臺灣博碩士論文加值系統

當下顎阻生智齒需要拔除時，因難以拔除而需要藉由手術開刀取出，且伴隨手術後疼痛。近年研究認為針灸可以用來鎮痛及減輕術後疼痛，也可減輕或治療慢性口面部疼痛。本研究的目的在於針刺單一穴位--合谷穴對於拔除下顎阻生智齒之術後疼痛以及術後出血、腫脹的療效評估，來探討合谷穴對於口面部疾患的療效。
將60位僅需要開刀拔除下顎阻生智齒的健康受試者，隨機分配至針刺實驗組（Real acupuncture group，RA）、空白對照組（Control group、CG）、安慰針組（Placebo needle group，PA）。以視覺疼痛類比量表（Visual Analogue Scale, VAS）及問卷來評估實驗結果，並以Kruskal-Wallis one-way ANOVA及卡方檢定（χ2 test）來分析結果；並以問卷來評估盲法執行的確實性。
本研究的主要結果是評估三組在手術中、手術後當天與手術後一週內各個時間點的疼痛程度與持續時間，止痛藥開始服用的時間與服用總數量，以及手術後預期症狀如出血、腫脹。結果顯示針刺實驗組（RA）在術後第三天的疼痛程度（VAS數值）顯著的低於空白對照組（p＜0.05）。針刺實驗組在術後一周內發生局部腫脹的情形僅約50%，明顯少於安慰針組（p＜0.05）。此外，針對術後局部傷口、生活影響、副作用、心理因素等進行評估，三組之間無顯著差異（p＞0.05）。而實驗中對於受試者的盲法執行的確實度，經問卷評估後發現，受試者術前無法預測分組情形（p＝0.8234）；針刺實驗組與安慰針組的受試者在手術後立即（p＝0.3505）及術後一週（p＝0.0595）仍無法正確分辨分組情形，顯示對於受試者的單盲法執行確實。
歸納上述結果，本研究的結論為：針刺合谷穴能在拔牙術後第三天明顯減少術後疼痛（p＜0.05）；且針刺合谷穴對於拔牙術後腫脹的發生亦有較好的預防的效果，這些效果並非安慰效應所致。本結論支持針刺合谷穴可治療牙痛、顏面浮腫，且不會引發其他嚴重的副作用的說法。因此可考慮在拔除阻生智齒手術中輔以針刺來減輕術後疼痛及預防腫脹發生。

It is normally very difficult to remove the impacted mandibular molars, and the pain management after the extraction is also tricky. Recent studies have shown that acupuncture can rapidly alleviate or even cure chronic orofacial pain. Also, acupuncture is very effective in controlling pain after the impacted mandibular third molar extraction, and therefore, decreasing the usage of Analgesic drugs.
The aim of this project is to evaluate the effect of acupuncture on a single point, Hegu, on the pain management after the impacted mandibular third molar extraction, and to study the application of Hegu acupuncture in treating orofacial pain and in dentistry.
60 subjects who needed to have their impacted mandibular third molar surgically extracted were randomly assigned to experimental group, control group and placebo needle group. The Visual Analogue Scales (VAS) and questionnaires were conducted to every subject to collect research data. The data are analyzed by Kruskal-Wallis one-way ANOVA and Chi-square test to compare postoperative pain and wound swelling respectively among three groups. The confidence of the single-blind design is also examined using the data from questionnaires.
As a result, the degree of pain on the third days after surgery was less in the experimental group(RA) than control group, and it reached a significant level at p<0.05.
Only 50% patients in the RA group experienced wound swelling within 1 week after surgery, which was much less than placebo needle group group (p<0.05).
Based on the analysis of data from questionnaires, subjects can not predict which treatment they will receive before surgery (p=0.8234); they also can not distinguish the treatment they received immediately after surgery (p=0.3505) and a week after surgery (p=0.0595). These results suggest that the single-blind design is convinced.
