What is TMJ Pain?

TMJ pain can be anywhere from distracting to debilitating.

TMJ stands for temporomandibular joints, referring to the anatomical structures that connect the jawbone to the skull. TMD is the term for temporomandibular joint disorders. According to the National Institute of Dental and Cranifascial Research “the prevalence of temporomandibular joint and muscle disorder (TMJD) is between 5% and 12%.” and while “there is no standard definition for TMJD; it is measured by asking about various types and durations of muscle, joint, and facial pain, difficulty with chewing, joint sounds, etc.”

Causes

The jaw area is a particularly complex meeting of several systems. In addition to this small but crucial joint there are myofascial connections from the scalp, neck, and shoulder all which attach nearby. There is the auditory tube and associated need for fluid passage deep behind these joints and muscles.

Therefore, there may be overlap with ear and sinus fluid congestion, issues with the joint itself, and the surrounding myofascia. Because of the close quarters of all of these different structures there can be several causes which perpetuate each other. Perhaps an initial trauma causes a dislocation, which lead to inflamation and tension. Or stress lead to unconscious clenching of the jaw causing trigger points and some degree of structural changes, etc.

TMD is generally classified by various causes including inflammation, structural changes, muscle tension, jaw dislocation, or degenerative conditions.

Eastern Medicine Perspective

The Eastern medicine perspective utilizes the above causes as additional data points in arriving at a pattern diagnosis. Individual diagnosis and treatment always takes the entire state of health into account.

An acupuncturist also asks other questions to determine best treatment: Are there other areas of inflammation in the body? Is there is tension in the neck, back, scalp, or shoulders? If there is a dislocation was it caused by external trauma or perhaps degeneration or laxity of the structures? If there are trigger points, adhesions, or other patterns of tension what is the underlying cause?

Stress can be a huge trigger in generating tension around the jaw and face, what are the factors contribute to holding stress in the body?

Is there fluid or heat stagnation in the area or in other parts of the body? Is pathological cold or wind a factor? Are there headaches, sinus issues, ear or throat congestion?

All of these together can help determine the best course of treatment.

Treatment with Acupuncture and Facial Gua Sha

In my practice I have found that directly addressing the areas of myofascial tension is tremendously helpful for the majority of TMJ pain. I release knots and areas of tension in and around the jaw, head, and neck using acupuncture. I use facial gua sha to coax residual tension out of the face and jaw and encourage circulation of blood and lymph. The acupuncture treatment in total addresses underlying imbalances while bringing about stress relief.

Self Care Strategies

Facial gua sha tools are easy to come by and use at home. The best tools for the face are the round edge semi-precious stone tools such as jade or quartz. Using a gently gliding motion, move from the chin along the jawline up to the area surrounding the ear. Use pressure as needed to give a massage to areas of tension.

If jaw clenching at night is an issue I receommend practicing letting your jaw go slack, literally having your mouth hang open, particularly before bed, and consciously letting all of those muscles relax. Taking several deep breaths with the jaw slack signals to the body what a relaxed jaw feels like before you fall asleep and help reset that pattern.

Work on any underlying condition whether it is inflammation, chronic stress, posture issues, or healing from an injury with the appropriate healthcare practitioner.

Sources

https://www.nidcr.nih.gov/research/data-statistics/facial-pain/prevalence

https://www.acupuncturetoday.com/mpacms/at/article.php?id=32862

There is a common misconception that dry needling is fundamentally different from acupuncture, that while dry needling treats pain, acupuncture works on supposedly imaginary acupuncture points and meridians.¹ The reality is that dry needling is acupuncture, but the vast majority of acupuncture is dry needling.

The term dry needling originally came from the use of empty (“dry”) syringes to stimulate trigger points for pain relief. This technique was developed by Janet Travell MD, who distinguished it from “wet” needling which used substances such as lidocaine injected into the trigger points.

Depending on state laws, dry needling can now be practiced by medical doctors, chiropractors, nurse practitioners, and physical therapists using the same filiform needles that acupuncturists use.

Dry needling essentially developed in parallel with the rise of acupuncture and Chinese medicine in the United States over the past 50 years or so, crossing over with the use of the filiform acupuncture needle.

Although dry needling is a new term, it overlaps exactly with the traditional acupuncture technique of treating ashi points.

