Acupuncture in the Treatment of Pain in Temporomandibular Disorders: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Can ChatGPT-4o provide new systematic review ideas to oral and maxillofacial surgeons?

OBJECTIVE

This study aims to evaluate the capacity of ChatGPT-4o to generate new systematic review ideas in the field of oral and maxillofacial surgery. The data obtained from this study will provide evidence-based information to oral and maxillofacial surgeons regarding the academic use of GPT-4o.

MATERIALS AND METHODS

ChatGPT-4o was asked to provide four previously unpublished systematic review ideas each for the topics of impacted third molars, dental implants, orthognathic surgery, and temporomandibular disorders. A literature search was conducted in the PubMed database to check if the ideas generated by GPT-4o had been previously published, and the search results were compared with the ideas generated by the AI.

RESULTS

The PubMed database search resulted in a total of 871 publications, with 37 publications found to be related to the topics generated by GPT-4o after the first and second screening. Out of the 16 publication ideas generated by GPT-4o, 9 (56.25 %) were determined to be previously unexplored according to the PubMed database search. There was no statistically significant relationship between the presence of ChatGPT's suggestions in PubMed and the subject areas of the studies.

CONCLUSION

ChatGPT-4o has a high potential to be used as a valuable tool for suggesting systematic review topics in oral and maxillofacial surgery. Additionally, this tool can assist researchers not only in proposing publication ideas but also in developing the methodology of the study.

Treatment options used in the management of people with temporomandibular disorders by Australian dentists and physiotherapists

BACKGROUND

Studies documenting the treatments used by dentists in the management of temporomandibular disorders (TMDs) have been undertaken in some countries; however, no such research has been conducted in Australia. No similar studies have been documented for physiotherapists.

OBJECTIVE

The aim of the study was to determine the treatment options and referral patterns used by Australian dentists and physiotherapists in managing people with TMDs.

METHODS

Prospective nationwide online questionnaires targeting Australian dentists and physiotherapists were created for Australian dentists and physiotherapists.

RESULTS

Seventy-eight respondents (27 dentists; 51 physiotherapists) completed all questions in the questionnaires. Sixty respondents reported actively treating people with TMDs. The treatment options used most frequently by dentists included advice and education, oral appliances, physical agents such as moist heat and medications. The treatment options most frequently used by physiotherapists included manual therapy, exercises, electrophysical agents and advice and education. Referrals were most frequently made to dentists and physiotherapists with experience and/or expertise in managing people with TMDs and to general dentists.

CONCLUSIONS

Commonly used treatment options were mostly conservative, reversible and evidence-based. More responses are required to draw conclusions representative of Australian dentists and physiotherapists in the management of people with TMDs.

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.

Temporomandibular disorders and the use of traditional and laser acupuncture: a systematic review

OBJECTIVE

To evaluate current studies to establish and compare the efficacy of traditional and laser acupuncture in reducing the signs and symptoms of temporomandibular disorders (TMD).

METHODS

PubMed, Cochrane, Scopus, and Web of Science databases were searched. Clinical, controlled, and randomized trials written in English and having used traditional or laser acupuncture as therapy for TMD and RDC/TMD or DC/TMD as a diagnostic criterion for TMD were included.

RESULTS

Six studies that evaluated the intensity of pain and the level of mouth opening of the patients submitted to acupuncture were selected, and all showed improvement. However, similar results were also observed in the groups treated with occlusal splint and placebo acupuncture. Only one study evaluated laser acupuncture and showed a higher proportion of patients with remission of symptoms in the experimental group.

CONCLUSION

The traditional acupuncture seems to relieve the signs and symptoms of TMD, as well as laser acupuncture when associated with occlusal splint. However, more rigorous and high-quality clinical trials are needed.

Is acupuncture an effective treatment for temporomandibular disorder?: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acupuncture is used for treating various disorders, but its effects on temporomandibular disorder (TMD) remain unclear. This study aimed to assess the effectiveness and safety of acupuncture for TMD via a systematic review of randomized clinical trials.

METHODS

A total of 11 Korean and worldwide databases were searched to identify acupuncture studies in adults with TMD. A Cochrane risk of bias assessment was performed on all articles; a meta-analysis, which involved the categorization according to the type of control used (inactive control, active control, or add-on), was subsequently performed. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation methodology.

RESULTS

The qualitative analysis of randomized clinical trials with acupuncture as the intervention included 32 articles, 22 of which were included in the quantitative analysis (471 participants). Acupuncture significantly improved outcomes (effect rate, relative risk [RR]: 7.00, 95% confidence interval [CI]: 1.91, 25, 62; visual analog scale, standardized mean difference: 0.49, 95% CI: 0.24, 0.73) versus active controls (effect rate, RR: 1.19; 95% CI: 1.12, 1.27). In the analysis of add-ons, acupuncture significantly improved the effect rate and pain intensity (effect rate, RR: 1.36; 95% CI: 1.04, 1.77; visual analog scale, mean difference: -1.23; 95% CI -1.79, -0.67). However, the quality of evidence was determined to range from low to very low.

