Acupuncture

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 Carolina Assaf Branco1, Rodrigo Borges Fonseca2, Renata Filgueira Borges1, Giovana Cherubini Venezian1, Laı´s Valencise Magri1, Marcelo Oliveira Mazzetto1 1

Department of Restorative Dentistry, School of Dentistry of Ribeira˜o Preto, University of Sa˜o Paulo (FORP-USP), Avenida do Cafe´, Ribeira˜o Preto, SP, Brazil, 2Federal University of Goia´s, Goiania, GO, Brazil Objective: The aim of this study was to evaluate the perceptions of two patient groups with temporomandibular disorder (TMD) (muscle and joint) in relation to the signs and symptoms before and after treatment with acupuncture, by using two protocols (local points and distant points), according to the ProTMDMulti protocol and the Visual Analog Scale. Method: Sixty-eight patients were divided into four groups: the muscle treated with acupuncture at local points (MUS-LP), muscle treated with acupuncture at distant points (MUS-DP), joint and muscle treated with acupuncture at local points (JOI-LP) and joint and muscle treated with acupuncture at distant points (JOI-DP) groups. The evaluations were performed at four times: initial (upon entry into the study), control (4 weeks after the initial, as of yet no intervention), final (after six sessions of acupuncture), and follow-up (four sessions after the end of treatment). 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 assessment (Pv0?05). In all groups, the final and the follow-up evaluations for the individual groups were similar, which suggests that the results achieved by using acupuncture remained even after completion of the sessions. Conclusions: For TMDs that involve joint components, the best acupuncture treatment involves local points and for the TMDs that involve muscle components, the best acupuncture treatment involves points at a distance.

Keywords: Acupuncture, Temporomandibular disorder, ProTMDMulti, Visual analog scale

Introduction In modern life, with the high degree of stress and excessive workloads, temporomandibular disorder (TMD) has become an increasingly frequent reality in people’s lives.1 The main signs and symptoms associated with this condition are restriction of mandibular movements, noises, and articular pain in the facial muscles and/or in Correspondence to: Laı´s Valencise Magri, Department of Restorative Dentistry, School of Dentistry of Ribeira˜o Preto, University of Sa˜o Paulo (FORP-USP), Avenida do Cafe´, Ribeira˜o Preto, SP 14040-904, Brazil. Email: [email protected] ß W. S. Maney and Son Ltd 2015 DOI 10.1179/2151090315Y.0000000004

the pre-auricular region.2–4 Temporomandibular disorder can have a major impact on an individual’s quality of life, and must be treated in a multidisciplinary manner. Acupuncture is a Chinese therapeutic method that originated more than 3000 years ago and is based on the insertion of disposable needles into specific body points to (purportedly) stimulate the central and peripheral nervous systems to release neurotransmitters that promote the health restoration and maintenance processes.5,6 In 2002, the World Health Organization

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(WHO) concluded that chronic orofacial pain, including pain associated with TMDs, responds well to acupuncture treatment, with results comparable to those obtained using other conventional therapies.7 Therefore, acupuncture may be considered to be an effective method for controlling such pain and improving the patient’s quality of life. The correct TMD diagnosis is fundamental to the establishment of the therapeutic plan. In 1992, Dworkin and LeResche8 developed a classification and diagnosis system, called the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/ TMD), for this condition. The system consisted of two coordinated axes (muscle and joints) and made it possible to maximize the reproducibility between researchers, thus facilitating research development and allowing comparisons of results among researchers through the use of a common set of evaluation criteria.8 The subjective evaluation of TMD’s signs and symptoms, especially pain, has been shown to be a great challenge in the treatment of these chronic conditions. The Visual Analog Scale (VAS) has been used as the main subjective evaluation instrument for pain. The scale is 100 mm long; its left edge represents zero discomfort or pain, and its right edge represents the largest possible discomfort, i.e., the highest imaginable pain. The patient records the pain’s intensity by marking a position on the line between the two extremes, with the intensity of the pain being described as the distance from the left edge to the patient’s mark.9,10 As TMD has a multifactorial etiology and is influenced by biopsychosocial aspects, quantifying the frequency and the severity of the signs and symptoms based on the patient’s perception is important. De Felicio et al.11 developed a protocol in 2006, called Protocol for Multidisciplinary Centers for the Determination of the Signs and Symptoms of Temporomandibular Disorders (ProTMDMulti), based on the signs and symptoms most often found in the literature and in situations that produce greater discomfort. This protocol was validated based on Helkimo’s Clinical Dysfunction Index,12 and can be used to complement clinical examinations by providing measurable information given by the actual patient. Considering all these aspects, the hypothesis that the pain caused by TMDs can be treated effectively by using acupuncture should be further investigated. In this regard, acupuncture, which is a general approach based on the individual, probably influences the selfperception of pain, thereby improving the quality of life and reestablishing the functions of the stomatognathic system. This study’s objective was to evaluate 2

