Pain Medicine, 22(4), 2021, 905–914

doi: 10.1093/pm/pnab048
Advance Access Publication Date: 9 February 2021
Original Research Article

HEADACHE & FACIAL PAIN SECTION

Short-Term Effect of Scalp Acupuncture on Pain, Sleep Disorders,

and Quality of Life in Patients with Temporomandibular Disorders: A

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A Randomized Clinical Trial
Karen Oliveira Peixoto , DDS, MSc, Aliane da Silva Bezerra, DDS, MSc, Rafaela Albuquerque Melo,
DDS, MSc, Camila Maria Bastos Machado de Resende, DDS, MSc, PhD, Erika Oliveira de Almeida, DDS,
MSc, PhD and Gustavo Augusto Seabra Barbosa, DDS, MSc, PhD

Dentistry Department, Federal University of Rio Grande do Norte (UFRN), Natal, RN, Brazil

Correspondence to: Karen Oliveira Peixoto, DDS, MSc, Dentistry Department, Federal University of Rio Grande do Norte, Salgado Filho Street,
Lagoa Nova, Natal, RN 59056-000, Brazil. Tel: þ55 (84) 3215-4100; Fax: (84) 3215-4112; E-mail: karenoliveirap@hotmail.com.

Conflicts of interest: There are no conflicts of interest to report. No funding was received for the preparation of this manuscript.

Abstract
Objetive. To evaluate the effects of Chinese scalp acupuncture in patients diagnosed with temporomandibular disor-
ders (TMD) on pain, sleep, and quality of life (QOL), and compare these results with the results from traditional thera-
pies. Methods. Sixty patients diagnosed with TMD using the research diagnostic criteria for temporomandibular dis-
orders (RDC/TMD) were allocated into four treatment groups: counseling (C ¼ 15), occlusal splint (OS ¼ 15), scalp
acupuncture (SA ¼ 15), and manual therapy (MT ¼ 15). Participants were re-evaluated within 1 month. Three ques-
tionnaires were used to access sleep disorders, QOL, and pain: The Pittsburgh Sleep Quality Index (PSQI), World
Health Organization Quality of Life (WHOQOL-bref), and the Visual Analogue Scale (VAS), respectively. The data
obtained were analyzed using the Statistical Package for the Social Science program (SPSS 22.0). Results. The SA
group significantly improved pain (P ¼ .015), as well as the OS (P ¼ .01) and MT groups (P ¼ .014). Only the OS
(P ¼ .002) and MT (P ¼ .029) groups improved sleep. MT group significantly improved QOL in terms of the physical
domain of the WHOQOL-bref (P ¼ .011) and the OS group in the psychological domain (P ¼ .012). Conclusions. The
scalp acupuncture proved to be another alternative for pain relief in patients with TMD, demonstrating positive
results in the short term. However, it was not as effective in improving quality of life and sleep.

Key Words: Temporomandibular Joint Disorders; Pain; Quality of Life; Sleep Disorders; Acupuncture; Manual Therapy

Introduction rate [3]. In this context, acupuncture has been inserted

Temporomandibular disorders (TMD) are clinical conditions among conservative treatments, mainly for having shown
that often affect the stomatognathic system, the masticatory benefits regarding analgesia while it acts at the central
muscles, the temporomandibular joint (TMJ), and associated nervous system (CNS) level, in which the usual therapies
structures [1]. It corresponds to the most frequent condition do not work efficiently [4].
of chronic orofacial pain and one of the musculoskeletal con- Scalp acupuncture is a contemporary acupuncture
ditions that most commonly results in pain and debilitation. technique in which needles are inserted into the scalp, in
The high degree of this dysfunction chronicity imposes signif- a way that integrates traditional acupuncture methods
icant personal burdens, whether physical or emotional, inter- with knowledge of Western anatomy, physiology, pathol-
fering on the patient’s quality of life (QOL) [3]. ogy, and neurology. The method has been internationally
Reversible and noninvasive therapies are usually the recognized for over 30 years and developed mainly for
first choice in the treatment of TMD, with a high success the treatment of chronic pain [5, 6].

C The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.
V
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906 Peixoto et al.

