Acupuncture in Dentistry: Its Possible Role and ... - SAGE Journals

Review

Acupuncture in Dentistry: Its Possible Role and Application Li Beng Wong, BDS, MDS, MRD RCS (Edinburgh) National Dental Centre (Singapore)

Abstract This article reviews the possible role and application of acupuncture in dentistry. The use of acupuncture in Traditional Chinese Medicine (TCM) has a long history and for the past forty years, many studies have been conducted to understand the scientific basis behind its therapeutic effects in Western medicine. The possible application of acupuncture in the dental field like managing post-operative pain, orofacial pain, xerostomia, Bell’s palsy and dental anxiety will be discussed in detail. The inherent challenges in conducting clinical trials in acupuncture using the evidence-based medicine model will also be covered. It is envisioned that acupuncture may play a promising role in complementing conventional treatment in certain dental conditions and more studies with improved methodology should be carried out to verify its application. Keywords: Adjunctive Treatment, Holism, Sham Acupuncture

Introduction The history of Traditional Chinese Medicine (TCM) can be traced back to the Warring States and the Qin and Han Dynasties more than 2000 years ago. The Huangdi’s Inner Classic of Medicine, of comparable importance to the Hippocratic Corpus in Greek Medicine, is a scholastic collection of medicinal doctrines and philosophies accumulated over the years. To date, it still provides a theoretical guide and basis for the practice and development of contemporary TCM. It consists of two parts, Plain Questions (素問) which is mainly on the theoretical aspects and diagnostic methods, and Miraculous Pivot (靈樞) which covers the practice of acupuncture. The TCM Practitioners Act in Singapore defines acupuncture, as “the stimulation of a certain point or points on or near the surface of the human body through any technique of point stimulation (with or without the insertion of needles), including the use of electrical, magnetic, light and sound energy, cupping and moxibustion to normalise

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physiological functions or to treat ailments or conditions of the human body”1. The story of James Reston, a New York Times editor, whose post-appendectomy pain was relieved by acupuncture and the visit of United States President Richard Nixon to China in 1971 brought acupuncture into the limelight and created much interest in the Western medical field. In 1979, the World Health Organization (WHO) endorsed the use of acupuncture to treat 43 symptoms. In 1996, this was extended to 64 indications. In the Geneva WHO 2003 report, pain in dentistry (including dental pain and temporomandibular dysfunction), facial pain and postoperative pain were listed among the conditions for which acupuncture has been proven through controlled trials, to be an effective treatment2. In Singapore, the use of TCM remains a popular choice. In a recent questionnaire survey conducted over a 12-month period in a selected housing

Proceedings of Singapore Healthcare  Volume 21  Number 1  2012

Acupuncture in Dentistry

Exogenous pathogens -wind -cold -summer-heat -dampness -fire-heat -pestilent pathogens

Endogenous pathogens -7 emotions -improper diet -maladjustment of work and leisure

Constitution of patient -yin and yang balance -qi-blood balance -status of vital-qi -qi flow in the meridian

Clinical presentation of disease based on the 8 principles for syndrome differentiation -exterior and interior -cold and hot -deficiency and excess -yin and yang

Secondary pathogenic factors -phlegm -stagnant fluid -stagnant blood Fig. 1. Pathogenesis of disease based on TCM philosophy.

estate on the use of complementary and alternative medicine (CAM), 76% of the respondents used CAM3. Among those who used CAM, TCM was the most widely used at 88%. In another survey conducted on the perceptions of CAM amongst medical students in Singapore, 77% of respondents believed in the effectiveness of acupuncture, although lack of scientific evidence and trained professionals were the top two perceived barriers to the use of CAM in the Western medical setting4. The aim of this article is to review the scientific evidence for as well as the possible application of acupuncture in the dental field. The challenges in conducting acupuncture research as well as future roles of acupuncture in dentistry will also be discussed. Concept of Traditional Chinese Medicine To understand the role of acupuncture therapy in TCM, we must first appreciate the fundamental treatment philosophies of TCM. TCM believes in the concept of holism, whereby the human body is seen as an “organic whole” and all the constituent parts are inter-connected and

