18% and 1.2 % respectively.7An epidemiological assessment of this disease

among Indian villagers gave a percentage prevalence of 0.2 in Gujarat. 0.4 in Kerala, 0.04 in

Andhra Pradesh and 0 to 0.07 in Bihar.8the state of Maharashtra was. 0.03%

7

Hydrolysis of arecoline produces arecaidine that has pronounced effects on fibroblasts.9

Arecoline in high doses was cytotoxic and cells showed detachment from the culture surface.

The copper content of areca nut is high and the levels of soluble copper in saliva may rise in

volunteers who chew areca quid.

10

The same group showed that the oral mucosa of areca nutchewers had significantly raised levels of copper when compared with the control subjects. The

association between copper and OSF has been linked on the basis that excess copper is found in

tissues of other fibrotic disorders Wilsons disease, Indian childhood cirrhosis and primary

biliary cirrhosis. The enzyme lysyl oxidase is found to be upregulated in OSF.11

This is a copper

dependent enzyme and plays a key role in collagen synthesis and its cross linkage.

An evaluation of the epithelial changes in the different grades of OSMF shows that

increase in the clinical severity of the disease may be accompanied by epithelial hyperplasia or

atrophy, which is associated with increased tendency for keratinizing metaplasia. The epithelial

atrophy reported by Pindborg et al is one of the marked changes in OSMF which contrasts with

the predominantly hyperplastic epithelium reported by Sirsat & Khanolkar and by Wahi et al.9Sirsat and Pindborg classified the histological picture of Oral submucous fibrosis into four

stages.11

Haider SM (2000) clinically graded OSMF into: Stage I: Faucial bands only.,Stage II:

Faucial bands and buccal bands., Stage III: Facial, buccal and labial bands and functionally

graded OSF into,stage A : Mouth opening 20 mm, Stage B : Mouth opening 10-19 mm ,Stage

C : Mouth opening 10mm

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The common presenting symptom is a burning when eating hot and spicy food and a

progressive decrease in the mouth opening, associated with difficulty in eating, changed

gustatory sensation, dryness of mouth and nasal voice.12

Ulcerations and vesicles are seen in the

initial stages of oral mucosa. Periods of exacerbations are manifested by the appearance of small

vesicles on cheek and palate.9The earliest clinical sign of OSF is blanching of the oral mucosa

followed by the appearance of fibrous bands in the areas affected.9The bands usually involve the

buccal mucosa, palate, posterior pharynx, lips and tongue.

Various treatment modalities have been proposed for this condition including steroid

injections, surgical interventions. Non invasive treatment modalities however have potential for

delivering the desired results.

Ultrasound has been used extensively in physical medicine with considerable success.

During ultrasound therapy13

cell membrane permeability is increased by altering sodium and

potassium ion gradients. This increased permeability improves gas exchange and promotes

healing. Ultrasound decreases inflammation, increases vasodilatation and waste removal.

Accelerates lymph flow, and stimulates metabolism. The objectives of ultrasound treatment areto accelerate healing, increase the extensibility of collagen fibers and provide pain relief. Given

that these are the requirements of any therapy used for the treatment of OSMF, therapeutic

ultrasound as a treatment modality merits investigation.

Kneading is a effective form of massage therapy in improving the elasticity of fibrous

tissues and mobilizing scar tissues.14

The gentle soft tissue manipulation is extensively used in

physiotherapy for improving their extensibility.The decrease in Temporo-mandibular joint

mobility is mobilized by forced passive mevements & manipulations to permit more mouth

opening.

PURPOSE OF THE STUDY. Although OSMF is a clinical problem mostly managed my dentalprofessionals, the question for improving the elasticity & thus increase mouth opening is

prevailing. Medical management may have on the effect on pain of sensory loss , but on tissue

extensibility is an argument. Hence with the basic physiotherapy techniques which has proved its

valid response on various clinical conditions , can it be effective in managing them. Hence the

study aims to find the effect of physiotherapy interventions in the management of OSMF (Oral

Submucous Fibrosis), by identifying the changes in mouth opening and tongue protrusion among

them.

METHODOLOGY

The study was conducted in the Department of Oral Medicine and Radiology and in the Dept. of

Physiotherapy at Dr. D. Y. Patil Medical College and Hospital, Pune. Fifteen patients, both male

and female , age between 23-56 years with signs and symptoms of Oral Submucous Fibrosis at

Dr D Y Patil Dental College were included in the study convenient sampling method, after

obtaining their informed written consent. They were assessed for a positive history of chewing of

areca nut or one of its commercial preparations, difficulty in chewing and swallowing, and

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having burning sensation on eating spicy food, Restricted mouth opening and changes in oral

mucosa including presence of palpable vertical fibrous bands, stiffness and blanching. A

Histopathology confirmation of OSMF by biopsy specimen was done.15

Patients who had

already undergone the treatment of OSMF and come after a relapse or follow up, Patients under

lycopene therapy, with mouth opening > 40mm , were excluded from the study.

Fig-1: Measurement of Mouth Opening Fig-2: Calculation of Mouth Opening

Fig- 3: Application of therapeutic ultrasound Therapy Fig-4:Kneeding on submucosal region

Before the treatment sessions, mouth opening was assessed as the interincisal distance as

measured from the mesioincisal edge of the upper left central incisor tooth to the mesioincisal

edge of the lower left central incisor tooth. The measurement was made using a geometric

divider and scale and was recorded in millimeters.15

Tongue protrusion was recorded the same

way in millimeters from the incisal edge of the lower teeth. This was done by viewing theprotruded tongue from the lateral aspect of the head and measuring the distance from the mesial

contact area of the lower central incisors to the tip of the protruded tongue73.