Unlike traditional acupuncture, scalp acupuncture symptoms were used to divide the participants into three
may have a direct effect on the central nervous system groups: muscle TMD (group 1 of the RDC/TMD), joint
(CNS), since it consists in needling areas corresponding TMD (group 2 and/or 3 from RDC/TMD), and mixed
to reflex areas of the cerebral cortex [7]. Thus, it is a DTM (groups 1 and 2 and/or 3 from RDC/TMD). The
promising technique in patients with TMD, as it is easy RDC/TMD was applied in the baseline period (T0) and
easily accessible, fast to apply, less expensive, and causes after 30 days (T1) for all treatment groups.
fewer side effects. In addition, it shows excellent results The following patients were excluded: patients with
in the treatment of various pathologies [5]. However, de- impaired cognitive ability; history of head trauma related
spite its vast clinical use, there is little research on its use to the etiology of orofacial pain; migraine or intracranial
in TMD. disorders; who used medications in the last 3 months that
Thus, the present study aimed to assess the short-term may interfere with the effect of therapies, such as muscle

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effects of scalp acupuncture in patients with TMD, in re- relaxants, anticonvulsants, antidepressants and anxio-
lation to pain, sleep, and QOL, and to compare its results lytics; who used medication to treat TMD or muscle
with the following therapies: occlusal splint, manual pain; who had other causes of orofacial pain such as car-
therapy, and counseling. The expected hypothesis is that ies, neuropathies and fibromyalgia; who had a phobia
the scalp acupuncture will improve all analyzed about needles or bleeding disorders.
variables. The full coverage occlusal splints were fabricated by
two calibrated researchers, following the technique de-
scribed by Okeson (2013) [9], and manufactured by the
Methods same laboratory technician previously calibrated, using
The present study is a blinded randomized controlled thermopolymerizable acrylic resin. For the OS group, the
trial. The researcher responsible for diagnosing TMD same methodology of Resende et al. [10] study was
according to the research diagnostic criteria for temporo- adopted. All the necessary occlusal adjustments were
mandibular disorders (RDC/TMD) [8] was not aware of made with the aid of carbon paper and a straight piece,
which treatment group the patients belonged to. The obtaining a uniform contact of approximately intensity
study was approved by the Research Ethics Committee of in all teeth. The patient was instructed on its night use.
Onofre Lopes University Hospital (CEP-HUOL), under The first return occurred within 15 days, to check the ad-
the number of 2,932,937. Developed in accordance with aptation of the splint and make further adjustments, if
the resolution 466/2012 for research involving human necessary. The second return occurred within 30 days
beings, registered on the Brazilian Clinical Trials Registry (T1), when the questionnaires for data collection were
(REBEC) platform under the number of RBR-7xx7g7, reapplied.
and conducted in accordance with the Declaration of the MT was based on the use of thermal agents (hot and cold)
World Medical Association of Helsinki. and therapeutic exercises performed clinically by a trained re-
The study included patients who attended the searcher. The therapeutic regimen followed the same preroga-
Integrated Service Center for Patients with tives as the study by Resende et al. [10], consisting of 40-
Stomatognathic Apparatus Dysfunction (CIADE), an ex- minute sessions, held twice a week, for 4 weeks. All patients,
tracurricular project developed by the TMD sector of the regardless of their diagnosis, were instructed to apply warm
 
Department of Dentistry at the Federal University of Rio compresses (40 to 50 Celsius) at home, in the masseter, tem-
Grande do Norte (UFRN), between December 2018 and poral, and TMJ regions, for 20 minutes, 3 times a day during
December 2019. All participants signed the Informed the entire treatment. As well as performing masseter and tem-
Consent Form (ICF), containing all information related poral massage, stretching exercises for the jaw muscles, and
to the research. coordinated and resisted exercises, 3 times a day, in 10 repeti-
In total, 295 patients were screened, of whom 214 tions each, after properly trained for its correct execution.
were excluded for not meeting inclusion criteria or for Counseling was carried out by two researchers.
exclusion criteria, leaving 81 participants, randomly dis- Patients received verbal and written guidelines, which
tributed among the intervention groups: occlusal splint were reinforced within 15 days from the first consulta-
(OS), manual therapy (MT), counseling (C), and scalp tion. General characteristics of the dysfunction were clar-
acupuncture (SA). Of these, 21 dropped out during the ified, so that they would feel able to self-manage
study due to personal reasons. Thus, the convenience themselves. At the end of the consultation, the patients
sample consisted of 60 TMD patients (Supplementary received a flyer with dietary guidelines and recommenda-
Data). tions on physical exercises, harmful habits, posture, and
The study included TMD patients diagnosed through sleep hygiene.
of the RDC/TMD, who underwent last treatment for The Chinese scalp acupuncture was performed by a
TMD with a minimum interval of 3 months; individuals single examiner previously trained. Each patient received
with reports of pain in the orofacial region in the last 8 sessions of 40 minutes, twice a week, totaling 4 weeks
3 months and aged between 18 and 65 years. The RDC/ of treatment. The following areas were selected, corre-
TMD Axis I guidelines for assessment of TMD signs and sponding to Dr. Zhu Ming’s technique [11]: GV20
Scalp Acupuncture in Patients with TMD 907