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the perception of two TMD (muscle and joint) patient groups in relation to their signs and symptoms before and after acupuncture treatment by using two protocols (local points and distant points), the ProTMDMulti and the VAS protocols.

Materials and Methods This work was approved by the Research Ethics Committee of the Faculty of Dentistry of Ribeirao Preto University of Sa˜o Paulo (Preto/USP) under protocol Number 2010?1.303?58.7. The patients were provided complete information on their participation in this study and signed Free and Informed Consent Forms (ICFs). Sixty-eight patients were selected, and the inclusion survey criteria were females over 16 years of age, presence of minimum occlusal stability (minimum of 20 functional teeth in their dentition), painful symptoms for at least 6 months, with a diagnosis of TMD and no other treatments for this condition. The exclusion criteria were the presence of extensive dental flaws (four or more contiguous teeth), severe rheumatologic alterations, a history of cervical spine trauma, any mental impairment, pregnancy, severe systemic diseases, and other TMD treatment. All selected patients underwent an evaluation by a previously calibrated examiner who used the RDC/ TMD to diagnose and classify the patients as having muscle TMD or joint and muscle TMD;8 no patient was classified as exclusively having joint TMD. From this initial classification, two groups were formed: the MUS-TMD group for muscle TMD, and the JOITMD group for joint and muscle TMD. Half of the patients in each group received treatment at local acupuncture points (according to Traditional Chinese Medicine), located close to the painful region (head and neck): GB20 located in the recess bone between the external occipital protuberance and the mastoid process, GV20 located at the top of the head, TE21 located in the depression formed when the mouth is opened (in front of the ear tragus), ST6 located below the ear lobe under the overhang of the masseter muscle in the bite, ST7 located in the palpated depression just below the zygomatic arch and the front of the head of the mandible.6 These patients formed the muscle treated with acupuncture at local points (MUS-LP) and the joint and muscle treated with acupuncture at local points (JOI-LP) groups. The other half of the patients in each group received treatment at a distant point (LI4) located in the hand, in half of the second metacarpal bone, as well as at the EX-HN3 (Yintang, extra point) located between the eyebrows, at the glabella, which was mainly to control VOL .

