There is not universal agreement as to which specific treatments ought to be labeled as CAM⁶; however, the term often is applied to such approaches as acupuncture, therapeutic massage, herbal remedies, homeopathy, naturopathy and yoga. Acupuncture is based on traditional Chinese medical theory and involves stimulating specific anatomical points in the body for therapeutic purposes by puncturing the skin with a needle. Therapeutic massage is the systematic manipulation of the soft tissues of the body to promote health. Herbal remedies employ plant preparations for therapeutic effects. Homeopaths aim to stimulate the body’s defense mechanisms and healing processes by administering minute doses of plant extracts and minerals. Naturopaths work to restore health through nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy, physical therapy, counseling and pharmacology. Uses of herbs and homeopathic remedies to enhance oral health^7–9 and reduce facial pain¹⁰ have been described, as have warnings about their use and potential herb-drug interactions.^7–10

Additional therapeutic techniques often classified as CAM are biofeedback, progressive muscle relaxation (systematic tensing and relaxing of muscle groups), meditation and chiropractic. Biofeedback entails electronic recordings of physiological measures such as muscle tension (electromyographic, or EMG, biofeedback) or skin temperature (thermal biofeedback) that are relayed to the subject as visual or auditory signals for purposes of training control over these parameters.

The purpose of this article is to inform dental professionals about CAM in general and for specifically treating facial pain by describing developments during the past decade at the NIH with regard to CAM research, reviewing the literature on the prevalence of the use of CAM generally and for chronic facial pain, and compiling reports of randomized clinical trials of CAM modalities for chronic facial pain.

	COMPLEMENTARY AND ALTERNATIVE MEDICINE AT THE NATIONAL INSTITUTES OF HEALTH

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In 1992, the Office of Alternative Medicine, or OAM, was established within the NIH Office of the Director with the mission of providing the American public with reliable information about the safety and effectiveness of CAM practices. A 1998 congressional mandate expanded OAM into NCCAM. OAM’s 1993 budget of $2 million grew to NCCAM’s 2001 budget of $89.1 million. NCCAM’s developing programs include funding extramural and intramural research, developing scientific databases, providing a public information clearinghouse, and facilitating national and international cooperative efforts in CAM research and education.⁵

The Office of Alternative Medicine was established with the mission of providing the American public with reliable information about the safety and effectiveness of complementary and alternative medicine practices.

Of particular relevance to dentistry, NCCAM is funding three relatively large-scale randomized clinical trials to investigate the effectiveness of CAM modalities for treatment of craniofacial disorders through a grant to the Oregon Center for Complementary and Alternative Medicine, or OCCAM, in Craniofacial Disorders, headquartered at the Kaiser Permanente Center for Health Research in Portland, Ore. The first study is comparing the effects of acupuncture, chiropractic, massage¹¹ and usual care on temporomandibular disorder, or TMD, symptoms. The second study is comparing the effects of traditional Chinese medicine that include a combination of acupuncture and herbal medicine, naturopathic medicine and usual care on TMD symptoms. The third study is comparing naturopathic medicine, standard care and placebo on chronic periodontitis symptoms. Patients randomized to traditional Chinese medicine in the second study or naturopathic medicine in the second and third studies are diagnosed and treated in the manner traditionally practiced by providers of these two modalities. The endpoints are scientifically validated measures of TMD (first and second studies), and reassessment of the traditional Chinese medicine (second study) or naturopathic medicine (second and third studies) diagnoses.¹²

	PREVALENCE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE USE

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For treating all causes. National surveys indicate that CAM therapies are used widely in the United States and are increasing in popularity. Eisenberg and colleagues conducted parallel nationally representative telephone surveys in 1990¹³ and 1997¹⁴ concerning health care practices including CAM use broadly defined. The 1990 survey had 1,539 participants, and the 1997 survey had 2,055 participants. The 1990 survey estimated that one-third of the U.S. adult population (60 million people) used at least one of 16 CAM therapies. The 1997 survey estimated that this proportion increased significantly to 42.1 percent (83 million people). They also found that use of 10 out of the 16 alternative therapies had increased significantly from 1990 to 1997. Visits to chiropractors and massage therapists accounted for nearly one-half of all visits to CAM professionals. CAM was used most frequently for chronic conditions including chronic pain, and its use was higher among women, participants between 35 to 49 years of age, participants who had some college education and participants who had annual incomes of more than $50,000. African-Americans reported using CAM less frequently than did people in other racial groups. Most people who had used CAM also had seen a physician during the prior 12 months, and only 39.8 percent in 1990 and 38.5 percent in 1997 disclosed to their physicians that they used CAM.¹⁴ It is unknown what percentage of CAM use is reported to dentists.