The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) Dry Needling Position Statement states, “Dry needling is a recently coined name for an acupuncture technique that involves the insertion of acupuncture needles directly into muscles and trigger points for the relief of musculoskeletal pain. Licensed acupuncturists have practiced and documented this acupuncture technique, now referred to as ‘dry needling’, for decades in the US.” ²

Acupuncture Approaches

Acupuncture is part of a system of Chinese and Eastern medicine used for thousands of years. But it is not an untouched fossil, this medicine is always evolving, just as Western medicine continues to grow based on clinical evidence and new research.

As a modality of medicine, acupuncture treats all manner of disorder and disease of the body, including musculoskeletal pain and dysfunction. Acupuncture tools are very simple: the filiform needle, but the methodology and application are very diverse.

Acupuncture may be applied according to any number of treatment theories, including: distal points on an affected channel, empirical points for a particular affliction, microsystems on the ear, scalp, hand, or foot, mirroring on the opposite side of the body, or opposite-analogous on the opposite but related joint. Acupuncture may also be applied directly to an affected area, focusing on a point of tension or soreness, called an ashi point.

Needling ashi points is a part of every acupuncturist’s training and scope of practice. Some acupuncturists get additional post-graduate training to specialize in orthopedic or sports acupuncture.

Trigger Points

Ashi points are found through palpation and are indistinguishable in function from trigger points. There is evidence that trigger points, as mapped out by Janet Travell MD in her book Myofascial Pain and Dysfunction: The Trigger Point Manual, have a high correspondence rate with traditional acupuncture points.³

Acupuncturists are trained to find traditional acupuncture points by way of physical anatomical landmarks, and all experienced acupuncturists know that the active point is ultimately found though palpation of the body.

Stimulating a tender and active point, (aka ashi point, aka trigger point) with a filiform needle to provide pain relief is a part of acupuncture theory, training, and practice.

Translation of Terms, Scope of Practice

There are efforts being made in several states to include the term dry needling in the acupuncture scope of practice, to protect this aspect of our medicine that is being taken out of context.

When the state scope of practice for acupuncturists is written with terms such as “ashi points” or “stimulation of qi” it is very difficult from outside the acupuncture profession to really qualify what type of medicine we are practicing.

As acupuncture moves more mainstream and its benefits become more widely accepted, there is a need for translation of language and concepts from Chinese medicine to Western medicine. This translation of language and concepts also has to be very conscientious to not lose the essence of what makes Chinese medicine so uniquely effective.

Acupuncture Training and Safety

One way to think about dry needling is that there are two kinds of acupuncturists practicing: licensed acupuncturists in the US who have completed at least 2000 hours of acupuncture-specific training, didactic material and supervised clinical training, as well as biomedical training; and practitioners of dry needling, who may be physical therapists, chiropractors, or medical doctors, but only complete up to 300 hours of acupuncture training, and in some states much less. ⁴

“As ‘dry needling’ is acupuncture, it presents the same inherent risks including but not limited to perforation of the lungs and other internal organs, nerve damage, and infection. Recent reports of serious and potentially life-threatening injuries associated with ‘dry needling’ include pneumothoraces and spinal cord injury. These and other injuries support the statement that ‘dry needling’ presents a substantial threat to public safety when performed without adequate education, training, and independent competency examination. Adequate training and competency testing are essential to public safety.“⁴

Dry Needling Billing Code

Currently the acupuncture CPT (Current Procedural Terminology) codes are based in units of 15 minutes. Acupuncture CPT codes did not used to be time-based, and since sometimes needles are not retained, particularly in ashi point treatment or trigger point treatment, there was a recent proposal of a Trigger Point Acupuncture code to the CPT committee, which is run by the American Medical Association. The proposal coincided with the submission by the physical therapists and chiropractors of a code for “Dry Needling” and so has been in discussion by the CPT committee.

The American Society of Acupuncturists (ASA) Report from the American Medical Association CPT Code Committee meeting ⁵  is worth reading in full, but the “Outcomes” and “Points to Take Home” sections are important so I am posting them here:

Eastern medicine is a term to describe systems of medicine that developed over thousands of years throughout China, Japan, Korea, and Southeast Asia. Eastern medicine uses non-invasive yet effective diagnostic and treatment methods.

