Perceived helpfulness of treatments for myofascial TMD as a function of comorbid widespread pain.

OBJECTIVE: This study examined whether patients with myofascial temporomandibular disorder (mTMD) comorbid with fibromyalgia (FM) receive different treatments or respond differently to these treatments than mTMD-only patients. MATERIALS AND METHODS: A total of 125 mTMD+ women were enrolled (26 FM+ and 98 FM-). mTMD and FM were assessed via clinical research examinations. Treatment histories and self-reported treatment-related improvement were obtained via interview. RESULTS: The top 3 most common treatments reported were oral appliances (59%), physical therapy (54%), and jaw exercises at home (34%). Use of alternative medicine was reported more frequently among FM+ women, but self-reported improvement did not differ by comorbid FM. Physical therapy was as likely reported by FM status but self-reported improvement scores trended higher for FM+ women. CONCLUSIONS: Oral appliances were as likely to be reported by FM comorbid as FM- women. Oral appliances did not outperform self-management treatments on self-reported improvement of facial pain. CLINICAL RELEVANCE: Results support the use of self-management as first-line treatment for mTMD and potential utility of inquiring about widespread pain for treatment planning.

Laser Therapy and Occlusal Stabilization Splint for Temporomandibular Disorders in Patients With Fibromyalgia Syndrome: A Randomized, Clinical Trial.

Context • Patients with fibromyalgia syndrome (FMS) report frequent and severe symptoms from temporomandibular disorders (TMDs). The appropriate treatment of TMDs remains controversial. No studies have occurred on the efficacy of therapy with a laser or an occlusal stabilization splint in the treatment of TMDs in patients with FMS. Objective • The study intended to investigate the therapeutic effects of laser therapy and of an occlusal stabilization splint for reducing pain and dysfunction and improving the quality of sleep in patients with TMDs and FMS. Design • The research team designed a single-blinded, randomized clinical trial. Setting • The study took place in the research laboratory at the University of Granada (Granada, Spain). Participants • Participants were 58 women and men who had been diagnosed with FMS and TMDs and who were referred from the clinical setting. Intervention • Participants were randomly assigned to the occlusal-splint or the laser group. The laser group received a treatment protocol in which laser therapy was applied to the participant's tender points, and the occlusal-splint group underwent a treatment protocol in which an occlusal stabilization splint was used. Both groups underwent treatment for 12 wk. Outcomes Measures • Pain intensity, widespread pain, quality of sleep, severity of symptoms, active and passive mouth opening, and joint sounds were assessed in both groups at baseline and after the last intervention. The measurements used were (1) a visual analogue scale (VAS), (2) the Widespread Pain Index (WPI), (3) the Symptom Severity Scale (SSS), (4) the Patient's Global Impression of Change (PGIC), (5) the Pittsburgh Quality of Sleep Questionnaire Index (PSQI), (6) an assessment of the number of tender points, (7) a measurement of the active mouth opening, (8) a measurement of the vertical overlap of the incisors, and (9) the measurement of joint sounds during mouth opening and closing. Results • The group X time interaction for the 2 × 2 mixed analysis of variance found no statistically significant differences between the 2 treatment groups: (1) VAS, P = .591; (2) WPI, P = .112; (3) SSS, P = .227; (4) PGIC, P = .329; (5) number of tender points, P = .107; (6) right and left clicking sounds in the jaw joint during palpation at mouth opening, P = .723 and P = .121, respectively; and (7) right and left clicking sounds in the jaw joint during palpation at mouth closing, P = .743 and P = .698, respectively. Compared with baseline, the laser treatment showed significant improvements on several outcomes, including the VAS, P < .001; WPI, P = .003; and SSS, P = .001. Overall, the study found an average improvement in symptoms from baseline of 21% , P < .001, based on the PGIC. Conclusions • Laser therapy or an occlusal stabilization splint can be an alternative therapeutic treatment for reducing pain symptoms and the clicking sound for TMDs in patients with FMS.