CONCLUSION

Acupuncture in TMD significantly improved outcomes versus active controls and when add-on treatments were applied. However, as the quality of evidence was determined to be low, well-designed clinical trials should be conducted in the future.

Nonsurgical Management of Temporomandibular Joint Arthropathy

Arthropathy is a broad diagnostic term for any pathologic condition afflicting one or more joints of the body. Temporomandibular joint (TMJ) arthropathy is an umbrella term that may be applied to mechanical dysfunction or disease of one or both TMJs. This article provides evidence-based recommendations for conducting a patient evaluation, initiating a diagnostic workup, formulating an assessment, and instituting various nonsurgical modalities for the treatment of TMJ arthropathies.

Thread Embedding Acupuncture for Temporomandibular Disorder: Protocol for a Pilot Randomized Controlled Trial

Background

Temporomandibular disorder (TMD) affects multiple tissues of the temporomandibular joint complex and manifests as orofacial pain and functional disturbance. While thread embedding acupuncture (TEA) is used for the treatment of TMD in clinical practice, sufficient clinical evidence is lacking. This pilot trial will explore the feasibility of a confirmatory randomized controlled trial (RCT) by considering the efficacy, safety, and cost-effectiveness of TEA to address pain, function, and quality of life in patients with TMD.

Methods

This randomized, assessor-blinded, controlled trial will include two parallel arms. Thirty patients with TMD and temporomandibular joint pain more severe than 40 mm on the 100-mm visual analog scale (VAS) and aged 19-70 years will be recruited and randomly allocated to either TEA or usual care groups. The TEA group will receive treatment at 14 predefined acupoints once weekly for 4 weeks. The usual care group will receive physical therapy consisting of transcutaneous electrical nerve stimulation and infrared therapy. The average VAS score over the last week for temporomandibular pain after four sessions will be assessed as the primary outcome. Furthermore, maximum pain VAS, vertical opening movement, Graded Chronic Pain version 2, Jaw Functional Limitation Scale 20, Patient Global Impression of Change, Korean version of Beck's Depression Index, Short Form-12 Health Survey, EuroQol 5-Dimension 5-level, treatment expectation, rescue medication consumption, adverse events, and medical costs for economic evaluation will be measured and analyzed as secondary outcomes during four follow-up visits and after the termination of all sessions.

Conclusion

The results of this trial will help evaluate the feasibility of a confirmatory RCT considering efficacy, safety, and cost-effectiveness and verify the effect size required to determine an appropriate sample size.

Trial Registration Number

KCT0007421.

Nonpharmacological Interventions for Pain in Patients with Temporomandibular Joint Disorders: A Systematic Review

This systematic review aimed to compare the efficacy of nonpharmacological therapies for painful temporomandibular joint disorders. The protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42020171364). The search was performed on the electronic databases PubMed, Google Scholar, Clinical Trials, and Web of Science. The eligibility criteria were randomized controlled trials in patients diagnosed with painful temporomandibular joint disorders comparing the pain relief between conventional treatment and nonpharmacological therapies such as acupuncture, physiotherapy, low-level laser, and massage. Fourteen articles were included in this review. At the overall bias of the studies included, 71.42% exhibited some concerns and 28.57% had high risk. The efficacy of nonpharmacological interventions was found to be moderate in the short term and variable in the long term for pain reduction in patients with temporomandibular joint disorders. The evidence pointed out that acupuncture, laser therapy, and physiotherapy are potentially useful interventions for pain relief in patients with temporomandibular joint disorders. However, there is a lack of consistency and short-term follow-up in the studies to determine the lasting of such effect.

Comprehensive evaluation of botulinum toxin treatment outcomes of a patient with persistent myofascial orofacial pain

The outcome evaluation method presented in this case study, including Axes I and II findings combined with the results of quantitative bite force and EMG measurements, provides a good tool for proper evaluation of the effect of BoNT-A on patients with myofascial orofacial pain and changes in jaw muscle function.

