Temporomandibular joint dysfunction has become an increasingly common complaint encountered in acupuncture clinics. While the cause of such discomfort is multifaceted, and includes joint degeneration, trauma and stress, there is frequently a myofascial component that can be treated effectively with acupuncture. Symptoms may include pain in the joint (or even in the ear); tinnitus; tenderness and swelling; difficulty chewing or opening the mouth; and a clicking sound heard by the patient or (with a stethoscope) the practitioner. Before beginning treatment, it is a good idea to have a workup performed by a physician or dentist who specializes in jaw pain in order to rule out other causative factors, such as a tumor.
Treatment of temporomandibular joint dysfunction involves three strategies using local, adjacent/local and distal points.
Primary local points: While several local points affect the joint, Stomach 7 (xia guan) is the primary point, along with San Jiao 21 (er men), Small Intestine 19 (ting gong) and Gallbladder 2 (ting hui).
Secondary adjacent/local points: While Stomach 6 (jia che), because of its effect on the masseter muscle, is thought to be the primary point in this category to be needled, other points are worth considering. I saw San Jiao 17 (ying feng) used effectively for such pain in Shanghai, and have periodically found it to be sensitive in TMJ patients. Two other points, both part of the French barrier point system, are equally worth examination. These points, Gallbladder 3 (shang guan) and Urinary Bladder 6 (cheng guang), can play an important supporting role in reducing pain, and are also particularly useful when there is referred pain from the joint. Interestingly, Stomach 7, the primary point mentioned above, is part of the barrier point system for the jaw as well.
Distal points: There are several distal points that prove useful. Large Intestine 4 (he gu), on the side opposite the pain, may be extremely effective. The purpose of using this point is because of its effect on the Large Instestine tendinomuscular (sinew) channel. The right channel has a branch that ends near the left temporomandibular joint; the left channel has a branch that ends near the right temporomandibular joint. Hence, treating contralaterally may prove more effective than treating ipsilaterally (though pressure/pain upon palpation of the points and improvement of symptoms should be the determining factor). If the pain is acute and there is much swelling and inflammation, contralateral Large Intestine 1 (shang yang) may be substituted instead, since it has a heat clearing, anti-inflammatory effect while activating the sinew channel.
While many other points have been deemed effective, I am partial to using either Stomach 36 (zu san li), Stomach 41 (jie xi) or Gallbladder 34 (yang ling quan) ipsilaterally as a local point. For treatment once or twice a week, I have not found Gallbladder 31 (feng shi), 32 (zhong du) or 33 (xi yang guang) particularly effective, though other practitioners have used them with good results. Thus, they should be considered part of the distal treatment strategy.
Treatment Protocol
Step I: The protocol begins with using distal points after thoroughly palpating the temporomandibular joint. The practitioner may begin by palpating the primary local and secondary local/adjacent points to determine which are most sensitive and making a note of them. After noting these points, and before testing the distal points, have the patient open his or her mouth and note the degree of discomfort, clicking, or reduced range of motion.
Step II: Begin with one of the distal points on the ipsilateral side. Find the most sensitive area in the vicinity of the point and massage it strongly. Ask the patient to open his or her mouth. See if there is any improvement, or palpate the most sensitive point near the joint, and see if the sensitivity has improved. One distal point will generally produce more improvement than the others. Needle that point, generally with reducing method. If there are no contraindications, electrical stimulation might prove useful as well (insert a second needle in the channel near the first distal point for the second electrode).
Step III: Palpate Large Intestine 4 on the contralateral side and needle it in its most sensitive area, again reducing. If ipsilateral Large Intestine 4 is more sensitive, and the contralateral point does not achieve good results, you might want to try the ipsilateral point at a later treatment. Again, depending on symptoms, you may consider using Large Intestine 1 instead.
Step IV: Needle the two most sensitive primary local points (always including Stomach 7) and two of the local/adjacent points.
Step V: After removing the needles (15-20 minutes is sufficient for retention), you may want to use ion spheres, press tacks, magnets or other treatments, in accordance with your training; scope of practice; and the patient's individual constitution and needs, to extend the effects of the treatment. Ear points in particular may produce a good response if vaccaria seeds are applied to them. You may also want to teach patients to massage Large Intestine 4 and the most effective distal leg point.
At the beginning of your treatment plan, it may be a good idea to treat at least twice a week. As symptoms improve, reduce treatment to a weekly basis. If symptoms do not improve significantly within a few weeks, another treatment strategy is probably indicated.
Finally, I would like to add that as with other complicated dysfunctional syndromes, the treatment of TMJ syndrome provides an opportunity for acupuncturists to collaborate with conventional practitioners in patient treatment and care. Such collaboration can benefit not only patients, but the acupuncturist as well.
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