"The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease." - Thomas A. Edison

Peter Varley BDSc, FDSRCS, DFHom(Dent.) and Simon Hayhoe MBBS, LRCP, MRCS, DA, FICAE.(profile)

History of Acupuncture

Acupuncture is used to some extent in the majority of hospital pain clinics and many general medical practitioners include it in their armamentarium. For most people however, there still seems to be a psychological chasm between Western medical logic and mediaeval Chinese theory.

Stone needles were found in the foothills of Eastern China, so it is thought that the practice of acupuncture originated there in the stone ages. The ‘Yellow Emperor’s Classic of Internal Medicine’ was probably started in the 5th century BC. It contains an account of acupuncture theory, and it is clear that acupuncture was fully integrated into what was the conventional medicine of the day.

In the mid 17th century, Western influences began to deprive acupuncture of its status. By 1822 acupuncture had fallen from grace and was banned from the Imperial Medical Institute. It remained a popular treatment with the people, but it was no longer practised by the court physicians. There was no research, no recording of observations and no new literature. This at a time when Western medicine had been making unprecedented advances that should have been incorporated into the theory and practice of acupuncture by leading lights of the Chinese medical profession.

It was not until the ‘Great Leap Forward’ in the 1950s that acupuncture re-emerged and was enthusiastically promoted by the government. Unfortunately, the two centuries of stagnation had prevented acupuncture from advancing medically in step with modern physiological research. It was brought back undeveloped, in the same state that it had been in before its decline. Surprisingly, there has been pressure from the West, notably from the non-medical practitioners, to retain acupuncture in its mediaeval state. The Chinese appear quite happy to provide courses in the old-fashioned theories; after all they bring in many much needed dollars.

This has meant that acupuncture has three distinct types of practice in the West:

• A small number of fully trained Chinese doctors practise traditional Chinese medicine (TCM) in Western cities.
• A huge number of non-medical Westerners who have had some training in traditional acupuncture use it to treat medical problems with varying degrees of success.
• Medical, dental and veterinary practitioners tend to practise a Westernised, ‘scientific’ form of acupuncture in which little account is paid to the traditional laws and theories, but points are selected according to neurological and muscular patterns.

Relief of pain

It is used in dentistry in the form of electroacupuncture and TENS

Facial neuralgia, now being seen more often by dentists, is one of the most distressing and debilitating afflictions. This is particularly so as its conventional treatment can be poorly effective or even destructive. However acupuncture is a highly effective (over 70% success), cheap, simple and non-intrusive treatment, sadly distinguished by its lack of use.

Mechanism of Action

Acupuncture works on Melzac and Wall’s Gate theory of Pain, releasing encephalins which block the release of neurotransmitters. This has been successfully established following research transferring the CSF and blood in rabbits following acupuncture.

Success Rates

Bonica investigated the general Chinese claim of a 94% success rate for acupuncture anesthesia and found that patients were graded into three levels of success and one of failure. Grade 1 (30%) was good analgesia, grade 2 (37%) was inadequate analgesia, grade 3 (27%) was pain that did not prevent the operation continuing and grade 4 (6%) was severe pain that disrupted the operation. From the Chinese point of view, the first 3 grades were successful since the operation was completed. From a Western point of view grades 2, 3 and 4 would all be considered failures of the technique since the patients were in pain. Further, only those patients (about 10%) who were psychologically suitable and who had already demonstrated an analgesic response to acupuncture were selected for acupuncture anesthesia Thus the westernised success rate was about 3% rather than the 94% quoted. This is reflected in the initial use that was made of the technique in China.

The foregoing highlights the problem of interpreting Chinese research papers, which often claim a success rate of over 90%, with many trials achieving 100%. It is not that there is any intention to mislead, as the true figures are usually given, but that the interpretation is of a culturally oriental, over enthusiastic variety rather than the typically Western, phlegmatic reporting that we have come to expect from our research papers. Each Chinese report, therefore, needs to be re-evaluated with this in mind, rather than being dismissed as simply unbelievable.