they coordinate and interact with one another functionally, and with the external environment. The state of the constitution of the human body, at the point of challenge by pathogenic factors (both internal and external), will determine the occurrence and progression of disease. The constitution of the body can be regulated by maintaining the yin-yang and qi-blood balance. The vital-qi , or life force, is what keeps the whole body system going. It circulates all over the body along designated pathways called meridians. Acupuncture therapy involves the stimulation of certain points along meridians to allow the free flow of qi. This promotes qi-blood equilibrium. The pathogenesis of disease based on TCM philosophy is summarised in Figure 1. This concept of a hostpathogen interaction, whereby the manifestation of disease depends on both the virulence of the invading pathogens as well as the host response, can draw parallel with some of the modern concepts of disease progression in Western Medicine such as the pathogenesis of periodontitis (Fig. 2), which is an inflammatory disease initiated by oral microorganisms resulting in the loss of the supporting structures around the dentitions5.


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Environmental, acquired and genetic risk factors

Specific pathogenic bacteria

Host Immunoinflammatory response

Connective tissue and bone metabolism

Clinical expression of disease initiation and progression

Fig. 2. Pathogenesis of periodontal disease ( Adapted from Page & Kornman 19972 (The Pathogenesis of Human Periodontitis: An Introduction).

Scientific basis of acupuncture The theoretical background of acupuncture therapy based on the metaphysical concepts of qi and yinyang balance seems to conflict with the practice of Western medicine which is based on anatomical, physiological and biochemical evidence. Since the introduction of acupuncture therapy into modern Western medicine, numerous studies have been carried out to investigate and explain the scientific basis behind it. The arrival of qi or “de qi” refers to the transmission of a needling sensation along the meridians, which is often described by the patients as soreness, numbness, fullness, warm sensations or aching as a result of needle manipulation6. This is perceived by acupuncturists as a needle grasp sensation, which is key in achieving therapeutic efficacy. Earlier studies explained this needle grasp to be due to muscular contractions7, although it has been refuted as the sensation also experienced in more superficial tissues where no skeletal muscle is present. Recent histological evidence using rat models seem to suggest this needle grasp sensation is the result of collagen and elastic fibres tightening around the needle during needle manipulation8.The authors went further to postulate this mechanical coupling between the needle and soft tissue to be responsible for transducing mechanical signals into fibroblasts and other cells, with resultant therapeutic downstream effects. According to TCM theory, the location of acupuncture points is found along meridians which are unlike tangible anatomical structures like blood vessels or nerve trunks. However, a high degree of correspondence was found between the location of acupuncture points and trigger points9. The authors proposed that stimulation of acupuncture points can relieve pain by causing “hyper-stimulation analgesia”, which can be explained by the concept

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of “gate control theory of pain”10. Subsequent publications proposed that the activation of A-δ and C afferent fibres through acupuncture point stimulation send signals to the spinal cord with local release of dynorphin and enkephalins11. Upon reaching the midbrain, both excitatory and inhibitory mediators are activated in the spinal cord. Neurotransmitters like serotonin, dopamine and norepinephrine are produced causing preand post-synaptic inhibition of pain transmission. When the signals reach the hypothalamus and pituitary gland, adrenocorticotropic hormones and endorphins may be produced. This forms the basis of our current understanding of the analgesic effect of acupuncture although other therapeutic effects of acupuncture for the treatment of nausea, gastritis, asthma and dsymenorrhoea are yet to be fully explained. In the case of asthma, one of the therapeutic acupuncture points, BL13 feishu, lies approximately 1.5 inches laterally to the level of the spinous process of vertebra T3. It was hypothesised that the location of BL13 feishu corresponds roughly to the sympathetic ganglion at the level of T3, which sends postganglionic fibres to the pulmonary plexus and cardiac plexus12. However, the scientific basis behind many therapeutic effects of acupuncture remains to be elucidated. Dental application of acupuncture Managing Dental Pain, Analgesic Effect and Postoperative Pain Relief A complex network of nerve fibres are found in dental pulp within the tooth and the periodontium surrounding it, and pain is quickly elicited when stimuli activate these nerve endings. The management of dental pain is to first identify and remove the cause (such as caries and gingival inflammation), followed by any analgesic medication if required. According to TCM theory, local acupuncture points