All the enrolled patients received consecutive sittings of therapeutic ultrasound of

prescribed dose ranging from 0.6 to 2.0 W/Cm2pulsed 1:1 or 1:2 ( 50% or 33.3 % duty cycle),

Frequency of 3 MHz, using a 5cm diameter transducer head for 3 to 4 minutes to each side

involved over the cheek for 15 consecutive days with permissible one day off each week. This

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dose is sought to create extensibility of soft tissues. During the study the all the patients were

treated with the same ultrasound equipment (electroson) which was regularly serviced &

calibrated by the company servicing authorities.

To increase the extensibility of the buccal mucosa & to break the fibrous bands, They

were given finger & thumb kneading at the buccal region in side the mouth with mild stretching

over the fibrous bands with in tolerable pain limits. They were provided with cryotherapy (by

having cubes of ice in the mouth) before & after the treatment for 5-7 minutes to perceive less

pain sensation. Gentle stretch over the buccal cavity was performed with the fingers.

Temporomandibular joint mobilization by Antero-inferior glides to improve jaw depression;

lateral glides for improving mandibular deviation with joint distraction were done.

Home programme was given to maintain the joint in distraction by placing ice-cream

sticks between the jaws and increasing one by one to provide stretch and maintaining for 3-5

minutes for 2-3 times a day. They were advised not to take any spicy foods, hot foods or

beverages, and continue with any medications they were on for any general physical / mental

illness.The patients were assessed for mouth opening , tongue protrusion, and burning sensation

every 5th

session of treatment and the data collected were computed using primer software of

biostatistics.

DATA ANALYSIS & RESULTS.

Mouth opening was measured on the first day of visit and subsequently every 5 days till 15th

day, and after a follow up period of 3 months. The improvement was recorded in millimeters.

Table 1: Mean of the mouth opening every 5 days and at 3rd month follow up

Examination No.of Observations Mean(mm) Variance SD Range Median

First day 15 24.07 10.30 3.21 19-30 25

Fifth day 15 24.93 13.75 3.73 20-31 25.5

Tenth day 15 26.93 12.78 3.57 22- 35 27

Fifteenth day 15 29.67 20.66 4.54 23-38 29

3rd month Follow up 15 30.40 20.54 4.53 23-38 29

The mean of the improvement in mouth opening was 6.33mm.The range showed a minimum

improvement of 2mm and a maximum of 11mm with 25% of patients showing improvement

upto3.5mm and 75% patients upto 9mm. Repeated Measures of Annova; F = 55.54 and p value

= 0.0001. Multiple Comparisons Dunnett ; p

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comparisons was applied, tenth day onwards there was statistically significant difference in the

mean mouth opening.

Graph 1.Mean of the mouth opening. Graph depicting the mean of the mouth opening seen

as a steady rising linear graph from 1st day to 15th day and follow up at 3 months.

Table 2:-Tongue Protrusion was measured on the first day of visit and subsequently every

five days for 15 days and after a follow up period of 3 months.

The improvement was recorded in millimeters. The mean of weekly tongue protrusion was

calculated. The mean improvement in tongue protrusion post treatment is 1.46 mm. The range

shows a minimum improvement of 0 and a maximum of 5mm. There are 75% observations

which show improvement upto 2mm.

Examination Observations Mean Variance SD Range MedianFirst day 15 16.53 12.69 3.56 12-23 16

Fifth day 15 16.66 12.66 3.55 12-23 16

Tenth day 15 17.27 12.06 3.47 12- 23 17

Fifteenth day 15 18 12.85 3.58 12-24 18

3rd month

Follow up

15 18 12.85 3.58 12-24 18

Mean of Mouth Opening

05

101520253035

1st day 5th day 10th day 15thday 3rd monthfoll.up

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Graph 2 : Mean of the tongue protrusion ( in mm)

As shown in the table, mean tongue protrusion increased as the treatment progressed over the

days. There was a statistically significant difference between the mean tongue protrusion with

different follow up periods.Repeated Measures of Annova; F= 12.59, p= 0.0001, Multiple

Comparisons Dunnett p

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a longer duration, a higher tissue temperature would have been achieved. This could have been

efective in imcreasing the mouth opening and subsequent place tor the tongue to extrude,

although minimal, but signiicant.

The changes in extensibility that occur with stretch (with or without heat) are small,

which is why serial treatments are required in the clinic. This is again seen by Multiple

Comparisons Dunnett ; p

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12.Indborg JJ, Bhonsle RB,Murti PR, Gupta PC, Daftary DK, and Mehta FS. Incidence andearly forms of oral submucous fibrosis. Oral Surg. 1980: 50, 40-44. 52; 375-378.

13.Carmine, Samuel and Allan Far man: Alleviation of myofascial pain with ultrasonictherapy.1984;Vol. 51 January

14.Carla-Krystin Andrade, Outcome Based massage, Lippincot Williams &wilkins,Philadelphia, 3

rd

ed, 2008, P 224.15.Abhinav kumar, Anjana Bagewadi, Vaishali Keluskar, Mohitpal Singh. Efficacy ofLycopene in the management of oral submucous fibrosis. Oral Surg Oral Med Oral

Pathol Oral Radiol Endod 2006. Vol. 103 No. 2 February 2007.16.Draper DO, Ricard MD. Rate of temperature decay in human muscle following 3 MHz

ultrasound: the stretching window revealed. ] Ath Train. 1995;30:304-307.17.Warren CG, Lehmann JF, Koblanski IN. Elongation of rat tail tendon: effect of load and

temperature. Arch PhysMed Rehabil. 1971;52:465-74.

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