Impact of prolotherapy in temporomandibular joint disorder: a quality of life assessment

Chronic pain and functional impairment associated with temporomandibular joint (TMJ) disorders (TMD) considerably reduce oral health-related quality of life (OHRQoL). In the present study we have assessed the influence of prolotherapy in patients with TMD by the subjective measurement of QoL using the Oral Health Impact Profile-14 (OHIP-14). Twenty-five patients diagnosed with TMD (mean (range) age 38 (18 - 70) years) were included. They had all undergone dextrose prolotherapy to the TMJ at regular time intervals (four times at intervals of two weeks) using the method suggested by Hemwall-Hackett. They were asked to answer the OHIP-14 questionnaire before and two years after prolotherapy. Seven domains of OHRQoL were rated on a 5-point Likert scale from 0 (never) to 4 (very often). Domain scores and total OHIP-14 scores were compared using inferential statistics (chi squared and Wilcoxon signed rank tests). Prolotherapy was effective over time, as all the domains' mean scores decreased considerably after treatment. The total mean score before prolotherapy was 21.20, which was extensively reduced to 13.08 after prolotherapy (p=0.001). There was statistically significant improvement in all domains, including functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap (p≤0.005 in all cases). We concluded that prolotherapy has a promising role in the improvement of OHRQoL of patients with TMD, and its beneficial effects persist at least two years after treatment.

Acupuncture for pain, mandibular function and oral health-related quality of life in patients with masticatory myofascial pain: A randomised controlled trial

BACKGROUND

Masticatory myofascial pain is the most prevalent muscular temporomandibular disorders (TMD). It primarily affects masseter and temporal muscles. Several treatments, including acupuncture, have been recommended. However, systematic reviews have highlighted gaps in studies and absence of conclusive results.

OBJECTIVES

We performed a randomised controlled clinical trial to evaluate the effectiveness of acupuncture in improving pain, mandibular function and oral health-related quality of life in women with masticatory myofascial pain.

METHODS

Thirty-six patients diagnosed with masticatory myofascial pain according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) were divided into the following two groups: acupuncture and control (non-penetrating acupuncture).Treatment was performed weekly for 5 weeks, and pain, mandibular function and oral health-related quality of life were evaluated one week before treatment, one week after treatment and one month after treatment. Non-parametric and parametric tests were used for comparisons between times and treatment groups (significance level of P ≤ .05).

RESULTS

The acupuncture group showed a significant reduction in pain (P ≤ .01), which was not observed in the control group. Pain intensity was reduced by 61% and 84% at 1 week and 1 month after treatment, respectively. Both groups showed significant improvements in mandibular function and oral health-related quality of life over time (P ≤ .01). Statistical analysis did not show a significant difference between the groups for any other evaluated outcome (P > .05).

CONCLUSION

Although acupuncture was effective in pain reduction, non-specific factors may have influenced mandibular function and oral health-related quality of life improvements in both groups, and this needs to be further addressed.

Interprofessional Collaboration in Dentistry: Role of physiotherapists to improve care and outcomes for chronic pain conditions and sleep disorders

Physiotherapists can manage chronic pain patients by using technical interventions such as mobility, strengthening, manual therapy, or flexibility in a specific and functional manner, being a key component of a multidisciplinary team. Dentists are involved in the management of different chronic pain conditions such as temporomandibular disorders and sleep disorders such as obstructive sleep apnea. However, they are frequently unaware of the benefits of collaborating with physical therapists. In this review, the collaboration of physical therapists and dentists will be explored when managing orofacial pain, headaches, and sleep disorders. The physical therapist is important in the management of these disorders and also in the screening of risk factors.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Overview of Treatment Guidelines and Clinical Practical Guidelines That Recommend the Use of Acupuncture: A Bibliometric Analysis

INTRODUCTION

As positive evidence emerges for the use of an intervention to treat a health problem, the intervention gradually becomes incorporated into treatment guidelines (TGs) or clinical practice guidelines (CPGs) that are related to that health problem. To assess whether this general hypothesis can apply to acupuncture, 96 health problems were identified for which positive conclusions in systematic reviews and meta-analyses regarding the effectiveness of acupuncture have been made and then searched for TGs or CPGs that have recommended the use of acupuncture.

METHODS

Through August 31, 2017, searches were performed in relevant medical databases and Google using "treatment guideline," "clinical practice guideline," and the names of the 96 medical conditions as search terms. A "snow-balling" search approach was adopted. All positive recommendations were added into the registry.

RESULTS

A total of 1311 publications were found that recommended using acupuncture published between 1991 and 2017. The number per year reached 50 in 2005 and 100 in 2009. In addition, 2189 positive recommendations were found for the use of acupuncture. Of these, 1486 were related to 107 pain indications and 703 were related to 97 nonpain indications. These recommendations were made by a wide range of groups, such as government health institutions, national guideline, and medical specialty groups. The recommendations came from around the world but were especially abundant in North America, Europe, and Australasia.

DISCUSSION AND CONCLUSION

Considerably more recommendations were found for the use of acupuncture than are known within the acupuncture or medical communities. A trend by year was also found; a rise in the number of positive statements about acupuncture was typically followed by a rise in the number of recommendations of acupuncture. Thus, the recommendations followed the emergent evidence for acupuncture. Better implementation plans need to be developed for the CPG/TG recommendations about acupuncture to be more effective/efficient.

