RestorativeDentistry

Martin Kelleher Lakshmi Rasaratnam and Serpil Djemal The Paradoxes of Phantom Bite Syndrome or Occlusal Dysaesthesia (‘Dysesthesia’)

Abstract: Phantom bite syndrome was first described by Marbach over 40 years ago as a mono-symptomatic hypochondriacal psychosis. He used the term to describe a prolonged syndrome in which patients report that their ‘bite is wrong’ or that ‘their dental occlusion is abnormal’ with this causing them great difficulties. This strong belief about ‘their bite’ being the source of their problems leads to them demanding, and subsequently getting, various types of dentistry carried out by multiple dentists and ‘specialists’. Sadly, even after exhaustive, painstaking, careful treatment, none of the dental treatments manages to solve their perceived ‘bite problems’. This is because they suffer from a psychiatric illness involving a delusion into which they continue to lack insight, in spite of the failures of often sophisticated dental treatments.1,2,3 In summary, dental practitioners, or other specialists, who suspect that they might be dealing with such a problem should refer these patients early on for specialist management by an appropriate specialist within the secondary care settings, preferably before they get trapped into the time-consuming quagmire of their management. A ‘Phantom Bite Questionnaire’, which is available to download free, might help. CPD/Clinical Relevance: This article aims to provide professionals in various fields with guidelines on detecting, diagnosing and managing patients with Phantom Bite Syndrome (PBS). This is desirable in order to prevent extensive, or unnecessarily destructive, or unstable dental treatment being undertaken on such patients in a vain attempt to solve their problems with ‘dentistry’ when, in fact, these are really due to underlying mental health issues.

WARNING Phantom bite patients are often highly resistant to being referred to psychiatrists as they lack insight into their behaviour. They often complain if even a gentle suggestion is made of a possible referral to a psychiatrist. They remain resolutely convinced that if they could only get someone competent enough to get their ‘bite right’ then all their problems would be solved.

Dent Update 2017; 44: 8–32

Introduction dentistry generally, but phantom bite then often become serial, time-consuming There are many difficult paradoxes in syndrome is riddled with them. For instance, complainers. They often write very long if a diagnosis of phantom bite syndrome, letters (‘graphitis’) detailing their problems. or occlusal dysaesthesia (dysesthesia), These letters or emails sometimes include Martin G Kelleher, Consultant in Restorative Dentistry, Department of is suspected then the offer to refer the details of the ‘research’ that they have Restorative Dentistry and Traumatology, patient to an ‘occlusion specialist’ can, done frequently with the help of Professor King’s College Hospital Dental Institute, paradoxically, serve merely to confirm in Google to support their view that their London SE5 9RW ([email protected]), patients’ minds that there is something various, sometimes bizarre, symptoms, Lakshmi Rasaratnam, Specialist Registrar, seriously wrong with them and that their often in remoter areas of their bodies, have King's College London and William Harvey perceived problems really are being caused all been caused by alleged imperfections Hospital, Ashford, Kent and Serpil Djemal, by ‘their bite’. For other dentists, another in their occlusion or bite. They frequently Department of Restorative Dentistry and paradox is that apparently technically have unusually long appointments, some Traumatology, King’s College Hospital, excellent dentistry fails to satisfy these unscheduled, in various vain attempts to Denmark Hill, London SE5 9RW, UK. patients’ demands about their bite and they ‘sort out their bite problems’. However, 8 DentalUpdate January 2017 RestorativeDentistry

