Acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders. II. A 1-year follow-up study

The effectiveness of different types of acupuncture to reduce symptoms and disability for patients with orofacial pain. A systematic review and meta-analysis

PURPOSE

To determine the effectiveness of different types of acupuncture in reducing pain, improving maximum mouth opening and jaw functions in adults with orofacial pain.

METHODS

Six databases were searched until 15 June 2023. The Cochrane risk of bias tool and GRADE were employed to evaluate bias and overall evidence certainty.

RESULTS

Among 52 studies, 86.5% (n = 45) exhibited high risk of bias. Common acupoints, including Hegu LI 4, Jiache ST 6, and Xiaguan ST 7, were used primarily for patients with temporomandibular disorder [TMDs]. Meta-analyses indicated that acupuncture significantly reduced pain intensity in individuals with myogenous TMD (MD = 26.02 mm, I2=89%, p = 0.05), reduced tenderness in the medial pterygoid muscle (standardised mean differences [SMD] = 1.72, I2 = 0%, p < 0.00001) and jaw dysfunction (SMD = 1.62, I2 = 88%, p = 0.010) in mixed TMD when compared to sham/no treatment. However, the overall certainty of the evidence was very low for all outcomes as evaluated by GRADE.

CONCLUSION

The overall results in this review should be interpreted with caution as there was a high risk of bias across the majority of randomized controlled trial (RCTs), and the overall certainty of the evidence was very low. Therefore, future studies with high-quality RCTs are warranted evaluating the use of acupuncture in patients with orofacial pain.

Complementary Effect of Electro Acupuncture on Refractory Head and Neck Myofascial Pain: A Retrospective Investigation of Patient-Reported Outcomes

Introduction:

Acupuncture (AC) is among the complementary treatment modalities to manage chronic myofascial pain. The aim of this investigation was to assess the additive effect of AC in reducing the intensity of primary chronic myalgia/myofascial head and neck pain in patients using oral orthotic appliances (OA).

Methods:

A retrospective chart review was conducted for 103 patients diagnosed with primary chronic myalgia/myofascial pain and received OA with/without AC at Tufts University School of Dental Medicine (TUSDM). Subjective reporting of face/TMJ/neck pain was recorded at the initial visit and at short-term and long-term follow-ups using patient-reported pain/discomfort numeric rating scale (NRS).

Results:

Most subjects were females (77.7%) with the mean age of the entire study population being 53 years old. In patients with refractory response to OA, combining AC with OA showed significant improvement in NRS score compared to baseline, in TMJ pain (P=0.023), neck pain (P= 0.055), facial pain (P=0.006). The addition of AC to OA has also brought refractory pain to low levels, comparable to what OA-only respondents reported [TMJ pain (P= 0.395), neck pain (P=0.694), face pain (P=0.553)].

Conclusion:

AC may provide a complementary therapeutic modality to manage refractory cases of primary chronic myofascial pain.

Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial

OBJECTIVE

To compare the effects of dry needling and upper cervical spinal manipulation with interocclusal splint therapy, diclofenac, and temporomandibular joint (TMJ) mobilization in patients with temporomandibular disorder (TMD).

METHODS

One hundred-twenty patients with TMD were randomized to receive six treatment sessions of dry needling plus upper cervical spinal manipulation (n = 62) or interocclusal splint therapy, diclofenac, and joint mobilization to the TMJ (n = 58).

RESULTS

Patients receiving dry needling and upper cervical spinal manipulation experienced significantly greater reductions in jaw pain intensity over the last 7 days (VAS: F = 23.696; p < 0.001) and active pain-free mouth opening (F = 29.902; p < 0.001) than those receiving interocclusal splint therapy, diclofenac, and TMJ mobilization at the 3-month follow-up.

CONCLUSION

Dry needling and upper cervical spinal manipulation was more effective than interocclusal splint therapy, diclofenac, and TMJ mobilization in patients with TMD.

Electromyographic evaluation of the effect of hard and soft stabilizing appliances on masseter and anterior temporalis muscles in asymptomatic individuals

Background/Aim: Stabilization appliances have traditionally been used for the treatment of temporomandibular disorders and bruxism. The aim of this study was to evaluate the effect of two appliances (hard and soft) with different thicknesses on the electromyographic (EMG) activities of masseter and anterior temporalis muscles. Material and Methods: 30 healthy subjects have been divided into two groups of 15, according to the appliance material used (soft, hard). For each subject in both groups, two appliances have been prepared with 3 mm and 6 mm thickness. EMG recordings of bilateral masseter and anterior temporalis muscles were taken for each appliance. Results: The results showed that, the decrease in average EMG values during maximum voluntary clenching with a 3-mm and 6-mm-thick hard appliance was statistically significant compared with the average EMG of maximum voluntary clenching in the intercuspal position. The increase in average EMG values during maximum voluntary clenching with a soft appliance of 3 mm and 6 mm thickness was statistically significant. Conclusions: The hard stabilization appliances decrease the activity of the masseter and temporalis muscles, while the soft appliances increase the activity of the masseter and temporalis muscles.