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Figure 2. Schematic demonstration of the scalp acupuncture
areas (source: authors).

Figure 1. Needles inserted in the areas of Scalp acupuncture

GV20, GV21, GV22 and GV24 (source: authors).

(Baihui), GV21 (Qianding), GV22 (Xinhui), and GV24

(Shenting), located in the Eding Zone, which runs from
the forehead to the top of the head (Figures 1 and 2). The
lower 2/5 of the motor and sensory area of Jiao Shunfa
were also selected, as they are related to motor neuron
paralysis (motor area) and sensory stimuli (sensitive area)
on the opposite side of the face, with needles being ap-
plied bilaterally (Figures 2 and 3).
Disposable and sterile needles for acupuncture, 0.25 
30, were used (DongBang Acupuncture, Inc.). They were
inserted into the scalp at an angle close to 25 (Figures 4
and 5), until resistance was found, followed by manual
stimulation of the needles through rotational movements
while the patient performed 6 cycles of diaphragmatic
breathing. The insertion started with GV20, considered
the basis for all points of the scalp, followed by GV21,
GV22, GV24, motor and sensitive area of the face. The
insertion was made from anterior to posterior but in the
region of GV24 another needle was inserted from poste-
rior to anterior, totaling 13 needles (Figures 1 and 2). Figure 3. Needles inserted in the motor area and Jiao Shunfa
sensory area, bilateral insertion (right and left side) (source:
There was a 30 minutes resting period for each partici- authors).
pant after the needles were removed. Also, antisepsis
with 70% alcohol at the insertion site was performed to
prevent infections. collection instruments, the World Health Organization
For all groups, an assessment was carried out in base- Quality Of Life (WHOQOL-Bref) to assess QOL, the
line and after 1 month using three validated data Pittsburgh Sleep Quality Index (PSQI) for the assessment
908 Peixoto et al.

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Figure 4. Needle inserted in the GV24 area, from posterior to anterior, at an angle of 25 (source: authors).

Figure 5. Needles inserted in the areas of Scalp acupuncture GV20, GV21, GV22 and GV24 (lateral view) (source: authors).

of sleep, and the Visual Analogue Scale (VAS) for mea- The PSQI is composed of 19 self-report questions re-
suring pain. No evaluated groups were left untreated. garding sleep disorders. The 19 items are combined into
The WHOQOL-Bref was used to analyze quality of seven components: sleep quality, sleep latency, sleep du-
life, taking as reference the participants last 2 weeks. It ration, habitual sleep efficiency, sleep disturbances, use
consists of 26 questions, two of which assess the per- of sleeping medications, and daytime dysfunction. Each
ception of quality of life and health of the patient, and component has a score ranging from 0 (no difficulty) to 3
the others (24 questions) are divided in four domains: (severe difficulty) [10]. All component scores are summed
physical, psychological, social, and environment to produce a global score ranging from 0 to 21.
domains. Each question has five options for answers, The VAS consists of a visual scale graded from 0 to
where quality of life is measured using an analog scale 10, where 0 means no pain at the moment and 10 means
from 0 to 100, the higher the score the better the qual- the worst pain the patient can bear. A moderate pain
ity of life [10]. should be marked within this range [10]. In the scalp
Scalp Acupuncture in Patients with TMD 909

Screened 214 patients were excluded for not

patients meeting the research criteria
(n=295)

OS (n=20) MT (n=19) C (n=24) SA (n=18)

21 drop outs
n=5 n=4 n=9 n=3

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OS (n=15) MT (n=15) C (n=15) SA (n=15)

Flowchart 1. Number of patients screened, excluded and allocated to groups (source: authors).