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emotions. These patients formed the muscle treated with acupuncture at distant points (MUS-DP) and the joint and muscle treated with acupuncture at distant points (JOI-DP) groups. The EX-HN3 point was selected because it was located on the face, but in a region where it would not interfere with the masticatory muscles. The LI4 point was manually stimulated until the De-qi sensation was obtained, which corresponds to a sensation of heaviness or numbness in the region of the point, and may radiate to the whole arm.13 Systemic acupuncture needles (0?25|40 mm DONGBANGH), were used for mechanical stimulation and were left in situ for 20 min. The needles showed, on average, a 20-mm penetration, with the depth of penetration varying with the anatomical characteristics of each region. Ten treatment sessions were performed on each patient, twice a week, wherein the same acupuncturist executed the treatment in all sessions for all volunteers. Two protocols were used for subjective evaluation of the signs and symptoms of TMD: the ProTMDMulti and the VAS protocol. The ProTMDMulti protocol consists of two parts: the first is composed of questions on the presence and absence of various signs and symptoms, and accepts only positive or negative replies (this was not considered in this analysis). The second part consisted of questions related to the signs and symptoms at four times during the day: waking, chewing, speaking, and resting. To answer each question, the patient used an 11-point numerical scale, 0 representing the absence of symptoms, and 10 being the highest possible pain. The final result for each of the 12 signs and symptoms was the sum of the values of all the daily situations, and therefore, varied between 0 and 40. In this study, only eight signs and symptoms were evaluated by using the ProTMDMulti protocol, because they were the most frequently reported; the others were not reported by the patients evaluated. The VAS reflects the pain perception in numbers from 0 to 10, in the same way as described for the above protocol (0 being no pain and 10 being the highest pain possible). The patients were instructed to record the intensity of the current pain by making a mark on a line between the two extremes of the scale; then, the researchers measured the distance between the left edge and the patient’s mark with the aid of a digital caliper. That distance was recorded as the intensity of the pain. The assessments with the tools illustrated earlier were made in four stages: initial (first time with the patient, with no intervention having been made); control (4 weeks after the initial assessment, still with no intervention having been made); final (after six acupuncture

Perception of signs and symptoms of TMD in females

sessions); and follow-up (4 weeks after the last acupuncture session). Additional VAS data were collected four times during the acupuncture sessions: time 2 (after the first acupuncture session), time 3 (after the second session), time 4 (after the third session), and time 5 (after the fourth session). The assessments were administered by a different researcher, not the acupuncturist who executed the treatments. After data collection, a statistical analysis was performed with the SPSS software 20?0 (IBM Corporation). As the data were nonparametric, the Wilcoxon test was used for paired intra-group comparisons between initial, control, final and follow-up, besides the times 2, 3, 4, and 5; Pv0?05 was considered to be statistically significant.

Results Protocol for multidisciplinary centers for determination of signs and symptoms of TMDs In the analysis between groups, statistical differences in the symptoms of muscle pain, joint pain and difficulty with swallowing were found only at the time of the final evaluation. As to muscle pain, the JOI-LP and the MUS-DP groups had the lowest scores. As to joint pain, the highest scores were recorded by the JOI-DP groups; these scores being similar only to the scores of the MUS-LP. As to difficulty with swallowing, the scores of the JOI-DP group were statistically higher than those of the other groups, and the scores of the other groups were similar to one another. For the remaining evaluation times (initial, control, and follow-up), no statistical differences were noted in the scores for any of the symptoms (Pw0?05), i.e. at those times, the scores recorded by all the studied groups were statistically similar. In the intra-group analysis, the paired comparisons between the initial, final, and follow-up time gave the following results: In the JOI-LP group, the scores for all symptoms were lower on the final evaluation than on the initial evaluation, except for difficulty with chewing, for which the final score was higher when compared with the initial score. In the JOI-DP group, only the symptom of difficulty with chewing was reported decreased on the final evaluation. In the MUS-DP group, the symptoms scores for tiredness in muscles, joint pain, neck pain, and headache were lower on the final evaluation. In the MUSLP group, a statistical difference was found only in joint pain, for which the scores were higher on the final evaluation than on the initial evaluation; the scores on the final and the follow-up evaluations were statistically similar.

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Visual Analog Scale An analysis of the VAS scores between the groups showed a statistical similarity between the scores recorded at pre-acupuncture (initial and control) and post-acupuncture (final and follow-up) times. In paired intra-group comparisons between times, all groups had the same following statistical behaviors: initial/control (similar, Pw0?05), initial/control versus final/follow-up (different, Pv0?05), and final/followup (similar, Pw0?05). Figure 1 shows that significant reductions in the symptoms were reported by the patients on the final and follow-up evaluations. By analyzing the VAS scores during the acupuncture treatment, it was possible to observe the evolution of the scores during treatment. The scores at the time ‘‘control’’, immediately preceding the first acupuncture session, were compared to those at all other evaluation times, as shown in Fig. 2. In this comparison, in the JOI-DP group, only evaluation at time 2 was statistically similar to the control (Pw0?05). For the JOI-LP group, the evaluations at all times were different from that at the control time. For the MUS-DP group, the evaluations at times 2, 3, and 4 were similar to that at the control time (Pw0?05), and for the MUS-LP group, only the evaluation at time 2 was similar to that at the control time (Pw0?05).