Comparison of acupuncture on specific and non-specific points for the treatment of painful temporomandibular disorders: A randomised controlled trial

BACKGROUND AND OBJECTIVE

The aim of this single-centre, two-arm, parallel-group, double-blinded, randomised controlled trial was to investigate the disputed specific effectiveness of acupuncture by comparing acupuncture on specific and non-specific points among patients with non-chronic, painful TMDs.

METHODS

Following predefined eligibility criteria, 49 consecutive patients of both sexes were recruited to the study. All subjects were diagnosed with a non-chronic (Graded Chronic Pain Scale grade <3) painful TMD, as assessed using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Patients were randomly assigned to group A (acupuncture on specific points) or group B (acupuncture on non-specific points) after the initial examination (T0). Both acupuncture treatment sessions were conducted by a trained dentist once a week for four weeks. The examination was repeated five weeks (T5) after T0 by one calibrated examiner who was unaware of the study groups. Characteristic pain intensity (CPI) was evaluated as the main outcome criterion and compared between times and treatment groups by means of non-parametric tests (significance level set at P = .05). Secondary outcomes comprised the maximum corrected active mouth-opening without pain (MAO); patients' expectations regarding acupuncture treatment and pain development; depressivity; and oral health-related quality of life (OHRQoL).

RESULTS

A total of 41 patients (38 female) successfully completed the study (mean age: 40.17 ± 16.61). The two groups did not differ significantly at any time in terms of age and CPI. However, CPI was significantly (P < .05) lower at T5 than at T0 for both groups (29.66 and 30.35% lower in group A and group B, respectively). An increase in MAO was observed at T5 for both groups but was significant for group B only (P = .016). All patients had positive expectations of acupuncture therapy, and the two groups did not differ significantly at T5 with regard to the extent to which their expectations had been fulfilled by the treatment (P = .717). Comparison of T0 and T5 showed a statistically significant reduction of depressivity for group A (P = .0205), but no significant change for group B (P = .329). At T5, OHRQoL had improved significantly for both groups (group A, P = .018; group B, P < .001) compared with at T0.

CONCLUSIONS

Acupuncture on both specific and non-specific points reduces the non-dysfunctional pain of TMD patients. The effect of acupuncture on painful TMD cannot be attributed to the specific point selection.

The Use of Acupuncture in the Treatment of Temporomandibular Dysfunction – An Audit

Objective

Temporomandibular dysfunction often represents a major therapeutic problem in a dental practice. Evidence from clinical studies suggests that acupuncture may be useful in the treatment of temporomandibular dysfunction. However, most studies have been performed in university settings. The aims of this study were to determine if the results of acupuncture treatment of temporomandibular dysfunction in general dental practice are comparable to the results obtained in previous studies in university clinics, and whether the treatment approach differs from that used in previous studies.

Methods

The case reports submitted by 15 dentists applying for the diploma of the British Dental Acupuncture Society were combined into one audit. All dentists were informed before submitting the forms that the data might be used for scientific purposes. The criteria for Pain Syndrome Dysfunction were used as inclusion criteria. A visual analogue scale (VAS) was used to assess the pain intensity before and after acupuncture treatment. The acupuncture points and technique used were recorded for each treatment.

Results

A total number of 70 case reports were received. Ten patients were excluded, as they did not fulfil the criteria. The remaining 60 patients (50 female) fulfilled an average of 3.2 of the Pain Syndrome Dysfunction criteria, out of a possible five. Their mean age was 40.6 years (range 14–68). The average duration of temporomandibular dysfunction was 32 months (range 1–180). The patients received a mean of 3.4 treatments, each treatment lasting on average 12 minutes. The dentists used only manual stimulation, and mainly acupuncture points over the temporomandibular joint and in the masticatory muscles, points on the neck, and additional relaxing points. The mean pain scores were 7.35 (SD 1.52) before treatment and 2.67 (SD 0.58) after treatment (P<0.001). A beneficial effect was observed in 85% with an average reduction in the pain intensity of 75%.

Conclusion

This audit shows that the results of using acupuncture in the treatment of temporomandibular dysfunction in a general dental practice are comparable to those obtained in clinical studies in university settings. Also the therapeutic approach of using acupuncture is similar. Thus, acupuncture is a simple, relatively safe and potentially efficacious and useful technique in the management of temporomandibular dysfunction in a general dental practice.

The Use of Acupuncture in Dentistry: A Systematic Review

Published controlled studies on the analgesic effect of acupuncture in dentistry are still relatively few, but those which fulfil predefined methodological criteria are reviewed to assess if acupuncture is effective in this field. A literature search identified 74 papers published between 1966 and 1996, and 48 are reviewed. Only 15 of the papers fulfil a number of predefined criteria: having a reference group, randomisation, blinding, appropriate statistics, sufficient follow-up, etc. Of the 15 papers only one study meets more than 85% of the criteria, five meet 70–84%, three studies meet 60–69%, and six do not reach 60% of the predefined criteria and are thus considered unreliable.