eventually that particular dental clinician’s In 1976, the term ‘Phantom bite’ sound quite strange, particularly when they treatment is declared a failure. The phantom was introduced by Marbach to describe are to be present in remoter areas of their bite syndrome patient then moves on to patients who were preoccupied with their body, will also be cured just by getting ‘the other general dentists, sometimes one supposedly abnormal dental occlusion. right bite’ or ‘the bite right’. Sometimes their with a special interest in occlusion, or to He considered the condition to be a form partners are convinced of this as well. In consult with a dental specialist of some of mono-symptomatic hypochondriacal psychiatric terms, this is known as a ‘folie sort. Some complain to various ‘regulators’,4 psychosis (abbreviated at the time to a deux’ (a delusion shared by two people). or to administrators, or sometimes to an ‘MHP’) in which a fantasy regarding a single Sometimes an inexperienced, or naïve, but apparently omniscient lawyer about the problem about their dental occlusion enthusiastic, ‘occlusion focused’ dentist joins previous dentist’s, or the dental profession’s, dominated their whole lives.1-3 This is in this folly. alleged incompetence in not getting their no longer the preferred term used by These patients often appear bite or their ‘occlusion’ quite right. psychiatrists. More recently, versions of to be superficially knowledgeable about Another paradox is that, even what sounds remarkably like Phantom Bite how their teeth should ‘bite normally’, but if the diagnosis of ‘phantom bite’ is made Syndrome (PBS) have appeared occasionally will sometimes also demonstrate how they by a clinician who is familiar with these in the literature, sometimes being referred meet in ‘different excursive movements’. problems, the patient then often refuses to as ‘Occlusal Dysaesthesia’ (The American Sometimes, they expound quite elegantly referral to a psychiatrist to confirm that spelling is ‘Occlusal Dysesthesia).5,6 on their views about their bite, cusps, slides diagnosis, or to attempt to treat it and can The Diagnostic and Statistical or interferences or ‘locking of their occlusion’ complain bitterly if such a suggestion is Manual of Mental Disorders (2000) previously and/or offer various ideas on what they need made even gently to him/her. used by psychiatrists to classify mental to have done to ‘correct their bite’ (Figures Sadly for all concerned, these illnesses (DSM−IV−TR version) referred to 2−4). patients fall into the category of ‘refractory this sort of condition as being one of a If a concerned dental clinician to any dental treatment’, even after hundreds number of ‘Somatoform Disorders’.7 suggests that all the reported problems in of hours of appointments. Many of these The current American Psychiatric remoter parts of the body are not being hours are spent on prolonged consultations Association’s DSM V (2013) preferred term is caused by the bite and gently offers to refer 8 and involve a variety of interventions of ‘Somatic Symptom Disorder’. the patient for mental health support then, variable destruction, stability, rationality or Whatever the current preferred paradoxically, that caring suggestion can retrievability. Unfortunately, none of these psychiatric term being advocated, those trigger a complaint. To avoid a complaint it treatments, however well-intentioned or patients with ‘Phantom bite syndrome’, can be safer for the dentist, paradoxically, meticulously carried out, effectively cures the or ‘Occlusal dysaesthesia’, can become not to suggest such a referral and instead affected patient’s prolonged concerns about nightmare patients for themselves, their attempt some intervention and thereby get ‘their bite’ or ‘dental occlusion’, because the family and dentists. They usually attend trapped. problem is mental illness and is not amenable any new dentist, or specialist, as apparently to even very elaborate dental treatment. routine patients, but often complain Occasionally, their behaviour and that their ‘bite is wrong’ in a very intense, Prevalence of phantom bite persistent demands for treatment can result characteristic way, often using dental terms syndrome in hospital security, or the police, having to such as ‘interferences’ or ‘slides’ or ‘cusps’ or There is an unknown prevalence be called in order to remove them from the ‘guidance’ or other bits of dental jargon and or incidence of this condition. However, premises (see Case PB3 below). Two patients describing how badly this has affected them. many experienced dentists will recall having in this case series have attempted suicide − Sometimes their problems with seen one or more patients presenting with one shortly after travelling over 200 miles for ‘their bite’ is not their first complaint and bizarre descriptions, or complaints allegedly a specialist consultation. instead they are adamant that their ‘teeth being caused by ‘their bite’ or ‘their occlusion’ In some other cases, clinicians do not look right’ and/or that their bite or at some point in their practising career. They involved have had to obtain legal injunctions ‘dental occlusion is wrong’ and that this usually remember these patients clearly to stop harassment of them and/or their is causing them sometimes quite weird because those now experienced, if not support staff, or their family at their homes problems elsewhere in their body. actually embittered, dentists usually wish or practices. They undergo extensive tests that, in retrospect, they had not got involved Regulators, administrators and and dental treatment by multiple dental with such patients at all. This is because of indemnifying organizations have become practitioners who, initially flattered by the prolonged and time consuming nature involved in various cases and at various the patient’s praise for their ‘knowledge of the subsequent multiple complaints stages. As most people working in those of occlusion’, at the beginning of the and their various costs, worries and other organizations are unlikely to be familiar with relationship, are often keen to try to resolve complications that ensued in trying to this relatively rare condition, they do not the patient’s reported suffering, which manage them, often involving complaint know what to look out for before assuming is, allegedly, all due to his/her ‘bite’ or managers or the GDC. that the complaining patient is rational, or ‘occlusion’. It appears, however, based on the mentally healthy, or that their sometimes Patients firmly believe that limited literature available, that patients with vindictive complaints are justified. their reported symptoms, which sometimes PBS can present at any age, in any gender, January 2017 DentalUpdate 9 RestorativeDentistry

