Hansson 87 is Acupuncture Sufficient as the Sole Analgesic in Oral Surgery

7/28/2019 Hansson 87 is Acupuncture Sufficient as the Sole Analgesic in Oral Surgery

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Is acupuncture sufficient as the soleanalgesic in oral surgery?Per Hansson, M.D., Ph.D., D.D.S.. Anders Ekblotp, M.D., Ph.D., D.D.S.,Mats Thornsson, D.D.S.,* and Thomas Lundeberg, M.D., Ph.D., Stockholm, SwedenDEPARTMENT OF PHYSIOLOGY II, KAROLINSKA INSTITU TET

Twenty-six patients who were undergoing operative removal of an impacte d third molar were givenacupuncture as an alternative to conventional local analgesia. Pain ratings during different stages of thesurgical procedure showed that gingival and periosteal incisions were tolerated, with only minor painexperienced by 18 of the patients. During mucoperio&a l flap disse ction 12 patients experiencedunacce ptable pain. In total, onty 2 of the patients tolerated the entire procedure; however, they reportedsevere pain during the final part of the operation. In conc lusion , it seem s that acupunctu re as performed inthe present study c ould not subserve as a routine method for analg esia in this type of operative procedure.(ORAL S LIIC. ORAL. MED. ORAL PATNIL 1987;64983-6)

A cupuncture as a pain-relieving method hasattracted enormous interest during the last decade aspart of the therapeutic arsenal in Western medicine.This is partly due to the ancient mysterious back-ground of the method as such, but also it can beattributed to the positive reports** made by Westernphysicians after visiting different acupuncture cen-ters in the Peoples Republic of China. In addition,reports have been published in Western medicalscientific papers3.4 on studies in which acupuncturewa s used for the alleviation of pain.In a previous articles we have reported on periph-eral afferent stimulation using transcutaneous elec-trical nerve stimulation (TENS) and vibration asalternatives to conventional local analgesia in dentaland oral surgery; however, this met with disappoint-ing results. In light of recent reports of successfulacupuncture analgesia in caries-excavating proce-dures, pulp surgery, and simple tooth extractions,b8 itseemed of interest to study the effect of acupunctureas an alternative to local analgesia in oral surgery(operative removal of impacted third molars).METHODS

Thirty-six rapdomly chosen patients who werescheduled for operative removal o f impacted thirdmolars (by M. T.) were asked (by A. E.) immediate-

*Department of Oral Surgery, Sidersjukhuset, Stockholm ,Sweden.

ly before surgery if they would participate in a studyin which acupuncture was to be used as an alterna-tive to local analgesia. All teeth were completelycovered with bone. Ten patients refused to partici-pate, eight of these because of anxiety about newmethods.

Twenty-six healthy patients (15 women 11 men)18 to 43 years of age (mean, 26 years), with noprevious experience of Bcupuncture agreed to partic-ipate. No patient had had pain during the last 7 daysin tbe area being operated on and none of them waspremed&ted, It was stressed that conventional localanalgesia (lidocaine, 20 mg/ml, with Adrenalin, 12.5rg/ml) would be given if. the acupuncture stimula-tion proved to be inefficient, that is, if the painexperienced during surgery was not acceptable to thepatient.All acupuncture procedures were conducted pre-operatively for 30 minutes by an experienced acu-puncturist (T. L. or a registered physical therapist).Except for five patients (see below), no furthercommunication took place about the expected effectof acupuncture. Only one of us (A. E.) was allowedto communicate with the patients before, during, andafter surgery. The acupuncture was applied at pointsSt 6, St 7,. Li 4, and an ear point (upper or lower jawpoint) ipsilateral tp the site of surgery and at P6contralaterally (Fig. 1). During treatment the need-les were inserted to a depth of0.6 io 1.3 cm with theuse of sterile procedures similar to those used forstarting intravenous infusions. It was ascertained

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284 Hansson et al. Oral Surg.September 1987

-St 6

P6

Li 4

Fig. 1. Schematic figure showing ocalization of differ-ent acupuncturepoints.