[The (putative) pathological impact of fibromyalgia on the orofacial system]. / De (vermeende) pathologische invloed van fibromyalgie op het orofaciale systeem.

Fibromyalgia is a syndrome without apparent aetiology, characterised by pain, fatigue, memory disorders, mood disorders, and sleep disturbances. The syndrome is considered to be one of the rheumatic diseases. In the general population, the prevalence varies from 2 to 8%, with a women-men ratio of about 2:1. Suspicion of fibromyalgia arises when a patient has pain at multiple locations that cannot be attributed to trauma or inflammation, and when the pain is especially musculoskeletal. Primary management includes explaining the syndrome and offering reassurance. In addition, one can also attempt to increase mobility, avoid overloading, and improve physical condition and the level of activity, and to activate problem-solving skills. Subsequently, behavioural therapy and pharmacotherapy may be considered. The most important manifestations of fibromyalgia in the orofacial and occlusal system seem to be temporomandibular dysfunction, headache, xerostomia, hyposalivation, burning mouth and dysgeusia. However, with respect to the precise relation of fibromyalgia with the orofacial system, much needs to be elucidated.

Metals as a common trigger of inflammation resulting in non-specific symptoms: diagnosis and treatment.

BACKGROUND: The multiple symptoms of chronic fatigue syndrome (CFS) and fibromyalgia resemble those described in patients suffering from autoimmune/inflammatory syndrome induced by adjuvants (ASIA). It has been suggested that chronic metal-induced inflammation might play a role both in CFS and fibromyalgia as well as in ASIA. Humans are exposed to metals mainly through the release of metal ions from corroding dental restorations and orthopedic implants, food, vaccines and jewelry. Metals readily bind to sulphur and other groups in the mitochondria, enzymes and cell proteins. Metal-bound proteins are recognized by the immune system of susceptible subjects and might trigger an abnormal immune response, including allergy and autoimmunity. OBJECTIVES: To study three subjects with CFS and two with fibromyalgia, all of whom suspected metal exposure as a trigger for their ill health. METHODS: We measured delayed-type hypersensitivity to metals (metal allergy) using a validated lymphocyte transformation test, LTT-MELISA. All patients except one were sensitized to metals present in their dental restorations. The remaining patient reacted to metals in his skull implant. The removal of sensitizing metals resulted in long-term health improvement. Nine healthy controls matched for gender and age showed only marginal reactivity to the metals tested. CONCLUSIONS: Patients with CFS and fibromyalgia are frequently sensitized to metals found in the environment or used in dentistry and surgery. This allergy to metals might initiate or aggravate non-specific symptoms in metal-sensitized patients.

A multidisciplinary approach to study the effects of balneotherapy and mud-bath therapy treatments on fibromyalgia.

OBJECTIVES: To study the effects of both balneotherapy and mud-bath therapy treatments in patients affected by primary fibromyalgia (FM) using rheumatological, psychiatric, biochemical and proteomic approaches. METHODS: Forty-one FM patients (39 females, 2 males), who fulfilled the American College of Rheumatology criteria received a 2-week thermal therapy programme consisting of therapy once daily for 6 days/week. Twenty-one patients received mud-bath treatment, while the other twenty balneotherapy. Pain, symptoms, and quality of life were assessed. Oxytocin, brain-derived neurotrophic factor (BDNF), ATP and serotonin transporter levels during therapy were assayed. Comparative whole saliva (WS) proteomic analysis was performed using a combination of two-dimensional electrophoresis (2DE) and mass spectrometry techniques. RESULTS: We observed a reduction in pain, FIQ values and improvement of SF36 in both groups of patients treated with mud-bath or balneotherapy. The improvement of the outcome measures occurred with different timing and duration in the two spa treatments. A significant decrease in BDNF concentrations was observed either after balneotherapy or mud-bath therapy when assayed after twelve weeks, while no significant change in oxytocin levels, ATP levels and serotonin transporter were detected. Significant differences were observed for phosphoglycerate mutase1 (PGAM1) and zinc alpha-2-glycoprotein 1 (AZGP1) protein expression. CONCLUSIONS: Our results showed that the thermal treatment might have a beneficial effect on the specific symptoms of the disease. In particular, while balneotherapy gives results that in most patients occur after the end of the treatment but which are no longer noticeable after 3 months, the mud-bath treatment gives longer lasting results.

