Acupuncture in the Management of Acute
ssia Maria Grillo, Ronaldo Seichi Wada,
Maria da Luz Rosa
rio de Sousa
Department of Social Dentistry, Piracicaba Dental School, University of Campinas,
o Paulo, Br azil
Available online 11 April 2013
Received: Jul 4, 2012
Revised: Feb 26, 2013
Accepted: Mar 5, 2013
Acute dental pain is the main reason for seeking dental services to provide urgent dental
care; there is consensus about the use of alternative therapies, such as acupuncture, to
control dental pain in pre-dental care. This study aimed to evaluate the use of acupunc-
ture in reducing the intensity of acute dental pain in pre-dental care in patients waiting
for emergency dental care, and was conducted at the After-Hours Emergency Dental
Clinic of Piracicaba Dental School, and at the Emergency Center Dental Specialties I in
Paulo, Brazil. The sample consisted of 120 patients. The Visual Analog
Scale (VAS) was used to measure pain intensity. All patients underwent one session of
acupuncture; the points LI4, ST44 and CV23 were selected and were used alone or in com-
binations. Reduction in pain was observed in 120 patients (mean initial VAS Z 6.558
1.886, p < 0; mean ﬁnal VAS Z 0.962 2.163, p < 0.00001). The results of this study indi-
cate that acupuncture analgesia could be a technical adjunct to pain control in patients
with acute dental pain, contributing to the restoration of health with social beneﬁt.
Acute dental pain, experienced by many people, without
distinction of sex, age, or race, is the most common reason
for the demand for health care, especially urgent dental
care provided at emergency care centers .
Pain is considered a common symptom of an oral con-
dition , and to control it, there is consensus about the
use alternative therapies combined with conventional
treatment. Conventional treatment for acute dental pain
management involves diagnosis of the condition causing the
pain, dental treatment, and drugs . Two groups of drugs
* Corresponding author. Department of Social Dentistry, Piracicaba Dental School University of Campinas, Av. Limeira, 901 e Area
Piracicaba CEP 13414-903, Sa
o Paulo, Brazil.
Copyright ª 2014, International Pharmacopuncture Institute
pISSN 2005-2901 eISSN 2093-8152
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J Acupunct Meridian Stud 2014;7(2):65e70
are used: non-narcotic analgesics, including anti-
inﬂammatory steroids, non steroidal anti-inﬂammatory
drugs (NSAIDs, e.g., ibuprofen, aspirin, mefenamic acid)
and paracetamol (acetaminophen) and narcotics (e.g.,
At present, acupuncture is an alternative therapy ,
the value of which has been recognized as a treatment for
pain [6,7]. In the Geneva WHO 2003 report, pain in
dentistry, including dental pain, facial, and postoperative
pain, were listed among the conditions for which
acupuncture appears to be an effective treatment [8,9].
No scientiﬁc literature was found on the use of
acupuncture in the management of acute dental pain in
pre-dental care, among the clinical trials published in the
past 10 years. However, in a systematic literature review
, according to data analysis, acupuncture can be
effective in relieving dental pain, either during surgical
procedures or after surgery.
Acupuncture involves inserting thin needles in some
points on the surface of the body, known as acupuncture
points, in order to obtain a therapeutic response, with the
aim of treatment and prevention of disease .
When a needle is inserted into the acupoint, a speciﬁc
feeling called De qi is felt, which can present as pain,
numbness, heat, weight, or distention around the area
where the needle was inserted, and this feeling can radiate
along the path of the meridian that belongs to the point
stimulated. It is a desired and necessary effect for
acupuncture to be effective [12,13].
The exact mechanism of action of acupuncture has not
yet been established . According to the literature ,
inserting a needle into an acupoint creates a small inﬂam-
matory process, with the release of neurotransmitters such
as bradykinin and histamine. Then, the stimuli are con-
ducted to the central nervous system through the thick and
myelinated A-delta ﬁbers, and the thin and unmyelinated C
ﬁbers, located in the skin and muscles. When the stimuli
end on the posterior horn of the spinal cord, they stimulate
enkephalinergic neurons, through synapses, to release
enkephalin, a blocker of substance P (a neurotransmitter
that stimulates pain), thus inhibiting the pain sensation.