Muscular diagnostics and the feasibility of microsystem acupuncture as a potential adjunct in the treatment of painful temporomandibular disorders: results of a retrospective cohort study

AIMS

To investigate the effect of microsystem acupuncture on painful temporomandibular disorders (TMD).

METHODS

We retrospectively analysed 887 treatments in 407 TMD-patients (mean age 45±1.5 years), who received microsystem acupuncture (mouth, scalp or fingers) with a focus on oral acupuncture. All patients systematically underwent palpation of specific muscular tender points and their pain rating was assessed on a four-point Likert scale (no pain to strong pain) before and after treatment. In 42 cases, the pain intensity was determined using a visual analogue scale (0-100 mm). As the data were normally distributed, analysis was performed with unpaired t-tests.

RESULTS

The pterygoid muscles were most painful to palpation, with the lateral pterygoid rated moderate to strong by 76% of patients and the medial pterygoid by 48% of patients. The palpation of microsystem acupuncture points revealed the strongest sensitivity (moderate or strong pain) of the oral retromolar points at the upper jaw (83%). After treatment, the pain intensity of all tender points had significantly decreased (P<0.001). The proportion of moderate to strong pain ratings was below 3% at most tender points. Overall pain intensity of the subjects (n=42) before treatment was 55.5±19.7 mm on the VAS scale and was significantly reduced to 29.6±20.9 mm (P<0.001) post-treatment.

CONCLUSIONS

This analysis suggests microsystem acupuncture could reduce the pain intensity of TMD in the short term. Considering the increased local muscular tenderness, further investigations regarding the key role of myofascial trigger points in the occurrence of TMDs are warranted and could lead to new comprehensive treatment strategies.

Management of pain in patients with temporomandibular disorder (TMD): challenges and solutions

Thanks to advances in neuroscience, biopsychosocial models for diagnostics and treatment (including physical, psychological, and pharmacological therapies) currently have more clinical support and scientific growth. At present, a conservative treatment approach prevails over surgery, given it is less aggressive and usually results in satisfactory clinical outcomes in mild–moderate temporomandibular disorder (TMD). The aim of this review is to evaluate the recent evidence, identify challenges, and propose solutions from a clinical point of view for patients with craniofacial pain and TMD. The treatment we propose is structured in a multi-modal approach based on a biobehavioral approach that includes medical, physiotherapeutic, psychological, and dental treatments. We also propose a new biobehavioral model regarding pain perception and motor behavior for the diagnosis and treatment of patients with painful TMD.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases

BACKGROUND

Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery.

METHODS

In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases.

RESULTS AND CONCLUSION

In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Needle Sensation and Personality Factors Influence Therapeutic Effect of Acupuncture for Treating Bell's Palsy: A Secondary Analysis of a Multicenter Randomized Controlled Trial

BACKGROUND

It has not been solved what kind of needle sensation might influence outcomes of acupuncture treatment. Effects of personality factors on the therapeutic effect of acupuncture have not been investigated. This study aimed to find the effects of the traits of personality on the objective outcome when different acupuncture techniques were used in treating patients with Bell's palsy.

METHODS

We performed a secondary analysis of a prospective multicenter randomized controlled trial of acupuncture for Bell's palsy. Patients were randomly assigned to the de qi and control groups, respectively. The primary outcome was facial nerve function at month 6. The intensity of each needle sensation was rated by a visual analog scale. Psychosocial factors were assessed by the pretreatment mediator questionnaire; 16 Personality Factor Questionnaire (16PF) was used for assessing personality factors and digit cancellation test for assessing attention.

RESULTS

After 6 months, patients in the de qi group had better facial function (adjusted odds ratio [OR]: 4.16, 95% confidence interval [CI]: 2.23-7.78). Path analysis showed that intensity of needle sensation of fullness had direct effect on House-Brackmann (HB) score at month 6. In de qi group, the low HB score on day 1 (OR: 0.13, 95% CI: 0.03-0.45) and the low Social Boldness score (OR: 0.63, 95% CI: 0.41-0.97) in 16PF were associated with better facial function. In control group, low HB score on day 1 (OR: 0.25, 95% CI: 0.13-0.50), low Vigilance score (OR: 0.66, 95% CI: 0.50-0.88), and high Tension score (OR: 1.41, 95% CI: 1.12-1.77) in 16PF were related to better facial function.

CONCLUSIONS

The needle sensation of fullness could predict better facial function and personality traits might influence outcomes of acupuncture treatment. Both of them should be considered seriously in acupuncture treatment and research.