Acute Caffeine Intake Reduces Perceived Exertion But Not Muscle Pain during Moderate Intensity Cycling Exercise in Women with Fibromyalgia.

OBJECTIVE: Exacerbated perceived exertion and muscle pain responses during exercise might limit physical activity practice in fibromyalgia patients. Thus, nutritional strategies that can reduce perceived exertion and muscle pain during exercise in fibromyalgia patients would be useful. The purpose of this study was to investigate the effects of acute caffeine intake on the perceptions of exertion and muscle pain during a moderate intensity exercise in women with fibromyalgia. METHOD: Using a randomized, double-blinded, placebo-controlled and crossover experimental design, eleven sedentary women diagnosed with fibromyalgia (age: 44.6 ± 10.5 years; body mass index: 28.5 ± 4.5 kg.m-2) ingested a capsule containing either caffeine (5 mg per kg of body mass) or cellulose (placebo), 60 minutes before performing a 30-minute constant-load cycling exercise, with work rate fixed at 50% of their individual peak workload attained in an incremental exercise test. Ratings of perceived leg muscle pain and perceived exertion were assessed every 5 minutes of exercise. RESULTS: The perceived leg muscle pain was similar (F(1,10) = 1.18, p = 0.30, ŋ2 = 0.11) between caffeine (2.1 ± 1.2 arbitrary units) and placebo conditions (2.2 ± 0.9 arbitrary units). The perceived exertion, however, was on average 8 ± 6% lower (F(1,10) = 12.13; p = 0.006; ŋ2 = 0.55) during exercise in the caffeine condition (12.4 ± 1.3 arbitrary units) than in the placebo condition (13.1 ± 1.1 arbitrary units). CONCLUSIONS: These findings indicate that acute caffeine intake could be an attractive strategy to attenuate the exacerbated perceived exertion of fibromyalgia patients during moderate intensity exercise.

Safety and efficacy of vagus nerve stimulation in fibromyalgia: a phase I/II proof of concept trial.

OBJECTIVE: We performed an open-label Phase I/II trial to evaluate the safety and tolerability of vagus nerve stimulation (VNS) in patients with treatment-resistant fibromyalgia (FM) as well as to determine preliminary measures of efficacy in these patients. METHODS: Of 14 patients implanted with the VNS stimulator, 12 patients completed the initial 3-month study of VNS; 11 patients returned for follow-up visits 5, 8, and 11 months after start of stimulation. Therapeutic efficacy was assessed with a composite measure requiring improvement in pain, overall wellness, and physical function. Loss of both pain and tenderness criteria for the diagnosis of FM was added as a secondary outcome measure because of results found at the end of 3 months of stimulation. RESULTS: Side effects were similar to those reported in patients treated with VNS for epilepsy or depression and, in addition, dry mouth and fatigue were reported. Two patients did not tolerate stimulation. At 3 months, five patients had attained efficacy criteria; of these, two patients no longer met widespread pain or tenderness criteria for the diagnosis of FM. The therapeutic effect seemed to increase over time in that additional participants attained both criteria at 11 months. CONCLUSIONS: Side effects and tolerability were similar to those found in disorders currently treated with VNS. Preliminary outcome measures suggested that VNS may be a useful adjunct treatment for FM patients resistant to conventional therapeutic management, but further research is required to better understand its actual role in the treatment of FM.

