THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 16, Number 1, 2010, pp. 107–112

ª Mary Ann Liebert, Inc.
DOI: 10.1089=acm.2008.0484

Effectiveness of Acupuncture in the Treatment

of Temporomandibular Disorders of Muscular Origin:
A Systematic Review of the Last Decade
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Roy La Touche, P.T., M.Sc.,1,2 Santiago Angulo-Dı́az-Parreño, M.Sc.,1,2 José Luis de-la-Hoz, M.D.,1
Josué Fernández-Carnero, P.T., M.Sc.,3 Hong-You Ge, M.D., Ph.D.,4 Marı́a Teresa Linares, P.T.,1
Juan Mesa, P.T.,1 and Jesús Sánchez-Gutiérrez, M.D., Ph.D.1,5

Abstract

Objective: The purpose of this review is to evaluate the effectiveness of using acupuncture treatment for tem-
poromandibular disorders (TMD) of muscular origin according to research published in the last decade.
Methods: The information was gathered using the MEDLINE, EMBASE, CINAHL, and CISCOM databases. The
inclusion criteria for selecting the studies were the following: (1) only randomized controlled trials (RCTs) were
selected; (2) studies had to be carried out on patients with TMD of muscular origin; (3) studies had to use
acupuncture treatment; and (4) studies had to be published in scientific journals between 1997 and 2008. Two (2)
independent reviewers analyzed the methodological quality of the studies using the Delphi list. A total of four
RCTs were chosen once the methodological quality was judged as being acceptable. All of the studies included in
the review compared the acupuncture treatment with a placebo treatment. All of them described results that were
statistically significant in relation to short-term improvement of TMD signs and symptoms of a muscular origin,
except one of the analyzed studies that found no significant difference between acupuncture and sham acu-
puncture.
Conclusions: In the authors’ opinion, research into the long-term effects of acupuncture in the treatment of TMD
is needed. We also recommend larger samples sizes for future studies, so the results will be more reliable.

Introduction there is currently not enough evidence to support the use of

this method for MP treatment.6,7 Physiotherapy and manual

T he term temporomandibular disorders (TMD) is a

general one that encompasses a group of clinical condi-
tions that affect the temporomandibular joint, the masticatory
therapy have proven to be somewhat effective in treating
MP,8,9 but more clinical trials are needed to confirm the ef-
fectiveness of these interventions.
musculature, and the associated structures.1 Muscular con- Occlusal splint therapy in MP related to the cranio-
ditions are the main cause of TMD.2 One of muscular condi- mandibular system has been shown to be effective when
tions that affect the craniomandibular system is myofascial compared with a control group not receiving treatment.
pain (MP), which is the most frequent type of TMD.3 However, these results must be interpreted with great care, as
MP is described as a musculoskeletal condition presenting the research design of some of the studies was not completely
a series of signs and symptoms caused by myofascial trigger reliable.10,11 Besides, these results are based on short-term
points.4,5 results, but not on long-term relief of painful symptoms.
There are numerous studies that analyzed MP treatment Acupuncture is frequently used for treating TMD, and
using botulinum toxin injections. However, the systematic studies using this type of therapy have been systematically
reviews of randomized controlled trials (RCTs) conclude that reviewed previously.12,13 Although positive results were

1
Program in Orofacial Pain and Craniomandibular Disorders, and 2University Research Center of the Cranial-Cervical-Mandibular System,
Faculty of Medicine, San Pablo CEU University, Madrid, Spain.
3
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón,
Madrid, Spain.
4
Centre for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
5
Oral and Maxillofacial Surgical Department, Hospital Clı́nico San Carlos, Madrid, Spain.

107
 108 LA TOUCHE ET AL.

found in those reviews, the authors concluded that the re- We excluded all the studies that presented multiple in-
search design of the trials was seriously inconsistent, and that terventions or were not RCT. Figure 114–19 shows how the
the samples of the study, in some cases, were not very rep- methodology was used and which studies were excluded.
resentative. Moreover, the comparisons were carried out with
control groups in which no placebo was used.12,13 It is also Search strategy
important to note that most of the studies analyzed in this
The following databases were used to search for articles:
review took place before 1994 and a systematic review related
MEDLINE,
EMBASE, CISCOM, and CINAHL. The terms
to the effectiveness of acupuncture in the treatment of TMD of
used for the search derived from a combination of the fol-
muscular origin is lacking.
lowing words: acupuncture, temporomandibular joint dys-
For this reason, the objective of this review is to evaluate
function, temporomandibular disorders, orofacial pain,
the effectiveness of acupuncture treatment in TMD of mus-
myofascial pain, and randomized controlled trial. Ten (10)
cular origin, according to RCT results published in the last
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potential studies were found. The studies were first analyzed