Role of Auriculotherapy in the Treatment of Temporomandibular Disorders with Anxiety in University Students

Introduction. The aim of this study was to evaluate the role of auriculotherapy with mustard seeds in the treatment of temporomandibular disorders (TMDs), anxiety, and electromyographic (EMG) activity in university students. Methodology. The State Trait Anxiety Inventory (STAI), Research Diagnostic Criteria (RDC) for TMDs (RDC/TMDs), and electromyography were used in this study of 44 college students with high levels of anxiety and TMDs. The subjects were divided into two groups: an auriculotherapy (AA) group (n = 31) and an AA sham group (n = 13). The mustard seeds were applied to the shenmen, rim, sympathetic, brain stem, and temporomandibular joint (TMJ) points in the AA group and to sham points in the external ear and wrist in the AA sham group. The treatment protocol was 10 sessions (two treatments per week). Results. Anxiety (p < 0.01) was significantly reduced in the AA group. This group also showed a decrease in tender points in the mandibular posterior region (p = 0.04) and in the right side of the submandibular region (p = 0.02). Complaints of bilateral pain were reduced in the temporal tendon (p ≤ 0.01) and in the left side of the ATM (p < 0.01). In addition, electromyographic (EMG) activity was reduced during temporal muscle contraction (p = 0.03).  Conclusion. Auriculotherapy was effective in the treatment of students with anxiety and TMDs.

Laser therapy on points of acupuncture: Are there benefits in dentistry?

Studies have shown the use of laser therapy at points of acupuncture as an alternative to metal needles. The scientific literature in the area of laser acupuncture is rather large; however, the actual mechanisms and effects have not yet been proven in detail. Therefore, the current manuscript reviews the existing literature regarding the effects of laser acupuncture in Dentistry, seeking treatment modalities in which this technique is used and which are able to generate positive clinical results. Thus, the literature survey was conducted in electronic databases--Medline/Pubmed, VHL and Science Direct--using the uniterms "alternative medicine", "low-power laser and acupuncture", "laser acupuncture and dentistry" and "laser therapy and acupuncture". Retrospective and prospective clinical studies were considered. According to the findings of the literature, laser therapy at points of acupuncture was effective for the treatment of various orofacial problems encountered in dentistry, but there are still many differences among the parameters used for irradiation and there is a lack of important information reported by the studies, such as the wavelength, dose, power density, irradiation time and frequency, points of acupuncture selected for irradiation and therapy outcomes. Although these results indicate the potential benefit of the use of laser therapy at points of acupuncture on Dentistry, further double-blinded, controlled clinical trials should be carried out in order to standardize protocols for clinical application.

Perception of the signs and symptoms of temporomandibular disorder in females by using the ProTMDMulti protocol and the visual analog scale before and after acupuncture treatment

OBJECTIVE

To evaluate the perceptions of patients with TMD in relation to the signs and symptoms before and after acupuncture treatment, according to the ProTMDMulti and the VAS.

METHOD

68 patients were divided into groups: muscle TMD treated with acupuncture at local points (MUS-LP), muscle TMD with acupuncture at distant points (MUS-DP), joint and muscle treated with LP (JOI-LP) and joint and muscle treated with DP (JOI-DP). The evaluations were performed at four times: initial, control, final and follow-up.

RESULTS

The best results were seen in the JOI-LP and the MUS-DP groups, in which the perceptions of the signs and symptoms were statistically lower in the final assessment than in the initial (P<0.05). In all groups, the final and the follow-up evaluations were similar.

CONCLUSIONS

For TMDs with joint components, the best acupuncture treatment involves local points and for the TMDs with muscle components, points at a distance.

Laser acupuncture therapy in patients with treatment-resistant temporomandibular disorders

Objective

To investigate the clinical effects of laser acupuncture therapy for temporomandibular disorders (TMD) after ineffective previous treatments.

Methods

A retrospective observational study was conducted in 29 treatment-resistant TMD patients (25 women, 4 men; age range, 17–67 years). Subjects were treated 3 times per week for 4 weeks with the Handylaser Trion (GaAlAs laser diode, 810 nm, 150 mW, pulsed waves), which delivered 0.375 J of energy (5 s) to ST7, ST6, and LI4 and 3 J (40 s) to each Ashi point, 7.5–26.25 J/cm² in total. The visual analog scale (VAS) and maximal mouth opening (MMO) were evaluated before and after treatment.

Results

VAS analysis showed that the patients were free of pain at rest (endpoint) after 5.90±6.08 sessions of laser acupuncture for acute TMD and after 16.21±17.98 sessions for chronic TMD. The VAS score on palpation of the temporomandibular joint reduced to 0.30±0.67 for patients with acute TMD (p = 0.005) and to 0.47±0.84 for those with chronic TMD (p<0.001). The MMO significantly increased in patients with acute TMD (7.80±5.43 mm, p = 0.008) and in patients with chronic TMD (15.58±7.87 mm, p<0.001).

Conclusions

Our study shows that laser acupuncture therapy improves the symptoms of treatment-resistant TMD. Further studies with a more appropriate design, involving long-term follow-up examinations in a larger patient sample, are needed to evaluate its efficacy.

