Dry Needling and Dental Pain

A recent multi-center randomized control trial found dry needling and upper cervical spinal manipulation to be more effective than interocclusal splint therapy, diclofenac, and TMJ mobilization in patients with TMD. 1 This treatment could also be suggested for patients with dental, orofacial pain, and neuralgia.

The temporomandibular-masticatory complex constitutes temporo-mandibular joint (TMJ) and masticatory system, including muscles and dentition. 2 The disorders associated with this complex commonly referred to as temporomandibular dysfunction (TMD) make up the second most common cause of pain in the orofacial region, next to odontogenic. 2 Odontogenic pain refers to pain initiating from the teeth or their supporting structures, the mucosa, gingivae, maxilla, mandible or periodontal membrane.


Symptoms of TMD may present in up to 35% of the general population samples, but only 5-10 % seek care.3 Orofacial pain is described as pain within the trigeminal system. 4 The trigeminal nerve supplies general sensory supply to face, scalp, and mouth, and is represented by about 40% of the sensory cortex. 4

Myofascial pain is the second most recurrent type of orofacial pain and is estimated that 33% of people have symptoms in the face and mastication muscles.5 Orofacial pain can be associated with numerous pathological conditions or disorders related to somatic and neurological structures, and have confounding biopsychosocial components.4

Central nervous system differences in the trigeminal nucleus and limbic structures have been demonstrated in people with myofascial pain, and chronic pain results in sympathetic nervous system overactivation. 3 The incidence of altered sensation after dental or mandibular surgery varies, ranging from 1% to 5% for third molar removal, up to 80% to 85% for sagittal split osteotomies. 6

There is a neurophysiological relationship between the upper cervical spine, TMD, tooth pain, and even headaches. 1 The trigeminal nerve is divided in to three branches. The ophthalmic nerve is responsible for sensory innervation of the face and skull above the palpebral fissure and the eye and portions of the nasal cavity.7 The mandibular nerve provides motor innervation to the muscles of mastication and sensory innervation to the TMJ, teeth, and jaw, via the auriculotemporal branch. 1 The maxillary nerve is a sensory branch and innervates portions of the nasal cavity, sinuses, maxillary teeth, palate, and the middle portion of the face and skull above the mouth and below the forehead.7 The spinal tract of the trigeminal nerve synapses with the dorsal horn of C1 – C3, thus, helping explain pain referral between the craniofacial area and upper cervical spine.8

The dense interconnections between the trigeminal as well as facial, glossopharyngeal and vagus nerves, can give rise to local and referred pain and associated symptomatology.8 Muscles of mastication may refer to the teeth.3 The anterior digastric muscle can cause toothache via referred pain to the central and lateral mandibular incisors.8 The masseter muscle can refer pain to the ipsilateral mandibular and maxillary three molars.8 The temporalis can refer pain to any of the ipsilateral maxillary teeth. 8 Odontogenic pain can mimic maxillary sinusitis-like symptoms in temporomandibular disorders or neuropathic pain. 4 One hypothesis for dental pain is the osmolality theory, whereby the dentine fluids can elicit an action potential within the A delta and C fibers in the pulp when stimulated by mechanical stimulation. 4

Dry needling can stimulate an analgesic response, by stimulating the tissues in the surrounding areas,   similar to the analgesic effects of commonly used pain medication, such as ibuprofen or paracetamol. 2,4 A systematic review and meta-analysis suggested dry needling increased pain pressure threshold compared with sham therapy, and decreased pain intensity compared to lidocaine injection and combination drug therapy (methocarbamol and paracetamol). 5 Dry needling can mitigate central sensitization by segmental inhibition or gate control, release of endogenous opioids, and activation of serotonergic and noradrenergic descending inhibitory tracts.8

A recent multi-center randomized control trial found dry needling and upper cervical spinal manipulation to be more effective than interocclusal splint therapy, diclofenac, and TMJ mobilization in patients with TMD.1 The semi standardized TMJ protocol used in the RCT targeted the inferior head of the lateral pterygoid muscle, the superficial masseter muscle, the anterosuperior and anteroinferior aspects of the temporalis muscle, and the periarticular capsule of the posterior TMJ. A retrospective study using many of the similar points as the RCT  and found decreased pain with improved mouth opening in TMD, compared to occlusal splints and low level laser therapy. 9

The evaluation process for patients presenting with orofacial or TMD pain to physical therapy should include a complete cranial nerve screen, with particular attention to the trigeminal nerve, as well as screening of the upper cervical vertebrae. 3 The  complex  interplay between the sympathetic and trigeminal nervous  systems  and  an  increased  understanding of the centralization of pain have resulted in an important role not only for dentists, physical therapists, but also behavioral scientists, for successful  management  of  chronic pain related to TMD. 3  


  1. Dunning J, Butts R, Bliton P, et al. Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial. CRANIO®. Published online April 12, 2022:1-14. doi:10.1080/08869634.2022.2062137
  2. Smita P Patil, Mangalgi A, Kashetty M, Patil S, Saraswati FK, Patil N. Acupuncture in the Management of Orofacial Pain and Related Disorders: A Review. Int J Clin Dent Sci. 2013;4(2):38-40.
  3. Harrison AL, Thorp JN, Ritzline PD. A Proposed Diagnostic Classification of Patients With Temporomandibular Disorders: Implications for Physical Therapists. J Orthop Sports Phys Ther. 2014;44(3):182-197. doi:10.2519/jospt.2014.4847
  4. Renton T. Dental (Odontogenic) Pain. Rev Pain. 2011;5(1):2-7. doi:10.1177/204946371100500102
  5. Vier C, Almeida MB de, Neves ML, Santos ARS dos, Bracht MA. The effectiveness of dry needling for patients with orofacial pain associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2019;23(1):3-11. doi:10.1016/j.bjpt.2018.08.008
  6. Walton JN. Altered sensation associated with implants in the anterior mandible: A prospective study. J Prosthet Dent. 2000;83(4):443-449. doi:10.1016/S0022-3913(00)70039-4
  7. Huff T, Weisbrod LJ, Daly DT. Neuroanatomy, Cranial Nerve 5 (Trigeminal). In: StatPearls. StatPearls Publishing; 2022. Accessed December 26, 2022.
  8. Kietrys DM, Palombaro KM, Mannheimer JS. Dry Needling for Management of Pain in the Upper Quarter and Craniofacial Region. Curr Pain Headache Rep. 2014;18(8):437. doi:10.1007/s11916-014-0437-0
  9. Shin BC, Ha CH, Song YS, Lee MS. Effectiveness of Combining Manual Therapy and Acupuncture on Temporomandibular Joint Dysfunction: A Retrospective Study. Am J Chin Med. 2007;35(02):203-208. doi:10.1142/S0192415X07004746