Discussion The systematic review and meta-analysis performed in 2011 by Jung et al.,14 which included only randomized clinical trials, showed limited scientific evidence for acupuncture as an effective method for treating symptomatic TMD, but that acupuncture certainly had an

undeniable scientific value for this indication, and that more work in this area was necessary. The results of the evaluations showed no statistical differences between the eight signs at the final and the follow-up times. This suggests that even after the completion of acupuncture treatment, the patients’ perceptions of the signs and symptoms statistically remained the same, showing that the benefits derived from acupuncture treatment lasted even after the completion of treatment. Intra-group analyses showed that the best results were achieved with the JOI-LP and the MUS-DP groups, because in those groups, the perceptions of the signs and symptoms on the initial evaluation were statistically worse than those on the final evaluation, with statistical significance. These results based on the ProTMDMulti protocol suggest that for TMD involving joint components, the best treatment with acupuncture is with local points, and that for muscular TMD, the best treatment with acupuncture is with distant points (points at a distance). TMD pain can have a myogenic and/or articulate origin. Joint pain can arise from structures sensitive to pain in joints and ligaments.3 Functional changes or nociceptive stimulations in innervated TMJ structures can induce muscle responses, as a protective co-contraction or local myalgia, contributing to the onset of a muscle TMD, associated with the articular condition.13 Thus, such pain can emanate from the soft tissue structures associated with the muscles used for articulation or from the bone tissues themselves, which justifies the results observed in this study, in which, for the muscle and articular TMD group, the best results with acupuncture treatment were with local points

Figure 1 Comparisons within and between groups by using the VAS data at different evaluation times (initial, control, final, and follow-up). The blue bars, which make comparisons within groups at different evaluation times in a paired manner by using the Wilcoxon test (P, 0.05), are similar to each other. *Comparisons between initial/ 4

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control versus final/follow-up (different, P, 0.05).

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Figure 2 Paired intra-group comparisons based on the VAS data for various evaluation times. In each group, the asterisk above the bar indicates that a statistical similarity between that group and the respective control group exists based on masticatory the Wilcoxon test (P, female hormones on nociceptive processes and their (JOI-LP), located in the muscles and0.05). associated structures of the stomatognathic system. A randomized controlled trial (RCT) indicates that acupuncture is one of the best treatments for TMD.15 According to Chinese tradition, the technique is able to adjust energy channels in the body according to balance of Yin and Yang. Modern Western medicine, however, suggests that this method stimulates the release of chemicals that modify the nervous system through the release of endogenous neurotransmitters that will promote an overall well-being and reduce the perceptions of pain and other symptoms.16 In relation to the evaluation by using the VAS, in general, a significant improvement in pain after acupuncture treatment was noted in all groups, with the best results being found in the JOI-LP group. These results were in agreement with those based on the ProTMDMulti protocol. In all groups, except in the JOI-LP group, time 2 (1st acupuncture session) was similar to the control. Thus, the JOI-PL group had already shown a significant reduction in pain by the first acupuncture session. The worst result was found in the MUS-DP because only at time 5 (fourth acupuncture session) was a reduction in pain recorded, which did not agree with the result found through the ProTMDMulti protocol. The treatment effects appear to be trending upward; statistically there is no difference between the final treatment and the 4-week assessment, indicating that the results last beyond the final treatment. As is well known from the scientific literature, women are more affected by TMD than men. This study did not consider the menstrual period of the research volunteers, which might have modified the patients’ perceptions of pain. The influence of

correlation with orofacial pain has been extensively studied and should be included in studies involving these aspects. This study opens the door to new research aimed at determining whether or not the effects of acupuncture treatment in women with TMD is related to their menstrual period.17 The healthy improvement induced by the acupuncture treatment is a consequence related with the balance of the energy meridians; it is impossible to determine if this kind of treatment reduces the signs and symptoms because of the hormonal balancing or analgesic effects. The acupuncture care involves a wide vision about health, in which the energy imbalance might cause body diseases, and if the meridians are re-established by the treatment, the mind comes into balance with the body. This sum of factors involved in this therapy makes the challenge of developing acupuncture research so provocative.

