Acupunture in Treating TMD

Definition of TMD

TMD (Temporomandibular Disorder) "is described as a collective term embracing a number of clinical problems that involve the masticatory muscles, the temporomandibular joint (TMJ) and associated structures, or both" (Okeson 1996).

Acupuncture originated in ancient China about 3000 years ago and has been used to manage various clinical disorders. Acupuncture techniques are based on the theory of meridians and energy flow .

Early Chinese physicians discovered that there is an energy network traversing just below the surface of the skin which communicates from the exterior to the internal organs and structures over 1,000 "Acupoints on the body.

History

This energy works in harmony with the other body s systems . When this vital energy becomes blocked or weakened, an effect in a body system or anatomic location becomes evident. Stimulation of one or a combination of key "Acupoints" on the body may restore harmony to the affected area.

Variation in acupuncture technique are seen in China, Japan, and Korea each with a distinct version of acupuncture with multiple approaches Japanese acupuncture is often more superficial than that practiced as part of Traditional Chinese Medicine (TCM). European interpretation of the original Chinese writings gave way to the energetic concept.

Somatotropic representations of the body are utilized in specialized systems of acupuncture developed in France (auriculotherapy, or ear acupuncture). Korea (Korean hand acupuncture) Japan (scalp acupuncture).

How does Acupuncture work?

Acupuncture activates small myelinated nerve fibres in muscle, which send impulses to the spinal cord and then activate the midbrain and pituitary-hypothalamus. It has been shown that enkephalin, beta-endorphin, serotonin and nor adrenaline are involved in this process.

It is accepted that insertion of a needle in an acupuncture point will create a small inflammatory process With the release of neurotransmitters such as bradykinin, histamine, etc. subsequently stimulate A fibres located in the skin and muscle. These fibres terminate in the second layer of the dorsal horn and inhibits the incoming painful sensations by release of enkephalin thus relieving pain.

Modulates pain by using bodys own anti nociceptive system

Stimulation of certain areas

Release of endorphins

Flooding of afferent inter-neuron with sub-threshold stimuli

Block the transmission of noxious stimuli

Reduction of pain sensation

In a Double-Blinded Study forty patients were randomly assigned to an experimental and a control group to assess the effectiveness of acupuncture in reducing chronic pain associated with osteoarthritis. The experimental group received treatment at standard acupuncture points, and the control group at placebo points. Analysis before and after treatment showed a significant (P < 0.05) improvement in tenderness and subjective report of pain in both groups.
Albert C. Gaw, M.D., Lennig W. Chang, M.D., and Lein-Chun Shaw, M.D. Efficacy of Acupuncture on Osteoarthritic Pain A Controlled, Double-Blind Study N Engl J Med 1975; 293:375-378.

Acupuncture In dentistry

Decreases salivary flow. Relief of postoperative pain after tooth extraction For periodontal disease Treatments in TMDs Facial pain Sjogrens syndrome In phobias and anxiety. Improve the immune response

Macdonald A. Acupuncture analgesia and therapy 44 49.

Part 2. Acupunct Med 1990; VIII:

Various Types of Needles

1. Filiform Needle Thick/thin length ranging from 0.5 t-sun to 0.8 Diameter: Selected according to the site Size and depth depends on the location of point that is stimulated.

2. Triangular needle/prismatic needle 3.Press needle 4.Hidden needle

5.Seven star / plum blossom needle

Acupuncture needles are typically solid stainless steel needles in sizes such as 28-40 Gauge or 0.320.14 mm in diameter. Hypodermic needles come as hollow syringe needles in sizes such as 7-28 Gauge or 4.57mm-0.36mm in diameter.

Unit of measurement

Direction of needle insertion

Manipulation of needle

Mode of Insertion of the needle

Point of Activation
Xiaguan (Hsiakuan) Location :centre of the depression of lower margin of zygomatic arch anterior to TMJ

It can be located by keeping the jaw slightly open or asking the patient to open and close the mouth and while keeping the finger in front of the ear for palpating the movements of TMJ

 Indications:
Arthritis or dislocation of TMJ Facial nerve paralysis

Needling :0.5 to 0.8 t-sun

straight

Characteristic needle-manipulation sensation manifests as

Numbness Heaviness Distention Soreness Spreading sensation

Indicates achievement of a clinical therapeutic effect.