that all patients experienced a tingling, nonpainfulsensation (de Qi) during insertion of the needles.Twenty-one patients were radomly assigned to thefour followjng groups:Group 1. Six patients received acupuncture byintroduction of the needles only into the different

points. Thereafter no further manipulation wa s car-ried out. The needles were left in situ during thesurgical procedure.Group 2. Five patients received acupuncture bythe same method as in Group 1, but with the additionof manual stimulation (the needle wa s rotated con-tinuously 180 manually) every 5 minutes for 10seconds before surgery was started. The needles wereleft in situ during surgery.Group 3. Five patients received electrical stimula-tion applied to the needles (not ear point) before thestart of the operation. The needles were connected toan acupuncture pulse stimulator (Electroform 8,Delta Medical, Denmark) producing bipolar squarewave pulses with a duration of 0.2 msec and afrequency of 2 Hz. The stimulus intensity wasadjusted to about twice the perception threshold thatproduced nonpainful muscular contractions in thestimulated area. During surgery the needles were leftin situ without electrical stimulation.

Group 4. Five patients received electrical stimula-

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g P mp br exFig. 2. Abscissa shows specific surgical procedure: gin-gival incision (g); periosteal ncision (p); mucoperiostealflap dissection mp); bone removal (br); extraction (ex).Ordinate shows ercentageof patientscontinuing after aspecificsurgical procedure.

tion of the needles before and during surgery (seeGroup 3).Another five patients, not randomly assigned,were given manual acupuncture every 5 minutesbefore and during surgery (see Group 2), and posi-tive suggestions were constantly given about theexpected good pain-relieving effect of acupuncture.Since they were draped during the operation andwere not free to use their hands, all patients rated thesubjective pain intensity verbally at certain intervalsaccording to an eleven-grade scale (Nos. 0 to lo),that is, at gingival incision, at periosteal incision, atmucoperiosteal flap dissection, at bone removal andtooth splitting (with a drill) and at extraction, thiswas done to evaluate whether acupuncture producedhypalgesia/analgesia differentially in different tis-sues. The patients were informed that 0 meant nopain and 10 meant the worst pain ever.All data were evaluated and put together by one ofus (P. H.), who was not present at the operations andwho had no contact with the other authors before theend of experiments.RESULTS

The total duration of the surgical procedure in allpatients wa s in the range of 10 to 20 minutes. Theoverall results are shown in Fig. 2. This figure showsat what stage of the operation the patients experi-enced pain of such an intensity that it was unaccept-able and therefore chose to terminate the procedure.


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Volume 64Number 3When the pain w as so severe that further treatmentwa s impossible without the addition of local analge-sia, the patients pain intensity was 7.7 + 1.9 (fSD). One patient chose to terminate the procedureduring gingival incision and seven patients duringperiosteal incision. In total, only 8 of 26 patientsexperienced pain of an unacceptable intensity duringgingival/periosteal incision. The average pain ratingduring gingival incision (n = 26) was 1.9 + 1.6 ( + SD) and 5.7 it 2.2 (-tS D) during periosteal incision(n = 25). At mucoperiosteal flap dissection another12 patients experienced intolerable pain, with a meanpain rating (n = 18) of 7.3 + 2.1 (+- S D). Thepain-intensity ratings during gingival incision, peri-osteal incision, and mucoperiosteal flap dissectionwere significantly different (p < 0.001, Student ttest). Two patients terminated the procedure duringtooth splitting and one at extraction. Only one of sixpatients experienced unacceptable pain during boneremoval. Two of 26 patients (one from Group 1 andone from Group 2; see Methods) tolerated the entireprocedure, but both patients reported severe painduring the final part of the operation. After surgerywas terminated, however, no or very slight pain(rating 1 to 3) was reported by the two patients. It isalso noteworthy that the patients generally reportedno or only slight pain when interruptions in thesurgical procedure were made.

In all 24 patients who experienced unacceptablepain during surgery with acupuncture only, theoperative procedures were painlessly completed afterthe addition of local analgesia.DISCUSSION

It must be pointed out, as an explanation of whywe have included only five patients in each group (sixin Group l), that it was not our intention to try tocompare different modes of acupuncture treatmentwith each other but, rather, to compare each modewith the well-known empiric success rate with lido-Caine, which almost without exception makes possi-ble painless surgical removal of impacted thirdmolars. Because of this, placebo and a control groupwere excluded. If acupuncture should merit consider-ation as an analgesic measure in surgery, it has to beproved effective in inducing analgesia in the majorityof patients.In the present study the points chosen for stimula-tion are in agreement with standard acupunctureprocedures. It is still possible that the disappointingresults are due to the selection of points stimulatedand the number of areas tried; that is, other pointsthat were not tested might have given a better effect.

