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11 Articles in Volume 16, Issue #2
Gender and the Pain Experience
Sex and Gender Differences In the Pain Experience
Medical Management of Diabetic Neuropathy
Comorbid Substance Use Disorders: Primer for Pain Management
Marijuana Use Disorder: Common and Often Untreated
Acupuncture: New Approach for Temporomandibular Disorders
Opioid-Maintained Patients Who Require Surgery
Natural Protein Points to New Inflammation Treatment
Lessons from the Murder Conviction of Dr. Hsiu-Ying “Lisa” Tseng
Zohydro vs Hysingla: What is the Difference in These Extended-Release Agents?
Letters to the Editor: Opioid Calculator, Testosterone for SCI

Acupuncture: New Approach for Temporomandibular Disorders

Acupuncture is a simple, safe, and efficacious technique in the management of TMD.

Temporomandibular disorder (TMD) is clinically characterized by pain in the masticatory muscles of the temporomandibular joint (TMJ). This affects an estimated 10 million Americans, and one-third of adults will experience symptoms of TMD over their life span.1,2

Myofascial pain is characterized by localized hypersensitive spots in palpable taut muscle fibers (myofascial trigger points). These trigger points may result from muscle overload from trauma or repetitive activities that cause abnormal stress on specific muscle groups. Clinically, patients complain of tenderness, headaches, restricted movement of the jaws, muscle stiffness, and weakness.

Although millions of Americans use acupuncture each year, often for chronic pain, there has been considerable controversy surrounding its value as a therapy and whether it is anything more than placebo.3 However, research of traditional Chinese medicine revealed that acupuncture is effective in the treatment for temporomandibular disorders and myofascial pain.4-8

Temporomandibular disorder affects an estimated 10 million American.

How it Works

Although the exact mechanism by which acupuncture may relieve TMD pain is not entirely understood, according to ancient theories of traditional Chinese medicine, acupuncture acts by restoring the balanced flow of Qi, or energy.

Modern research has revealed scientific reasons why acupuncture is a successful therapy. In the 1970s, reports appeared in Western medical literature suggesting that acupuncture reduces pain sensation through direct stimulation of the nerve, which changes the quality of signaling along nerve cells.

In fact, research suggests that acupuncture may suppress the nociceptive trigeminal nucleus caudalis and spinal dorsal horn neurons via modulation of the release of neuropeptides and neurotransmitters.9,10

Further studies support this idea that acupuncture directly stimulates the release of endorphins and neurotransmitters, among other biological actions. These are naturally occurring substances that help dampen and block pain perception by the brain. Additional research is needed to further study the mechanisms behind acupuncture since many of acupuncture’s effects can still not be explained by either of these medical theories.

Whether by affecting Qi or biological chemicals, what may be more important is simply the evidence that it does work. According to the National Center for Complementary and Integrative Health (NCCIH), “results from a number of studies suggest that acupuncture may help ease chronic low-back pain, neck pain, and osteoarthritis/knee pain. It also may help reduce the frequency of tension headaches and prevent migraine headaches.”3

Measuring the effectiveness of acupuncture is only beginning to be understood. “Current evidence suggests that many factors—like expectation and belief—that are unrelated to acupuncture needling may play important roles in the beneficial effects of acupuncture on pain,” noted NCCIH.

Acupuncture and TMD

Acupuncture is frequently used to treat TMD and TMJ with positive results.6 As a long-standing treatment approach, research has determined the recommended acupuncture points (Table 1), frequency (weekly), and duration (30 minutes per session) of acupuncture treatment for TMD-related problems. In treating TMD, acupuncturists often find a deficiency in Qi in the liver (LV) meridian and an excess of Qi in the gallbladder (GB) meridian.11

Needles may be inserted in the area of the pain, around the ear and the jaw. However, because of the interconnecting pathways between the meridians, the needles may be inserted near the elbows, knees, and big toe. These distal locations can alter the flow of Qi through the jaw to relieve pain and inflammation as well. Additional acupuncture points are to address other disharmonies detected in the body. Correcting the overall flow of energy in the body can help relieve stress and other possible contributing factors to TMJ disorder.12

Several clinical studies demonstrated the validity of acupuncture as an effective therapeutic intervention for head and facial pain.13,14 While acupuncture therapy may not eliminate the cause of TMD resulting from structural anomalies, such as degenerative changes and disc displacement, acupuncture can help relieve the pain and discomfort associated with the conditions. It has been documented that acupuncture can help muscle relaxation and reduce muscle spasms, if the spasms are muscular in origin.15 Acupuncture can also help minimize TMJ “clicking” by relaxing the lateral pterygoid muscles, and therby reducing the anterior displacing force on the meniscus of the TMJ.16

In a 2007 study, TMJ-related short-term muscle pain was significantly improved in people receiving acupuncture.17 A recent British study of 70 cases of dental patients receiving acupuncture for TMJ indicated that 85% of patients benefited with an average reduction in pain intensity of 75%.18 A 2008 study reported long-term high patient satisfaction and improvement of symptoms 18 to 20 years following acupuncture and/or interocclusal appliance (bite plate or splint) therapy.19