on facial regions such as ST6 jiache, ST7 xiaguan and distant points like LI4 hegu can be used to treat dental pain. They belong to the stomach and large intestine meridians which converge at the facial region and link up with the maxillary and mandibular teeth, respectively. Western medical literature proposed that acupuncture can produce analgesic effect at a distant site by diffusing noxious inhibitory control13. This provides a possible explanation to how the acupuncture point LI4 hegu, which is located on the radial side of the second metacarpal bone on the dorsum of the hand, can elicit an analgesic effect on the orofacial region. The role of acupuncture in dentistry may not involve removing the cause of dental pain, but rather, as an adjunct in achieving anaesthesia during dental procedures as well as providing postoperative pain relief. Studies have shown that the onset time for regional anaesthesia after administration of prilocaine hydrochloride is around two minutes14. A pilot study was conducted to investigate whether the induction time of local anaesthetic can be reduced if acupuncture is given before injection15. The results showed that in the group where local acupuncture points SI19 tinggong, ST5 daying and ST6 jiache (within the innervations of the mandibular branch of the trigeminal nerve) were used before an inferior alveolar nerve block was given using prilocaine hydrochloride, the induction time was 62 seconds versus 119 seconds in the control group where only the nerve block was given. Findings from this study suggest that regional acupuncture can accelerate the induction time after an inferior alveolar nerve block. More studies are required to investigate if acupuncture can reduce the amount of local anaesthetic required to achieve optimal anaesthesia, and if acupuncture can compensate for an insufficient nerve block. Several studies have shown that acupuncture can reduce postoperative pain. A systematic review of 16 studies suggests that acupuncture therapy can help to alleviate post-operative pain, although heterogeneity in the methodological details among the studies may limit the conclusions that could be drawn16. Acupuncture therapy in alleviating postoperative pain may help to reduce the patients’ dependence on systemic analgesic medications. The use of non-steroidal anti-inflammatory drugs for pain control is associated with increased risk of gastrointestinal complications like ulceration

and bleeding17. A randomised placebo-controlled trial was conducted to evaluate the efficacy of acupuncture in treating postoperative oral surgery pain18 at the University of Maryland in Baltimore. The treatment group that received real acupuncture treatment immediately after the surgical removal of impacted lower third molar had significantly longer pain-free postoperative time (172.9 minute) compared to the placebo group (93.8 minutes), in which the subjects had plastic needles applied to the same locations without insertion into the skin. More importantly, the treatment group took a significantly longer time (242.1 minutes) to request for analgesic medication compared to the placebo group (166.2 minutes). They also consumed significantly less medication (1.1 tablet of acetaminophen 600mg with codeine 60mg) compared to the placebo group (1.65 tablet).This difference was still evident at seven days postoperative follow-up (7.7 tablets versus 11.3 tablets) although it was not statistically significant. More randomised controlled clinical trials to verify the role of acupuncture therapy in dental pain management, particularly in postoperative pain, may be necessary. Management of Temporomandibular Disorders and Orofacial Pain Temporomandibular disorders (TMDs) is a term which includes a group of conditions that affect the temporomandibular joint (TMJ), the muscles of mastication, and the associated head and neck musculoskeletal structures19. The Clinical Diagnostic Criteria for TMD was created to provide a standardised definition of diagnostic subgroups of patients with orofacial pain and TMD20. It classifies the most common forms of TMD into the following: masticatory muscle disorder, TMJ internal derangement and TMJ degenerative joint disease. While acupuncture therapy may not be useful in eliminating the cause of TMD if it is due to structural anomalies like disc displacement and degenerative changes, it may help to relieve the pain and discomfort associated with the conditions, especially if they are muscular in origin. It has been documented that acupuncture can help in muscle relaxation and reduce muscle spasms. Relaxing the lateral pterygoid muscles can reduce the anterior displacing force on the meniscus of TMJ and help to minimise TMJ clicking.