decade.
based on the information provided in the summary, the title,
and the key words. The articles selected were analyzed in
Materials and Methods
great depth using the complete text in the evaluation phase.
Inclusion criteria
Methodologic quality and data extraction
The inclusion criteria used to select studies for this review
were the following: (1) only RCT were selected; (2) studies had The evaluation of the methodological quality of these
to be carried out with TMD patients, especially those with studies was carried out using the Delphi list.20 This list is a
orofacial pain of muscular origin; (3) studies had to include generic criteria list developed by international consensus and
acupuncture treatment; and (4) studies had to be published in consists of (1) randomization, (2) adequate allocation con-
scientific journals between 1997 and 2007. No restrictions cealment, (3) groups similar at baseline, (4) specification of
were used in terms of the language of publication. eligibility criteria, (5), blinding of outcome assessor, (6)

FIG. 1. Representation of the systematic review phases. RCT, randomized controlled trial.
 ACUPUNCTURE AND TEMPOROMANDIBULAR DISORDERS 109

blinding of care provider, (7) blinding of patient, (8) presen- throughout the analysis. Disagreements between reviewers
tation of point estimates and measures of variability, and were resolved by including the criteria of a third reviewer so
(9) intention-to-treat analysis. The additional item concerned that a consensus could be reached.
(10) withdrawal=dropout rate (>20% or selective dropout) The intra-assessor reliability of the overall quality assess-
unlikely to cause bias, which was found relevant for these ment and clinical relevance assessment was derived by k
studies. The methodological criteria were scored as yes (1), coefficient statistics (>0.7 means high level of agreement
no (0), or don’t know (0). A quality score for individual between assessor; between 0.5 and 0.7 a moderate level of
Delphi items, resulting in possible score of 0–10, high quality agreement, and <0.5 a poor level of agreement).
is defined as six or more criteria fulfilled.21 The characteristics of the treatment applied, as well as the
Two (2) independent reviewers analyzed the quality of results and conclusions presented in the studies analyzed,
all of the articles selected using the same methodology are fully described in the Results section.
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Table 1. General Characteristics of the Studies

Subjects used
Authors Design for study Treatment Outcome measures Results

Shen and RCT N ¼ 15 Study group (SG) ¼ Numeric scale Decrease in facial pain
Goddard22 Double- Age: average Acupuncture Visual analogue ( p ¼ 0.003), neck
blinded 43.1
13.6 Control group (CG) ¼ scale (VAS) pain ( p ¼ 0.011) and
14 women, Sham acupuncture Pressure algometer headache
1 man ( p ¼ 0.0159)
Increasing the pain
tolerance ( p ¼ 0.027)
Smith et al.23 RCT N ¼ 27 SG ¼ Acupuncture VAS Improvement in functional
Double- Age: average CG ¼ Sham Incisor opening and impairment ( p ¼ 0.003)
blinded 40.5
13.63 acupuncture lateral movement Improvement in pain
24 women, measurement= intensity ( p ¼ 0.001)
3 men measured in Improvement in pain
millimeters using distribution, left
Vernier style bite ( p ¼ 0.0003), right
TMJ sounds= ( p ¼ 0.005)
stereo-stethoscope Improvement in maximum
Pain distribution interincisor opening
( p ¼ 0.029)
Improved maximum
pain-free opening
( p ¼ 0.029)
Extent of lateral movement,
left ( p ¼ 0.06), right
( p ¼ 0.008)
Improvement in tenderness
of masticatory muscles
( p ¼ <0.05)
No improvement in joint
sounds ( p ¼ 0.317)
Schmid-Schwap RCT N ¼ 23 SG ¼ Acupuncture VAS No mouth opening
et al.24 Single- Age: average CG ¼ Sham laser Manual palpation improvement ( p ¼ 0.114)
blinded 35
14 Electronic No improvement in
23 women axiography retrusion and protrusion
movements ( p ¼ 0.084)
Improvement in pain
( p ¼ 0.033)
Improvement in muscular
pressure-point tolerance
( p ¼ <0.05)
Goddard RCT N ¼ 18 SG ¼ Acupuncture VAS Both groups showed a
et al.25 Double- Age: CG ¼ Sham- Pressure algometer statistically significant
blinded EG: 35.4
10.63 acupuncture reduction in VAS pain
CG: 34.53
6.78 scores ( p ¼ 0.001)
15 women, There was no significant
3 men difference between the
2 groups ( p ¼ 0.255)

RCT, randomized controlled trial; VAS, visual analogue scale; TMJ, temporomandibular joint.
 110 LA TOUCHE ET AL.