5
4.5
4
3.5
3
VAS(cm)

2.5
2
1.5
1
0.5
0
Session Session Session Session Session Session Session Session 30
I II III IV V VI VII VIII days
Before Aer 30 days

Graph 1. Mean values of pain intensity (VAS) reported before and after each scalp acupuncture session, as well as after 30 days of
treatment (Natal / RN) (source: authors).

acupuncture group, VAS was applied before and after greatest percentage reduction of mixed TMD, from 80%
each session and repeated after 30 days of treatment. For (n ¼ 12) to 26.7% (n ¼ 4%). In the T1 period, 15%
the remaining groups, the VAS was applied twice: at (n ¼ 9) of the participants no longer presented TMD di-
baseline and at 30 days evaluation. agnosis, from which 55.5% (n ¼ 5), belonged to the SA
The statistical analysis of the data was performed us- group (Table 1).
ing the SPSS 22.0 program, comparing the results ob- It was observed at baseline there was no significant dif-
served between the two periods in question. The Kruskal- ference between the treatment groups regarding pain
Wallis test (P < .05) was used for intergroup analysis, the (P ¼ .794). All groups improved significantly (P ¼ .015)
Mann Whitney post-test (Bonferroni adjustment within 1 month, with significant difference only between
P < .025) and the Wilcoxon Signed Classifications Test, the MT and C groups, according to the Mann-Whitney
for the intragroup analysis over the periods (P < .05). post-test (P ¼ .004). The OS group reduced the pain inten-
sity by 48.49%, the MT by 59.25%, the SA by 43.94%
and the C by 2.94%. Over time, only the C group did not
Results significantly reduce pain (P ¼ .843) (Table 2).
As for the TMD diagnosis in the baseline period, 81.7% An immediate decrease of pain after the insertion of
(n ¼ 49) of the patients presented mixed TMD (joint and the needles was observed in 94.2% of the sessions in
muscle) and after the 30 days of treatment this number which the pain was present. Before starting the scalp acu-
decreased to 53.3% (n ¼ 32). The MT group showed the puncture, the average pain was 4.4, reducing
910 Peixoto et al.

Table 1. TMD diagnoses for each treatment group at the different evaluated times

TMD diagnoses

Baseline (T0) 30 days (T1)

Group Muscle TMD Joint TMD Mixed TMD No diagnosis Muscle TMD Joint TMD Mixed TMD No diagnosis
OS (n ¼ 15) 6.7% (n ¼ 1) 13.3% (n ¼ 2) 80% (n ¼ 12) 0% (n ¼ 0) 6.7% (n ¼ 1) 33.3% (n ¼ 5) 53.3% (n ¼ 8) 6.7% (n ¼ 1)
SA (n ¼ 15) 13.3% (n ¼ 2) 6.7% (n ¼ 1) 80% (n ¼ 12) 0% (n ¼ 0) 0% (n ¼ 0) 53.3% (n ¼ 8) 26.7% (n ¼ 4) 20% (n ¼ 3)
C (n ¼ 15) 6.7% (n ¼ 1) 0% (n ¼ 0) 93.3% (n ¼ 14) 0% (n ¼ 0) 6.7% (n ¼ 1) 6.7% (n ¼ 1) 86.7% (n ¼ 13) 0% (n ¼ 0)
MT (n ¼ 15) 26.7% (n ¼ 4) 0% (n ¼ 0) 73.3% (n ¼ 11) 0% (n ¼ 0) 6.7% (n ¼ 1) 13.3% (n ¼ 2) 46.7% (n ¼ 7) 33.3% (n ¼ 5)
Total (n ¼ 60) 13,3% (n ¼ 8) 5% (n ¼ 3) 81,7% (n ¼ 49) 0% (n ¼ 0) 5% (n ¼ 3) 26.7% (n ¼ 16) 53.3% (n ¼ 32) 15% (n ¼ 9)

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n ¼ number of participants; OS ¼ occlusal splint; SA ¼ scalp acupuncture; C ¼ counseling; MT ¼ manual therapy.