The stimuli continue mainly through the lateral spinotha-
lamic tract until the brainstem, releasing serotonin, which
is responsible for increased levels of endorphin and ACTH
(adrenocortical hormone), and increasing cortisol in the
adrenal glands, thus ensuring the beneﬁcial effect on the
patient’s stress and anxiety .
Acupuncture is considered a safe procedure ,if
performed by a professional with proper training
[5,11,14,15]. It is a natural, low cost therapeutic resource,
which has an advantage, because the use of conventional
drugs to treat acute dental pain can have adverse effects
such as stomach ulcers and bleeding problems (ibuprofen),
dizziness, constipation, sleep disorders (tramadol) , and
hives, skin rashes, and blood dyscrasias (paracetamol) .
Acupuncture does not replace conventional surgical
procedures . According to current evidence suggesting
that acupuncture is effective as a symptomatic treatment
of dental pain , its use in pain patients awaiting dental
care generates a social beneﬁt and improves the patient’s
physical and emotional condition, thereby contributing to
the success of the professional service.
In view of the foregoing discourse, the objective of this
study was to evaluate the effect of acupuncture on
reducing acute dental pain in patients awaiting care at the
after-hours emergency dental care centers.
2. Material and methods
This study was conducted at the after-hours emergency
dental care center of the Piracicaba Dental School, Uni-
versity of Campinas and at the Emergency Center Dental
Specialties I in Piracicaba (Sa
o Paulo), from September 2009
to July 2010.
The study was conducted in accordance with ethical
criteria, in compliance with the standards required by the
Declaration of Helsinki and was approved by the Research
Ethics Committee of the Piracicaba Dental School FOP/
UNICAMP (number 020/2009).
A convenience sample was used, which included all pa-
tients with acute dental pain, who were waiting for dental
care, aged between 18 years and 90 years and who agreed
to participate in the study by signing the terms of free and
informed consent. Pregnant women and patients partici-
pating in other researches were excluded from the sample.
The survey was carried out in the dental ofﬁce of the
emergency dental care centers, prior to the activities of
doctors on duty began. To undergo the procedure, the pa-
tient was accommodated in the dental chair. After
acupuncture, all patients were asked whether they would
recommend the procedure to another patient in the same
During the study, the intensity of pain reported by pa-
tients was measured by a Visual Analog Scale (VAS), ranging
from 0 (VAS 0 Z no pain) to 10 (VAS 10 Z maximum pain);
the initial VAS score was measured at the time of invitation
to participate, and the ﬁnal VAS score, on completion of the
The acupoints selected for the study were according to
the therapeutic indication, related to orofacial pain and
dental pain, according to Traditional Chinese Medicine
2.1. Description of points
LI4 (Hegu): fourth point of the large intestine meridian (LI),
located in the back of the hand; point of analgesia in
painful disorders of the face and teeth. It is a point of great
analgesic importance . In its internal pathway, the
meridian is strongly associated with the oral cavity.
ST44 (Nei Ting): penultimate point of the stomach me-
ridian (ST), located in the foot, between the second and
third metatarsal; indicated for toothache and in the
reduction of edema. The stomach meridian runs through
the area around the mouth, mandible, and gums of the
CV23 (Lian Quan): penultimate point of the conception
vessel. It is located in the midline of the ventral depression
above the hyoid bone, with the patient sitting with the
neck in extension; indicated for facial pain .
Points elected were used individually or combined, with
the aim of reducing the intensity of acute dental pain
66 C.M. Grillo et al.
2.2. Application of the acupuncture
(1) Note the initial VAS.
(2) Inserting a needle into one of the points to get the
feeling of De qi, after the patient reports the De qi
sensation the ﬁnal VAS was noted and the point used.
(3) In the case of VAS Z 0, indicating no pain, the needle
was removed and acupuncture was concluded.
(4) In cases where there was a reduction in pain, but
VAS > 0 remained, or the pain remained the same, the
ﬁrst needle remained in the insertion site and another
needle was inserted into one of the two remaining
points elected to obtain a De qi. After the patient re-
ported the De qi sensation, the ﬁnal VAS was noted.
(5) Similarly, in the case of VAS Z 0, indicating no pain, the
needle was removed and acupuncture was concluded.