Table 2. Representation of Evaluation Scores on the Methodological Quality Applied

to the Delphi List in the Four Studies

Study Year 1 2 3 4 5 6 7 8 9 10 Total

Shen and Goddard22 2007 1 0 1 1 1 0 1 1 1 0 7

Smith et al.23 2007 1 0 1 1 1 0 1 1 1 1 8
Schmid-Schwap et al.24 2006 1 0 1 1 0 0 1 1 1 1 7
Goddard et al.25 2002 1 1 1 1 1 0 1 1 1 1 9

Results depth of needle insertion,22,23,25 which varied from 6 mm to

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30 mm. Duration of acupuncture treatment varied from 15

In the first phase of the analysis, 4 RCTs were selected22–25
minutes to 30 minutes.22,23,24,25
where acupuncture was applied to treat TMD of muscular
origin. Table 1 represents the general characteristics of the
studies in a descriptive way. Discussion
The four studies analyzed consistently showed that acu-
Methodological quality puncture is effective in the treatment of TMD. All studies
showed TMD pain reduction for both verum and sham
When evaluating the quality design of the studies, the
acupuncture interventions, and three of the four studies22–24
results showed that the methodology of all those included
demonstrated that verum acupuncture produced statistically
trials was acceptable.22–25 Table 2 shows the methodological
significant improvements in pain compared to sham acu-
quality of the studies. The two reviewers had a discrepancy
puncture.
in the evaluation of three studies.22,24,25 The discrepancy for
The study designs of the four RCT were appropriate, and
those three studies concerned their scores for items 2, 6, and
their methodological quality was acceptable. Some of the
10 on the Delphi list. A consensus was reached after the third
highlights of these studies were that both the randomized
reviewer intervened. The intra-assessor reliability of the
method and the blinding technique were described in detail.
methodological quality assessment was high (k ¼ 0.85).
Most significantly, all studies used a placebo treatment in
their control groups, which is essential to try to confirm that
Participants the verum acupuncture analgesic effects are due to the acu-
According to the inclusion criteria of each of the studies, we puncture intervention rather than due to placebo effects, as
interpreted that all the subjects had a TMD of muscular origin other studies have suggested.26,27 A recent review has dem-
and, more specifically, had orofacial pain of myofascial origin. onstrated that the placebo effect in analgesia is a real phe-
There were no dropout subjects in three of the stud- nomenon measurable with brain-imaging analyses, and that
ies22,24,25 during the whole research process, and all of their every pain treatment has a placebo component that can be
results were analyzed. The other study23 only had 1 subject very strong.28 The study of Goddard et al.25 reviewed herein
drop out during its course. suggest this, as both placebo (sham) and verum acupuncture
treatment groups had improvements of their TMD pain that
were not statistically significantly different.
Interventions
Three (3) of the four studies included in this review found
The results of the studies analyzed showed positive effects that verum acupuncture produced statistically significant vi-
of acupuncture in improving the signs and symptoms of TMD sual analogue scale (VAS) pain reduction compared to sham
of muscular origin (Table 1). In all of the studies, the only acupuncture, yet only two studies also demonstrated clini-
treatment used in the study group was acupuncture, and in cally significant reductions in VAS pain scores, with one study
the control group, all of the studies used a placebo. In three of showing a VAS improvement of 33 mm23 (baseline VAS ¼
the studies, sham acupuncture22,23,25 was used, and in the 62 mm) and the other an improvement of 19.1 mm24 (baseline
other, sham laser.24 The sham needle acupuncture interven- VAS: 44 mm). Bird and Dickson29 have postulated that clini-
tions included minimal penetration (2–4 mm) of points 1 cm cally significant changes in pain are not uniform along the
distal to the verum acupoints bilaterally in one study,25 while VAS scale, and recommend defining a clinically significant
two studies22,23 had the needle touch the skin at or near the change as a decrease of 17 mm when the baseline VAS score is
verum acupoint without piercing the skin. The fourth study24 between 34 and 66 mm, and a decrease of 28 mm when the
used sham laser (inactivated) applied randomly at several baseline VAS is 67 mm. Todd et al.,30 however, have sug-
acupoints. gested that a 13-mm alteration in the VAS score is the mini-
The verum acupuncture points chosen for treatment of mum change that should be considered clinically significant.
TMD pain varied widely between the four studies. One study Three (3) studies reviewed herein examined the effect on
examined only one local acupoints, Stomach 7 (ST-7).23 Two TMD pain of distal acupoints, most notably LI-4.22,24,25 Hui
(2) studies examined only distal acupoints. Both examined et al.31 observed that the stimulation of LI-4 modulates
Large Intestine 4 (LI-4),24,25 but one study24 also included specific areas of the subcortical gray matter and limbic sys-
Small Intestine 2 (SI-2) and Small Intestine 3 (SI-3) in its acu- tem involved in pain perception. Hsieh et al.32 demonstrated
puncture protocol. The fourth study25 examined both local that the stimulation of LI-4 activates different areas of
(ST-6) and distal (LI-4) acupoints. Three (3) studies described the hypothalamus on single photon emission computed
 ACUPUNCTURE AND TEMPOROMANDIBULAR DISORDERS 111