Effective recruitment strategies in an exercise trial for patients with fibromyalgia.

BACKGROUND: Recruitment of fibromyalgia populations into long-term clinical trials involving exercise interventions is a challenge. We evaluated the cost and randomization yields of various recruitment methods used for a fibromyalgia trial in an urban setting. We also investigated differences in participant characteristics and exercise intervention adherence based on recruitment source. METHODS: We recruited individuals with fibromyalgia in the greater Boston area to a randomized controlled trial (RCT) using six recruitment strategies: newspaper advertisements, web advertisements, flyers, clinic referrals, direct mailing to patients in a clinic database, and word of mouth. We used the American College of Rheumatology 1990 and 2010 diagnostic criteria to screen and enroll participants. During an initial phone call to an interested participant, the study staff asked how they heard about the study. In this study, we compared the cost and yield of the six recruitment strategies as well as baseline characteristics, adherence, and attendance rates of participants across strategies. RESULTS: Our recruitment resulted in 651 prescreens, 272 screening visits, and 226 randomized participants. Advertisements in a local commuter newspaper were most effective, providing 113 of 226 randomizations, albeit high cost ($212 per randomized participant). Low-cost recruitment strategies included clinical referrals and web advertisements, but they only provided 32 and 16 randomizations. Community-based strategies including advertisement and flyers recruited a more racially diverse participant sample than clinic referrals and mailing or calling patients. There was no evidence of difference in adherence among participants recruited from various strategies. CONCLUSIONS: Newspaper advertisement was the most effective and most expensive method per randomized participant for recruiting large numbers of individuals with fibromyalgia in an urban setting. Community-based strategies recruited a more racially diverse cohort than clinic-based strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT01420640 . Registered on 19 August 2011.

The Impact of a 20-Minute Animal-Assisted Activity Session on the Physiological and Emotional States in Patients With Fibromyalgia.

OBJECTIVE: To study the direct physiological and emotional impact of an animal-assisted activity (AAA) session (a form of complementary and integrative medicine) in patients with fibromyalgia (FM). PATIENTS AND METHODS: The study population consisted of 221 participants with FM who were attending Mayo Clinic's Fibromyalgia Treatment Program between August 5, 2017, and September 1, 2018. This was a randomized controlled trial. Participants were randomly assigned to either the treatment group (a 20-minute session with a certified therapy dog and handler) or the control group (a 20-minute session with a handler only). To gain a better understanding of the direct physiological and emotional effects of AAA in patients with FM, we used multiple noninvasive physiologic-emotional biomarkers, including salivary cortisol and oxytocin concentrations, tympanic membrane temperatures, and various cardiac parameters, in addition to standardized pain and mood-based questionnaires. RESULTS: Results show a decrease in heart rate, an increase in heart rate variability, an increase in well-being survey scores, an increase in salivary oxytocin, and subsequent tympanic membrane temperature changes, suggesting that participants in the treatment group were in a more positive emotional-physiologic state as a result of the AAA session compared with the control group. CONCLUSION: Our results suggest that a 20-minute therapy dog visit in an outpatient setting can significantly and positively impact the physical and mental health of patients with FM.

[Functional somatic syndrome in dental practice].

Functional somatic syndromes (FSSs) are common in dental as well as medical practice. Many patients with unexplained symptoms in oro-maxillo-facial areas visit dentists, but they are not diagnosed and treated properly. Temporomandibular disorder, atypical facial pain, and glossodynia (burning mouth syndrome) are included in dental FSSs. These diseases overlap with each other and with FSSs in other organs, such as myofacial pain syndrome, tension-type headache, fibromyalgia, and chronic fatigue syndrome. They coexist with mental disorders, such as anxiety disorder, mood disorder, and somatoform disorder. Multidisciplinary and holistic approaches should be applied to dental FSSs; pharmacological therapy (antidepressants), physical therapy, and cognitive-behavioral therapy. Clinicians have to support a patient in"enjoying his/her life with symptoms". Dental specialists in "oral medicine" with psychosomatic viewpoints are now required.