(6) If, after association of the second point in the cases of
VAS > 0, a third needle was inserted at the last point,
associated with the two preceding points, acupuncture
was applied and the VAS was recorded in the same way
as in the two previous points, thus ending the
acupuncture application, even if the VAS was > 0
There was no manipulation of the acupuncture needle
(dispersion or toniﬁcation). In patients who did not report
feeling the De qi, the needles remained in place for 5
The choice of point to begin the acupuncture was
random, and so was the sequence of association of the
In cases of acute pain, acupuncture at the points with
signiﬁcant analgesic effects (LI4, ST44) provided relief in a
short time .
Needle insertion was unilateral on the side of the
referred pain and for patients who reported pain in more
than one tooth on both sides. The needle was inserted on
the side with the severest pain, and the initial VAS recorded
was equivalent to the pain of higher intensity.
At the LI4 and ST44 points, needle insertion was
perpendicular, and at the CV23 point, it was inserted to-
ward the base of the tongue .
The depth of needle introduction was appropriate to the
points, respecting the physical constitution, the patient’s
age, and the location of the point .
The needles used were disposable, sterile, individually
packed, 0.25 25 mm in size, stainless steel, Huan Qiu
brand (Suzhou Huanqiu Acupuncture Medical Appliance Co.
Ltd., Suzhou, Jiangsu, China). Prior to the placement of
needles, skin antisepsis was performed with 70% alcohol and
cotton. The researcher is an experienced acupuncturist.
After acupuncture application, all patients were
instructed to remain in the waiting room and wait for
2.3. Statistical analysis
The statistical analysis was performed using Microsoft Of-
ﬁce Excel 2007. First, a descriptive analysis of the variable
under review (VAS) was made, to obtain the absolute and
percentage distribution, mean and median, and standard
deviation (SD), initial VAS and VAS after acupuncture. Dif-
ferences between responses were evaluated by ANOVA,
followed by Tukey’s test . Statistical differences were
considered signiﬁcant at p < 0.05.
2.4. Main outcome measures
The main outcome measure was pain intensity, measured
by VAS. The secondary measure was to achieve VAS Z 0; for
this purpose, we added each acupuncture point to evaluate
the response by the differences between Group 1 (one
acupuncture point), Group 2 (2 acupuncture points), and
Group 3 (3 acupuncture points).
One hundred and twenty patients participated in the sur-
vey, aged from 18 years to 71 years, mean age of 35 years
(35.82 11.98). Out of the total number of patients invited
to participate in the study (n Z 317), there was a loss of
62.14% (n Z 197) from the sample, because 145 patients
were without pain at the time of the invitation, 29 patients
had pain and were afraid of the acupuncture needle, 22
patients with pain did not disclose the reason for refusal,
and one patient with pain refused to participate because
without pain, it would not be possible to tell the dentist
which tooth was causing the problem.
Acupuncture signiﬁcantly decreased the pain intensity
(mean pain value at baseline Z 6.558 1.875 and after
intervention, mean Z 0.963 2.164); the t test was
applied, based on the initial VAS and ﬁnal VAS scores
(measured in the same individual) to obtain a value of
p < 0.00001; there was a signiﬁcant reduction in pain. In all
groups, there was a reduction in pain, which can be veriﬁed
by observing the mean values (Table 1). The group of pa-
tients who needed one point (n Z 29) to obtain VAS Z 0, on
Figure 1 Sequence of application of acupuncture in this
Acupuncture in the management of acute dental pain 67
an average, had a lower initial VAS score than the group of
patients who needed 2 points (n Z 43), and these in turn,
had a lower mean initial VAS score than the group who
needed three points (n Z 33).
The mean pain reduction scores prior to and after the
application of acupuncture at one point, was statistically
signiﬁcant (p < 0.0001). Based on these results, the appli-
cation of acupuncture differs statistically from point to
point. At point LI4, we found the largest decrease in pain
assessed prior to and after application of acupuncture; at
point CV23, pain reduction was greater than at point ST44,
but smaller than at point LI4; and at point ST44 we found
less reduction in pain compared with the other points
As regards the patients who participated in the study, 77
(64.17%) were women and 43 (35.83%) were men (Table 3).
Only 2.5% of patients did not respond to acupuncture,
irrespective of the starting point and of the sequence used.
In the total sample, 119/120 patients (99.17%), would
recommend acupuncture treatment to relieve acute dental
pain in dental pre-care to another patient in the same sit-
uation and 1/120 (0.83%) would not recommend it.
