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18 TRENDS & APPLICATIONS Dental Tribune United Kingdom Edition | 3/2017 When the signals reach the hypo- thalamus and pituitary gland, adrenocorticotropic hormones and endorphins may be produced. This forms the basis of our current understanding of the analgesic effect of acupuncture in Western medicine, although other thera- peutic effects of acupuncture, such as in the treatment of nausea, gas- tritis, asthma and dysmenorrhoea, are yet to be fully explained. In the case of asthma, one of the thera- peutic acupuncture points, BL13 (feishu), lies approximately 1.5 in. (38.1 mm) lateral to the level of the spinous process of vertebra T3. It has been hypothesised that the lo- cation of BL13 (feishu) corresponds roughly to the sympathetic gan- glion at the level of T3, which sends postganglionic fibres to the pul- monary plexus and cardiac plexus.7 Dental application of acupuncture Managing dental pain, analgesic effect and postoperative pain relief According to TCM theory, local acupuncture points on the facial regions, like ST6 (jiache) and ST7 (xiaguan), and distant points, like LI4 (hegu), can be used to treat dental pain. They are part of the stomach and large intestine me- ridians, which converge at the fa- cial region and link up with the maxillary and mandibular teeth, respectively. Western medical lit- erature has proposed that acu- puncture can produce an analgesic effect at a distant site by diffuse noxious inhibitory control.8 This provides a possible explanation as to how the acupuncture point LI4 (hegu), which is located on the ra- dial side of the second metacarpal bone on the dorsum of the hand, can elicit an analgesic effect in the orofacial region. The role of acupuncture in contemporary dentistry may not be so much the removal of the ae- tiology of dental pain, but rather as an adjunct in achieving anaes- thesia during dental procedures and providing postoperative pain relief. A pilot study was conducted to investigate whether the induc- tion time of local anaesthesia can be reduced if acupuncture is given before results showed that, in the group in which local acupuncture points SI19 (tinggong), ST5 (daying) and ST6 (jiache)—within the innervations of the mandibular branch of the trigeminal nerve—were stimu- lated before an inferior alveolar nerve block was given using prilo- injection.9 The caine hydrochloride, the induction time was 62 seconds, versus 119 seconds in the control group, in which 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. The results of another study indicate that acupuncture before inferior alveolar nerve block may increase its effectiveness in endo- dontic treatment of mandibular molars with symptomatic irre- versible pulpitis.10 Several studies have shown that acupuncture can reduce post- operative pain. A systematic re- view of 16 studies found that acu- puncture therapy can help to alle- viate postoperative pain, although heterogeneity in terms of method- ological details among the studies reviewed may limit the conclu- sions that can be drawn.11 The prac- tical implication of acupuncture therapy in alleviating postopera- tive pain may be helping to reduce the patients’ dependence on sys- temic analgesic medications. It is well documented that the use of non-steroidal anti-inflammatory drugs for pain control is associated with increased risk of gastrointes- tinal complications, like ulcera- tion and bleeding. A randomised placebo-controlled trial was con- ducted to evaluate the efficacy of acupuncture in treating postoper- ative oral surgery pain.12 The treat- ment group that received real acu- puncture treatment immediately after the surgical removal of im- pacted lower third molars had a significantly longer pain-free post- operative period (172.9 minutes) compared with the placebo group (93.8 minutes). More importantly, the treatment group took a signif- icantly longer time (242.1 minutes) to request analgesic medication compared with the placebo group (166.2 minutes). They also took sig- nificantly less medication (1.1 tab- lets of 600 mg acetaminophen with 60 mg codeine) compared with the placebo group (1.65 tab- lets); this difference was still evi- dent at the seven-day follow-up (7.7 tablets versus 11.3 tablets). More randomised controlled clini- cal trials to verify the role of acu- puncture therapy in dental pain management, particularly in post- operative pain, may be warranted. Management of temporomandibu- lar joint dysfunction syndrome and orofacial pain Temporomandibular joint dys- function syndrome (TMD) is a term that includes a group of Clinical posting module in graduate diploma in acupuncture course. A patient receiving acupuncture treatment (left).—Modern prepacked, sterilised acupuncture needles used for treatment(right). conditions that affect the tempo- romandibular joint (TMJ), the mus- cles of mastication, and the associ- ated head and neck musculoskele- tal structures. The clinical diagnos- tic criteria for TMD classify the most common forms of TMD into the main subgroups of mastica- tory muscle disorder, TMJ internal derangement and TMJ degenera- tive joint disease.13 The treatment of TMD de- pends on the aetiologies of the conditions. While acupuncture therapy may not be useful in elim- inating the cause if it is due to structural anomalies, like capsuli- tis and degenerative changes, it may help to relieve the pain and discomfort associated with the conditions, especially if it is mus- cular in nature. It has been docu- mented that acupuncture can help in muscle relaxation and reduce muscle spasm. Relaxing the lateral pterygoid muscles can reduce the anterior displacing force on the meniscus of the TMJ and help to minimise TMJ clicking. A systematic review of 19 ran- domised controlled trials was con- ducted to assess the effectiveness of acupuncture for symptomatic treatment of TMD.14 The findings suggest moderate evidence for ac- upuncture as an effective inter- vention for the reduction of TMD symptoms, although more studies of larger sample sizes are needed to investigate the long-term effec- tiveness of acupuncture. Trigeminal neuralgia is a sud- den, unilateral, brief, stabbing, re- current 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 standard, but it also has various including drowsiness, dizziness and consti- pation. There are several case re- ports and case series in the Chi- side-effects, nese literature on the success of acupuncture treatment on pa- tients with trigeminal neuralgia. Acupuncture points GB14 (yang- bai) and EX-HN5 (taiyang) are used if the ophthalmic branch is af- fected, ST2 (sibai) and ST3 (juliao) if the maxillary branch is affected, and ST6 (jiache) and ST7 (xiaguan) if the mandibular branch is af- fected. The choice of acupuncture points coincides with the distribu- tion of the nerve branches. There is however, a paucity of reports in the Western literature and a lack of randomised controlled trials to verify its effectiveness in treating trigeminal neuralgia. Editorial note: A list of references is available from the publisher. Dr Wong Li Beng is a consultant periodontist at Ng Teng Fong General Hospi- tal and Jurong Medical Centre in Singapore and Director of Preventive Dentistry at the centre. In 2011, he obtained a graduate diploma in acupuncture from the Singapore College of Traditional Chinese Medi- cine and is now a registered acupunc- turist with the Traditional Chinese Medicine Practitioners Board. He can be contacted at Li_Beng_Wong@ juronghealth.com.sg. Environmental, acquired and genetic risk factors (cid:25) (cid:25) Fig. 2: Pathogenesis of periodon- tal disease.3 Specific pathogenic bacteria (cid:25) Host immuno- inflammatory response (cid:25) Connective tissue and bone metabolism (cid:25) Clinical expression of disease initiation and progression