ra ae (199) 4, 10104 2198 on Ps Aree SAS 0 Tepe con prncoabiod The use of acupuncture in dentistry: a review of the scientific validity of published papers P Rosted ‘Shefeld University, 200 Abbey Lane, Sheffield $8 0BU, UK ‘OBJECTIVE: To review the scientific validity of published papers on the efficacy of acupuncture in dentistry based ‘on predefined methodological criteria. MATERIALS: A literature search performed by the Royal Society of Medicine and the University Library, Copen- hagen, Denmark was able to identity 74 papers written in English, German, Danish, Swedish, Norwegian, Itallan, Franch and Russian published between 1966 and 1996. ‘The search words were: acupuncture and electro- acupuncture, randomised controlled trials (RCT), dental pain, postoperative dental pain, palnrelieving in dentistry, And dental analgesia. Among the 74 listed papers, 48 pap- fers were reviewed In the following languages: English, Danish, Swedish, Norwegian and German. Fifteen papers were exclided because they were written in French, Ial- lan or Russian; 11 papers were excluded because the abstract clearly indicated the paper was not a RCT or the paper was of a general nature without relevance to acu- 5: To assess the methodological quality of the Included papers, all papers were scored on the basis of predefined criteria. A total of 92 points could be achieved land on the basis of cis scale papers were rated as: Excel- lent (85-10%), Good (70-84X), Fair (60-69%) and Bad (<60%). MAIN OUTCOME: Fifteen out of 48 papers met the inclusion criteria, RESULTS: Only one study met the criteria with more than 85%. Five studies met the criteria with 70-24%, Three studies met the criteria with 60-69%. Six studies did not meet the criteria. Acupuncture in I! out of 15 studies proved effective in the treatment of tempero- ‘mandibular dysfunction (TMD) and as analgesia. Four studies showed no effect of acupuncture. CONCLUSION: The value of acupuncture as an analgesic ‘must be questioned. The effect of acupunctutre in treat- ing TMD and facial pain seems real and acupuncture ould be a valuable alternative to orthodox treatment. Keywords: acupuncture: comperomandibulr dysfunction; éen- ‘al pain; dena! analgesic CConespundence: Dr Palle Rose, Tels +84 0 116 2360077, Fax: +44 0 nia 30491 Received 9 December 1997; revised 16 February 1998; accepted 12 March 1998 Introduction Acupuncture is @ technique that originated in China more than 3000 years ago. By this method diseases are treated by inserting needles in different pars of the body—acu- puncture points. Today, additional techniques are available, for example, electro-acupuncture, ear-acupuncture and transcutaneous nerve stimulation. The main target for acun- pponcture treatment is pain management and acupuncture has in a number of studies (Richardson and Vincent, 1986) proved effective particularly in the treatment of pain of musculoskeletal origin. Moreover there have been some suggested theories that acupuncture might be able to improve the immune system (Lundeberg, 1993) and the level of stress and anxiety (Tao, 1993). Like other disciplines in medicine, dentists often meet problems which do not respond to orthodox treatment. For example, it is well known that a number of patients suffer from phobias and anxiety during dental treatment. For obi fous reasons (stress, anxiety and phobias are difficult 10 assess) no controlled studies are available on this subject. However itis a general impression that acupuncture is able to help a substantial numbér ofthese patients and acupunc- ture might be an alternative to tranquillisers, which is the normal standard treatment. Facial pain is another major problem which often gives rise to diagnostic difficulties. There are several instances where patients have been misdiagnosed and mis-treated because of a lack of knowledge of the musculoskeletal component of facial pain. The orthodox treatment often involves surgical intervention, eg, on the sinuses, partial removal of the trigeminal nerve or removal of teeth. Too ‘many patients have had a aumber of healthy teeth removed. ‘There are several reasons for facial pain but the pains are often of a musculoskeletal nature and these respond well to acupuncture. ‘Temperomanidubular dysfunction (TMD) is another ‘common condition in dental practice. There is no standard treatment but tranquillisers, physiotherapy, occlusal splint ‘and counselling are among those