Practising Acupuncture

Needle Stimulation

The amount of stimulation required after insertion of a needle is still a source of controversy. Traditionally needles are pushed through into muscle and rotated to induce ‘needling sensation’, which is variously described as a ‘deep seated hurt’ or an ‘electric tingle’, depending on the site stimulated. More commonly now, brief, superficial needling is considered sufficient, even for trigger point deactivation, as induced activity of the A-delta nerves overlying the trigger point often seems to be as effective as needling into the point itself.

Treatment Frequency

In China treatment may often be given daily, but in the West it is rare to treat more than once a week. Apart from the obvious practical aspect of providing sufficient clinic time, weekly treatment seems logical since needling causes a small amount of injury, with consequent release of tissue injury factors, that last for about a week.

Side Effects

Not only is acupuncture sufficiently powerful that over-treatment can cause worsening but, like any other effective therapy, it can have side effects, some dangerous.

Fainting

One such side effect is fainting, sometimes accompanied by an epileptiform fit, which occurs as an autonomic over-response to needling, particularly in young men at their first treatment session. In general, therefore, a first acupuncture treatment should be given lying rather than sitting.

Pneumothorax

The most common major complication of acupuncture that has many reports in a wide variety of journals is pneumothorax. A point on the ridge of the shoulder near the nape of the neck, GB.21, which is a very commonly used tender spot associated with neck pain and headache, has been the source of many pneumothoraces, as the apex of the lung comes close to the skin surface there; to avoid danger needles should be inserted superficially, parallel to the skin.

Internal Organ Damage

There are reports of puncture of most other major organs, notably the liver, spleen and gall bladder in malarial areas when these organs are enlarged or abnormally positioned.

Cranial Damage

Certain midline points on the skull itself are commonly used to induce relaxation. However, they are deemed forbidden points in children because of the danger of penetrating a fontanelle.

Infection

Bacterial

Bacterial infection is very rare with simple needling into normal tissue as the skin is self cleansing. There is no need to use alcohol wipes, indeed unless a full antibacterial alcohol cleansing is used, a brief wipe can destroy normal commensals and allow overgrowth of pathogenic bacteria. The only cases where bacterial infection is a problem are when indwelling needles are left in the skin and in the immuno-compromised patient, particularly after radiotherapy.

Viral

Viral infection, notably Hepatitis B, is quite another matter. There have been several recorded outbreaks of Hepatitis B in the West from lack of sterilisation of acupuncture needles and the endemic nature of hepatitis in China may in part be due to the widespread use of unsterilised needles. With a more general understanding of the need for sterilisation and the availability of cheap, disposable needles this problem should become a thing of the past.

Patients also worry about transmission of the AIDS virus; perhaps needlessly, since there are no proven recorded cases. There is unlikely to be any appreciable volume of blood transmitted. Unlike hepatitis where only a trace of serum is required, AIDS transmission is probably only possible with a hollow needle, that should not be used for acupuncture anyway.

The public assume that acupuncture is a totally complication free therapy. In medical and dental hands, they do not expect harm from the insertion of a needle. It is vital that we use acupuncture in a safe manner, avoiding the risks that are inherent in some traditional teaching, by thinking of the anatomy of any structure that we intend to puncture and bearing in mind that superficial needling is frequently as effective as deep stimulation.

Training

The British Medical Acupuncture Society (BMAS) is happy to give advice about courses in Great Britain and has international contacts with equivalent medical societies throughout the world.

Treatment Modalities Used in Dentistry

Use a small number of points briefly for sensitive patients and more, with increased stimulation, for less strong responders. Below we have selected a number of points for specific treatment modalities, so that although the following may appear as a cookbook listing of traditional points, most can be justified on a neurological basis. The points below are described below using the traditional acupuncture code. The meridian code is described in Figure 4 and the position of each point on the meridian is described in detail in the book ‘Complementary therapies in Dental Practice’ from which this article has been taken.

Figure 4. Traditional acupuncture meridians in the upper part of the body.

TMJ pain

There have been quite a number of reports in which acupuncture has proved effective in the relief of TMJ pain, indeed it seems logical to try this cheap and pain free option before attempting surgical treatment which can be expensive, hazardous and painful.