Therefore, we conclude that acupuncture on Hegu point significantly decreases postoperative pain and is superior to the placebo in preventing postoperative wound swelling in the impacted mandibular third molar extraction. This result is not just a placebo effect.

第一章 前言..........................................1
第二章 文獻探討......................................3
2.1 下顎阻生智齒............................3
2.2 合谷穴的功用及解剖位置..................7
2.3 評估疼痛的量表..........................11
2.4 安慰針具Park Sham Device（PSD）介紹.....12
第三章 材料與方法....................................14
3.1 研究目的與設計..........................14
3.2 所需藥品或儀器設備之名稱和數量..........15
3.3 針刺穴位選取與操作......................17
3.4 樣本的收集..............................18
3.5 試驗流程................................19
3.6 術後疼痛之評估..........................24
3.7 針刺效用、併發症與盲法之評估............25
3.8 統計分析................................26
第四章 結果........................................27
4.1 基本資料分析............................27
4.2 三組對於各時間點的疼痛發生情形比較......30
4.3 三組對於各時間點的疼痛程度比較..........32
4.4 三組對於各種疼痛持續時間的比較..........34
4.5 三組對於止痛藥服用情形、數量及服用時間的比較...................................................37
4.6 三組對於術後引起之腫脹的比較............40
4.7 三組對於拔牙後局部感覺及每日生活影響的比較...................................................42
4.8 三組對於副作用及併發症的比較............45
4.9 三組對於術前及術後心理影響的比較........47
4.10 盲法執行與得氣感的比較.................48
第五章 討論..........................................50
第六章 結論..........................................59
參考文獻.............................................60
附錄一 人體試驗委員會同意書..........................70
附錄二 受試者同意書..................................72
附錄三 下顎智齒切除手術標準化步驟....................80
附錄四 問卷一........................................81
附錄五 問卷二........................................82
附錄六 問卷三........................................89
附錄七 問卷四........................................90
附錄八 受試者參與意願問卷............................91
附錄九 研究衛教單....................................92
英文摘要.............................................93
謝辭.................................................95

1.Ness GM, Peterson LJ. Principle of Oral and Maxillofacial Surgery., 2004. pp. 139-156.
2.林昭庚、鄢良. 針灸醫學史. 北京: 中國中醫藥出版社, 1995. pp. 4-9.
3.林昭庚. 新針灸大成. 台中: 中國醫藥學院針灸研究中心, 2001. pp. 989-991.
4.Tsai HY, Chen YF, Lin JG. Effect of electroacupuncture analgesia on serotoninergic neurons in rat central nervous system. Chinese Pharmacology Journal 1989;41.
5.Han Z, Jiang YH, Wan Y, Wang Y, Chang JK, Han JS. Endomorphin-1 mediates 2 Hz but not 100 Hz electroacupuncture analgesia in the rat. Neurosci Lett 1999;274(2):75-78.
6.Tsai HY, Lin JG, Inoki R. Further evidence for possible analgesic mechanism of electroacupuncture: effects on neuropeptides and serotonergic neurons in rat spinal cord. Jpn J Pharmacol 1989;49(2):181-185.
7.Zhang RX, Lao L, Wang X, Fan A, Wang L, Ren K, Berman BM. Electroacupuncture attenuates inflammation in a rat model. J Altern Complement Med 2005;11(1):135-142.
8.Hsieh CL, Kuo CC, Chen YS, Li TC, Hsieh CT, Lao CJ, Lee CJ, Li JG. Analgesic effect of electric stimulation of peripheral nerves with different electric frequencies using the formalin test. Am J Chin Med 2000;28(2):291-299.
9.Hsu CC, Weng CS, Liu TS, Tsai YS, Chang YH. Effects of electrical acupuncture on acupoint BL15 evaluated in terms of heart rate variability, pulse rate variability and skin conductance response. Am J Chin Med 2006;34(1):23-36.
10.Yim YK, Lee H, Hong KE, Kim YI, Lee BR, Son CG, Kim JE. Electro-acupuncture at acupoint ST36 reduces inflammation and regulates immune activity in Collagen-Induced Arthritic Mice. Evid Based Complement Alternat Med 2007;4(1):51-57.