Table 2. Comparison of painful symptoms obtained by the Visual Analogue Scale (VAS) between groups and in relation to different
times

Visual Analogue Scale (VAS)

Baseline (T0) 30 days (T1)

P**
95% CI 95% CI
Group Mean (SD) Median Rank average LL UL Mean (SD) Median Rank average LL UL
OS (n ¼ 15) 4.53 (3.11) 5 32,57 2.80 6.25 2.33 (1.54) 3 29,70 1.47 3.18 .01
MT (n ¼ 15)† 3.60 (2.22) 4 26,67 2.36 4.83 1.46 (2.06) 0 21,40 0.32 2.61 .014
C (n ¼ 15)† 4.53 (2.61) 4 31,37 3.08 5.98 4.40 (2.82) 4 41,43 2.83 5.96 .843
SA (n ¼ 15) 4.40 (2.79) 4 31,40 2.85 5.94 2.46 (2.50) 1 29,47 1.08 3.85 .015
Total (n ¼ 60) 4.26 (2.66) – – – 2.66 (2.47) – – – –
P* .794 .015

†
Mann-Whitney post-test (among groups that there was a statistically significant difference).
OS ¼ occlusal splint; MT ¼ manual therapy; C ¼ counseling; SA ¼ scalp acupuncture; SD ¼ standard deviation; LL ¼ lower limit and UL ¼ upper limit of the
95% CI ¼ confidence interval; significance level P (<.05).
*Kruskal-Wallis test;
**Wilcoxon signed-rank test.

approximately 83.4% at the end of the 8 sessions, with a However, the MT group improved QOL in terms of
final average of 0.73. However, after 1 month of treat- physical domain (P ¼ .011), and the OS group in terms of
ment, this average was 2.46 (Supplementary Data). the social domain (P ¼ .012), while the C group wors-
Regarding the pain variable, the power of the sample ened in relation to the social domain (P ¼ .015) and the
reached 98.41%. environment (P ¼ .048) (Table 4).
As for the subjective quality of sleep, there was no sig-
nificant difference between groups in the baseline
(P ¼ .988). However, a significant difference was ob- Discussion
served after 30 days (P ¼ .046). When performing the The hypothesis presented in the present study was par-
Mann-Whitney post-test, a difference was observed only tially accepted, as patients who underwent scalp acu-
between the OS and C groups (P ¼ .007). Over time, only puncture significantly improved painful symptoms but
the OS (P ¼ .002) and MT (P ¼ .029) groups significantly did not significantly improved sleep and quality of life.
improved sleep (Table 3). Comparing the averages be- Correia et al. [12], evaluated the control of chronic
tween times, only the C group worsened sleep by 8.54%, myofascial pain in the head and neck using Yamamoto’s
the OS improved by 35.34%, the MT by 19.16%, and scalp acupuncture, as well as its effectiveness in emer-
the SA by 13.79%. gency conditions. There was a significant reduction in
As for the variable QOL, there was no statistically sig- pain in 100% of patients shortly after the application of
nificant difference between the treatment groups for any the needles. Likewise, scalp acupuncture provided imme-
of the aspects of the WHOQOL-Bref analyzed, both at diate pain relief in women suffering from cervical and
baseline and after 30 days. Over time, there was no sig- lumbar osteoarthritis [13]. In another study, scalp acu-
nificant difference for groups in the WHOQOL-bref puncture also reduced pain in 100% of health professio-
General, as well as for the psychological domain. nals with nonspecific pain [13].
Scalp Acupuncture in Patients with TMD 911

Table 3. Comparison of the quality of sleep obtained by the PSQI between the groups and in relation to different times

Pittsburgh Sleep Quality Index (PSQI)

Baseline (T0) 30 days (T1)

P**
95% CI 95% CI
Group Mean (SD) Median Rank average LL UL Mean (SD) Median Rank average LL UL
OS (n ¼ 15)† 7.73 (2.98) 8 30,00 6.07 9.38 5.00 (2.77) 5 22,23 3.46 6.53 .002
MT (n ¼ 15) 8.00 (2.50) 8 31,90 6.61 9.38 6.46 (2.92) 6 29,90 4.84 8.08 .029
C (n ¼ 15)† 7.80 (3.02) 7 30,13 6.12 9.47 8.46 (3.41) 8 40,07 6.57 10.36 .144
SA (n ¼ 15) 7.73 (3.63) 7 29,97 5.72 9.74 6.66 (3.19) 6 29,80 4.89 8.43 .114
Total (n ¼ 60) 7.81 (2.98) – – – 6.65 (3.25) – – – –
P* .988 .046