Acupuncture as sole analgesic in oral surgery 285

It must be pointed out, however, that w e are notconvinced that stimulation of a number of selectedacupuncture points is important in acupuncture anal-gesia, as long as some of the points used are locatedintrasegmentally to the origin of the pain. This hasalso been pointed out by others.g Earlier reports10-2have presented evidence that other types of peripher-al sensory stimulation (TENS and vibration) shouldbe employed intrasegmentally to the origin of thepain in order to obtain the best pain-reducing effect.TENS and vibration however, did not give sufficientpain relief for use in dental and oral surgery.5The success rate obtained is not impressive, and itmust be pointed out that the two patients whounderwent complete operations with acupuncture asthe sole analgesic experienced severe pain during thefinal part of the operative procedure. Furthermore,acupuncture analgesia requires longer induction timethan local analgesia. It is also more uncomfortablefor the patient, as well as for the surgeon. Theprocedure also requires special facilities as, forexample, a separate treatment room for induction ofacupuncture analgesia.In summary, our findings support the conclusionthat acupuncture, as used in the present study, is nota sufficient analgesic method in surgical removal ofimpacted third molars.

This work was supported by grants from KarolinskaInstitutets fonder and by the Swedish Dental Society. Theauthors thank Ms. Ulla Lindgren for secretarial help andMrs. Monica Tunberg-Eriksson for help with line draw-ings.REFERENCES

1. Bonica JJ. Anesthesiology in the Peoples Republic of China.2.3.

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Anesthesiology 1974;40:775-86.Kerr NW. Acupuncture for therapy and analgesia: a possibleapplication in dental surgery. Br Dent J 1973;6:201-4.Richardson PH, Vincent CA. Acupuncture for the treatmentof pain: a review o f evaluative research. Pain 1986;24:15-40.Melzack R. Acupuncture and related forms of folk medicine.In: Wall PD, Melzack R, eds. Textbook of pain. Edinburgh:Churchill Livingstone, 1984;691-700.Hansson P, Ekblom A. Afferent stimulation induced painrelief in acute oro-facial pain and its failure to inducesuffi cient pain reduction in dental and oral surgery. Pain1984;20:273-8.Brandwein A, Corcos J. Extraction of incisors under acupunc-ture anesthesia: a standardized method. Am J Acupuncture1975;3:352-4.

7, . Brandwein A, Corcos J. Acupuncture analgesia in dentist ry:I. Treatment of asymptomatic dental caries. Am J Acupunc-ture 1976;4:269-75.8. Brandwein A, Corcos J. Acupuncture analgesia in dentist ry:II. Pulp exposure and root canal. Am J Acupuncture1976;4:370-5.9. Taub HA, Mitchell JN, Stuber FE, Eisenberg L, Beard MC,McCormack RK. Analgesia for operative dentistry: a com-


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288 Hansson et al.parison of acupuncture and placebo. ORAL SURG ORAL MEDORAL PATHOL 1979;48:205-10.10. Ekblom A, Hansson P. Extrasegmental transcutaneous elec-trical nerve stimulation and mechanical vibratory stimulationas compared to placebo fo r the relief of acute oro-facial pain.Pain 1985;23:223-9.

11. Lundeberg T. Vibratory stimulation for the alleviation ofchronic pain [Thesis]. Acta Physiol Stand 1983;523(Suppl):l-52.

Reprint requests to:Dr. Per HanssonDepartment of Physiology IIKarolinska InstitutetBox 60400S-104 01 Stockholm, Sweden

12. Thorsteinsson G, Stonnington HH, Stillwell GK, ElvebackLR. The placebo effe ct of transcutaneous electrical stimula-tion. Pain 1978;5:31-41.

Oral Surg.September 1987

Hansson 87 is Acupuncture Sufficient as the Sole Analgesic in Oral Surgery

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