tomography scanning, and suggested that this could be an 7. Clark GT, Stiles A, Lockerman LZ, Gross SG. A critical re-
important mechanism to explain the acupuncture’s analgesic view of the use of botulinum toxin in orofacial pain disor-
efficacy. The present systematic review provides limited ders. Dent Clin North Am 2007;51:245–261.
evidence that stimulation of LI-4 alone reduces TMD pain, 8. Hou CR, Tsai LC, Cheng KF, et al. Immediate effects of
though the improvement is of uncertain clinical significance. various physical therapeutic modalities on cervical myo-
More clinical studies using distal points alone (e.g., LI-4) are fascial pain and trigger-point sensitivity. Arch Phys Med
needed to confirm these findings and determine whether Rehabil 2002;83:1406–1414.
these pain improvements are large enough to be clinically 9. Hanten WP, Olson SL, Butts NL, Nowicki AL. Effectiveness
important. of home program of ischemic pressure followed by sus-
tained stretch for treatment of myofascial trigger points.
Two (2) studies reviewed herein used specific local acu-
Phys Ther 2000;80:997–1003.
points located in the craniomandibular region (ST-625 and
10. Al-Ani Z, Gray RJ, Davies SJ, et al. Stabilization splint
ST-723) in their verum acupuncture for TMD pain, and the
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therapy for the treatment of temporomandibular myofascial

study by Smith et al.,23 which treated only ST-7, had the most pain: A systematic review. Dent Edu 2005;69:1242–1250.
statistically (and clinically) significant reductions of TMD 11. Al-Ani MZ, Davies SJ, Gray RJ, et al. Stabilisation splint
pain. These points may be coincident with masseter muscle therapy for temporomandibular pain dysfunction syn-
trigger points.33 Further research is needed to determine drome. Cochrane Database Syst Rev 2004;1:CD002778.
whether addition of a distal acupuncture point enhances the 12. Fink M, Rosted P, Bernateck M, et al. Acupuncture in the
efficacy of pain reduction produced by stimulation of a local treatment of painful dysfunction of the temporomandibular
craniomandibular acupoint in TMD pain conditions. joint: A review of the literature. Forsch Komplement Med
Shortcomings of the studies22–25 analyzed in this review 2006;13:109–115.
include their very small sample sizes, though their method- 13. Ernst E, White AR. Acupuncture as a treatment for tempo-
ological quality were higher than studies carried out in the romandibular joint dysfunction: A systematic review of
previous decade.12,13 These studies also only examined the randomized trials. Arch Otolaryngol Head Neck Surg
short-term effects of acupuncture for TMD pain, and future 1999;125:269–272.
research should include analysis of the long-term effect of 14. Xue WH, Ding M, Su XC, et al. Clinical observation on
acupuncture on TMD pain of muscular origin, including the warming needle moxibustion plus exercise for treatment of
duration of analgesia produced by acupuncture. temporomandibular joint dysfunction syndrome. Zhongguo
Zhen Jiu 2007;27:322–324.
15. Widerström-Noga E, Dyrehag LE, Börglum-Jensen L, et al.
Conclusions
Pain threshold responses to two different modes of sensory
Based on this review, it would seem the evidence is (1) stimulation in patients with orofacial muscular pain: Psy-
limited in amount, (2) shows short-term benefit for acu- chologic considerations. J Orofac Pain 1998;12:27–34.
puncture for TMD pain of muscular origin; the study also 16. Mazzetto MO, Carrasco TG, Bidinelo EF, et al. Low intensity
showed that (3) local acupuncture had greatest pain reduc- laser application in temporomandibular disorders: A phase I
tion, (4) distal points had efficacy, and (5) a lot more research double-blind study. Cranio 2007;25:186–192.
is needed as to which points and=or combination of points to 17. McMillan AS, Nolan A, Kelly PJ. The efficacy of dry nee-
use and duration of efficacy of acupuncture. The authors of dling and procaine in the treatment of myofascial pain in the
jaw muscles. J Orofac Pain 1997;11:307–314.
the present review suggest the use of ST-6, ST-7, and LI-4
18. Rosted P. The use of acupuncture in dentistry: A review of
acupoints for the treatment of TMD pain of muscular origin.
the scientific validity of published papers. Oral Dis
1998;4:100–104.
Disclosure Statement 19. Ernst E, Pittler MH. The effectiveness of acupuncture in
No competing financial interests exist. treating acute dental pain: A systematic review. Br Dent J
1998;184:443–447.
20. Verhagen AP, de Vet HC, de Bie RA, et al. The Delphi
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