with the condition often lasting between which they tend to finish their story with dentistry done on a sophisticated articulator, 10−20 years. something like ‘treatment xyz helped for a or tweaks being done to some careful while, but then the problems returned’. orthodontic treatment, or by equilibration of Clinical history The history will sometimes the natural teeth, the patient’s latest whim to involve a specific dental event trigger, ‘have the occlusion altered just slightly again’ The pattern of presentation of in which an initial dentist altered their to a newly stated ‘ideal’ is expressed. PBS often involves patients giving a long occlusion, usually with an apparently Eventually, those ‘nearly, and detailed history, often without needing innocuous restoration, a simple extraction, or but not quite right’ demands produce to make reference to any notes, after with some orthodontic appliance. However, understandable frustration in that particular at the end of that intervention they will say dentist, or specialist, who then, rather something like ‘they needed further bite belatedly, begins to realize that the patient’s treatment’, usually by someone else, to ‘fix real problems lie somewhere ‘north of the a their bite problem’. Any, or all, subsequent maxillary occlusal plane’. dental treatments do not alleviate their The patient then moves on to a ‘occlusal’ or ‘bite problems’, but instead new helpful, if initially naïve, dentist, or to apparently exacerbate them, with the now a different dental specialist and adds that disgruntled patients deeming the original former dentist’s name to their list about problem-causing dentist, or the subsequent whom they can then complain (Figures dentist(s) to be ‘incompetent’ owing to their 1a–d). b inability to resolve their bite problems to their entire satisfaction. The real problems with these Interestingly, they frequently patients manage to instil a belief into any new dental clinician that only he/she can correct The persistent perception in the occlusal problems that have been phantom bite syndrome patients of having erroneously managed by the previous ‘an abnormal bite’ almost always coincides dentist(s), often over several years. They with underlying psychiatric issues and this 1–3 seem to do this by praising the new dentist was originally described by Marbach as for their reputation for ‘occlusal knowledge’ a mono-symptomatic hypochondriacal and/or their special skills. This flattery of psychosis. c the new dentist’s ego then leads the new The three important hallmarks of dentist down the pathway of further, often PBS that Marbach described in a number of more destructive, operative intervention, or his publications were that it is: unstable orthodontic treatment, in a vain 1. Mono-symptomatic (= only one symptom attempt to try to ‘perfect their occlusion’. ie ‘the bite’); Given the frequency of occlusal 2. Hypochondriacal (= a self-diagnosed contact variations in the normal population, anxiety disorder that the patient has got a it is not difficult to find some dentist, serious illness); perhaps someone with strong, or rather 3. A psychosis (= a severe mental disorder fundamentalist, beliefs about occlusion, in which thought and emotions are so d or some aspect of a particular occlusal impaired that contact is lost with external philosophy,9 who agrees with the patient reality). that something should be done to help Marbach’s seven diagnostic change things in order to get a better indicators for patients with PBS with the ‘occlusal arrangement’. current authors’ additional comments are However, failure to recognize presented in Table 1.10 the possibility of the reported problems In phantom bite cases, there actually being caused by ‘phantom bite are indeed sometimes detectable ‘occlusal syndrome’ early on means that significant, problems’, or at least ‘suboptimal occlusal often destructive or unstable, treatment is contacts’ according to some occlusal Figure 1. (a−d) Clinical photographs carried out by that new clinician in order to philosophy.9 demonstrating a third full mouth reconstruction try to achieve the supposed benefits of this However, unlike most normal with all ceramic crowns provided by a specialist putative ‘ideal occlusion’. patients, any dentist’s attempts to improve to ‘correct the bite.’ Unfortunately, this extensive Sadly for everyone involved, their occlusion, or aesthetics, no matter how treatment did not cure the patient’s symptoms just before this supposedly ‘perfect bite’ is skilfully done, will fall short of the patients’ either and she presented with suggestions for achieved, usually with different occlusal expectations, usually at the very last meeting further adjustments to ‘perfect’ her occlusion. adjustments, often on already elaborate with that particular dentist. 10 DentalUpdate January 2017 RestorativeDentistry