Eleven out of the 15 studies were in favour of acupuncture and showed standard acupuncture to be more effective than placebo, non-standard (sham) acupuncture, or showed it to be able to produce better or similar results to an accepted treatment procedure. The higher the standard of the paper, the more likely it was to have a positive result in favour of acupuncture: all those in the excellent or good categories gave a favourable result Acupuncture proved effective in 73% of the reviewed papers for the treatment of Temporomandibular dysfunction or as an analgesic, and should be considered as a reasonable alternative or supplement to current dental practice in these areas.

Temporomandibular Disorders: "Occlusion" Matters!

By analogy with the journal's title Pain Research and Management, this review describes TMD Research and Management. More specific are the (1) research aspects of “occlusion,” still one of the most controversial topics in TMD, and (2) as much as possible evidence-based management aspects of “TMD” for the dental practitioner. Research. The disorders temporomandibular dysfunction and the synonymous craniomandibular dysfunction are still being discussed intensely in the literature. Traditionally, attention is mostly devoted to occlusion and its relationship with these disorders. The conclusions reached are often contradictory. Considering the definitions of temporomandibular and craniomandibular dysfunctions/disorders and “occlusion,” a possible explanation for this controversy can be found in the subsequent methodological problems of the studies. Based on a Medline search of these terms over the past 40 years related to contemporary terms such as “Evidence Based Dentistry” and “Pyramid of Evidence,” these methodological aspects are examined, resulting in recommendations for future research and TMD-occlusal therapy. Management. To assist the dental practitioner in his/her daily routine to meet the modern standards of best practice, 7 guidelines are formulated that are explained and accompanied with clinical examples for an evidence-based treatment of patients with this disorder in general dental practices.

Acupuncture therapy in the management of the clinical outcomes for temporomandibular disorders: A PRISMA-compliant meta-analysis

PURPOSE

The purpose of this study was to evaluate conventional acupuncture therapy in the management of clinical outcomes for temporomandibular disorders (TMD) in adults.

METHODS

The electronic databases PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinical Trails.gov were searched for reports published until March 31, 2016.

RESULTS

Nine eligible studies from 8 publications involving 231 patients were included in the meta-analysis. A comparison of the main outcome of visual analog scale (VAS) values of pain between the acupuncture group and control group showed a significant decrease (MD = -0.98, 95% CI [-1.62, -0.34], I=54%, P = 0.003) in the VAS following acupuncture treatment. However, subgroup analysis according to the type of sham control group indicated that there were significant differences in the results when sham acupuncture was used as the control group (MD = -1.54, 95% CI [-2.63, -0.45], I=58%, P = 0.006) as well as when sham laser treatment was used as the control group (MD = -1.29, 95% CI [-2.32, -0.27], I = 0%, P = 0.01). However, there was no significant difference when the splint treatment group was used as the control group (MD = -0.09, 95% CI [-0.69, 0.50], I = 0%, P = 0.76). Subgroup analyses of VAS for pain by the classification of diseases indicated that the myogenous TMD subgroup demonstrated a significant difference (MD = -1.49, 95% CI [-2.45, -0.53], I = 47%, P = 0.002), and TMD showed no statistically significant difference (MD = -0.42, 95% CI [-1.14, 0.30], I = 46%, P = 0.25). Subgroup analysis according to whether the subgroup penetrated the skin showed that nonpenetrating sham acupuncture as the control group showed a significant difference (MD = -1.56, 95% CI [-2.70, -0.41], I = 58%, P = 0.008) compared with the conventional acupuncture as the treatment modality, while penetrating sham acupuncture as the control group showed no significant difference (MD = -1.29, 95% CI [-3.40, 0.82], I = not applicable, P = 0.23). No publication bias was observed considering the symmetry of the funnel plots.

CONCLUSIONS

Our results indicate that conventional acupuncture therapy is effective in reducing the degree of pain in patients with TMD, especially those with myofascial pain symptoms.

Evaluation of Efficacy of Ultrasonography in the Assessment of Transcutaneous Electrical Nerve Stimulation in Subjects with Myositis and Myofascial Pain

Background

The study aimed to determine if ultrasonography of masseter can be used to evaluate the outcome of transcutaneous electrical nerve stimulation (TENS) in subjects with temporomandibular disorders (TMDs) such as myositis and myofascial pain.

Methods

Fifteen TMD subjects with myofascial pain/myositis who satisfied the RDC/McNeil criteria were included in the study. All the subjects were administered TENS therapy for a period of 6 days (30 minutes per session). The mouth opening (in millimeters) and severity of pain (visual analogue scale score) and ultrasonographic thickness of the masseter (in millimeters) in the region of trigger/tender areas was assessed in all the subjects both prior and post TENS therapy. A comparison of the pre-treatment and post-treatment values of the VAS score, mouth opening and masseter thickness was done with the help of a t-test.

Results

There was a significant reduction in the thickness of masseter muscle (P = 0.028) and VAS scores (P < 0.001) post TENS therapy. There was also a significant improvement in the mouth opening (P = 0.011) post TENS therapy.

Conclusions

In the present study, ultrasonography was found to be an effective measuring tool in the assessment of TENS therapy in subjects with myositis and myofascial pain.