The results of this study indicated that acupuncture
reduced pain intensity (VAS Z 0), in 72.50% of patients with
acute dental pain, awaiting care in an emergency dental
The point LI4 (Hegu) had a better analgesic effect
(p < 0.0001), as in other studies [7,13,15,21]. Although it is
located in the hand, LI4 is frequently used for pain control
in cases of oral and craniofacial surgery, because of its
analgesic value in dental-facial pain [12,22,23] .
According to Chinese medicine, pain can be caused by
stagnation of Qi , thus the LI4 acupoint was selected
because it is an important point of analgesia , and
because the main pathway of its meridian (large intestine)
Yang Ming (hand), its secondary path which passes through
the mandible and maxilla and the meeting point Yuan
[18,24], are used in order to relieve the obstruction of
meridians and collaterals, promoting the free ﬂow of Qi and
thereby eliminating pain .
The needling of a speciﬁc point contributes to the relief
of pain, and the location of the stimulus determines the
therapeutic effect and physiological response  . Each
point has a speciﬁc function and indication for its use. For
example, stimulation of certain acupuncture points distant
from the source of pain can provide excellent analgesia,
whereas stimulation of improperly selected points near the
source of pain may be ineffective or even aggravate the
With technological advances in neuroimaging, a study 
with acupoint LI4 using magnetic resonance imaging (fMRI),
concluded that acupuncture can decrease the activity of
regions of the brain, disabling the limbic system that re-
lates to pain perception, however the small sample size is a
limitation of the study.
LI4 was the point used in a study  involving maxil-
lofacial surgery, in which the selection of points was per-
formed individually by selecting distal points and those that
passed next to the surgery site. Acupuncture was per-
formed prior to, during, and after surgery, and the authors
concluded that acupuncture analgesia can be a supplement
to conventional anesthesia in maxillofacial surgery.
We found no previous studies that used the CV23 point for
acute dental pain. This was one of the points used in a study
 on the use of acupuncture anesthesia combined with
techniques for performing maxillofacial surgery. The results
suggested that the application was appropriate for this asso-
ciation with clinical surgery for the relief of postoperative
pain, because of the technical simplicity and low cost. In this
study, a reduction in the intensity of acute dental pain was
shown, demonstrating the therapeutic effect of acupuncture
Table 1 Mean, standard deviation, ﬁrst quartile, and third quartile of initial Visual Analog Scale (VAS), of ﬁnal VAS, and
according to the number of points applied.
Pain Number of
Quartile Median 3
Initial (n Z 29) 1 5.6896 1.7341 5 6 6
Initial (n Z 43) 2 6.3488 1.6018 5 6 7
Prior to 2 points 2 3.6744 1.8480 2 3 4.5
Initial (n Z 15) 3 6.8333 2.3350 5 7 8.75
Prior to 2 points 3 4.9333 1.9988 3.5 4.5 6.25
Prior to 3 points 3 2.4333 1.8113 1.25 2 3
Initial (n Z 33) >3 7.4697 1.7497 6 8 9
Prior to 2 points >3 6.1061 2.0262 5 6 8
Prior to 3 points >3 4.7879 2.0001 3 4 6
After 3 points >3 3.5000 2.8723 1 2 6
Table 2 Mean pain reduction prior to and after applica-
tion of acupuncture in a point.
Point Mean difference in pain prior to and after
*Points differed statistically, according to Tukey’s test
(p < 0.005).
68 C.M. Grillo et al.
in promoting dental analgesia. Moreover, at this acupuncture
point, patients reported the sensation of De qi as a tingling, as
though the jaw had been anesthetized.
Point ST44 alone did not reduce pain intensity, although
the stomach meridian, Yang Ming (foot) goes through the
face and to be the Ying point that promotes the free ﬂow Qi
and pain relief [18,24]. This differed from the literature
[12,25], in which it was reported that ST44 is a point of
great analgesic importance, designed to treat acute pain.
According to the literature , the therapeutic effect of
each point has been deﬁned, and they can be combined
with other points to perform a speciﬁc treatment, as in this
study, when we used CV23, ST44, and LI4.