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A systematic review of randomised controlled trials to assess the effectiveness of acupuncture for symptomatic treatment of TMDs was conducted21. Nineteen reports were included and the review suggests moderate evidence for acupuncture as an effective intervention to reduce TMDs symptoms, although more studies of larger sample sizes are needed to investigate the long-term efficacy of acupuncture. Trigeminal neuralgia is a sudden, unilateral, brief, stabbing, recurrent pain in the distribution of one or more branches of the trigeminal nerve. Carbamazepine is often the first-line treatment for this condition and is considered the gold standard22, but it also comes with various side-effects such as drowsiness, dizziness and constipation. There are several case reports and case series in Chinese literature on successful acupuncture treatment for patients with trigeminal neuralgia. Acupuncture points GB14 yangbai and EX-HN5 taiyang are used if the ophthalmic branch is affected, ST2 sibai and ST3 juliao are used if the maxillary branch is affected and ST6 jiache and ST7 xiaguan are used if the mandibular branch is affected. These acupuncture points seem to coincide with the distribution of the nerve branches. There is however, a paucity of reports in Western literature and lack of randomised controlled trials to verify the effectiveness of acupuncture in the treatment of trigeminal neuralgia. Management of Xerostomia Xerostomia, which is dryness in the mouth is due to decreased or arrested salivary secretion. It affects up to 40% of adults who are over 50 years old23. Common causes of xerostomia include autoimmune conditions like SjÖgren’s syndrome, irradiation of the head and neck region, and can also be medication-induced. Conventional management of xerostomia includes use of saliva substitutes or gum chewing, and systemic medication like pilocarpine. The use of acupuncture as an alternative treatment modality for xerostomia has been documented in the Western medical field since the 1980s. Observational studies have demonstrated that acupuncture treatment may increase salivary flow in healthy volunteers24, patients with SjÖgren’s syndrome25 and patients who have undergone radiotherapy in the head and neck region25,26.

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A long-term retrospective study involving 70 patients with xerostomia due to primary and secondary SjÖgren’s syndrome, irradiation and other causes was carried out by Blom and coworkers25. The patients received a course of 24 acupuncture treatment sessions over the first six months. Acupoints include those on the head and neck region as well as distal points on the upper and lower limbs. The results showed that salivary flow rate (SFR) in both stimulated and unstimulated saliva were significantly higher after six months compared to baseline and this was consistent with the subjective improvement described by the patients. Data was also analysed up to three years comparing those who chose to receive additional acupuncture treatment after six months with those who did not. Patients who received additional acupuncture treatment after six months had a consistently higher median SFR in both stimulated and unstimulated saliva compared to those who opted not to, suggesting that supportive acupuncture treatment given over a long-term period may help to maintain its therapeutic effect. This finding is in line with the TCM concept that the effect of acupuncture may be accumulative after repeated sessions. Johnstone and co-workers found that acupuncture treatment may provide relief for pilocarpineresistant xerostomic patients following radiotherapy for head and neck malignancies26. However, the treatment outcome for this study was only based on the Xerostomia Inventory27 score, which is a self-report questionnaire. In contrast, Blom and co-workers proposed that observation of any increase in SFR following administration of a single dose of pilocarpine to be an indicator of residual salivary gland function28. They found that patients with a positive pilocarpine test resulted in having significantly higher SFR after acupuncture treatment. Based on these studies, acupuncture therapy seemed to be able to increase SFR, provided that salivary glands were still functional. For patients whose salivary glands were severely affected by radiotherapy and had became resistant to pilocarpine, acupuncture may, to a limited extent, provide subjective relief for the patients. The realistic expectation of acupuncture therapy in such patients must be managed. The mechanism behind how acupuncture can increase SFR is still not fully understood. It can be a placebo effect as shown in Pavlovian conditioning,



in which expectation alone from those receiving treatment can induce saliva production. Local acupoints in the head and neck region may also directly stimulate the nerves innervating the salivary glands. Some authors suggest that the release of neuropeptides from acupuncture treatment can affect blood flow, have antiinflammatory properties and trophic effects on salivary glands29. Another possibility can be related to neuronal activations. In a descriptive study, cortical regions were evaluated using functional magnetic resonance imaging on volunteers undergoing acupuncture treatment30. It was observed that acupuncture treatment activated the parietal, rolandic and frontal operculum as well as the insula, which overlapped with the regions involved in gestation and salivation. The authors proposed that acupuncture treatment may tap into the neuronal circuit which activates the salivary nuclei in the pons and subsequently the salivary glands via the cranial nerves. More studies are needed to investigate how acupuncture therapy can increase salivary flow. Management of Bell’s Palsy Bell’s palsy is a unilateral, lower motor neuron facial paralysis of acute onset. It is often idiopathic in nature, although underlying causes like viral infection, vascular ischaemia and autoimmune inflammation have been proposed. According to TCM concept, Bell’s palsy is caused by the invasion of external wind pathogens into the meridians of the face. A weak body constitution, like one with qi-blood deficiency, may predispose oneself to pathogenic wind invasion to the face, resulting in facial paralysis.