Ear Acupuncture Therapy for Masticatory Myofascial and Temporomandibular Pain: A Controlled Clinical Trial

Ear acupuncture works by reducing painful sensations with analgesic effect through microsystem therapy and has been demonstrated to be as effective as conventional therapies in the control of facial pain. This clinical trial aimed to evaluate the adjuvant action of auricular acupuncture through an observation of the evolution of temporomandibular and masticatory myofascial symptoms in two groups defined by the therapies elected: auricular acupuncture associated with occlusal splint (study) and the use of the occlusal splint plate alone (control). We have selected 20 patients, who were randomly allocated into two groups of ten individuals. Symptoms were evaluated in five different moments, every seven days. We analyzed the orofacial muscle and joint palpation in order to measure the intensity of the experienced pain. Both groups showed a statistically significant decrease in muscle and joint symptoms (p < 0.05). However, comparisons between the groups showed an expressive and significant reduction of symptomatology in the study group (p < 0.05) already on the first week of therapy. According to the results, to the methodological criteria developed and statistical analysis applied, the conclusion is that auricular acupuncture therapy has synergistic action on conventional occlusal splint treatment. It was demonstrated to be effective in the reduction of symptoms in the short term.

Could Acupuncture Be Useful in the Treatment of Temporomandibular Dysfunction?

In this study, the effects of acupuncture in comparison with flat occlusal plane appliance were evaluated in patient with myogenic temporomandibular dysfunction (TMD). The sample consisted of 40 women with TMD and unbalanced energy predominance of Yang Liver Ascension, selected using the Renying and Cunkou pulses, randomly divided into two groups: acupuncture and splint. The effect of treatments on the masseter and anterior temporal muscles was evaluated after 4 weeks of treatment, by means of electromyographic activity (root mean square) and pain pressure threshold. Pain intensity was measured using the visual analog scale, and range of mouth opening was evaluated using a millimeter ruler. All evaluations were performed at the beginning and end of the treatment. Visual analog scale score was reduced equally in the two groups (p < 0001), and the increase in range of mouth opening was significant in both groups. A significant difference was detected only in pain pressure threshold of the left masseter in the acupuncture group (p < 0.05). Only root mean square in the at rest position of the right temporal muscle diminished in the final stage of the splint group (p < 0.05). Both treatments reduced the pain intensity of myogenic TMD in the short term and may be considered strategies for control of chronic pain related to TMD.

Laser acupuncture in patients with temporomandibular dysfunction: a randomized controlled trial

A prospective, double-blind, randomized, and placebo-controlled trial was conducted in patients with chronic temporomandibular disorder (TMD) to check the analgesic efficacy of infrared low-power GaAlAs diode laser applied to acupuncture points. Forty female subjects, ranging in age from 20 to 40 years, with diagnoses of chronic myofascial pain and arthralgia were randomly allocated to two groups: an experimental group (EG) who received the laser acupuncture as adjunct to reversible occlusal splint therapy and a control group (CG) who received a placebo laser associated with occlusal splint therapy. Both approaches were applied once a week for 3 months. Laser acupuncture was defined by the following parameters: 50-mW continuous radiation for 90 s to acupoints ST6, SI19, GB20, GB43, LI4, LR3, NT3, and EX-HN3; defining 4.5-J energy; 1250-W/cm(2) density point; and 112.5-J/cm(2) total density. The outcome measurements included a symptom evolution assessment carried out by checking spontaneous and palpation pain intensity, which was indicated on a visual analog scale (VAS). All evaluations were made by an assessor who was blind to the treatment. The symptom reduction was significant in both groups (EG: VAS = 0, n = 20; CG: VAS between 2 and 4, n = 18). The measurements showed significantly faster and lower pain intensity values in the EG (p ≤ 0.002), where there was a higher proportion of patients with remission of symptoms related to the action of laser acupuncture. For patients in whom conservative treatment was adopted, the laser acupuncture is a secure, noninvasive, and effective treatment modality because it improves the chronic pain associated with TMD and has no side effects.

The efficacy of acupuncture and decompression splints in the treatment of temporomandibular joint pain-dysfunction syndrome

OBJECTIVES

The goal of the present study was to evaluate the results of applying acupuncture or occlusal decompression splints in the treatment of patients diagnosed with the temporomandibular joint pain-dysfunction syndrome.

DESIGN OF THE STUDY

We conducted a randomized clinical trial including 20 patients to whom the mentioned treatments were applied. Results were evaluated through an analogue pain scale, measurements of mouth opening and jaw lateral deviation in millimetres, and assessment of sensitivity to pressure on different points: preauricular, masseter muscle, temporal muscle and trapezius. Parameters were evaluated before and 30 days after the treatment. For standardized pressure, we used a pressure algometer.

RESULTS

Patients treated with decompression splints showed reductions in subjective pain and pain upon pressure on temporal, masseter and trapezius muscles, as well as increased mouth opening after the treatment. Patients treated with acupuncture showed pain reduction in the short term and improvements in all of the evaluated para-meters (stronger pressure was required to produce pain; mouth opening was improved).

CONCLUSION

Acupuncture was an effective complement and/or an acceptable alternative to decompression splints in the treatment of myofascial pain and temporomandibular joint pain-dysfunction syndrome.