normally prescribed. Here too acupuncture might have something to offer. ‘Among the more rare conditions is Sigrens disease, 2 disease involving a decrease of the salivary flow and pain. ‘The teatment that conventional medicine can offer is lim= ited to antficial saliva and painkillers, therefore any sup- plement to this treatment must be considered beneficial to the patientIn recent years an interest in the use of acupuncture in entistry has increased, because of the published results of its efficacy. However, the literature dealing with the use of acupuncture in dentistry is not extensive and the results recorded vary considerably from ‘no effect’ to ‘sign cant improvement’ ‘The aim of this article is to review and discuss the pub- lished controlled clinical trials (CCT) on the use of acu- puncture in dentistry and to determine whether clear con- clusions may be obtained by assessing the available literature according to methodological criteria Materials and methods To ensure reasonable methodological soundness of the involved studies, only randomised and blinded studies are included. Unfortunately, double-blinded studies are nearly impossible in acupuncture. The person who inserts the needles will in most cases always know if he is inserting the needles in a real acupuncture point or in a sham acu- puncture point. in an effort to minimize this problem the assessments can be performed by an independent clinician Which has been the case in a number of studies. ‘The placebo response in acupuncture has given rise to a lot of speculation. At one time it was accepted that inserting needles in non-acupuneture points or in points which have ro relevance to the ested disease could be used as sham acupuncture. Today we know (Stux and Pomeranz, 1987) that inserting needles in any part of the body will have a physiological effect but normally less than the effect achi- ved by inserting the needles in real acupuncture points. In all the quoted studies where sham acupuncture has been used, needles have been inserted in aon-acupuncture points or points regarded as having no effect on the treated dis- ‘The present study is based on a computer search of pap- ers published between 1966 and 1996 performed by The Royal Society of Medicine, London, England; The Univer- sity Library, Copenhagen, Denmark: and Research Council for Complementary Medicine (RCCM), London, England. ‘The following databases have been used: Medline, Biologi- cal Abstracts, Excerpta Medica, Science Citation Index, Embase and Ciscom. The search words were: acupuncture and electro-acupuncture, randomised controlled trials, den- tal pain, postoperative dental pain, painrelieving by acu- puncture in dentistry, and dental analgesia. Papers were reviewed in the following languages: Danish, Swedish, ‘Norwegian, English and German, ‘A total of 74 papers were listed in English, German, Dan- ish, Swedish, Italian, French and Russian. Among the listed papers, 48 were reviewed. Eleven papers listed were excluded before reviewing for the following reasons: (1) the abstract clearly indicated thatthe paper was not a ran- domised controlled trial; (2) the paper was of a more gen- eral nature or had no relevance to acupuncture, eg. hyp- nosis, homeopathy etc. Another 15 papers were excluded because they were written in French, Italian and Russian. “This review includes papers which fulfil the following criteria: (1) Acupuncture needles were used: studies in which TENS and laser acupuncture were used were ‘excluded, Suidies on eleciro-acupuncture were included in Se tao etry % the cases where needles were used. (2) A reference group existed, whether either sham acupuncture or an existing tteatment modality was wed (Table 1). “To assess the methodological quality of the paper, all those included were scored on the bass of alist of prede- fined criteria (Table 2). Every paper was ranked as “Very pod! (4), Good” (3), ‘Fair’ 2), "Not satisfactory" (1), and *Poor’ (0) as suggesed by (Vickers, 1995). "Very good” indicates thatthe demand has been met adequately andthe results must be considered vali "Good" indicates thatthe Imajor demands were met adequately, andthe results have not been affected. “Fair indicates that demand has not been fully met, but results have probably not been affected. ‘Not satsfacton” indicates that some ofthe major criteria have not been met adequately and tis might affect the outoome ofthe study. Poor indicates