How many treatments are needed?

It is unrealistic to expect to gain control of chronic conditions with only a couple of treatment Control of orofacial conditions such as TMD may require several cycles of treatments.

Does acupuncture always work?

No, and neither does anything else!

It is not a miracle cure and in general if a significant improvement has not occurred after three sessions it is not worth continuing. Two reasons for Failure are: (i) some patients fail to respond to acupuncture per se (ii) the original diagnosis could be wrong. A lack of response should always result in re-examination and refinement of the diagnosis.

Adverse effects
Pain Vegetative reactions . Syncope Drowsiness Bacterial or Viral Infection Septicaemia Endochondritis Perichondritis Hepatitis AIDS

Trauma to the tissues Cardiac Tamponade Pneumothorax Vascular lesions Trauma to the skin, peripheral nerves ,spinal cord Miscellaneous

After acupuncture: A review. Critical Rev Phys Rehabil Med 1997; 9: 245 264.

Acupuncture as an adjunct therapy

Because of the complexity and multi factorial features of TMD, a multidisciplinary therapeutic approach may be used to assure a more effective management .

Acupuncture plays an important role in the management of TMD providing pain relief without interfering with other conventional therapies (occlusal appliances, physical therapy, surgery, medications, injections, etc).

Cases in which acupuncture is contraindicated

Patients taking anticoagulant medication Press needles in patients with prosthetic or damaged heart valves Electro acupuncture in patients with pacemaker

Particular caution required: Acupuncture points on thorax Immuno-suppressed patients In pregnant women

General Precautions

Diagnostic skills Use sterile disposable needles Use aseptic technique with press needles Lie the patient down during treatment Advise patient to avoid driving after treatment Count needles before and after treatment Observe patient for bleeding

Recent findings
Acupuncture is more effective than physical therapy and Indomethacin plus vitamin B1. Acupuncture s effects are similar to those of occlusal splint therapy. Acupuncture is more effective than placebo in reducing pain intensity in TMD.

Acupuncture in the treatment of painintemporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials. Clin J Pain. 2010 Jul-Aug;26(6):541-50. Review Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehabil. 2010 May;37(6):430-51. Epub 2010 Apr 20.

Conclusion

Despite its long history there still exists a great deal of skepticism in the professional community as to its efficacy. This is understandable as the scientific study of acupuncture has occurred only relatively recently The management of TMD with Oriental medicine is holistic in nature and addresses both the physical and emotional components of the disorder.

In addition to acupuncture, the practitioner should provide nutritional, behavioral and lifestyle counseling to address TMD and related conditions.

With the robust scientific evidence of acupuncture efficacy and effectiveness in treating TMD it has to become as an adjunct component of a multidisciplinary pain management program.

References

Ernst E, Pittler M H. The effectiveness of acupuncture in treating acute dental pain: a systemic review. Br Dent J 1998; 184: 443 472. Rosted P. The use of acupuncture in dentistry: a review of the scientific validity of published papers. Oral Dis 1998; 4: 100 104. Blom M, Dawidson I, Angmar-Mnsson B. The effect of acupuncture on salivary flow rates in patients with xerostomia. Oral Surg, Oral Med, Oral Pathol 1992; 73: 293 298.

Lundeberg T. Peripheral effects of sensory nerve stimulation (acupuncture) in inflammation and ischemia. Scand J Rehab Med Suppl. 1993; 29: 61 86. Richardson P H, Vincent C A. Acupuncture for the treatment of pain: a review of evaluative research. Pain 1986; 24: 15 40 Tao D J. Research on the reduction of anxiety and depression with acupuncture. Am J Acup 1993; 21: 327 329.Vickers A. Ensuring scientific rigor in literature review. Acup Med 1995; 13: 93 96.

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