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†
Mann Whitney post-test (among groups that there was a statistically significant difference).
OS ¼ Occlusal splint; MT ¼ manual therapy; C ¼ counselling; SA ¼ scalp acupuncture; SD ¼ Standard deviation; LL ¼ lower limit and UL ¼ upper limit of
the 95% CI ¼ confidence interval; significance level P (<.05).
*Kruskal-Wallis test;
**Wilcoxon signed-rank test.

This corroborates with the findings of the present re- period may have not been enough for a significant
sult, in which 94.2% of the patients reported immediate improvement.
pain relief after the insertion of the needles. This analge- In regard to the TMD diagnosis, according to
sia may be due to the needles stimulating the release of Schiffman et al. [19], muscle and joint dysfunctions are
endogenous opiates from the pituitary gland into the easily found in the same individual, which corroborates
plasma, thereby resulting in analgesia in the central ner- with the present study in which 81.7% of the sample pre-
vous system [14]. In addition, immediate pain relief can sented mixed TMD. As for the TMD patients in the SA
work as a motivational factor, encouraging the patients group, after 1 month of treatment, 1/3 were no longer di-
to continue the treatment. Another benefit is the fact that agnosed with TMD, comprising more than half of the to-
the needles are not applied directly to the painful place tal patients without a TMD diagnosis. This result may be
[11]. attributed to the acupuncture action mechanism, since
Occlusal splint and manual therapy also significantly the insertion of needles causes responses both at the pe-
reduced pain. The occlusal splint seems to be effective as ripheral and central levels, in which the usual therapies
it causes cognitive-behavioral changes and not only may not reach efficiently [3].
purely mechanical [15]. Manual therapy, on the other We must also consider the cyclical characteristic of
hand, can help restore normal function of muscles and TMD, in which there is often spontaneous remission of
joints, reducing local inflammation and stimulating tissue symptoms [20]. Thus, high-intensity pain tends to regress
repair [16]. spontaneously over time, regardless of whether they re-
As for the sleep variable, only the OS and MT groups ceive treatment, which is also known as regression to the
provided significant improvement, which may be a good mean [21], which may have influenced the diagnosis ab-
option for patients with sleep disorders. However, the in- sence for TMD in 15% of cases in the T1 period.
strument in use assesses the subjective quality of sleep, However, based on our results, it can be inferred that
which may be related to several factors other than just the improvement in pain seen in the SA group was associ-
TMD, such as bedtime unwanted mental activity and af- ated to the treatment. The patients presented a pain re-
fective factors (e.g., irritability, concerns, catastrophiz- duction of 83.4% at the end of the 8 scalp acupuncture
ing) that play an important role in sleep [2], which may sessions and after 30 days without any therapy the reas-
have interfered with this result. sessment showed a pain reduction of 44.09%. In addi-
A study by Bollini et al. [17] used the scalp acupunc- tion, there was immediate pain relief, when pain was
ture in individuals with repetitive strain injury, showing present, in 94.2% of patients, thus, weakening the idea
reduced pain and improved QOL in all patients evalu- that there was simply a regression to the mean.
ated. Another study used scalp acupuncture to treat tinni- Several studies have continued to accumulate knowl-
tus by reducing its level of intensity and improving the edge regarding the effectiveness of acupuncture in the
QOL of participants in the short term [18]. However, in treatment of TMD, especially regarding pain relief [4,
the present study, the SA group did not improve QOL, as 22–25]. However, according to Peixoto et al. [26], no
did the OS and MT groups. This may suggest that other other studies were found using scalp acupuncture to spe-
dimensions of the participants’ own quality of life, which cifically treat TMD patients. Thus, the present results are
were not the subject of the present study, may have influ- relevant, considering that scalp acupuncture, had similar
enced their perception. Also, the short term evaluating results regarding pain improvement as traditional
912 Peixoto et al.