Conclusions Despite the limitations of this study, by using the developed methodology, it is possible to draw the following conclusions: first, the VAS and the ProTMDMulti protocols have proven to be efficient for evaluating the patients’ perceptions of the signs and symptoms of TMD. Second, according to evaluations using the ProTMDMulti protocol, the best results were found in the JOI-LP and the MUS-DP groups, which suggest that for TMDs that involve joint components, the best acupuncture treatment involves local points, and for the TMDs that involve muscle components, the best acupuncture treatment involves points at a distance. Third, according to the evaluations using the VAS protocol, the best

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results were found in the JOI-LP group, in agreement with the results found by using the ProTMDMulti protocol. Fourth, after acupuncture treatment, in all groups studied, the results found by using both the VAS and the ProTMDMulti protocols showed that the patients’ perceptions of the signs and symptoms of TMD on the final and the follow-up evaluations were similar, which suggests that even after the completion of the acupuncture sessions, the benefits achieved by the acupuncture treatment (local points and points at a distance) remained.

Disclaimer Statements Contributors All authors have contributed to the paper. Funding Conflicts of interest There is no conflicts of interest. Ethics approval This study has had the ethics approval.

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6 Rosted P. Practical recommendations for the use of acupuncture in the treatment of temporomandibular disorders based on the outcome of published controlled studies. Oral Dis. 2001;7:109–15. 7 WHO. Acupuncture: review and analysis of reports on controlled clinical trials. Geneva: World Health Organization; p. 81 2002. 8 Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomand Disord. 1992;6:301–55. 9 Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27: 117–26. 10 Conti PC, de Azevedo LR, de Souza NV, Ferreira FV. Pain measurement in TMD patients: evaluation of precision and sensitivity of different scales. J Oral Rehabil. 2001;28:534–9. 11 De Felicio CM, Mazzetto MO, de Silva MA, Bataglion C, Hotta TH. A preliminary protocol for multi-professional centers for the determination of signs and symptoms of temporomandibular disorders. J Craniomandib Pract. 2006;24:258–64. 12 De Felicio CM, Melchior MO, Da Silva MA. Clinical validity of the protocol for multi-professional centers for the determination of signs and symptoms of temporomandibular disorders. Part II. J Craniomandib Pract. 2009;27(1):62–7. 13 Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. 2008;359(25):2693–705. 14 Jung A, Shin BC, Lee MS, Sim H, Ernst E. Acupuncture for treating temporomandibular joint disorders: a systematic review and meta-analysis of randomized, sham-controlled trials. J Dent. 2011;39:341–50. 15 La Touche R, Goddard G, De-la-Hoz JL, Wang A, AnguloDiaz-Parreo S, Mesa J, et al. Acupuncture in the treatment of pain in temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials. Clin J Pain. 2010;26:541–50. 16 Ritenbaugh C, Hammerschlag R, Dworkin SF, Aickin MG, Mist SD, Elder CR, et al. Comparative effectiveness of traditional Chinese medicine and psychosocial care in the treatment of temporomandibular disorders – associated chronic facial pain. J Pain. 2012;13:1075–89. 17 Madani AS, Shamsian AA, Hedayati-Moghaddam MR, FathiMoghadam F, Sabooni MR, Mirmortazavi A, et al. A crosssectional study of the relationship between serum sexual hormone levels and internal derangement of temporomandibular joint. J Oral Rehabil. 2013;40:569–73.

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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.

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