A patient attends acupuncture treatment the medical diagnosis: Tinnitus aurium. The patient asks is that acupuncture can treat the disorder?
Acupuncturist answered yes, the patient asks the illness is in middle ear how does ACU can treat? The medical Dr say that is untreated able. Acupuncturist asks the patient why you come here for?
Acupuncturist examination the patient right ear at ACU point TH21 can palpate the superficial temporal artery pulsation.
Artery vein and parotids gland surrounding the ear
The practitioner following the anatomy illustration needling into the skin and connective tissues at the side of the artery vein and parotid gland released the obstructive tissue the tinnitus symptom is released. To cure the illness require balance both side temporo- mandipular joint and sternomastoid muscles movement.
In other case for example: the illness for more then ten years the TMJ joint is compressed to the ear the patient had tinnitus one side and lost hearing on other side the ACU treatment is too late.
TEMPOROMANDIBULAR JOINT SYNDROME
GENERAL CONSIDERATION
Temporomandibular joint (TMJ) pain is one of the major causes of the headaches. Headache associated with TMJ syndrome is common in adults and children, frequently, go with TMJ acute inflammation and chronic inflammation, chronic pain, tinnitus aurium, and others impairment.
In medicine there are a variety of treatment can be use to treat this disorder, in particular, in the field of dentistry and neurology.
In this discussion is mainly focus on acupuncture approach to TMJ.
PATHOPHYSIOLOGY
The essential TMJ disorder is in loss of equilibrium of both side of the function of the temporomandibular joint (TMJ) or/and TMJ restriction.
Structurally, the illness is involved the mandible ramus (bone) the TMJ (joint), the ligaments and the muscles in which are attached to the bone and joint, the skin and connective tissue envelop the joint. At the head of the joint and the external acoustic meatus where is the neurovascular pass through. (CNX) A normal TMJ movement also involved to the tooth, which is of the necessity a correct tooth biting position.
In acupuncture practice require observing these factors:
- Acute or chronic inflammation of the TMJ, the joint capsule is swelling or the joint movement is restricted.
- Both side of the mandible ramus, is there, structurally, a history of one side is abnormal or fracture or the clavicle fracture.
- Age changing in childhood such as lost tooth or the tooth is growing on faulty tooth position.
- Both sites of the muscles those attaching to the TMJ and bone are lost of coordinate movement cause imbalances of both side joint movements.
5.The ligament attached to the TMJ is trauma.
- Poor bite habit in which increasing damage to the joints etc.
- Ageing processes lost tooth the skin is degeneration.
Any of which can interrupted the TMJ function. When the joint is in unstable position the participant in eating, especially, biting a hard food such as a nut can increase trauma to the joint causing acute inflammation. In this state, the patient resting and the pain symptom will reduce. However, the cause of the disorder is remains and repeat over used may lesion to the joint, chronic inflammation and joint restriction is result. In this stage, the pain is occurs when the patient largely open the jaw or biting the hard food, when it is sever even open the mouth singing or talking become difficult, frequency headache go after all that activities.
In the case of chronic inflammation located on the head of the temporomandibular joint, the trauma causing the articular dist thinner or disappeared: the condylar process may direct impacts to the external acoustic meatus that will affected to the ear and the cranial nerves pathway in this region, especially lesion to CNX. The symptoms such as tinnitus aurium, nausea, and lost of balances may presented.
In this stage, all this syndrome is initial by the chronic inflammation, additionally, the lesion is not limited in superficial of the joint deeper tissue also involved; the swollen tissues, faulty bone position that compress to the neurovascular pathway, tissues adhesion over stretch the skin muscle increasing tension surround the TMJ and scalp and also will affected to the involved cranial nerve function.
Clinical Finding
One side of the joint capsule is swollen and pain to palpate. Joint movement is restricted more often that occurs in one side of the joint.
The lesion muscles include: masseter, temporoparietalis, temporalis, three auricularis, sternocleidomastoid, are chronic tighten and contracted.
The lesion neurovascular involved: superficial temporal vein and artery, auriculotemporal nerve (V3), facial nerve (CNVII), Vagus nerve (CNX), the artery pulsation can be palpated, local skin sensation at between the joint, especially, at the head of mandible and external acoustic meatus is over sensitive.
The patient complain headache, stiffness of neck, insomnia, crunching teeth at night and sore jaw, difficulty in transportation, inanition, feel dizziness or nauseas.
The young patient do known carefully avoid the difficulty occurred and when the symptom appear the patient will quickly lying in bed to release the symptom.
In adult, in many instances not have the necessity able to achieve the symptom relieved, even taken medication before or after the symptom occurred. Frequency headache, the patient is stressful, tinnitus, hearing difficulty in one side of the ear, insomnia, stiffness of neck, difficulty in air flight more often after air flight increasing the syndrome such as the poor hearing, headache frequency and dizziness.