acupuncture points used include ST6 jiache, located near the angle of the mandible at the prominence of the masseter muscle and ST7 xiaguan, located at the depression between the zygomatic arch and the mandibular notch. These two points are found to be anatomically close to branches of the facial nerve. Several multi-centred randomised controlled trials done in China have shown beneficial effects of acupuncture as an adjunctive treatment for Bell’s palsy33,34. In the Cochrane review on the use of acupuncture for Bell’s palsy, three studies involving 288 patients in total showed that the therapeutic effect of acupuncture alone were superior to that of medication or that acupuncture combined with medication was better than medication alone35. However, the varied experimental designs and lack of objective outcome measures preclude a firm conclusion on the beneficial effect of acupuncture. Higher quality randomised control trials are required. Management of Dental Anxiety and Gag Reflex A recent Cochrane Review showed that 31% of adults are fearful of dental treatment36. A phobic patient may develop reluctance or avoidance towards dental treatment and deprive themselves from receiving proper dental care. An anxious patient during dental procedures may also hinder the operator from executing proper treatment.

The treatment for Bell’s palsy in Western medicine is still controversial due to the lack of large, prospective randomised controlled trials, although systemic steroids are widely used31. The uses of antiviral medications have also been advocated, although its short- and long-term benefit remains inconclusive based on the Cochrane review32.

Traditionally, medications like benzodiazepines and midazolam have been used to manage dental anxiety. The use of acupuncture may provide an alternative treatment modality without possible adverse drug reactions. Several reports on the use of auricular acupuncture for treating chronic and acute anxiety have shown promising results37,38. A randomised controlled trial comparing auricular acupuncture with intranasal midazolam for managing dental anxiety suggested that both treatment methods were similarly effective39. More large scale studies are needed to verify this finding.

The use of acupuncture to treat Bell’s palsy is based on the TCM concept that needle manipulation at both the local and distal sites can regulate the flow of qi in the meridians, harmonise qi-blood balance and strengthen the body’s resistance to external wind pathogens. It may also help to increase the excitability of nerves and to promote the regeneration of nerve fibres. Some local

Gag reflex is a normal protective, physiological mechanism which occurs to prevent foreign objects or noxious material from entering the pharynx, larynx or trachea40. Its causes can be somatic, brought about by stimulating certain trigger areas in the oral cavity, or psychogenic, which is induced by thought stimulus modulated by higher brain centres. Hyperactive gag reflex can be a hindrance


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to dental procedures, such as taking of alginate impression for denture fabrication. The use of acupuncture points like PC6 neiguan and CV24 chengjiang have been reported to significantly reduce gag reflex41. Auricular acupuncture has also been suggested for treating severe gag reflex42. According to TCM theory, the acupuncture point PC6 neiguan, located on the palmer side of the forearm — two inches above the transverse crease of the wrist, belongs to the pericardium meridian, which has the effect of “calming the heart which houses the spirit”. It is often used to treat heart palpitation, nausea and vomiting. In providing an explanation in the Western medicine context, it was proposed that acupuncture may trigger an increase in circulating β-endorphine, which binds to the opioid receptor, creating an anti-emetic effect43. The anti-gagging point located on the ear corresponds with the skin of the external acoustic meatus (innervated by the auricular branch of the vagus nerve) and that adjacent to the auricle (innervated by the auriculotemporal branch of the mandibular division of the trigeminal nerve). Both the vagus and trigeminal nerves have branches responsible for the sensory and motor function of the larynx, pharynx and palatal region. It can be postulated that stimulation of the auricular acupuncture point may inhibit the muscular activity in gag reflex. More studies to verify the effectiveness of acupuncture in controlling gag reflex should be carried out. Addressing the challenges in acupuncture research According to the National Institutes of Health (NIH) Consensus Development Panel on acupuncture published in 1998, promising results have been shown in the treatment of postoperative dental pain44. They concluded that there is sufficient evidence of its potential value to expand its use in conventional medicine and that further studies on its clinical value should be carried out. They also acknowledged the limitations of acupuncture studies in terms of the design and sample size. The use of appropriate controls, better definition of the placebo and sham acupuncture treatment, still pose many challenges. To illustrate this point, a systematic review of randomised clinical trials which used acupuncture,