Effects of a health education program on cytokines and cortisol levels in fibromyalgia patients: a randomized controlled trial.

BACKGROUND: Fibromyalgia (FM) is a syndrome characterized by widespread chronic pain associated to other symptoms, such as: fatigue, anxiety, depression and sleep disorders. Health education programs (HEP) have emerged as good non-pharmacological strategies to treat it. However, it is still not clear if the benefits are only subjective, or it has also objective impacts on immune and or neuroendocrine systems. METHODS: Fifty-eight fibromyalgia women were randomly allocated in experimental group (n = 27) or control group (n = 31). The experimental group was submitted to HEP treatment for 11 weeks, while control group did not receive intervention at the same period. All data were collected at zero and 11th week by a blinded researcher. The statistical analysis were made in GraphPad Prism software (version 5.0) with significant level adjusted for α = 0.05. RESULTS: Forty-four patients concluded the full study, 21 in the experimental group and 23 in the control group. Intragroup and intergroup analysis revealed that treatment induced significant increases of IL-4 plasma levels, anti-inflammatory cytokine/inflammatory cytokine ratio (AC/IC ratio), salivary cortisol levels, in addition to significant decreases on FIQ scores. Intergroup variation analyses revealed also significant increases of IL-10 plasma levels. CONCLUSION: The results presented suggest that this kind of HEP could induce subjective and objective changes (immune and neuroendocrine), that could explain, at least in part the improvement of fibromyalgia patient's health status. (Clinical Trial Registration Number - ReBEC - RBR-5tdnbr).

Massage therapy in cortisol circadian rhythm, pain intensity, perceived stress index and quality of life of fibromyalgia syndrome patients.

We investigate the effects of a massage therapy program (MTP) in cortisol concentration (CC), intensity of pain, quality of life and perceived stress index of fibromyalgia patients. Volunteers (n = 24, aged 26-55 years) were treated with MT, twice a week for three months. They answered the Fibromyalgia Impact Questionnaire (FIQ), Perceived Stress Questionnaire (PSQ) and McGill Pain Questionnaire (MPQ-Br), and collected saliva to evaluate CC before and after the end of each month. The MT had improvement in quality of life, according to the FIQ results, and promoted reduction in PSQ values after the second (PSQ2-0.62 ± 0.04vsPSQ0-0.71 ± 0.04) and third month (PSQ3-0.64 ± 0.04vsPSQ0-0.71 ± 0.04). The MTP also promoted reduction in pain after the third month (MQP-Br1-44.50 ± 2.15vsMQP-Br4-35.38 ± 3.71). Despite PSQ reduction, the CC were not affected by the program. This pilot suggests that this treatment improved quality of life, reduced perceived stress index and pain in these volunteers.

Changes in salivary cortisol and corticosteroid receptor-alpha mRNA expression following a 3-week multidisciplinary treatment program in patients with fibromyalgia.

The aim of the present study was to investigate the effects of a 3-week residential multidisciplinary non-pharmacological treatment program (including individually prescribed aerobic exercise and cognitive-behavioral therapy) on fibromyalgia symptoms and hypothalamic-pituitary-adrenal (HPA) axis function. Salivary and venous blood samples were collected from 12 female patients with fibromyalgia (age: 25-58) the day before and the day after the treatment period: saliva, eight times (every two hours from 0800 to 2200 h); venous blood, at 0800 h. Peripheral blood mononuclear cells (PBMC) were separated and analyzed for glucocorticoid receptor-alpha (GR-alpha) mRNA expression by semi-quantitative RT-PCR, while the salivary cortisol concentration was determined by RIA. At the same time, pain and aerobic capacity were evaluated. Aerobic capacity improved at the end of the treatment program. The slope of the regression of salivary cortisol values on sampling time was steeper in all patients after treatment, indicating that the cortisol decline was more rapid. Concomitantly, the area under the cortisol curve "with respect to increase" (AUC(i)) was higher and there was a significant increase in GR-alpha mRNA expression in PBMC. The number of positive tender points, present pain, pain area and CES-D score were significantly reduced after the treatment, while the pressure pain threshold increased at most of the tender points. Our findings suggest that one of the active mechanisms underlying the effects of our treatment is an improvement of HPA axis function, consisting in increased resiliency and sensitivity of the stress system probably related to stimulation of GR-alpha synthesis by the components of the treatment.