that the criteria have not been met, and this has probably influenced the outcome ofthe study ‘A total of 92 points could be achieved. On the basis of this scale the papers were assessed as: Excellent (85~ 1008), the data must be considered as valid and reliable, Good (70-84%), the data must be considered valid bat eon: tzins minor methodological erors without importance for the outcome: Fair. (60-695) medium methodological terrors which are nt likely to lafluence the results signif Gantly; Bad (60%), major methodological defences Which are likely to have influenced the outcome ‘Among the reviewed 48 papers, 33 were rejected forthe following reasons: Aneedoial nature (Gerschman and Wikstém, 1988; Changxin, 1989; Jiashs, 1989: Silva, 1989; Ho and Brady, 1992: Yunmeng, 1993). Other papers were ofa general nature (Editorial, 197; Hensen 1982: TKezono, 1983: Foreman, 1985; Jacobs, 1985; Sokol etal 1985; Lapeer. 1986; Wong, 1989; Rasmussen, 1991: Rowe, 1992; Matick, 1995: Wright and Schiffman, 1995), or of an experimental nature (Borzecki and. Boréecki, 1975: Chapman et al, 1975, 1976, 1977, 1983; Bakke, 1976: Gerschman and Giebatowski, 1991; Simmons and Oleson, 1993), orcscussed oter techniques not related to acupunc- ture (Hansson and Ekblom, 1983; Hansson er al, 1986, Ekblom and Hansson, 1988; Kefei, 1992). “Table Accepted popes and type of convo used Suds Main Year Type of comrol used 0 Burschhow 1991 Acypuncre >< Noo westment 5 Hansson 1987. Acupuncure >< Conventional (86 Johanson 1991 Acopuneture >< Conveationsl “ke” 1973. Patan act a5 own cond 0 List’ 1967 Pater act as oma consol 10 Uist 1982. Acupuncare >< Spin 12 Raia 1985 Acupunctare >< Splint 13 Scone 1904, Palens at as own conrol 1 “Sing” 1977 Aoupunctare > < Placebo acupunctureUe tac diy Results ‘The remaining 15 papers were found to fulfil the inclusion criteria (Lee et al, 1973; Sung et al, 1977: Taub eral, 1979; Raustia and Pobjola, 1986; Raustia et al, 1986, 1995; Lapeer ef al, 1987; List and Helkimo, 1987; Barashkow ‘and Stosch, 1991; Ekblom et al, 1991; Johansson et al, 1991; List and Helkimo, 1992; List et al, 1992; Lao et al, 1994; Scarsella etal, 1994; Lao et al, 1995), and the results are shown in Tables 1 and 2. Tree papers (Raustia er al, 1985, 1986; Raustia and Pohjola, 1986), deal with the same study and are therefore counted as one. Only one study fulfilled more than 85% of the requested criteria (Sung ef al, 1977). Five studies fulfilled between 70-84% of the criteria (Raustia er al, 1985, 1986; Raustia and Pohjola, 1986; Johansson et al, 1991; List and Helk- imo, 1992; List er al, 1992; Lao er al, 1995). Three studies met the criteria 60-69% (Taub et al, 1979; Ekblom et al, 1991; Lao etal, 1994). Six studies did not meet the criteria (Lee et al, 1973; Hansson et al, 1987; Lapeer er al, 1987; List and Helkimo, 1987; Baraschkow and Stosch, 1991; Scarsella er al, 1994). Eleven out of 15 studies were in favour of acupuncture and four studies demonstrated no “Table Breakdown ofthe nvidia effect. Itis particularly interesting to notice that all the stud- ies which scored the highest were in favour of acupuncture. ‘The results compared to the quality of the study are shown in Table 3. Discussion Regarding the effect of acupuncture as an analgesic, seven studies dealt with extraction of teeth, in particular impacted third molars, which allow us to make a comparison of the results, Of these papers three did not meet the criteria (Hansson er a, 1987; Lapeer er al, 1987; Baraschkow and Stosch, 1991) more than 60%. Among the papers which ‘Table3 The cutcome compared wo the quality of he sey Quality ofthe sty Postive Megane Tou Excelent (85-1009) 1 (Good 70-84%) 5 Fair (60-09%) 1 Bad (<608) 4 Total " Publication 1 Comparciity of sure population Subjects and cone drawn from same source popution Ful int of inclusion ad excision ceria piven Cita appropiate CGice of eters Ukly to infence outcome ‘Adequacy of sample ie Sample ne Cont group ‘Approcteness of control prop Taare plano sed ‘Asie plcebo used Randomization Method described and adequate forthe sy Baseline matching Blinding Blinding of subject Binding of therapist Independent observer Crediy of binding Treament ‘renment deserted in dei Placebo weatment decribed in dels (Quslifeation of terapst desribes ‘Outcome measures appropriate 1 conton Messues reliable an vad Follow uptime sppropsate fr the condton Wiherawas and Non responders Staves Approprinteness