Paramore¹⁵ reported responses obtained from a national probability sample of 3,450 people to the 1994 National Access to Care Survey, which included questions about chiropractic, relaxation techniques, therapeutic massage and acupuncture. With a response rate of 75 percent, results indicated that nearly 10 percent of the U.S. population (approximately 25 million people) saw a professional for at least one of the listed CAM therapies. More than 17 million people consulted a chiropractor, 8 million received professional massage therapy, nearly 3.5 million consulted a professional for relaxation training, and slightly more than 1 million received acupuncture. Pain was the most frequently cited reasons for CAM use. Unlike Eisenberg and colleagues’^13,14 studies, neither sex nor race/ethnicity was a predictor of CAM use.

Astin¹⁶ reported results from a random sample national mail survey completed by 1,035 people. CAM use was predicted by anxiety, back problems, chronic pain and urinary tract problems. Dissatisfaction with conventional medicine did not predict CAM use, nor did sex, age, income or race/ethnicity.

The authors were unable to locate any published report of a nationally representative study that examined the prevalence of complementary and alternative medicine use specifically for treating facial pain.

For treating pain. Studies indicate more frequent CAM use among patients who had a high probability of experiencing pain. Boisset and Fitzcharles¹⁷ reported that 66 percent of 235 consecutive patients attending a rheumatology clinic had used CAM in the preceding 12 months, including over-the-counter herbs, vitamins, minerals and topical remedies (54 percent); prayer, meditation or self-relaxation (39 percent); and professionally administered chiropractic, acupuncture or massage (13 percent).

Krauss and colleagues¹⁸ interviewed 401 adults who had physically disabling conditions. When they compared their results with those of Eisenberg and colleagues,¹³ they found a higher proportion of chronic pain (14 percent vs. 8 percent) and a higher rate of CAM treatments (57 percent of the sample had used CAM with 22 percent having consulted a CAM professional vs. 34 percent of general population had used CAM with 10 percent having consulted a CAM provider). CAM therapies were chosen more frequently than conventional therapies to treat pain in those who had disabilities (51.8 percent vs. 33.9 percent); relaxation, massage and chiropractic were the most commonly used therapies. People experiencing chronic pain appear to be more likely to use CAM therapies, making the investigation of the prevalence of CAM use for chronic facial pain important.

For treating chronic facial pain. As yet, relatively little is known about the prevalence of CAM use to treat chronic facial pain. We were unable to locate any published report of a nationally representative study that examined the prevalence of CAM use specifically for treating facial pain. Türp and colleagues² reported on the prior health-care–seeking patterns of 206 consecutive patients who were predominantly from suburban and rural southeastern Michigan and were referred to the University of Michigan’s Facial Pain Clinic in Ann Arbor. Most patients had consulted one to four health care providers before being referred to the facial pain center; several had seen more. In addition to seeing conventional specialists, patients had consulted chiropractors (14.6 percent of patients), acupuncturists (3.9 percent), massage therapists (1.9 percent) and homeopaths (0.5 percent).

More recently, 196 Kaiser Permanente Northwest health plan members, recruited into OCCAM studies on the basis of their diagnosis of TMD as documented in their electronic medical record charts, were surveyed about prior CAM use specifically for treating TMD. With a response rate of 76.5 percent, results indicated that 36 percent of the participants had used CAM for treating TMD. A total of 32.6 percent consulted massage therapists, 17.6 percent consulted chiropractors, 6.9 percent consulted acupuncturists, 4.3 percent consulted naturopaths, and 5.7 percent consulted an alternative practitioner for supervised use of herbal supplements. Additionally, 16.8 percent used biofeedback or visual imagery, 12.3 used herbal supplements, and 3.7 percent used homeopathic remedies. Massage (54 percent) and chiropractic (45.5 percent) were most frequently rated as "very helpful" for treating TMD by participants who used these therapies, and massage therapy was rated as the most satisfactory.³

	CLINICAL TRIALS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE FOR FACIAL PAIN

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Methods. To compile research highlighting the most rigorous work in which pain outcomes could be linked to specific CAM interventions, we searched for reports of clinical trials that randomized to a CAM intervention or to either a control or comparison group and that compared outcomes on at least one patient self-report measure of facial pain (Box). In the National Library of Medicine’s PubMed electronic database for 1963 through March 2002; the Cinahl Information System’s Cumulative Index to Nursing and Allied Health Literature, or CINAHL, electronic database for 1982 through March 2002; and the American Psychological Association’s PsycINFO electronic database for 1967 through March 2002, we successively paired the word "pain" with "facial," "orofacial," "TMJ," "TMD" and "temporomandibular." We combined these pairs with the following CAM search terms: "complementary," "alternative," "acupuncture," "biofeedback," "relaxation," "herbal," "meditation," "massage," "yoga," "chiropractic," "homeopathic" and "naturopathic." We also paired the term "trigeminal neuralgia" with each CAM search term.