Fibromyalgia syndrome: considerations for dental hygienists.

PURPOSE: Fibromyalgia syndrome (FMS) is a neurosensory disorder characterized by widespread musculoskeletal pain. Typically persistent fatigue, depression, limb stiffness, non-refreshing sleep and cognitive deficiencies are also experienced. Oral symptoms and pain are common, requiring adaptations in patient management strategies and treatment interventions. Appropriate dental hygiene care of patients suffering with this disorder is contingent upon an understanding of disease epidemiology, pathophysiology, clinical characteristics, oral signs and symptoms, as well as treatment approaches. With this information dental hygienists will be better prepared to provide appropriate and effective treatment to patients with FMS.

IL-10 Cytokine as Potential Biomarkers in Women with Fibromyalgia Who Underwent to a Short Balneotherapy Treatment

Abstract Fibromyalgia (FM) is a nonarticular rheumatic syndrome that leads to diffuse myalgia, sleep disturbances and morning stiffness. Balneotherapy has been shown an effective strategy to improve the health conditions of patients; however, the treatment follow-up is based on patient report due to the lack of biomarkers. Thus, this study evaluated the application of cytokines and phosphoglycerate mutase I (PGAM-I) to monitoring FM patient underwent to balneotherapy treatment. Eleven healthy and eleven women with FM were submitted to daily sessions of balneotherapy during 10 days. Clinical and quality of life parameters were assessed through a FIQ questionnaire. Blood levels of TNF-(, interleukins (IL-1, IL-2 and IL-10) and PGAM-I expression in patients' saliva were also evaluated. Patients with FM showed significant improvements in their clinical status after treatment. Also, FM patients has IL-10 levels lower than healthy women and the balneotherapy increased the expression of this cytokine in both groups, concomitantly to pain relief. Although inflammatory cytokines (IL-1, IL-2 and TNF-() were more expressed in FM patients than healthy patients their levels did not reduce after treatment. A slight increase of PGAM-I expression was observed. In conclusion, IL-10 levels could be a useful biomarker to balneotherapy follow-up of FM patients. However, these findings must be analyzed in a larger number of patients in order to validate IL-10 as an effective biomarker.

Effects of exercise training and photobiomodulation therapy (EXTRAPHOTO) on pain in women with fibromyalgia and temporomandibular disorder: study protocol for a randomized controlled trial.