In this state or the complicate syndrome occurred, the illness is regarded as a difficult case to manage especially, in western medicine regards unable to treat.
ACUPUNCTURE MANAGEMENT
Acupuncture is one form of medical management can be considered in treating TMJ disorder.
When illness is in acute inflammation stage the treatment will improve rapidly, only need few treatments is requires.
In this case, frequently, occurs in childhood the patient has some difficulty in the dentistry: in the time of changing tooth loosing or growing, or prolong mouth open in tooth extracted. The TMJ trauma is not have the necessity too severe, acupuncture needle is inserted at the acute inflammation pain point can rapidly relieves the pain and improve the healing. The patient should aware in eating, should eating soup instead of chewing food, just need few days the pain is gone.
When illness is in chronic state the patient had experiences many type of treatment and lost confident in all the treatments, in this case, acupuncture treatment can be difficult, frequently, the patient come for acupuncture is tried acupuncture for reduce severe headache frequency, and stress relieved.
CLINICAL PRACTICE
In Chinese Medicine, when illness is in acute state and/or the patient asking for pain relieves, the initial treatment should focus on the request of the patient.
In this case, a good relaxation treatment is on going. A peaceful quiet environment, gentle facial massage, and few facial points are selected. Acupuncture point such as facial points BL2, TaiYang, ST5, ST6, ST7, TH21, TH22, TH17, SI19, and extremities points such as LI4, Liv3, are selected and gentle needle insertion method is used and the needle is retentions in the points for 15minutes.
Most of the patients feel relax and the headache is reduced immediate after treatment, but pain syndrome rapidly return. The pain syndrome return is because the illness other factors still remain that need more treatment to remove the others’ factors. Some patients are not have the necessity listen to the treatment explanation or to known the illnesses recovery processes and withdrawn the treatment.
Relaxation is part of the acupuncture treatment. In this case, the illness had a long period of history, and the illness is severed, and the body damaging tissue is complicated, in which is need times for treatment to assist the body healing process. Without good communication between the patient and practitioner and knowing the treatment plan and illness recovery need times, the treatment is difficult proceeding.
The Treatment Plan
The practitioner needs to make a plan for the treatment that involved on looking at the illness whole outline, in which should be individual. If that is possible the practitioner should confidently tell the patient how many treatments is required.
Anatomy of TMJ is involved the joint capsule and ligament.
The muscle involved to the TMJ and mandible (bone) movement is the muscle attached to the joint and bone.
The mastication is included:
Temporalis
Masseter
Ptorygoideus medialis and pterygoideus lateralis
The associate muscle is sternocleidomastoideus.
The skin and connective tissue is enveloped the joint bone and muscles.
The TMJ is the body most active and larger motion joint and both side of the TMJ need to balance and harmoniously work together. The TMJ is also involved to the mouth and teeth movement. There fore, TMJ is situated in a high risk of trauma and cause disorders. When TMJ severe syndrome is occurred in which is the faulty position of the jaw compressing to the neurovascular tissues will affected to the cranial nerves, the senses organs and affected to CNS and ANS as well.
The acupuncture management needs to concern the others’ type of treatments for TMJ, without specific reason; it is preferable focus on acupuncture treatment only. That will avoid confusing the patient; in which is the different treatment provided different approach and different conception.
The planning and approach of acupuncture seems more often than not is focus on the muscle, however, the treatment is focus on relieved the tension in the skin and muscles to balance the mechanical force to stabilize the joint and bone, hence, it is able to reduce the pain. The needle is inserted into the skin and muscle receptors that are the way to get the first relieve, the relaxation treatment.
After pain reduced the needle insertion method is focus on the treatment on correlation of the muscles joint and bone. Thus, the needle insertion direction and depth are going with the treatment. The needle may go through the skin, the side of the muscle, the joint, and deep into periosteum, which included the correlative of the skin muscle joint and bone. An adequate needle technique can rapidly achieve the results. The Chinese called [heaven, man, earth] needle technique.
Needle Insertion Method
TMJ joint capsules
For example: TH21 GB2 SI19
These three points are located on the TMJ joint capsules. An acute inflammation of TMJ for example: located the swelling point, needle is inserted precisely into the inflammation lump, three needles are inserted into the lump can immediately relieved the swollen and pain.
When the TMJ is restricted the needle is inserted into the skin and into the joint capsules and the ligament attached to the joint to remove the adhesion. A single needle not good enough to remove the obstruction, in which is need three points in one side of the joint and need others needle insertion to the other side of the joint. Here is the point ST7 can be selected.
ST7 XIA-GUAN
The point is located at the medial side of the condylar process of mandible TMJ; slightly open the mouth there is a hole of the mandibular notch. The TMJ joint capsules and ligament attach to condylar process, superficially, is the masseter, and deep internal is pterygoid muscles. The needle is inserted into the side of the condylar process and deep into the pterygoid muscle. The needle insertion is involving joint capsules ligament and muscles. The result is remove the joint restriction open the mouth and jaw.