We also sought review articles in the six databases identified previously and in the Cochrane Library, an electronic database based in Oxford, England, that features systematic reviews of evidence-based medicine. We did not search for case studies or studies in which a CAM modality was administered in combination with one or more other interventions (for example, relaxation training or biofeedback as a component of cognitive behavioral stress management training).

Results. We found 13 trials—three acupuncture, eight biofeedback, two relaxation—that met our inclusion criteria (Table).^19–34 Several case reports (for example, chiropractic for treating TMD) and uncontrolled clinical trials (for example, acupuncture for treating trigeminal neuralgia) were located, but we did not include them, as our aim was to compile only reports of randomized clinical trials.

Raustia and colleagues^19,20 and Raustia and Pohjola²¹ report on one study that randomly assigned 50 patients who had TMD to acupuncture or stomatognathic treatment (counseling, occlusal adjustment, splint therapy and exercises). Posttreatment results appeared to favor stomatognathic treatment slightly, but the patients in the results did not differ at follow-up. The study’s limitations included unequal treatment time across groups and lack of blinding of the assessor to the assignment.

Johansson and colleagues²² randomly assigned 45 patients who had TMD to acupuncture, splint therapy or control groups. They measured pain before treatment and at the three-months follow-up in the two treatment groups, and at the two-months follow-up in the control group. The treatment groups showed significant improvement compared with the control group posttreatment, with no difference between treatments. The examiner was blinded to the treatment condition. Interpretation was complicated by the use of differing follow-up periods.

List and colleagues²³ and List and Helkimo²⁴ reported on one study in which they randomly assigned 110 patients who had TMD to acupuncture or splint groups or to a wait list. Pain diaries kept by a subset of 96 patients indicated significant pain reduction posttreatment and at follow-up in both the acupuncture and splint groups. We were not able to tell if systematic differences distinguished patients who completed their diaries from patients who did not.

Biofeedback. Crider and Glaros³⁷ reviewed the literature on EMG biofeedback treatment alone or in combination with stress management training for the treatment of TMD. They identified six trials with a no-treatment or placebo control, four comparative trials and three uncontrolled trials. Results generally supported the use of biofeedback as a conservative measure for the treatment of TMD. Of the six no-treatment or placebo-controlled trials,^{25–27,33,38,39} three met our search criteria by assessing the effects of EMG biofeedback alone on patients’ report of pain.

In a sample of patients who had myofascial pain disorder, or MPD, Dalen and colleagues²⁵ reported significant reductions in pain intensity and pain duration at follow-up that were associated with participation in either eight biweekly EMG sessions (n = 10) or the control condition (n = 9). Dohrmann and Laskin²⁶ instructed patients who had MPD in how to use EMG biofeedback (n = 16) and found reduced masseter muscle EMG levels and reduced pain compared with a placebo group (n = 8). Also in a sample of patients who had MPD, Hijzen and colleagues²⁷ compared EMG biofeedback, intraoral splint therapy and no-treatment control. They found that biofeedback was associated with significantly greater reduction in pain compared with splint therapy or no therapy.

Popular interest appears to have outpaced scientific interest in complementary and alternative medicine modalities.

Of the four comparative trials^28,29,32,40 Crider and Glaros³⁷ identified, three met our inclusion criteria. Dahlstrom and Carlsson²⁸ compared the long-term treatment effects of EMG biofeedback training to effects of occlusal splint therapy in a sample of 30 female patients. During reexaminations at one and 12 months after completion of therapy, the authors found that subjective pain was significantly reduced in both groups, with no significant difference between groups. A stepwise analysis of regression suggested that biofeedback training may be a useful alternative to splint therapy in cases in which nighttime bruxing is not the dominating feature.

Funch and Gale³² randomly assigned patients who had chronic temporomandibular joint pain to receive either relaxation (n = 27) or biofeedback training (n = 30). They found no significant differences in outcomes between groups, but results indicated that pretreatment factors differentially predicted success in the two groups, providing important initial information about optimal assignment to therapy conditions.