BACKGROUND: Fibromyalgia (FM) is a syndrome most prevalent in women, in whom it is characterized mainly by chronic pain. An important issue is that many patients with FM are reported to have temporomandibular dysfunction (TMD), and the coexistence of these pathologies generates a clinical outcome of high complexity. The literature is unclear regarding an effective therapy for reducing pain in patients with both comorbidities. Exercise training and phototherapy (low-level laser therapy with light-emitting diode) are two of the approaches used to treat pain. Thus, the aim of this study is to assess the potential role of exercise training plus phototherapy in reducing chronic pain in women with FM and TMD. A further aim is to determine whether the interventions can improve quality of life and modulate endogenous serotonin. METHODS/DESIGN: A randomized controlled clinical trial will be conducted. It will involve 60 women ≥ 35 years of age with a diagnosis of FM and TMD. After recruitment, patients will be randomly allocated to one of four groups: a control group (no intervention), a group that will receive a phototherapy intervention (PHO), a group that will be prescribed muscle-stretching, aerobic, and facial exercises (EXT), or a group that will receive phototherapy plus exercise interventions (PHO + EXT). The trial will last 10 weeks, and the following outcomes will be evaluated on two separate occasions (baseline and within 24 h after the last day of the protocol). Pain intensity will be analyzed using a visual analogue scale and the McGill Pain Questionnaire, and pain thresholds will be punctuated using a digital algometer. FM symptoms will be assessed using the Fibromyalgia Impact Questionnaire, and quality of life will be determined with the 36-item Short Form Health Survey. Serotonin levels will be evaluated in salivary samples using a competitive enzyme-linked immunosorbent assay. DISCUSSION: This is the first randomized controlled trial in which the role of phototherapy, exercise training, and a combination of these interventions will be evaluated for chronic pain in patients with FM and TMD. The results will offer valuable clinical evidence for objective assessment of the potential benefits and risks of procedures. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02279225. Registered 27 October 2014.

Disordered sleep in fibromyalgia and related myofascial facial pain conditions.

Myofascial pain and fibromyalgia have a recognized relationship to sleep disturbances. Understanding the comorbidity of these entities helps the practitioner, physician and dentist alike, be better prepared to manage the causative factors related to these conditions rather than treating only the symptoms. The increasing recognition of the coexistence of fibromyalgia, myofascial pain in the head and neck region, and the presence of temporomandibular disorders further increases the need for the dentist to be aware of sleep as a contributory factor from the diagnostic and the therapeutic aspects. This awareness results in more comprehensive management and an improved opportunity for optimal patient management as well as improved sleep and diminished pain levels.

Sleep cycles, TMD, fibromyalgia, and their relationship to orofacial myofunctional disorders.

Poor quality sleep is caused by many factors including orofacial myology disorders. TMJ and fibromyalgia patients demonstrate a variety of similar symptoms making diagnosis difficult. A team approach utilizing appropriate referrals is critical to successful patient treatment.

Acupuncture and chronic pain management.

INTRODUCTION: Although acupuncture has been widely used to treat a variety of pain conditions, convincing scientific evidence for its efficacy is lacking. Earlier randomised controlled trials attempted to follow a double-blind, placebo-controlled model. This approach has encountered many problems such as the virtual impossibility of blinding the acupuncturist and the uncertainties inherent in choosing control acupuncture points. The objective of this review is to assess if acupuncture is an effective treatment for chronic pain. In addition, a number of key methodological issues that arise in the controlled evaluation of acupuncture will be discussed. METHODS: This review is based on the result of previous reviews, meta-analyses and consensus conference. The search was performed with MEDLINE (from 1966), EMBASE (from 1980) and Cochrane library (1999, volume 1). Only randomised trials of acupuncture (involved needling) for subjects with chronic pain published in English were included. RESULTS: Basic science research has demonstrated convincingly that at least in the context of acute pain, acupuncture's effects are related to the release of a variety of natural opioids. Acupuncture has been shown to be effective for postoperative dental pain. There are reasonable studies showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, low back pain and fibromyalgia. This suggests that acupuncture may have a more general effect on pain. However, there are also studies which provide equivocal results because of design, sample size and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebo and sham acupuncture groups. CONCLUSION: As most of the studies were of poor methodological quality, there is a need for further high quality randomised controlled trials. Future studies should also have larger sample sizes, use a valid acupuncture treatment, and have both a short-term and long-term follow-up.

Fibrositis (fibromyalgia syndrome) and the dental clinician.

The purpose of this article is to inform the general dentist treating the temporomandibular joint complex about fibrositis (fibromyalgia syndrome). Patients may present with spasms in the muscles of mastication, which may mimic joint pain or cause joint dysfunction. Tooth pain, which may mimic endodontic pain, may also be referred from a trigger pain in a muscle.