MUSCLES OF MASTICATION
Temporalis: origin—temporal and parietal bones. Insertion—coronoid process of mandible.
Masseter: origin—zygomatic arch. Insertion—angle of mandible.
Lateral pterygoid:
Superior head: origin—sphenoid bone, insertion—temporomandibular disk.
Inferior head: origin—lateral pterygoid plate, insertion—neck of mandible.
Medial pterygoid: origin—medial and lateral pterygoid plates, insertion—angle of the mandible.
MASSETER
Needle insertion method
There are four points ST5, ST6, ST7, and SI18.
The two points ST5 and ST6 are located at the insertion of masseter.
The needle is obliquely inserted into the skin and the side of the muscle from ST5 toward ST6. The other needle is obliquely inserted from ST6 toward the ST5.
The ST7 and SI18 are located at upper section of the origin of masseter. For relieve the tension of the masseter, the needle insertion method is the same as above; the needle is obliquely inserted into the skin and the muscle from ST7 toward SI18, and from SI18 toward ST7. Needle insertion remain mouth close and the needle is obliquely along the edge of the zygomatic arch.
Here is another approach for ST7 and SI18.
ST7 is located at the condylar process is that TMJ capsules, ligament, and pterygoid lateralis attached. The needle is along the side of the condylar process perpendicularly inserted into the skin, masseter, joint capsules, ligament, and pterygoid lateralis, can relieved all these tissues tension.
It is the same as the point SI18. The point SI18 is inserted needle into the skin masseter deep interior is temporalis tendon and pterygoid muscles. When needle is inserted into this point need to slightly open the mouth and get in to different layer tissues. Needle insertion depth is 0.7 cm limited to the tendon only, deep interior the blood vessel plexus is near to the point.
(Facial nerve zygomatic branches and the trigeminal maxillary division are distributed in this area. Transverse facial artery and vein, deep facial vein, posterior superior alveolar vein and pterygoid plexus are also located deep interior near this point. Still deeper interior is the buccinator muscle.)
TEMPORALIS
There are some points that located at skull, most of which is involved the scalp and muscle. Such as TH22 and GB3, these two points are located at superior border of the zygomatic arch can feel superficial temporal artery pulsation, deep interior is the temporalis tendon or muscle. The tendon is attached to the coronoid process that involved to the point SI18. If the needle insertion is concerned or target to the temporalis, these three points should be selected and go with GB8 SHUAI-GU that located at the scalp and temporalis muscle.
The temporalis is the large muscle and strongly closes the jaw, clenches teeth. In the case of epilepsy when the temporalis muscle contraction, frequently, may severely damage the teeth and the jaw. The anterior auricula arteries, superficial temporalis artery and vein are run through the point, auriculotemporal nerve (CN V), temporal branches of facial nerve also distributed in this point. (Anatomy) The interference of anatomy structure and function of the temporalis can cause damage to the TMJ. In the case of difficulty of extract the wisdom tooth, frequently, is the example.
Acupuncture able to relieve the tension or the lesion in the temporalis and is obliging in the treatment of TMJ.
STERNOCLEIDOMASTIOD
There are three points in which is located at the sternocleidomastoid muscle attached to the mastoid process. Two needles are inserted into the side of the muscle and one needle is inserted into the center of the muscle that can rapidly relieve the tension of the skin and the muscle.
SI 17 TIAN-RONG SI16 TIAN-CHUANG TH16 TIAN-YOU BL10 TIAN-ZHU
The point SI 17 is located posterior to the angle of the mandible at the lateral side of the sternocleidomastoid muscle and the posterior belly of the digestive muscle.
The point SI16 is located at medial side of strenocleidomastiod.
The point TH 16 is located at the medial side of the sternocleidomastoideus posterior inferior to the mastoid process.
The point BL10 is located at lateral side of trapezius, on the line of GV15.
Initial SI17 make a line connected to BL10, several points are made at 0.5cm interval, and the needle is inserted perpendicularly into the skin and the muscle fascia. The result of the treatment is better than using single point. It is used to relieve the skin muscle tension in this region.
After needle insertion tension headaches, the skin and neck muscles are relaxes, the patient able to open the jaw largely.
CONCLUSION
Acupuncture able to manage the TMJ syndrome. In the case of an early stage, such as in acute inflammation state require few treatments can relieve the symptom. In a chronic and complicate case, acupuncture able to achieve the result that largely dependent upon the experiences of the practitioner, and what the patient want to achieve. In general, acupuncture can reduce the headaches; relieve the stress, improving the tinnitus at the early stage. When the hearing is lost and containing severe tinnitus aurium that nerve tissue is damaged difficult to achieve the result.