Systematic review and recommendations for nonodontogenic toothache

Nonodontogenic toothache is a painful condition that occurs in the absence of a clinically evident cause in the teeth or periodontal tissues. The purpose of this review is to improve the accuracy of diagnosis and the quality of dental treatment regarding nonodontogenic toothache. Electronic databases were searched to gather scientific evidence regarding related primary disorders and the management of nonodontogenic toothache. We evaluated the level of available evidence in scientific literature. There are a number of possible causes of nonodontogenic toothache and they should be treated. Nonodontogenic toothache can be categorised into eight groups according to primary disorders as follows: 1) myofascial pain referred to tooth/teeth, 2) neuropathic toothache, 3) idiopathic toothache, 4) neurovascular toothache, 5) sinus pain referred to tooth/teeth, 6) cardiac pain referred to tooth/teeth, 7) psychogenic toothache or toothache of psychosocial origin and 8) toothache caused by various other disorders. We concluded that unnecessary dental treatment should be avoided.

Two sets of acupoint combination of similar functions engage shared neural representation: a functional magnetic resonance imaging study

OBJECTIVE

To investigate whether the neural representations underlying alternating two acupoint combinations (ACs) are the same or not.

METHODS

In this functional magnetic resonance imaging study, two sets of analgesia ACs were utilized, including Waiguan (TE5) and Qiuxu (GB40) for Group A, and Neiguan (PC6) and Taichong (LR3) for Group B, which are the most commonly adopted in clinical treatment. Each group had 20 healthy subjects. An experimental design was proposed, which consisted of a pre-needling resting phase, a needling phase and a post-needling resting phase. This paradigm optimally mimics the clinical protocol as well as focuses on both the stimulation and the resting periods. The results were subjected to general linear model analysis, conjunction analysis and the functional connectivity analysis.

RESULTS

The rostral anterior cingulated cortex was engaged in the initiative period of the acupuncture effect in both groups, and it was chosen as the seed region for the functional connectivity analysis for the following resting period. The results showed that several shared brain regions were involved in both groups, in particular the insula, amygdala and hypothalamus. Moreover, significant differences were located at the posterior cingulated cortex as revealed by a two sample -test (P<0.05, corrected). Other regions showed no significant differences. This finding was further supported by the spatial correlation analysis that the two groups were significantly correlated (r =0.51, P<0.01).

CONCLUSION

This preliminary research helps us understand the neurophysiological mechanisms of acupuncture when following clinical guidelines on ACs, as well as provides an important opportunity to develop better treatment strategies for reducing, or even preventing pain.

Oral surgery: part 3. Temporomandibular disorders

Temporomandibular disorders (TMDs) are a collection of conditions affecting the temporomandibular joint (TMJ), the muscles of mastication and/or associated structures. They are probably one of the most commonly presenting chronic orofacial pain complaints to the dental profession. TMDs are recognised as a chronic illness and exert biopsychosocial effects on the patient and should therefore be managed in a biopsychosocial manner. This chapter will firstly cover the basic anatomy of the TMJ and its associated structures and then go on to discuss the signs and symptoms, aetiology, diagnosis, and broad management options for TMDs.

Differential diagnosis of facial pain and guidelines for management

The diagnosis and management of facial pain below the eye can be very different dependant on whether the patient visits a dentist or medical practitioner. A structure for accurate diagnosis is proposed beginning with a very careful history. The commonest acute causes of pain are dental and these are well managed by dentists. Chronic facial pain can be unilateral or bilateral and continuous or episodic. The commonest non-dental pains are temporomandibular disorders (TMDs), especially musculoskeletal involving the muscles of mastication either unilaterally or bilaterally; they may be associated with other chronic pains. A very wide range of treatments are used but early diagnosis, reassurance and some simple physiotherapy is often effective in those with good coping strategies. Dentists will often make splints to wear at night. Neuropathic pain is usually unilateral and of the episodic type; the most easily recognized is trigeminal neuralgia. This severe electric shock like pain, provoked by light touch, responds best to carbamazepine, and neurosurgery in poorly controlled patients. Trauma, either major or because of dental procedures, results in neuropathic pain and these are then managed as for any other neuropathic pain. Red flags include giant cell arteritis which much be distinguished from temporomandibular disorders (TMD), especially in >50 yr olds, and cancer which can present as a progressive neuropathic pain. Burning mouth syndrome is rarely recognized as a neuropathic pain as it occurs principally in peri-menopausal women and is thought to be psychological. Chronic facial pain patients are best managed by a multidisciplinary team.

