Acupuncture for facial pain.
A number of conditions can cause facial pain including temporomanibular joint (TMJ) disorder, trigeminal neuralgia, Bell’s palsy and toothache.
Temporomandibular joint disorder (TMJ).
Facial pain commonly results from temporomandibular joint (TMJ) disorder. Many practitioners refer to TMJ disorder, or syndrome, as a single disorder but there are various sub-diagnoses (e.g. myofascial pain, temporomandibular joint inflammation). The disorder is common and most often occurs in people aged between 20 and 40 years. Around 33% of the population has at least one temperomandibular symptom and 3.6% to 7% of the population has TMJ disorder with sufficient severity to cause them to seek treatment.
TMJ disorder is an umbrella term covering acute or chronic pain, especially in the muscles of mastication, or inflammation of the temporomandibular joint. The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, neoplasia and reactive lesions. Symptoms usually involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth. Symptoms can include difficulty in biting or chewing, jaw pain or tenderness of the jaw, clicking, popping, or grating sound when opening or closing the mouth, reduced ability to open or close the mouth, a dull, aching pain in the face, dizziness, headache or migraine (particularly in the morning), neck and shoulder pain, blinking, ear pain, hearing loss and tinnitus.
There have been a number of controlled randomized trials and a number of systematic reviews into the treatment of TMJ by acupuncture. Most concluded that acupuncture was effective over and above placebo and that it often was more effective than conventional care but all also concluded that more rigorous trials were needed. A typical systematic review was as follows:
A systematic review that assessed the effectiveness of acupuncture for the symptomatic treatment of temporomandibular disorders (TMD). It included 19 randomised controlled trials. There was moderate evidence that classical acupuncture had a positive influence beyond that of placebo (3 trials, 65 participants); had positive effects similar to those of occlusal splint therapy (3 trials, 160 participants); and was more effective for TMD symptoms than physical therapy (4 trials, 397 participants), indomethacin plus vitamin B1 (2 trials, 85 participants), and a wait-list control (3 trials, 138 participants). Two trials addressed adverse events and reported no serious adverse events. The reviewers concluded that their review noted moderate evidence that acupuncture is an effective intervention to reduce symptoms associated with TMD, but that there is a need for acupuncture trials with adequate sample sizes that address the long-term efficacy or effectiveness of acupuncture.
More research summaries and descriptions can be found on the British Acupuncture Council’s factsheet.
According to the NHS choices website, trigeminal neuralgia is:
Trigeminal neuralgia is a sudden, severe facial pain, described as sharp, shooting or like an electric shock.
It usually occurs in sudden short attacks lasting from a few seconds to about two minutes, which stop just as abruptly.
In the vast majority of cases it affects part or all of one side of the face, with the pain most commonly felt in the lower part of the face. Very occasionally it affects both sides of the face, but not normally at the same time.
People with the condition may experience attacks of pain regularly for days, weeks or months at a time. In severe cases, attacks may occur hundreds of times a day.
It’s possible for the pain to improve or even disappear altogether for several months or years at a time (known as a period of remission), although these periods of remission tend to get shorter with time. Some people may then go on to develop a more continuous aching, throbbing and burning sensation, sometimes accompanied by the sharp attacks.
Typically, the attacks of pain are brought on by activities that involve lightly touching the face, such as washing, eating and brushing the teeth, but they can also be triggered by wind (even a slight breeze or air conditioning) or movement of the face or head. Sometimes, the pain can occur without any trigger whatsoever.
Living with trigeminal neuralgia can be very difficult and it can have a significant impact on a person’s quality of life, resulting in problems such as weight loss, isolation and depression.
A large number of clinical trials have been conducted and acupuncture appears to be an effective treatment compared to conventional care and with less side effects. A systematic review concluded:
A systematic review that assessed the efficacy of acupuncture treatment for trigeminal neuralgia. Twelve randomised controlled studies involving a total of 920 people were included that compared acupuncture with carbamazepine. Four trials reported that acupuncture was superior to carbamazepine, and the remaining eight studies showed no difference between the treatment and control groups. Adverse effects with acupuncture, which were reported in three studies, were mild. The reviewers concluded that the evidence suggests that acupuncture is of a similar efficacy to carbamazepine, but results in fewer adverse effects in treatment of trigeminal neuralgia.
Bell’s palsy is a condition that causes temporary weakness or paralysis of the muscles in one side of the face. It is the most common cause of facial paralysis.
The symptoms of Bell’s palsy vary from person to person. The weakness on one side of the face can be described as either:
- partial palsy, which is mild muscle weakness
- complete palsy, which is no movement at all (paralysis) – although this is very rare
Bell’s palsy can also affect the eyelid and mouth, making it difficult to close and open them. In rare cases, it can affect both sides of a person’s face.
Bell’s palsy doesn’t really cause pain but there can be a tight uncomfortable sensation in the affected area.
Few quality studies have been completed but the following trial shows very promising results from the acupuncture arm of the study:
A multicentre single-blind randomised controlled trial involving 480 patients with Bell’s palsy (1-90 days after onset) that compared acupuncture alone with acupuncture in combination with drug treatment (i.e. prednisolone 30mg daily for 3 days, B vitamins and dibazole) and with drug treatment alone (the control group). The outcome assessors were unaware of the interventions assigned in the trial. The outcome measures were facial function graded using the House-Brackmann scale both pre- and post-treatment at 4 weeks, and disability and psychosocial status evaluated using the Facial Disability Index. A total of 41 patients did not complete the trial and were not included in the analysis. Significantly more patients were cured (House-Brackmann grade I) with acupuncture alone than in the control group (41% vs. 28.1%, respectively, p=0.013), but not the combined treatment group (31%). In all, 95.5% were cured, or obviously improved (House-Brackmann grade II) with acupuncture alone and with combined treatment compared with 87.5% in the control group (p=0.024 and 0.014, respectively). It is worth noting that among the 314 patients followed up at 3 and 6 months post-treatment, no difference was found between the three groups, with all patients reaching grade III or better on the House-Brackmann scale.
Whilst your first port of call for toothache should always be your dentist, acupuncture is actually a very well accepted treatment for dental pain. Whilst most problems are easily dealt with by dentists this isn’t always the case and I do occasionally see patients with chronic dental pain which is unresponsive to conventional care and I feel that acupuncture may have much to offer in these circumstances. The British Acupuncture Council has a comprehensive fact sheet on dental pain.