Studies of its application to TMD show acupuncture comparable to more conventional treatments.20,21 Very credible evidence from the University of Maryland Medical Center suggests that acupuncture can treat TMJ dysfunction.11 In addition, research by Park et al and Shen et al revealed the effectiveness of acupuncture in the treatment of myofascial pain.7,8

In 2012, researchers conducted the study in 2 pain clinics in Tucson, Arizona, and Portland, Oregon.22 They enrolled 168 adults with TMD. Initially, all patients attended a 2-hour class on TMD. At week 2, the researchers assigned patients with the worst TMD pain (above a predetermined level) either to a traditional Chinese medicine or self-care group. The traditional Chinese medicine intervention (consisting of up to 20 visits within 1 year) was tailored to the patient and could include acupuncture, Chinese herbs, massage, and lifestyle counseling. The self-care intervention included patient education, jaw stretching exercises, training in relaxation and stress management, and cognitive behavioral therapy. Participants in the self-care group also received a self-help manual. 

The researchers found that traditional Chinese medicine provided significantly greater short-term pain relief than self-care, as well as greater reduction in interference with social activities. They concluded that this kind of stepped-care, community-based approach using traditional Chinese medicine is safe and could offer short-term relief of pain and improved quality of life for patients with TMD. The long-term outcomes of this study are forthcoming and will provide a more complete picture of the impact of this treatment strategy.22 Combined Therapies

Current medical interventions for the management of TMD consist of jaw appliance therapy (stabilization splint or bite guard), medications, physiotherapy, home self-care (Table 2), and surgery.2,3 Acupuncture may be used alone or in conjunction with these other treatment approaches. Medications for TMJ disorders can include non-steroidal anti-inflammatory drugs (NSAIDs), analgesics (opioids), antidepressants, and muscle relaxants. In severe cases, local injections of corticosteroids may be recommended. Acupuncture does not interact with these modern medical treatments and can often replace them as therapy without the risks of side effects.

Unfortunately, pharmaceutical treatments only provide symptomatic relief of TMD. However, acupuncture can target the root cause of the condition by balancing the mind and body through a network of energy channels called meridians, helping to reset the neuromuscular tension in the jaw. Often TMD is due to underlying stress held in the jaw or contracted muscles in the jaw and face. Acupuncture can help to both relax these targeted muscles and decrease the overall stress level in the body to relieve TMJ discomfort.

Long-term care of TMD requires important lifestyle changes. Dietary changes may be necessary, depending on any underlying health disharmony that may be identified by the acupuncturist. When teeth grinding or clenching is an issue, wearing a mouth night guard from your dentist can help prevent these actions in sleep. Bite plates can also help correct misalignment.

Stress reduction, relaxation techniques, jaw stretching exercises, and modifying chewing habits are all behavioral approaches that have proved effective. An acupuncturist can help guide patients with these lifestyle changes to eliminate TMJ discomfort.17,18,23

Acupuncture may be used as a stand-alone treatment, or as part of an integrated treatment plan for the management of TMD (or any other problem). The technique offers a significant and effective alternative to occlusal splint therapy, and for patients with low tolerance for occlusal splints, this is generally acceptable. Johansson et al.24 showed that both acupuncture and occlusal splints significantly reduced the symptoms of TMD.

In cases that show limited response to splint therapy, acupuncture may offer an additional therapy to enhance treatment. An alternative application may be the use of acupuncture to gain initial control of symptoms, with the progression to an occlusal splint to control symptoms on a longer term basis when nocturnal bruxism continues to be a problem. TMD may be well treated with acupuncture, both in acute and chronic cases. Response times correlate with histories, for example, acute cases respond quickly and chronic cases take longer.

During the many years of utilizing acupuncture in the daily treatment of patients with TMDs and neuromusculoskeletal pain symptoms, the author found the following acupuncture points to be most effective in the treatment of these painful head, neck, and face symptoms: LI-4, ST-6, ST-7, ST-8 Touwgi, ST-44 Neiting, BL-10, GB-14 Yangbai, and GB-20.These points are normally stimulated for 10-20 minutes after needle insertion using a combination of LI-4 and multiple other points, bilaterally, based upon location of pain and severity. The points are stimulated by using electrical stimulation to the inserted needles. Evidence of the effectiveness of the treatment consists of direct observation of the change in the patient’s pain perception.

Contraindications

Contraindications to the use of acupuncture are listed in Table 3. The following are common-sense guidelines and precautions for the use of acupuncture treatment:

  • If the discomfort from needle insertion persists, it should be removed
  • Patients who are unable to remain still for the required treatment time are not suitable for acupuncture treatment
  • Acupuncture treatment should not be utilized if there is any indication of possible infection at the site being considered for needle insertion

General precautions should be strictly adhered to and include: the use of sterile, disposable needles; the use of aseptic techniques for needle insertion; observing patients for bleeding; counting needles before and after treatment; using supine position for needling; and advising patients to avoid driving after treatment.25

Conclusion

Overall, acupuncture offers a useful treatment modality in the management of TMD. It is a simple, relatively safe and efficacious, and useful additional technique in the management of TMD.

Last updated on: March 15, 2016
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