11.Bing Z, Villanueva L, Le Bars D. Acupuncture and diffuse noxious inhibitory controls: naloxone-reversible depression of activities of trigeminal convergent neurons. Neuroscience 1990;37(3):809-818.
12.林昭庚. 新針灸大成. 台中: 中國醫藥學院針灸研究中心, 2001. pp. 991-995.
13.Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration. Spine 2005;30(8):944-963.
14.Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S, Irnich D, Walther HU, Melchart D, Willich SN. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 2006;166(4):450-457.
15.Thomas KJ, MacPherson H, Thorpe L, Brazier J , Fitter M, Campbell MJ , Roman M, Walters SJ , Nicholl J. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006;333(7569):623-626.
16.Weidenhammer W, Linde K, Streng A, Hoppe A, Melchart D. Acupuncture for chronic low back pain in routine care: a multicenter observational study. Clin J Pain 2007;23(2):128-135.
17.Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery. Pain 2002;99(3):509-514.
18.Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med 2004;141(12):901-910.
19.Witt C, Brinkhaus B, Jena S, Linde K, Streng A , Wagenpfeil S, Hummelsberger J, Walther HU, Melchart D, Willich SN. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. . The Lancet 2005;366:136-143.
20.White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford) 2007;46(3):384-390.
21.Manias P, Tagaris G, Karageorgiou K. Acupuncture in headache: a critical review. Clin J Pain 2000;16(4):334-339.
22.Melchart D, Thormaehlen J, Hager S, Liao J, Linde K, Weidenhammer W. Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial. J Intern Med 2003;253(2):181-188.
23.Karst M, Rollnik JD, Fink M, Reinhard M, Piepenbrock S. Pressure pain threshold and needle acupuncture in chronic tension-type headache--a double-blind placebo-controlled study. Pain 2000;88(2):199-203.
24.Alimi BD, Rubino C, Pichard-Le´andri E, Fermand-Brule´ S, M.-L. Dubreuil-Lemaire, Hill aC. Analgesic effect of auricular acupuncture for cancer pain: A randomized, blinded, controlled trial. Journal of clinical oncology 2003;21:4120-4126.
25.Bardia A, Barton DL, Prokop LJ, Bauer BA, Moynihan TJ. Efficacy of complementary and alternative medicine therapies in relieving cancer pain: a systematic review. J Clin Oncol 2006;24(34):5457-5464.
26.Mehling WE, Jacobs B, Acree M, Wilson L, Bostrom A, West J, Acquah J, Burns B, Chapman J, Hecht FM. Symptom management with massage and acupuncture in postoperative cancer patients: a randomized controlled trial. J Pain Symptom Manage 2007;33(3):258-266.
27.Resim S, Gumusalan Y, Ekerbicer HC, Sahin MA, Sahinkanat T. Effectiveness of electro-acupuncture compared to sedo-analgesics in relieving pain during shockwave lithotripsy. Urol Res 2005;33(4):285-290.
28.Rosted P, Warnakulasuriya S. A survey on the uses of acupuncture by a group of UK dentists. Br Dent J 2005;198(3):139-143.
29.Goddard G. Short term pain reduction with acupuncture treatment for chronic orofacial pain patients. Med Sci Monit 2005;11(2):CR71-74.
30.Myers CD, White BA, Heft MW. A review of complementary and alternative medicine use for treating chronic facial pain. J Am Dent Assoc 2002;133(9):1189-1196; quiz 1259-1160.
31.Schmid-Schwap M, Simma-Kletschka I, Stockner A, Sengstbratl M, Gleditsch J, Kundi M, Piehslinger E. Oral acupuncture in the therapy of craniomandibular dysfunction syndrome -- a randomized controlled trial. Wien Klin Wochenschr 2006;118(1-2):36-42.
32.Rosted P, Jorgensen V. Acupuncture treatment of pain dysfunction syndrome after dental extraction. Acupunct Med 2002;20(4):191-192.