General: LI.4, GB.20
Local: GB.2, SI.17, ST.7

Dental pain

Acupuncture has little place in the usual forms of dental pain, since this can be relieved so simply by conventional means, e.g. local anaesthetic. However, it can certainly be useful in particular cases and for post extraction pain.

General: LI.4, ST.44, KI.3
Local: ST.6,7, TE.21

Facial neuralgias

This is the treatment of choice for facial neuralgias, certainly in the first instance, since it has a high success rate (over 70% in some centres), is non-invasive and complication free, unlike most of the other treatment options. Carbamazepine and tricyclic antidepressants are commonly used drug treatments, both of which can be effective at damping down neuralgic pain. Do not stop or reduce these drugs while giving acupuncture, as both appear to enhance the benefit derived from the acupuncture treatment. Once treatment has proved effective, the drugs may be reduced very cautiously.

General: LI.4, ST.44, GV.20
Local: Mandibular: GB.2, ST.4,5,6
Maxillary: SI.18, 19, ST.2,3,7.

Headache and Migraine

A number of controlled clinical trials have demonstrated the effectivity of acupuncture in headache and migraine. Unlike most drug treatments, acupuncture is of long term, prophylactic benefit, but can also be used effectively in acute episodes.

Figure 5. Acupuncture for migraine using traditional points in the neck and the sedation point GV20.

There are many causes of headache, some of which can also act as triggers for migraine. We have therefore suggested points for the different causes, which should be combined prophylactically with points for the area where headache is predominantly felt. During a headache, LI.4 alone often gives rapid relief.

General: LI.4, LR.3, GB.20, GV.20
E ar: Shenmen, Sympathetic, Occiput, Forehead
Causes:
Tension: GB.20,21, BL.10, TE.16, LI.4, LR.3, GV.15,20
Myofascial: Trigger points, particularly in sterno-mastoid
Allergic: LI.4,11, SP.10
Sinusitis: LI.20, ST.2, BL.2, EX.1
Eyes (myopia): EX.2, GB.20
Earache: GB.2,20, TE.17,21, SI.19
Pre-menstrual: SP.6, GV.20
Hypertension: LR.3, ST.36, LI.4, SP.6, GV.20
Migraine with nausea: PC.6, LI.4, LR.3, GB.20, GV.20
Dry mouth or over-salivation
Surprisingly, the same points are used for both ends of the spectrum; there seems to be a rebalancing effect, just as traditional Chinese teaching suggests.
General: LI.4, PC.6, GV.20
Local: SI.17, ST.4,5,6, CV.23
Retching or excessive gag

A recent paper has found that acupressure at PC.6 is ineffective alone for retching. However, acupuncture at other points may be useful,¹¹² or it may well be that sedative points are indicated initially, particularly GV.20 and LI.4.

General: PC.6, GV.20, LI.4
Local: CV.22,23, ST.9

Conclusion

Used sensibly by doctors and dentists, acupuncture is an extremely safe method of treatment that has a surprisingly high level of success in the relief of facial pain, even where conventional medicine has failed to give benefit. It is worth trying also in non painful facial disease, although the physiological rationale is sometimes less obvious. Even beginners can expect encouraging results, so do not be put off by the complicated traditional Chinese theory: use Western medical logic as We have described and have a go. Your patients will be delighted!

Simon Hayhoe MBBS, MRCS, LRCP, DA, FICAE.

Simon is an anesthetist with an Acupuncture and Hypnotherapy practice in Colchester (UK). He has a particular interest in dental anesthesia and teaches on the Society for the Advancement of Anesthesia in Dentistry (SAAD) sedation courses, lecturing on alternative methods of pain control.

He was a founder member of the British Medical Acupuncture Society (BMAS) and later became a lecturer on both their medical and dental courses and Chairman of the Society.

Simon is Treasurer and British representative of the International Council for Medical Acupuncture and Related Techniques (ICMART) and has been awarded the ICMART diploma for service in the promotion of medical acupuncture. He is a Fellow of the International College of Acupuncture and Electro-Therapeutics and on the Editorial Board of their Journal. As Editor of ‘Acupuncture in Medicine’, the BMAS Journal, Simon has sought to encourage doctors and dentists to accept Acupuncture as a logical Western tool.

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