Table 4. Comparison of quality of life obtained by each WHOQOL-Bref domain between groups and in relation to different times

Baseline (T0) 30 days (T1)

P**
95% CI 95% CI
Group Mean (SD) Median Rank average LL US Mean (SD) Median Rank average LL US
WHOQOL-Bref—Psychological Domain
OS (n ¼ 15) 60.71 (13.22) 60.7 28,97 53.39 68.04 67.83 (13.56) 71.4 30,27 60.32 75.35 .059
MT (n ¼ 15) 65.24 (11.72) 64.3 36,60 58.75 71.73 75.0 (8.32) 75 39,83 70.39 79.60 .011
C (n ¼ 15) 58.33 (12.71) 57.1 25,60 51.29 65.38 60.23 (15.25) 57.1 22,60 51.78 68.68 .444
SA (n ¼ 15) 61.42 (13.58) 60.7 30,83 53.90 68.94 66.66 (16.17) 67.9 29,30 57.70 75.62 .102
P* 0.367 0,058
WHOQOL-Bref—Psychological Domain

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OS (n ¼ 15) 69.18 (13.23) 66.7 33,67 61.85 76.51 68.88 (11.23) 70.8 31,23 62.66 75.11 .706
MT (n ¼ 15) 65.84 (12.72) 66.7 31,60 58.80 72.88 68.61 (13.53) 70.83 32,13 61.11 76.10 .509
C (n ¼ 15) 64.17 (15.17) 66.7 30,43 55.77 72.58 67.22 (17.18) 66.7 30,87 57.70 76.73 .326
SA (n ¼ 15) 63.06 (12.68) 62.5 26,30 56.06 70.09 66.10 (14.58) 70.8 27,77 58.02 74.17 .291
P* .695 .911
WHOQOL-Bref—Social domain
OS (n ¼ 15) 64.44 (13.15) 66.7 25,20 57.15 71.37 75.56 (14.25) 75 34,60 67.67 83.45 .012
MT (n ¼ 15) 72.23 (16.87) 75 34,07 62.88 81.57 73.33 (16.72) 75 34,67 64.07 82.59 .861
C (n ¼ 15) 70.01 (22.23) 66.7 33,40 57.70 82.32 64.44 (19.78) 66.7 25,27 53.48 75.39 .015
SA (n ¼ 15) 63.89 (24.12) 75 29,33 50.53 77.25 67.77 (18.60) 75 27,47 57.47 78.07 .396
P* .456 .315
WHOQOL-Bref—Environmental domain
OS (n ¼ 15) 55.41 (11.53) 53.1 25.13 49.02 61.8 54.40 (7.26) 56.3 25.40 50.38 58.42 .469
MT (n ¼ 15) 62.1 (13.68) 62.5 35.10 54.52 69.68 60.83 (16.31) 65.62 35.17 51.79 69.86 .865
C (n ¼ 15) 55.85 (13.24) 56.3 28.57 48.52 63.19 52.31 (12.12) 56.3 24.63 45.59 59.02 .048
SA (n ¼ 15) 60.21 (10.84) 62.5 33.20 54.21 66.22 62.93 (13.24) 62.5 36.80 55.59 70.27 .097
P* .388 .11
WHOQOL-Bref—General
OS (n ¼ 15) 62.43 (10.46) 58.9 26.77 56.64 68.22 66.67 (9.60) 65.7 30.83 61.35 71.99 .088
MT (n ¼ 15) 66.33 (8.54) 66.5 35.33 61.60 71.06 70.93 (15.29) 75 37.57 62.46 79.40 .173
C (n ¼ 15) 62.09 (13.20) 63.5 30.17 54.78 69.40 61.05 (13.92) 61.4 24.50 53.34 68.76 .414
SA (n ¼ 15) 62.14 (12.50) 63.2 29.73 55.22 69.07 65.87 (12.95) 64.8 29.10 58.69 73.07 .065
P* .6 .227

†
Mann-Whitney post-test (among groups that there was a statistically significant difference).
OS ¼ occlusal splint; MT ¼ manual therapy; C ¼ counseling; SA ¼ scalp acupuncture; SD ¼ standard deviation; LL ¼ lower limit and UL ¼ upper limit of the
95% CI ¼ confidence interval; significance level P (<.05).
*Kruskal-Wallis test,
**Wilcoxon signed-rank test.