In this study, needle insertion was unilateral on the side
of the pain reported by the patient, in agreement with
another study  that evaluated the use of acupuncture
for postoperative pain control in third molar surgery. In this
case, the acupuncture needle was inserted on the side of
the extracted tooth. In the mentioned study, the partici-
pant’s eyes were covered during treatment in both the
placebo and acupuncture groups. Those in the placebo
group were not needled and treatment received was tap-
ped with plastic tubing in areas near the acupoints chosen
for the acupuncture group. Pain parameters in the
acupuncture group were observed to be signiﬁcantly
improved postoperatively. The ideal time for acupuncture
has been shown to be the time immediately after the
In our study, due to individual variation, we were un-
successful in applying acupuncture in 2.5% of patients, a
result that differs from another study, in which the value
was 10% .
During the study no patient had adverse reactions to the
treatment, however, the literature  reports that 7e11%
of patients treated with acupuncture, have adverse re-
actions such as sweating, dizziness, drowsiness, and
bleeding. In our clinical practice, we consider it important
to note the number of needles inserted and the related
acupoints, so that all are removed at the end of the session.
In this study, more women (64.17%) sought the assistance
of emergency services when compared to men (35.83%);
preventive health habits are more associated with women.
Most patients (99.17%) would recommend acupuncture
therapy to another patient in the same situation, in
agreement with another study , which evaluated pa-
tients with problems of temporomandibular disorder
treated for 18e20 years. Patients who received acupunc-
ture, occlusal splint, and other therapies (physiotherapy,
drugs, etc.), said they would recommend the treatment to
another patient with similar complaints.
The study sample did not meet the external validity of
the results; we cannot infer that the results apply to the
Table 3 Number and percentage of patients without pain (VAS Z 0) and with pain (VAS > 0), after application of 1, 2 ,and 3
points, according to gender.
Pain After application Points applied
Female Male Total of
VAS Z 0 1 13 8 21 17.50
1 point 2 0 0 0 0.00
3 7 1 8 6.67
Subtotal 20 9 29 24.17
1e2 2 0 2 1.67
1e3 7 4 11 9.17
2 points (sequence) 2e1 5 1 6 5.00
2e3 4 3 7 5.83
3e1 4 3 7 5.83
3e2 8 2 10 8.33
Subtotal 30 13 43 35.83
1e3 1 2 3 2.50
1e3e2 0 1 1 0.83
3 points (sequence) 2e1e3 1 1 2 1.67
2e3e1 1 1 2 1.67
3e1e2 1 1 2 1.67
3e2e1 2 3 5 4.17
Subtotal 6 9 15 12.50
VAS > 01e2e3 2 2 4 3.33
1e3e2 2 3 5 4.17
3 points (sequence) 2e1e3 1 1 2 1.67
2e3e1 7 2 9 7.50
3e1e2 2 1 3 2.50
3e2e1 7 3 10 8.33
Subtotal 21 12 33 27.5
Total 77 43 120 100.00
F Z female; M Z male; VAS Z Visual Analog Scale.
* Identiﬁcation of points: 1 Z LI4; 2 Z ST44; and 3 Z Cv23.
Acupuncture in the management of acute dental pain 69
whole population, because of the small sample size, and we
could not split the group by gender.
It is recommended that in further studies, the profes-
sional who performs the acupuncture should not be the
same as the one who performs the data collection, and that
studies should be conducted to evaluate the duration of the
effect of acupuncture, which was done in this study.
Pain that leads to a patient seeking emergency dental
care can result from various diseases or dental, oral, and
facial conditions, or those in nearby structures, therefore,
the use of drugs should be restricted to situations of real
necessity  and should be indicated by the dentist after
his diagnosis. Therein lies the importance of pain control in
pre-service therapy practice, using a simple, low cost
technique, without any adverse effects, for the beneﬁt of
the patient awaiting conventional treatment.
In conclusion, the results of this study indicated that the
effects promoted by acupuncture analgesia could be a
technical adjunct to pain control in patients with acute
dental pain, contributing to the restoration of health with
social beneﬁt. However, further studies are needed to in-
crease the understanding of its effects.
The author afﬁrms there are no conﬂicts of interest and the
author has no ﬁnancial interest related to the material of
The authors thank Dr. Jou E. Jia and Dr. Jorge E. Sato for
their cooperation in the selection of acupuncture points. No
ﬁnancial support was received for this study.
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