Adjacent, distal, or combination of point-selective effects of acupuncture on temporomandibular joint disorders: A randomized, single-blind, assessor-blind controlled trial

Background

The objectives of this study were to compare the efficacy of acupuncture among different types and to evaluate point-selective pain relief effects between selected adjacent or distant points in participants with temporomandibular joint disorders (TMDs).

Methods

Forty-two participants were randomly allocated to three groups: an adjacent point selection group (Trt, n = 14), a distant point selection group (Con1, n = 14), or a combination group (Con2, n = 14). All three groups received a total of six acupuncture sessions (twice a week for 3 weeks), the outcomes being assessed pain intensity using a 10-cm visual analogue scale, and the palpation index of the muscle and temporomandibular joint every week of treatment and 4 weeks after the end of treatment.

Results

The pain intensity was reduced in the Trt (34%), Con1 (31%), and Con2 (36%) groups after 3 weeks compared with each group's baseline, with no significant difference among the three groups (p = 0.5867). Similarly, the palpation index was decreased by 52% (Trt), 62% (Con1), and 50% (Con2) after 3 weeks of treatment, but no significant differences between groups were shown (p = 0.3289).

Conclusion

Our results suggest that point-selective effects among adjacent, distal, or a combination of acupoints are hardly associated with pain intensity or palpation index in participants with TMDs. Larger sample size trials are required to overcome the shortcomings of the study.

Clinical effectiveness of laser acupuncture in the treatment of temporomandibular joint disorder

BACKGROUND/PURPOSE

Temporomandibular joint disorder (TMD) is a general term for diseases of the temporomandibular joint and orofacial muscles. In this study, we tested whether laser acupuncture was effective for the treatment of TMD.

METHODS

Twenty patients with TMD were treated with diode K-Laser (wavelength 800 nm, energy density 100.5 J/cm(2)) once a week at four acupuncture points including three standard ipsilateral local points (ST6, ST7, Ashi point) and one contralateral distal point (LI4). A 10-cm visual analogue scale (0 no pain and 10 the most severe pain) was used for measuring the pain intensity before and after the treatment.

RESULTS

Seventeen out of 20 patients (85%) showed various degrees of pain relief after laser acupuncture treatment. The average pain score was 6.3 ± 1.6 before treatment and 2.5 ± 2.2 after treatment. Significant pain relief after laser acupuncture treatment was achieved (p = 0.0003, Wilcoxon signed rank test). The 17 patients showed an average pain relief of 63 ± 31%. There were six patients who showed no TMD symptoms after an average of four treatments of laser acupuncture. The other 11 patients showed partial relief of TMD symptoms after treatment. Although the pain was still present, it was less and was acceptable. No side effects were reported in any patients during or after laser acupuncture treatments.

CONCLUSION

Laser acupuncture may be an alternative treatment modality for TMD because it is non-invasive, results in partial or total relief of pain, and has no side effects.

Effects of trigger point acupuncture treatment on temporomandibular disorders: a preliminary randomized clinical trial

We compared the effects of trigger point acupuncture with that of sham acupuncture treatments on pain and oral function in patients with temporomandibular disorders (TMDs). This 10-week study included 16 volunteers from an acupuncture school with complaints of chronic temporomandibular joint myofascial pain for at least 6 months. The participants were randomized to one of two groups, each receiving five acupuncture treatment sessions. The trigger point acupuncture group received treatment at trigger points for the same muscle, while the other acupuncture group received sham treatment on the trigger points. Outcome measures were pain intensity (visual analogue scale) and oral function (maximal mouth opening). After treatment, pain intensity was less in the trigger point acupuncture group than in the sham treatment group, but oral function remained unchanged in both groups. Pain intensity decreased significantly between pretreatment and 5 weeks after trigger point (p<0.001) and sham acupunctures (p<0.050). Group comparison using the area under the curve demonstrated a significant difference between groups (p=0.0152). Compared with sham acupuncture therapy, trigger point acupuncture therapy may be more effective for chronic temporomandibular joint myofascial pain.

A follow-up study of subjective symptoms of temporomandibular disorders in patients who received acupuncture and/or interocclusal appliance therapy 18-20 years earlier

OBJECTIVE

To evaluate the presence of symptoms of temporomandibular disorders (TMDs) in patients referred to a specialist clinic because of muscular problems 18-20 years earlier and who had received mainly acupuncture and/or interocclusal appliance therapy.

MATERIAL AND METHODS

Sixty-five subjects who had received therapy at a TMD specialist clinic 18-20 years earlier were mailed a questionnaire with questions about TMD symptoms, their attitude towards the therapy, and their opinion about the outcome. Fifty-five subjects (85%) answered and returned the questionnaire.

RESULTS

Before therapy, 87% had had severe TMD symptoms, but this figure decreased to 38% at the long-term follow-up. The mean values of the subjects' complaints at worst and at best before treatment, measured with a visual analog scale, were 66 (range 26-100) and 31 (range 0-100), respectively. The corresponding figures at the long-term follow-up were 32 (range 0-96) and 16 (range 0-70). Headache at least once a week was originally reported by 73% of the women and by 77% of the men. Headache prevalence 18-20 years later was 35% in women and 54% in men. The majority of patients were positive about the therapy they had received, and would recommend it to a friend with similar complaints.