Eastern medicine treatment can include acupuncture, acupressure, massage, cupping, moxibustion, nutrition, exercises, and herbal medicine. While having a connection to an ancient lineage, Eastern medicine continues to evolve with high standards for education, research, and integrative care.

Acupuncture uses small needles, gently inserted into specific, responsive points to help regulate body functions. Acupuncture treats many health conditions without causing adverse side effects or interference with medications, and can bring a state of deep relaxation. Acupuncture is safe for people of all ages.

Seasonal Illness

• Seasonal allergies
• Colds
• Influenza
• Seasonal mood disorders

Women’s Health

• Menstrual irregularities
• Painful periods and PMS
• Pregnancy support
• Morning sickness and nausea
• Perimenopausal support
• Hot flashes and sweating

Neurological

• Dizziness and vertigo
• Tinnitus
• Parasthesia and neuropathy
• Bell’s palsy
• Temperature disregulation

The Chinese character for acupuncture, zhenjiu, means “acupuncture-moxibustion”. Moxibustion provides penetrating warmth, pain relief, and increased circulation. Both needles and heat therapy are the foundations of a balanced acupuncture treatment, and many acupuncturists find moxibustion to be an indispensable tool to their practice.

Yin and Yang

Yin and yang, the principles of relativity and duality, are the foundation of Chinese medicine in the cosmology, diagnosis, and treatment. In Chinese medicine the goal is to achieve balance between hot and cold, internal and external, up and down etc.

Many diseases and disorders arise from a preponderance of cold in the body, which some people can be more sensitive to do to their constitution and other factors.

Cold in the body can occur from exposure to cold in the environment which can get into the energy channels in the limbs, or into the lungs via the nose and throat. Cold can enter into the internal organs from cold food and drinks or too much raw food. Cold slows down organ function and can be a contributing factor in muscle pain, digestive problems, menstrual problems and PMS, and chronic colds and flus.

By using the fire element along with the inmate yang quality of the mugwort herb, moxibustion is very effective for dispelling cold in the organs, bringing in warmth and increasing the circulation of blood, fluids and qi.

This article is from an acupuncturist who grows and processes her own moxa.

The Mugwort Plant

Moxa in various states of refinement.

Moxibustion refers to heat therapy that uses the leaf of the mugwort plant Artemisia vulgaris, called ai ye in Chinese. The leaf is processed into a “wool” and referred to as moxa. There are several traditional ways of applying moxibustion including direct, indirect, warming needle, and tiger warmers or moxa boxes. More recent inventions include liquid moxa, TDP lamps and moxa devices.

Direct Moxa

This includes traditional Japanese “rice grain” moxa where tiny rolled pieces are burned directly on acupuncture points.

Direct moxa can also be a larger amount of moxa burned on the lower abdomen or on the umbilicus. There is a barrier over the skin and/or the moxa is quickly removed before burning the skin.

In some traditions “scarring moxa” is used and meant to burn the skin and create a blister and scar, but this is rarely used in the West.

Indirect Moxa

Moxa can be applied indirectly where it is burned in a metal box called a tiger warmer, or in wooden “moxa box” near the skin.

Warming needle moxa is loosely rolled and piled on the handle of an acupuncture needle and burned there. The heat transfers through the needle deeply into the point.

Moxa can also be compressed into charcoal “poles” and burned near the body to warm up the areas.

Modern Uses

While traditional direct and indirect moxibustion is still widely used in the West, Japan and China, some other applications exist. Sometimes clinics cannot allow herbs to be burned for various reasons, or patients may be sensitive to even small amounts of smoke, have very fragile skin, or other reasons where the benefits of moxa may need to be accessed other ways.

Liquid Moxa

A tincture or liniment made with ai ye and sometimes other warming herbs. Apply directly to areas of pain or cold and ideally apply TDP lamp heat in the area.

TDP Lamp

TDP lamps uses far infra-red heat to deeply and safely penetrate into the tissues. TDP can be used on injured, cold, or tense areas of the body and is ideal for heating up areas where liquid moxa was applied.

Moxa Device

This device is a recent Japanese invention and has yet to make it’s way into distribution in the West. It provides a gentle and effective heat that can be applied to acupuncture points or channels in the same way burning moxa would.