Olson and Malow²⁹ randomly assigned adult patients who had MPD to one of three treatments: masseter muscle EMG biofeedback (n = 6), frontalis EMG biofeedback (n = 6) or frontalis EMG biofeedback plus psychotherapy (n = 6). The treatments were associated with reduced subjective pain and reduced tenderness on examination, compared with normative data on pain and tenderness from patients treated at the same clinic. The treatment groups did not differ with regard to report of pain, but patients treated with frontalis EMG biofeedback plus psychotherapy reported a greater reduction in tenderness.

In addition to the biofeedback trials identified by Crider and Glaros,³⁷ we identified two additional ones that met our search criteria. Erlandson and Poppen³⁰ randomly assigned female outpatients who had MPD to three groups of eight. All of the patents received bilateral masseter muscle EMG biofeedback training. One group received biofeedback only, one group received additional instructions to place their jaws in a resting position, and one group received prosthetic guides to space their incisors 6.8 millimeters apart. Of the subset of patients who had pain, one of four in the EMG biofeedback-only group reported a decrease in pain, four of five in the EMG biofeedback-plus-instructions group reported a decrease in pain, and four out of four in the biofeedback-plus-prosthesis reported a decrease in pain. Across treatment groups, the authors found a significant reduction of pain among those who initially had pain; however, comparisons between groups were not reported.

In the second trial we identified, Mishra and colleagues³¹ randomly assigned 94 patients who had TMD to four groups: biofeedback training (EMG and thermal); cognitive-behavioral skills training, or CBST; combination of biofeedback and CBST; and no-treatment control. Patients in all three active treatment groups reported pain reduction compared with pretreatment on a composite self-report pain measure, and the biofeedback-only group attained the greatest improvement. One year later, the authors found that combined biofeedback and CBST treatment was associated with the most comprehensive improvement.⁴¹

Relaxation. We located three trials in which relaxation training was tested against a control or comparison group and the patient’s report of pain was assessed. Funch and Gale’s³² study, which we discussed in the previous section on biofeedback training, compared relaxation training involving the use of audiotaped instructions for muscle relaxation with biofeedback and did not find differences between groups on pain report.

Brooke and Stenn³³ randomly assigned 190 patients who had MPD to four groups: ultrasonography, occlusal splint, biofeedback-assisted relaxation training or relaxation training alone. Immediately after treatment, the two groups that received the relaxation training had the highest percentage of successful outcomes, with no significant difference between the two relaxation training groups. At six months, patients who used occlusal splints had reached a level of improvement similar to that of those trained in relaxation. Interpretation of the study results is complicated by the fact that ultrasonography was provided for 10 minutes three times per week for three weeks, compared with the hour-long relaxation training sessions provided weekly for seven weeks and occlusal splint use nightly for two months.

Sherman and colleagues³⁴ randomly assigned 21 patients who had orofacial pain with mixed primary diagnoses to either a stretch-based relaxation session or a resting session. No statistically significant group differences were found in self-rating of pain, and treatment effects on pain were not reported.

We located one trial in which relaxation was compared with splint therapy; however, the measure of pain employed was not the patients’ self-reports, but the dentists’ observations of pain behaviors; therefore, we do not discuss the results.⁴² We located additional studies in which relaxation training was provided as a component of self-regulation training, stress management training or cognitive behavioral treatment for TMD^43–45; however, as it was our aim to identify those trials in which a single CAM intervention was tested against a control or comparison, we do not discuss the results.

Other CAM modalities. We did not locate any randomized, controlled clinical trials testing the effects of homeopathy, naturopathy, chiropractic, massage, meditation, yoga or herbal remedies for chronic facial pain through our search strategy.

	CONCLUSIONS

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Significant gaps in the available scientific knowledge base limit the ability of dental professionals to guide patients with regard to CAM approaches to TMD treatment. Although acupuncture and biofeedback have been studied and show promise as part of conservative TMD treatment, other CAM approaches remain relatively or completely unstudied from the standpoint of randomized, controlled clinical-trial research, or the results of such studies were not available for review.

Popular interest appears to have outpaced scientific interest in CAM modalities; however, more resources have been allotted to studying them, and a clear research agenda recently has been delineated to prioritize and guide the design of future rigorous clinical trials.¹² To determine if treatment packages produce superior outcomes, each CAM modality needs to be studied to understand its potential contribution to treatment outcomes and its part in combined treatment. The popularity of CAM interventions for chronic facial pain makes the scientific evaluation of their safety, efficacy and effectiveness an important public health objective.