Effect of low-level laser therapy on pain levels in patients with temporomandibular disorders: a systematic review

Temporomandibular disorders (TMD) are characterized by the presence of temporomandibular joint (TMJ) and/or masticatory muscle pain and dysfunction. Low-level laser is presented as an adjuvant therapeutic modality for the treatment of TMD, especially when the presence of inflammatory pain is suspected.

The effectiveness of acupuncture research across components of the trauma spectrum response (tsr): a systematic review of reviews

BACKGROUND

Co-morbid symptoms (for example, chronic pain, depression, anxiety, and fatigue) are particularly common in military fighters returning from the current conflicts, who have experienced physical and/or psychological trauma. These overlapping conditions cut across the boundaries of mind, brain and body, resulting in a common symptomatic and functional spectrum of physical, cognitive, psychological and behavioral effects referred to as the 'Trauma Spectrum Response' (TSR). While acupuncture has been shown to treat some of these components effectively, the current literature is often difficult to interpret, inconsistent or of variable quality. Thus, to gauge comprehensively the effectiveness of acupuncture across TSR components, a systematic review of reviews was conducted using the Samueli Institute's Rapid Evidence Assessment of the Literature (REAL©) methodology.

METHODS

PubMed/MEDLINE, the Cochrane Database of Systematic Reviews, EMBASE, CINAHL, and PsycInfo were searched from inception to September 2011 for systematic reviews/meta-analyses. Quality assessment was rigorously performed using the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Adherence to the Standards for Reporting Interventions in Clinical Trials in Acupuncture (STRICTA) criteria was also assessed.

RESULTS

Of the 1,480 citations identified by our searches, 52 systematic reviews/meta-analyses, all high quality except for one, met inclusion criteria for each TSR component except post-traumatic stress disorder (PTSD) and sexual function. The majority of reviews addressed most STRICTA components, but did not describe safety.

CONCLUSIONS

Based on the results of our review, acupuncture appears to be effective for treating headaches and, although more research is needed, seems to be a promising treatment option for anxiety, sleep disturbances, depression and chronic pain. It does not, however, demonstrate any substantial treatment benefit for substance abuse. Because there were no reviews on PTSD or sexual function that met our pre-defined inclusion criteria, we cannot comment on acupuncture's effectiveness in treating these conditions. More quality data are also needed to determine whether acupuncture is appropriate for treating fatigue or cognitive difficulties. Further, while acupuncture has been shown to be generally safe, safety was not described in the majority of studies, making it difficult to provide any strong recommendations. Future research should address safety reporting in detail in order to increase our confidence in acupuncture's efficacy across the identified TSR components.

Comparative effectiveness of traditional Chinese medicine and psychosocial care in the treatment of temporomandibular disorders-associated chronic facial pain

This dual-site study sought to identify the appropriate role for traditional Chinese medicine (TCM; acupuncture and herbs) in conjunction with a validated psychosocial self-care (SC) intervention for treating chronic temporomandibular disorders (TMD)-associated pain. Participants with Research Diagnostic Criteria for Temporomandibular Disorders-confirmed TMD (n = 168) entered a stepped-care protocol that began with a basic TMD class. At weeks 2 and 10, patients receiving SC whose worst facial pain was above predetermined levels were reallocated by minimization to SC or TCM with experienced practitioners. Characteristic facial pain (CFP: mean of worst pain, average pain when having pain, and current pain; each visual analog scale [VAS] 0-10) was the primary outcome. Social activity interference (VAS 0-10) was a secondary outcome. Patients were monitored for safety. TCM provided significantly greater short-term (8-week) relief than SC (CFP reduction difference, -.60 [standard deviation of the estimate .26], P = .020) and greater reduction in interference with social activities (-.81 [standard deviation of the estimate .33], P = .016). In 2 of 5 treatment trajectory groups, more than two thirds of participants demonstrated clinically meaningful responses (≥30% improvement) in pain interference over 16 weeks. This study provides evidence that TMD patients referred for TCM in a community-based model will receive safe treatment that is likely to provide some short-term pain relief and improved quality of life. Similar designs may also apply to evaluations of other kinds of chronic pain. (ClinicalTrials.gov number NCT00856167).

PERSPECTIVE

This short-term comparative effectiveness study of chronic facial pain suggests that TCM is safe and frequently efficacious alone or subsequent to standard psychosocial interventions. TCM is widely available throughout North America and may provide clinicians and patients with a reasonable addition or alternative to other forms of therapy.

Acupuncture-induced pain relief and the human brain's default mode network - an extended view of central effects of acupuncture analgesia

As a complementary medical procedure, acupuncture has a significant impact on the treatment of acute and chronic pain. Though the physiological mechanisms behind this method are still unclear, acupuncture has been claimed to rely also on changes in the central nervous system. Recent functional imaging studies indicate that the so-called default mode network (DMN) which consists of cortical midline structures and lateral parietal regions plays an important role in these processes. This brief overview describes the effects of analgesic acupuncture on the DMN architecture. The stronger interplay between systems dedicated to endogenous analgesia (periaqueductal gray), affective processing (anterior cingulate cortex, amygdala), memory (hippocampus), and self-projective thinking (DMN) following this therapy supports the notion that acupuncture is a mind-body therapy which helps to reintegrate important neural dimensions of inner life and to establish psychophysical pain homeostasis.