CONCLUSIONS

A majority of the patients reported a lasting improvement in their symptoms. Patients' overall opinions of the therapy received were positive.

Complementary and alternative medicine for persistent facial pain

This article discusses complementary and alternative medicine (CAM), reviews literature on the prevalence of use of CAM by the general adult population in the United States and by patients with persistent facial pain, and summarizes published, peer-reviewed reports of clinical trials assessing the effects of CAM therapies for persistent facial pain. Results indicate that many patients use CAM for musculoskeletal pain, including persistent facial pain. Preliminary work on selected complementary therapies such as biofeedback, relaxation, and acupuncture seems promising; however, there are more unanswered than answered questions about cost-effectiveness, efficacy and mechanisms of action of CAM for persistent facial pain.

Anterior midline point stop device (AMPS) in the treatment of myogenous TMDs: Comparison with the stabilization splint and control group

Two occlusal splints, the full-arch stabilization splint and the anterior midline point stop (AMPS) device, were evaluated for their efficiency in relieving myogenous temporomandibular disorders (TMD). One hundred and fourteen patients with myogenous TMD were distributed into 3 groups. The first group was treated with the AMPS device, the second with the stabilization splint, and the third group was the control group. Pain intensity was scored using the visual analogue scale before treatment and 1 month and 3 months after treatment. Statistical Package for the Social Sciences (SPSS, Chicago, Ill) and multiple comparisons tests were used to compare results before and after treatment and to compare the groups. The use of AMPS device in the first group resulted in a significant improvement after 1 month and 3 months (P < or = .001) and showed a 56.66% pain reduction. A significant improvement was also noticed in the second group (P = .001) with a 47.71% pain reduction. Although pain reduction percentage appeared more in the first group, this was not statistically significant. There was a highly significant difference between groups treated with both kinds of splints and the control group. It was concluded that both types of occlusal splints are beneficial to patients with myogenous TMD.

Acupuncture in the treatment of painful dysfunction of the temporomandibular joint -- a review of the literature

OBJECTIVE

The aim of the present study was to analyze the results of randomized clinical trials on the efficacy of acupuncture in the treatment of painful dysfunction of the temporomandibular joint.

MATERIALS AND METHODS

A literature search of 3 electronic databases was performed, and only randomized studies comparing acupuncture-treated patients with either untreated or conservatively treated control groups were included. For this purpose, results were compared in narrative and tabular form.

RESULTS

To date, only 8 publications representing 6 randomized clinical trials have looked into the efficacy of acupuncture in the treatment of craniomandibular dysfunction. With the exception of one, all studies were published in Sweden, between 1985 and 1992. A more recent US study was the only one to apply sham acupuncture to test the efficacy of acupuncture. All studies share methodological shortcomings, including a lack of detailed descriptions of the randomization procedures, point selection, possible dropouts and undesirable events as well as attempts to identify a possible placebo effect of the acupuncture. Only 1 study investigated long-term results. Although based on the improvement of subjective and objective criteria, all studies consider acupuncture as an effective treatment for painful dysfunction of the temporomandibular joint, the good results achieved must be interpreted with caution because of the methodological shortcomings identified.

CONCLUSION

Acupuncture appears to be a suitable complementary treatment method in the management of craniomandibular dysfunction. However, its significance has to be further evaluated in future studies.

Physiotherapy in the management of TMD: A review of the literature part 1

‘Temporomandibular disorders’ (TMD) is a generic term encompassing a group of musculoskeletal conditions that affect the temporomandibular joint, masticatory muscles and surrounding soft tissues. Physiotherapy is used to treat TMD. The first of this two-part article reviews the current literature to determine what TMD are and how effective physiotherapy is in their treatment. This section defines TMD and examines the evidence investigating the effectiveness of exercise, postural correction and acupuncture.

The author concludes from the studies reviewed that there is insufficient evidence to establish the effectiveness of exercise, postural correction or acupuncture in treating TMD. He recommends that a number of large, well designed blinded randomized controlled trials, with between-group comparison assessing individual treatment interventions, are required to evaluate the effectiveness of these three techniques in the treatment of TMD.

Efficacy of stabilization splints for the management of patients with masticatory muscle pain: a qualitative systematic review

This study aimed at providing an answer to two clinical questions related to patients with masticatory muscle pain: 1) Does the use of a full-coverage hard acrylic occlusal appliance (stabilization splint) lead to a significant decrease of symptoms? and 2) Is the treatment success achieved with a stabilization splint more pronounced than the success attained with other forms of treatment (including placebo treatment) or no treatment? A systematic search was carried out in different electronic databases, supplemented by handsearch in four selected dental journals and by examination of the bibliographies of the retrieved articles. Thirteen publications, representing nine controlled clinical studies, could be identified. Reporting quality of most studies as assessed with the Jadad score ranged from 1 to 5. Based on the currently best available evidence it appears that most patients with masticatory muscle pain are helped by the incorporation of a stabilization splint. Nevertheless, evidence is equivocal if improvement of pain symptoms after incorporation of the intraoral appliance is caused by a specific effect of the appliance. A stabilization splint does not appear to yield a better clinical outcome than a soft splint, a non-occluding palatal splint, physical therapy, or body acupuncture. The scarcity of current external evidence emphasizes the need for more and better clinical research.