therapies (such as manual therapy and occlusal splint) failure, history of gastrointestinal hemorrhage, and for the
that present excellent results for TMD patients [16, 27]. older people who use multiple medications [29]. It can be
Counseling did not show good results in the present performed in the pretreatment of anxious and stressed
study, diverging from the literature in general [27, 28], patients, due to its analgesic, sedative, and relaxing effects
which may be due to a possible lack of collaboration on [30], being indicated in cases of chronic orofacial pain with
the part of the patients, which is fundamental for the suc- resistance to conventional treatments [29].
cess of the treatment. The present study has some limitations, such as the
From a clinical point of view, immediate pain reduction small sample and absence of a group with simulated
can be of great value in cases of hyperalgesia, allodynia, and “sham” therapy, since the results can be attributed to the
even moderate to severe pain, situations that would make placebo effect. It is also important to notice that the partic-
manipulation through manual therapy impossible and treat- ipants had different TMD diagnoses according to the
ments that demand a longer waiting period as the occlusal RDC; therefore, varying symptoms, and the fact that the
splint not ideal. Immediate pain relief function as an emer- same acupuncture areas were used for every patient in-
gency therapy to relieve severe pain is also valuable. stead of a personalized treatment may influence the results.
Furthermore, scalp acupuncture stands out from the In addition, the exclusion of patients with migraine and fi-
other therapies not only because it requires little clinical bromyalgia must be considered, since those are clinical
time but also due to its low cost. It can also replace drug conditions commonly present in patients with TMD, and
therapy, when the patient has allergies or suffers serious ad- therefore the results of this study may not be reproducible
verse effects from the use of drugs, cases of renal or hepatic in a clinic treating more challenging TMD patients.
Scalp Acupuncture in Patients with TMD 913

Conclusion 11. Institute for Traditional Medicine. Synopsis of scalp acupunc-

ture. Available at: http://www.itmonline.org/arts/newscalp.htm
Based on the study, it is possible to conclude that the (accessed January 2021).
scalp acupuncture was effective in TMD patients in terms 12. Correia LM, Alberti D, Lopes SS. Evaluation of chronic head
of pain intensity, as well as OS and MT, reducing it in and neck myofascial pain control with Yamamoto new scalp
the short term. Long-term studies are still necessary. acupuncture in eight weeks follow-up period. Revista Dor 2015;
Scalp acupuncture was not effective in improving quality 16(2):81–5.
of life and sleep. In general, scalp acupuncture may be 13. Allam H, Mohammed NH. The role of scalp acupuncture for re-
lieving the chronic pain of degenerative osteoarthritis: A pilot study
another alternative to conventional treatments for TMD,
of Egyptian women. Medical Acupuncture 2013;25(3):216–20.
being indicated as emergency therapy to relieve the 14. Barreiros RN, Dutra LB, da Silva RC, Ribeiro YC, Louro LD,
patient’s pain to an acceptable level and then start other Louro TQ. The Japanese scalp acupuncture as an instrument for
therapies, if necessary. non-specific pain treatment in health professionals [A

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Craniopuntura Japonesa como Instrumento para o Tratamento
da Dor n~ ao Especıfica em Profissionais de Saude]. Rev Pesquisa
Acknowledgments 2020;11(3):594–8.
15. Wu JY, Zhang C, Xu YP, et al. Acupuncture therapy in the man-
The authors would like to acknowledge the patients who
agement of the clinical outcomes for temporomandibular disorders:
trusted and accepted to be part of this study, without A PRISMA-compliant meta-analysis. Medicine 2017;96(9):e6064.
whom this research would not exist, and to all the others 16. Costa YM, Porporatti AL, Stuginski-Barbosa J, Bonjardim LR,
who somehow contributed to the construction of these Conti PC. Additional effect of occlusal splints on the improve-
results. ment of psychological aspects in temporomandibular disorder
subjects: A randomized controlled trial. Arch Oral Biol 2015;60
(5):738–44.
Supplementary Data 17. MICHELOTTI A, WIJER A, STEENKS M, FARELLA M.
Home-exercise regimes for the management of non-specific tem-
Supplementary data are available at Pain Medicine poromandibular disorders. J Oral Rehabil 2005;32(11):779–85.
online. 18. Bollini e Silva F, Sacomani DG, Fregonesi CE, Masselli MR, de
Oliveira DL, de Camargo MR. The effect of craniopuntura on
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