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placebo acupuncture and no acupuncture groups to study the analgesic effect of acupuncture was carried out45. Only a small difference, of about 4mm on a 100mm visual analogue scale, was found between the acupuncture and placebo acupuncture groups. Moderate difference was found between placebo acupuncture and no acupuncture groups. The authors acknowledged that there was no clear definition of “placebo acupuncture” among the studies. In another systematic review to investigate the effectiveness of acupuncture for non-specific lower back pain, there was no significant difference between acupuncture and sham acupuncture for short term and intermediate pain relief, although there was strong evidence that acupuncture combined with conventional therapy was more effective than conventional therapy alone for pain relief46. The use of appropriate controls in the studies were questioned by the authors. The different studies have shown considerable variation in defining sham acupuncture. Some defined it as superficial needling outside the course of the meridians, some defined it as insertion of needles into non-acupuncture points but not stating if they were still along the meridians, while others used non-penetrative needles. The influence of specific needling parameters which bring about therapeutic effects is still poorly understood and there has been little investigation on the importance of needle placement location and depth, type and intensity of stimulation and number of needles to be used47. It can be postulated that the therapeutic effects reported in sham acupuncture are a result of these poorly defined parameters. According to the teaching philosophy of TCM acupuncture “ 寧可失其穴 ﹐ 不可失其經 “, the acupuncturist may miss the exact location during placement of the needle, but he or she should not place the needle totally out of the course of the meridian if “de qi” or the therapeutic effect is to be achieved. Thus, experimental designs which define sham acupuncture as inserting needles into nonacupuncture points, may still elicit a therapeutic effect because the acupuncturist may unknowingly place the needles along the meridian. Besides the difficulty in defining a true control group using a placebo or sham acupuncture, blinding the acupuncturist is also impossible. Blinding the subjects is also a challenge as they will be able to tell, through the needling sensation, whether they belong to the treatment or control



group. In an experimental setting, the acupuncturist has to follow the treatment protocol and use exactly the same acupuncture locations and number of needles for all the patients with the same disease. However, this is in sharp contrast to the treatment philosophy in TCM based on syndrome differentiation. For example, cough, can be due to the invasion of external pathogens like wind-cold or wind-heat, or it can be due to internal factors like phlegm dampness or lung deficiency. The choice of acupuncture point(s) would be different based on the underlying pathogens/pathogenic factors. In an experimental setting, the therapeutic effect of acupuncture may thus be reduced. A better understanding of the underlying mechanism of how acupuncture works with due appreciation of the fundamentals of TCM would allow future researchers to come up with better experimental designs. As quoted from a recent review on TCM, the lack of evidence may impede the evaluation of TCM, but it does not imply absence of efficacy48. The White Paper published by the Society for Acupuncture Research (SAR) symposium in 2007 recommended a bi-directional translational research strategy between the basic sciences and clinical researchers49. Basic research can focus on the individual treatment components of acupuncture so that clinical researchers can be advised on how best they can design an appropriate sham acupuncture procedure. The clinical researchers can advise the basic sciences researchers on clinically relevant biomarkers and suitable outcome measures that can be investigated. Whilst the recognition and application of acupuncture in the medical field has made much progress over the past 10 years, its development in the dental field is currently in its infancy stage. More clinical research on its possible application in dentistry can be conducted in our local dental institutions. After its effectiveness and efficacy in complementing conventional treatment have been sufficiently evaluated, acupuncture can be implemented as one of the treatment modalities available for dental patients in the near future. Conclusion The use of acupuncture has a long history and has

been proven to be an effective treatment modality in the TCM field. Research has been carried out and there has been a gradual acceptance of its therapeutic effects although it is still not fully understood. The scientific evidence for its role in pain management is strong, although more large scale studies with better experimental designs should be carried out to verify its application in other areas. The use of acupuncture in dentistry may provide an added dimension to the patientorientated holistic treatment approach that all healthcare providers strive to achieve. References

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