33.Bausell RB, Lao L, Bergman S, Lee WL, Berman BM. Is acupuncture analgesia an expectancy effect? Preliminary evidence based on participants'' perceived assignments in two placebo-controlled trials. Eval Health Prof 2005;28(1):9-26.
34.Rosted P. Introduction to acupuncture in dentistry. Br Dent J 2000;189(3):136-140.
35.Ka L, Hirata Y, Kobayashi A, Wake H, Kino K, Amagasa T. [Treatment results of acupuncture in inferior alveolar and lingual nerves sensory paralysis after oral surgery]. Kokubyo Gakkai Zasshi 2006;73(1):40-46.
36.Kohjitani A, Miyawaki T, Kasuya K, Shimada M. Sympathetic activity-mediated neuropathic facial pain following simple tooth extraction: a case report. Cranio 2002;20(2):135-138.
37.Johnstone PA, Niemtzow RC, Riffenburgh RH. Acupuncture for xerostomia: clinical update. Cancer 2002;94(4):1151-1156.
38.Rosted P, Bundgaard M. Can acupuncture reduce the induction time of a local anaesthetic?--A pilot study. Acupunct Med 2003;21(3):92-99.
39.Kitade T, Ohyabu H. Analgesic effects of acupuncture on pain after mandibular wisdom tooth extraction. Acupunct Electrother Res 2000;25(2):109-115.
40.Lao L, Bergman S, Hamilton GR, Langenberg P, Berman B. Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Arch Otolaryngol Head Neck Surg 1999;125(5):567-572.
41.Lao L, Bergman S, Langenberg P, Wong RH, Berman B. Efficacy of Chinese acupuncture on postoperative oral surgery pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79(4):423-428.
42.黃維三. 針灸科學. 台北: 正中書局, 1985. pp. 436.
43.黃維三. 針灸科學. 台北: 正中書局, 1985. pp. 131.
44.Rantanen AV. The age of eruption of the third molar teeth. Acta Odontol Scand 1967;25 Suppl 1:48.
45.Engstrom C, Engstrom H, Sagne S. Lower third molar development in relation to skeletal maturity and chronological age. Angle Orthod 1983;53(2):97-106.
46.Richardson ER, Malhotra SK, Semenya K. Longitudinal study of three views of mandibular third molar eruption in males. Am J Orthod 1984;86(2):119-129.
47.Richardson ME. The effect of mandibular first premolar extraction on third molar space. Angle Orthod 1989;59(4):291-294.
48.Lysell L, Rohlin M. A study of indications used for removal of the mandibular third molar. Int J Oral Maxillofac Surg 1988;17(3):161-164.
49.Nordenram A, Hultin M, Kjellman O, Ramstrom G. Indications for surgical removal of the mandibular third molar. Study of 2,630 cases. Swed Dent J 1987;11(1-2):23-29.
50.Stanley HR, Alattar M, Collett WK, Stringfellow HRJ, Spiegel EH. Pathological sequelae of "neglected" impacted third molars. J Oral Pathol 1988;17(3):113-117.
51.von Wowern N, Nielsen HO. The fate of impacted lower third molars after the age of 20. A four-year clinical follow-up. Int J Oral Maxillofac Surg 1989;18(5):277-280.
52.Schroeder DC, Cecil JCr, Cohen ME. Retention and extraction of third molars in naval personnel. Mil Med 1983;148(1):50-53.
53.Nitzan D, Keren T, Marmary Y. Does an impacted tooth cause root resorption of the adjacent one? Oral Surg Oral Med Oral Pathol 1981;51(3):221-224.
54.Yamada T, Sawaki Y, Tohnai I, Takeuchi M, Ueda M. A study of sports-related mandibular angle fracture: relation to the position of the third molars. Scand J Med Sci Sports 1998;8(2):116-119.
55.Safdar N, Meechan JG. Relationship between fractures of the mandibular angle and the presence and state of eruption of the lower third molar. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79(6):680-684.