Physiotherapy in the management of disorders of the temporomandibular joint--perceived effectiveness and access to services: a national United Kingdom survey

Up to a quarter of the general population has experienced temporomandibular joint disorder (TMD) at some point in time. Physiotherapy has been used in the management of TMD for many years, but evidence supporting its clinical effectiveness is limited. We investigated the perceived effectiveness of physiotherapy for patients with TMD among consultants in oral and maxillofacial surgery (OMFS) and the accessibility of these services in the United Kingdom (UK). Information was gathered from a postal or electronic questionnaire sent to the 356 OMFS consultants listed on the British Association of Oral and Maxillofacial Surgeons' website. A total of 208 responded (58%) and 72% considered physiotherapy to be effective. Amongst these respondents, jaw exercises (79%), ultrasound (52%), manual therapy (48%), acupuncture (41%) and laser therapy (15%) were considered to be effective. Twenty-eight percent of respondents did not consider physiotherapy to be effective. Reasons for this included lack of knowledge or expertise of the physiotherapist (41%) and lack of awareness of the benefits of physiotherapy (28%). In relation to access to physiotherapy services, 10% of respondents had a designated physiotherapist for patients with TMD, 89% could refer directly to physiotherapy and 7% worked in an environment that provided training for physiotherapists. Patients were prescribed jaw exercises by 69% of respondents. Despite limited evidence to support its effectiveness, approximately three-quarters of OMFS consultants in the UK regard physiotherapy to be beneficial in the management of TMD.

Limited evidence that acupuncture is effective for treating temporomandibular disorders

DATA SOURCES

Medline, PubMed, The Cochrane Library 2010, CINAHL, Embase, seven Korean Medical Databases and a Chinese Medical Database (China Academic Journal, www.cnki.co.kr).

STUDY SELECTION

Parallel or cross-over RCTs that assessed the efficacy of acupuncture regardless of blinding, language and type of reporting published in English, Chinese and Korean were included. Dissertations and abstracts were included provided they contained sufficient detail. Complex interventions in which acupuncture was not a sole treatment and studies with no reported clinical data were excluded.

DATA EXTRACTION AND SYNTHESIS

All RCTs were obtained and read in full by two independent reviewers and data extracted according to pre-defined criteria. Quality was assessed using the Cochrane risk of bias criteria. Meta-analysis was conducted using random effect models if excessive statistical heterogeneity did not exist. Additional subgroup analysis or sensitivity analysis additionally was conducted to explore heterogeneity. Publication bias was assessed by funnel plot using the Cochrane software.

RESULTS

Seven RCTs (including 141 patients) met our inclusion criteria. Six studies comparatively tested needle acupuncture against penetrating sham acupuncture, non-penetrating sham acupuncture or sham laser acupuncture, whilst the remaining study tested laser acupuncture against sham laser acupuncture. Five studies were considered to be at low risk of bias. Outcomes were reported for pain intensity, facial pain, muscle tenderness and mouth opening.

CONCLUSIONS

This systematic review produced limited evidence that acupuncture is more effective than sham acupuncture in alleviating pain and masseter muscle tenderness in TMD. Further rigorous studies are, however, required to establish beyond doubt whether acupuncture has therapeutic value for this indication.

Acupuncture for treating temporomandibular joint disorders: a systematic review and meta-analysis of randomized, sham-controlled trials

OBJECTIVE

The aim of this article was to assess the clinical evidence for or against acupuncture and acupuncture-like therapies as treatments for temporomandibular joint disorder (TMD).

DATA

This systematic review includes randomized clinical trials (RCTs) of acupuncture as a treatment for TMD compared to sham acupuncture. The search terms were selected according to medical subject heading (MeSH).

SOURCES

Systematic searches were conducted in 13 electronic databases up to July 2010; Medline, PubMed, The Cochrane Library 2010 (Issue 7), CINAHL, EMBASE, seven Korean Medical Databases and a Chinese Medical Database.

STUDY SELECTION

All parallel or cross-over RCTs of acupuncture for TMD were searched without language restrictions. Studies in which no clinical data and complex interventions were excluded. Finally, total of 7 RCTs met our inclusion criteria.

CONCLUSIONS

In conclusion, our systematic review and meta-analysis demonstrate that the evidence for acupuncture as a symptomatic treatment of TMD is limited. Further rigorous studies are, however, required to establish beyond doubt whether acupuncture has therapeutic value for this indication.