Can acupuncture reduce the induction time of a local anaesthetic?--A pilot study

We report on a pilot study we undertook to investigate if segmental acupuncture treatment, given two minutes prior to a regional inferior dental block (ID) with Prilocaine Hydrochloride, would reduce the onset time of a local anaesthetic. Thirty healthy people, who needed a regional inferior dental block (ID) as part of dental treatment in the lower jaw, were randomly allocated to three groups. They received segmental acupuncture, heterosegmental superficial acupuncture, or standard treatment (regional inferior dental block) without acupuncture. In the segmental acupuncture group, acupuncture was given within the innervation of the trigeminal nerve. The needles were left in for two minutes, followed by a regional inferior dental block (ID). In the second group, acupuncture needles were inserted superficially in extra-segmental points and left in for two minutes without stimulation, followed by the regional inferior dental block. A control group received standard treatment only, of a regional inferior dental block. The concept 'pain free for dental work' was defined as 'patients reporting pins and needles in the lower lip' and measured by a drilling test. Patients who reported no pain during the drilling test were included in the study. The time from administration of the injection to the patients' reporting pins and needles was recorded by an independent dental nurse. All tested patients reported sufficient anaesthesia during the drilling test. In the segmental acupuncture group, anaesthesia was achieved after 62 seconds, compared to the heterosegmental superficial acupuncture group, who took 115 seconds and the control group, who received standard treatment only, and took 119 seconds. The difference between the segmental acupuncture group and the heterosegmental superficial acupuncture group was statistically significant (p < 0.015); the difference between the segmental acupuncture group and the control, who received a regional inferior dental block only, was also significant (p < 0.032). No significant difference was found between the heterosegmental superficial acupuncture group and the control group who received a regional inferior dental block only (p < 0.84). It appears from this pilot study that the onset time of local anaesthesia is reduced if segmentally administered acupuncture is given prior to the regional inferior dental block. However, it needs to be reproduced including objective measurements.

The Use of Acupuncture in Implant Dentistry

This article aims to review how acupuncture can provide complimentary treatments to patients through implant rehabilitation. The following topics are discussed: control of gagging reflex, control of postoperative vomiting, control of postoperative pain, enhance anesthetic effects, control of anxiety, increase saliva production, enhance immune responses, management of temporomandibular dysfunction, smoking cessation, control diabetic mellitus, stimulation of peripheral nerve regeneration, and adverse effects.

Treatment of temporomandibular disorders among adolescents: a comparison between occlusal appliance, relaxation training, and brief information

In a randomized trial the effects of occlusal appliance and relaxation therapy, each combined with brief information, were compared with brief information only, in adolescents with temporomandibular disorder (TMD) pain. One-hundred-and-twenty-two adolescents (93 F and 29 M aged 12-18 years) were randomly assigned to one of the following 3 groups: brief information + occlusal appliance (BI + OA), brief information + relaxation therapy (BI + RT), or brief information (BI). Included were subjects reporting pain once a week or more often, in addition to receiving a diagnosis of TMD according to the Research Diagnostic Criteria (RDC/TMD). They were evaluated before and after treatment and at a 6-month follow-up by means of self-reports and clinical assessment. The result revealed a significantly higher reduction in frequency of pain, in pain intensity (visual analog scale [VAS]), and in a composite pain index (intensity x frequency) for patients treated with BI + OA compared with those treated with BI alone. In the BI + OA group, 60% of the patients attained a clinically significant improvement (at least 50% or more) on the pain index, a significantly higher proportion compared to that obtained in the other 2 treatment groups. Analgesic consumption was also significantly more reduced in the BI + OA group compared to the BI group. However, no significant differences were found between the treatment groups in jaw opening or in muscle and TMJ tenderness scores. Occlusal appliance was found to be superior to both relaxation therapy and brief information regarding pain reduction and can therefore be recommended when treating adolescents with TMD pain.

Acupuncture treatment of pain dysfunction syndrome after dental extraction

A successful treatment with acupuncture of a patient with Pain Dysfunction Syndrome is presented. The patient developed restricted mouth opening after removal of a third molar in the lower jaw. Despite orthodox treatment no improvement was noticed after three months, and his general practitioner was contacted. After two acupuncture sessions the patient felt normal and the jaw movement was within the normal range. A follow-up four weeks after the first treatment showed a further increase in the jaw movement. If restricted movement in the temporomandibular joint occurs after operative procedures in the mouth, acupuncture should be considered at an early stage.

A review of complementary and alternative medicine use for treating chronic facial pain

BACKGROUND

The authors compiled information on the prevalence of complementary and alternative medicine, or CAM, use, as well as on reports of randomized clinical trials of CAM modalities used to treat chronic facial pain.

TYPES OF STUDIES REVIEWED

The authors searched several databases for reports of clinical trials randomizing patients who had facial pain to a CAM intervention or to a control or comparison group. Search terms included "complementary," "alternative," "acupuncture," "biofeedback," "relaxation," "herbal," "meditation," "massage," "yoga," "chiropractic," "homeopathic" and "naturopathic."