of sass ° Score * “ is ee eee eee Outcome ofthe it Pos P44 ree soe eari|e a4 04 422 a Ee ee ee 0] tt al al apa 204442004 4 ea 2044420044 6 1 42 ioe eer tel #0] eal eal alee als M0 % 4 10 19 1 20 1 10 80 5020 4 St 42404 4 104 FS KOH GS 00044 000000048 0240040 442400 Doses 6s 9 eee 40402208 44 404 & 44044 000004 44 4 Deo 6 000 0 0 mo onan o4e eh O00 HOES etree 0) 008 eee ea Saas ee ee era’ S444 44004 a a 2444 4000004022 eee eee 224220114 642 4 0 fell eae ae eat tet tt atte 0216210 0000200044 0000 42402 400444242 SR2nsteaenanT 2D s st 4 77 @ 1 47 2 2 7 Be BH 35 86 Neg Neg Pos Pos Pos Neg Pos Pos Pos Pos Pot Pos Pos Negmet the criteria, three were in favour of acupuncture (Sung. et al, 1977; Lao et al, 1994, 1995) and one was not (Ekblom er al, 1991). The paper by Ekblom er al (1991) conly just passed the critical figure with 61% and was encumbered with methodological errors, but it is not likely that these errors influenced the outcome significantly, The authors discuss the problem and suggest that a vasodilat- ation followed by a faster wash-out of the anaesthetics, thereby shortening the effect of the anaesthetics, could explain the outcome. Another reason could have been that ‘wrong acupuncture points were used. This explanation is not very likely because a segmental approach was used which is known to produce the best results. Moreover the sample size in this study was larger (110 subjects) than any of the other studies which varied between 10 and 40 sub- jects. Furthermore it has not been possible to identify any Gifference in the treatment among the four papers which ‘met the criteria. In general the same acupuncture points were used. In all cases manual stimulation was used and the needles were left in situ for approximately the same Jength of time, Therefore it is very unlikely that this accounts for the contradictory results. Despite three papers being in favour of acupuncture, the inerpretation ofthese findings should be cautious and more rigorous studies including a sufficient number of patients are needed before definite conclusions can be drawn. More over the practical value must be questioned. Modern tech: niques to produce analgesia in dentistry are cheap, easy to administer, and work reliably within minutes, and in most ‘cases without side effets. In contrast acupuncture is more difficult to administer, less reliable and requires stimulation ‘of between 20 to 30 min before being effective Regutding the teatment of facial pain and TMD the ovt- ‘come of the papers is more clear. Four papers (Raustia et al, 1985, 1986; Raustia and Pohjola, 1986; Johansson eal, 1991; List and Hetkimo, 1992; Lister al, 1992), which met the criteria with only minor methodological laws all dem- onstrated a postive effect of acupuncture. OF course, more studies ave needed but the above results suggest that acu- ‘puncture could be considered as a valid alternative to ortho- ddox treatment including occlusal splints. The treatment is simple and cheap. The effect often occurs after only a few treatments, whereas the occlusal splint often has to be used for a considerable length of time. 1 appears from the analysed papers that acupuncture is effective in reducing dental pain and one might ask by what mechanism this is achieved. Although we are still without ‘a complete understanding of acupuncture’s mode of action, there are some suggested theories. Today itis accepted that acupuncture activates small myelinated nerve fibres in the ‘muscle, which send impulses to the spinal cord and then activate three centres: the spinal cord, the midbrain and the pituitary-hypothalamus. Moreover, it has been shown that enkephalin, beta-endorpin, dynorphin, serotonin and norad- renalin are involved in this process (Stwx and Pomeranz, 1987), Conclusions Eleven out of 15 papers were in favour of acupuncture and hhave shown acupuncture to be better than sham acupunc- ef epintr i detry Phan ture or having 2 similar effect as conventional treatment. ‘The value as an analgesic is questioned but the effect in ‘weating TMD and facial pains seems real and acupuncture could be a valuable altemative to onhodox treatment, [Nevertheless the number of randomised controlled trials (RCT) are sill scanty and more studies are required. References Lundeberg T (1993) Peripheral effects of sensory nerve simi Tation (acupuncture) in inflammation and ischemia. 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