56.Tevepaugh DB, Dodson TB. Are mandibular third molars a risk factor for angle fractures? A retrospective cohort study. J Oral Maxillofac Surg 1995;53(6):646-649; discussion 649-650.
57.Nordenram A. Postoperative complications in oral surgery. A study of cases treated during 1980. Swed Dent J 1983;7(3):109-114.
58.Goldberg MH, Nemarich AN, Marco WP. Complications after mandibular third molar surgery: a statistical analysis of 500 consecutive procedures in private practice. J Am Dent Assoc 1985;111(2):277-279.
59.Forsgren H, Heimdahl A, Johansson B, Krekmanov L. Effect of application of cold dressings on the postoperative course in oral surgery. Int J Oral Surg 1985;14(3):223-228.
60.Pedersen A. Interrelation of complaints after removal of impacted mandibular third molars. Int J Oral Surg 1985;14(3):241-244.
61.Wang B, Tang J, White PF, Naruse R, Sloninsky A, Kariger R, Gold J, Wender RH. Effect of the intensity of transcutaneous acupoint electrical stimulation on the postoperative analgesic requirement. Anesth Analg 1997;85(2):406-413.
62.Yang ZL, Ouyang Z, Cheng YG, Chen YX. A neuromagnetic study of acupuncturing LI-4 (Hegu). Acupunct Electrother Res 1995;20(1):15-20.
63.Schlunzen L, Vafaee MS, Cold GE. Acupuncture of LI-4 in anesthetized healthy humans decreases cerebral blood flow in the putamen measured with positron emission tomography. Anesth Analg 2007;104(2):308-311.
64.Park H, Park J, Lee H. Does Deqi (needle sensation) exist? Am J Chin Med 2002;30(1):45-50.
65.Shedletsky P, Gale EN, Levine MS. The effects of ice massage applied over the "Hoku" acupuncture point in reducing spontaneous pain of endodontic origin. J Can Dent Assoc 1984;50(8):635-638.
66.Lin TB, Fu TC, Chen CF, Lin YJ, Chien CT. Low and high frequency electroacupuncture at Hoku elicits a distinct mechanism to activate sympathetic nervous system in anesthetized rats. Neurosci Lett 1998;247(2-3):155-158.
67.Liao JM, Lin CF, Ting H, Chang CC, Lin YJ, Lin TB. Electroacupuncture at Hoku elicits dual effect on autonomic nervous system in anesthetized rats. Neurosci Res 2002;42(1):15-20.
68.Weiner D, Peterson B, Keefe F. Evaluating persistent pain in long term care residents: what role for pain maps? Pain 1998;76(1-2):249-257.
69.Christensen PA, Rotne M, Vedelsdal R, Jensen RH, Jacobsen K, Husted C. Electroacupuncture in anaesthesia for hysterectomy. Br J Anaesth 1993;71(6):835-838.
70.Schanberg LE, Lefebvre JC, Keefe FJ, Kredich DW, Gil KM. Pain coping and the pain experience in children with juvenile chronic arthritis. Pain 1997;73(2):181-189.
71.Chibnall JT, Tait RC. Pain assessment in cognitively impaired and unimpaired older adults: a comparison of four scales. Pain 2001;92(1-2):173-186.
72.Kremer E, Atkinson JH, Ignelzi RJ. Measurement of pain: patient preference does not confound pain measurement. Pain 1981;10(2):241-248.
73.Cignacco E, Mueller R, Hamers JP, Gessler P. Pain assessment in the neonate using the Bernese Pain Scale for Neonates. Early Hum Dev 2004;78(2):125-131.
74.Rosier EM, Iadarola MJ, Coghill RC. Reproducibility of pain measurement and pain perception. Pain 2002;98(1-2):205-216.
75.Taylor LJ, Herr K. Pain intensity assessment: a comparison of selected pain intensity scales for use in cognitively intact and cognitively impaired African American older adults. Pain Manag Nurs 2003;4(2):87-95.