RESULTS

Three acupuncture trials, eight biofeedback trials and three relaxation trials met the authors' inclusion criteria. Across studies, results suggested that acupuncture, biofeedback and relaxation were comparable to conservative treatment (for example, an intraoral appliance) and warranted further study. The authors did not locate any randomized clinical trials that tested the effects of homeopathy, naturopathy, chiropractic, massage, meditation, yoga or herbal remedies for chronic facial pain.

CLINICAL IMPLICATIONS

Significant gaps in the scientific knowledge base limit the accuracy with which dental professionals can guide their patients regarding CAM approaches used to treat chronic facial pain.

Introduction to acupuncture in dentistry

An introduction to the practical application of acupuncture in dentistry is presented in the light of current research. It is concluded that acupuncture could supplement conventional treatment modalities. Its value in the treatment of temporomandibular dysfunction syndrome and facial pain has been well documented and supported by randomised controlled trials. Although it may be useful in the control of post-operative pain, its use as sole analgesia for operative care is questionable. The mode of action of acupuncture can be explained with reference to modern neurophysiology. A short training course can allow the technique to be an effective tool in every dentist's hands.

Is acupuncture effective for the treatment of chronic pain? A systematic review

Pain is the major complaint of the estimated one million U.S. consumers who use acupuncture each year. Although acupuncture is widely available in chronic pain clinics, the effectiveness of acupuncture for chronic pain remains in question. Our aim was to assess the effectiveness of acupuncture as a treatment for chronic pain within the context of the methodological quality of the studies. MEDLINE (1966-99), two complementary medicine databases, 69 conference proceedings, and the bibliographies of other articles and reviews were searched. Trials were included if they were randomized, had populations with pain longer than three months, used needles rather than surface electrodes, and were in English. Data were extracted by two independent reviewers using a validated instrument. Inter-rater disagreements were resolved by discussion. Fifty one studies met inclusion criteria. Clinical heterogeneity precluded statistical pooling. Results were positive in 21 studies, negative in 3 and neutral in 27. Three fourths of the studies received a low-quality score and low-quality trials were significantly associated with positive results (P=0.05). High-quality studies clustered in designs using sham acupuncture as the control group, where the risk of false negative (type II) errors is high due to large sample size requirements. Six or more acupuncture treatments were significantly associated with positive outcomes (P=0.03) even after adjusting for study quality. We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. However, we have found an important relationship between the methodology of the studies and their results that should guide future research.

Occlusal treatments in temporomandibular disorders: a qualitative systematic review of randomized controlled trials

Occlusal treatments (occlusal splints and occlusal adjustment) are controversial but widely used treatment methods for temporomandibular disorders (TMD). To investigate whether studies are in agreement with current clinical practices, a systematic review of randomized controlled trials (RCTs) of occlusal treatment studies from the period 1966 to March 1999 was undertaken. Eighteen studies met the inclusion criteria, 14 on splint therapy, and 4 on occlusal adjustment. The trials were scored using the quality scale presented by Antczak et al., 1986a (A.A. Antczak, J. Tang, T.C. Chalmers, Quality assessment of randomized control trials in dental research. I. Methods, J. Periodontal Res. 1986a;21:305-314). The overall quality of the trials was fairly low, the mean quality score was 0.43/1.00 (range 0.12-0.78). The most obvious methodological shortcomings were inadequate blinding, small sample sizes, short follow-up times, great diversity of outcome measures and numerous control treatments, some of unknown effectiveness. Splint therapy was found superior to 3, and comparable to 12 control treatments, and superior or comparable to 4 passive controls, respectively. Occlusal adjustment was found comparable to 2 and inferior to one control treatment and comparable to passive control in one study. Because of the methodological problems, only suggestive conclusions can be drawn. The use of occlusal splints may be of some benefit in the treatment of TMD. Evidence for the use of occlusal adjustment is lacking. There is an obvious need for well designed controlled studies to analyse the current clinical practices.

Physical therapy: a critique

Some forms of physical therapy are used relatively frequently in the treatment of chronic musculoskeletal pain conditions, including the temporomandibular disorders. We found evidence that cold seems to be a useful treatment for postsurgical pain and swelling and that most patients being treated for most chronic musculoskeletal pain seem to do better with most forms of therapy. However, we agree with the authors of previous reviews that there is little evidence that these methods of management cause long-lasting reductions in signs and symptoms. Findings of recent clinical trials tend to support this conclusion, although evidence is beginning to accumulate that exercise programs designed to improve physical fitness have beneficial effects on chronic pain and disability of the musculoskeletal system.

Treatment alternatives for patients with masticatory myofascial pain

Alternative therapies are used by many people, and the dental literature has reported that some alternative therapies are comparable to splint therapy in the effective treatment of masticatory myofascial pain. The authors review the efficacy of alternative therapies and discuss their clinical implications. This review is intended to help dental practitioners to select alternative therapies they can use with or instead of splint therapy for treating patients who have a primary diagnosis of myofascial pain.