76.Melzack R, Torgerson WS. On the language of pain. Anesthesiology 1971;34(1):50-59.
77.Streitberger K, Kleinhenz J. Introducing a placebo needle into acupuncture research. Lancet 1998;352(9125):364-365.
78.Park J, White A, Lee H, Ernst E. Development of a New Sham Needle. Acupunct Med 1999;17(2):110-112.
79.Park J, White A, Stevinson C, Ernst E, James M. Validating a new non-penetrating sham acupuncture device: two randomised controlled trials. Acupunct Med 2002;20(4):168-174.
80.Malamed SF. Handbook of Local Anesthesia 5th ed, St. Louis, Mosby, 2004. pp. 228-242.
81.黃維三. 針灸科學. 台北: 正中書局, 1985. pp. 248.
82.林昭庚. 新針灸大成. 台中: 中國醫藥學院針灸研究中心, 2001. pp. 511-512.
83.黃維三. 針灸科學. 台北: 正中書局, 1985. pp. 51-54.
84.Kruger E, Thomson WM, Konthasinghe P. Third molar outcomes from age 18 to 26: findings from a population-based New Zealand longitudinal study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92(2):150-155.
85.Venta I, Turtola L, Ylipaavalniemi P. Radiographic follow-up of impacted third molars from age 20 to 32 years. Int J Oral Maxillofac Surg 2001;30(1):54-57.
86.Hattab FN. Positional changes and eruption of impacted mandibular third molars in young adults. A radiographic 4-year follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84(6):604-608.
87.Kleinhenz J, Streitberger K, Windeler J, Gussbacher A, Mavridis G, Martin E. Randomised clinical trial comparing the effects of acupuncture and a newly designed placebo needle in rotator cuff tendinitis. Pain 1999;83(2):235-241.
88.Streitberger K, Diefenbacher M, Bauer A, Conradi R, Bardenheuer H, Martin E, Schneider A, UnnebrinkK. Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: a randomised placebo-controlled patient and observer blind trial. Anaesthesia 2004;59(2):142-149.
89.Schneider A, Enck P, Streitberger K, Weiland C, Bagheri S, Witte S, Friederich HC, Herzog W, Zipfel S. Acupuncture treatment in irritable bowel syndrome. Gut 2006;55(5):649-654.
90.Scharf HP, Mansmann U, Streitberger K, Witte S, Kramer J, Maier C, Trampisch HJ, Victor N. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Annals of Internal Medicine 2006;145(1):12-20.
91.Park J, White AR, James MA, Hemsley AG, Johnson P, Chambers J, Ernst E. Acupuncture for subacute stroke rehabilitation: a Sham-controlled, subject- and assessor-blind, randomized trial. Archives of Internal Medicine 2005;165(17):2026-2031.
92.Macklin EA, Wayne PM, Kalish LA, Valaskatgis P, Thompson J, Pian-Smith MCM, Zhang Q, Stevens S, Goertz C, Prineas RJ, Buczynski B, Zusman RM. Stop Hypertension with the Acupuncture Research Program (SHARP): results of a randomized, controlled clinical trial. Hypertension 2006;48(5):838-845.
93.Ernst E, White AR. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med 1998;158(20):2235-2241.
94.Seymour RA, Blair GS, Wyatt FA. Post-operative dental pain and analgesic efficacy. Part II. Analgesic usage and efficacy after dental surgery. Br J Oral Surg 1983;21(4):298-303.
95.Seymour RA, Meechan JG, Blair GS. An investigation into post-operative pain after third molar surgery under local analgesia. Br J Oral Maxillofac Surg 1985;23(6):410-418.
96.Yukizaki H, Nakajima S, Nakashima K, Yamada Y, Sato T. Electroacupuncture increases ipsilaterally tooth pain threshold in man. Am J Chin Med 1986;14(1-2):68-72.
97.White AR, Filshie J, Cummings TM. Clinical trials of acupuncture: consensus recommendations for optimal treatment, sham controls and blinding. Complement Ther Med 2001;9(4):237-245.