Perceived dental knowledge Intensely involved and have some knowledge of dental anatomy, physiology and dentistry. They often know bits of dental jargon, and use abbreviations or terminology regarding occlusion. Will talk endlessly about their 'bite' or 'occlusal' problems, or their 'issues around' the shape, colour and contour of their teeth, or various restorations and suggest how they should be changed, or altered, to correct their problems.

Keep study casts and detailed clinical records These patients often present at the first, or at subsequent, appointments with numerous diagnostic casts that they have accumulated over the years. They will point at which parts of which cusps need adjustment to fix the problem. Diagrams, some beautifully illustrated, are sometimes presented for inspection (Figures 2 and 3).

Severe symptoms all being due to their occlusion Complain of, or believe that, they have a serious bite or cosmetic defect. They have an ongoing and unshakeable belief that their 'bite or occlusion' is wrong, or that their bite looks wrong.

Sustained delusion The delusion is sustained for many years in spite of sympathetic explanations and careful reassurance. Apart from the initial placebo effect these particular patients’ symptoms are rarely improved by occlusal splint therapy, orthodontics, occlusal adjustments or 'equilibration', or prosthodontic interventions of different types by different dentists or various specialists.

Unwilling to accept referral to, or help from ,psychiatrists Resist the suggestion very strongly that their problem is psychiatric in origin and therefore they refuse to accept psychiatric help, or to be referred for psychiatric assessment. Patients are convinced that previous dentists have caused their problems and that further 'bite' or orthodontic or prosthodontic treatment, or surgical treatment, if it were just to be done correctly, would rectify all their bite and/or other issues.

Socio-economic status High socio-economic status patients undergo extensive restoration of the occlusion indefinitely (because they can afford it). Patients of more moderate means are limited by financial constraints but still have uncontrollable impulses to have various people 'correct their bite', in the belief that the right occlusal therapy, or the right articulator, will solve their agony. Such dilemmas produce desperate people and they often seek multiple referrals to hospitals where treatment might be free, or they sometimes borrow money in order to have treatment of varying complexity, stability or retrievability.

IQ These problems often occur in patients with above average intelligence and often very articulate or literate about their problems and what needs to be done.

Table 1. Marbach’s seven diagnostic indicators10 for patients with PBS with the current authors’ additional comments.

January 2017 DentalUpdate 11 RestorativeDentistry

Unfortunately, these patients often do not accept the psychiatrist’s about PBS was in a gentleman who usually refuse to be referred to a psychiatrist diagnosis, nor necessarily comply with attended over 200 appointments with at and often resent the suggestion that their taking any prescribed medication, or accept least 20 different clinicians, many of whom problem is mental rather than dental if it other types of treatment such as Cognitive were recognized specialists, in different is made by a dental clinician. If they do Behaviour Therapy (CBT). hospitals and locations around the UK, in eventually attend a psychiatrist, it is usually Instead, they wander nomadically order for someone to ‘correct his bite’ to his reluctantly. Sometimes this is even after from dentist to dentist, or to dental personal specifications. Sadly, none of them the perceived failure of prolonged, serious specialists of different types, in different seemed to have recognized the psychiatric and often expensive dental interventions locations and have different treatments condition before being lured into doing done, often to their personal specification even more futile extensive dentistry or of different types, none of which manages and at their insistence. recommending it. to solve their underlying mental problems. The record in this case series Paradoxically, even if they do attend they Presentation warning signs Patients with phantom bite usually give a long and detailed clinical history of their problems and relate this to 'their occlusion,' often using dental terminology such as 'canine guidance', 'slides' or 'occlusal interferences'. They sometimes have multiple dated study models, various images, or different occlusal devices with them. They give a definite sense of knowing exactly what needs to be done to correct their 'occlusal disharmony'. They articulate these problems in detail verbally, with or without diagrams, and later on in multiple hand written or typed letters, or they send numerous emails to the practice, department or to the GDC.

Clinical examination in relation to the symptoms Close dental examination will often reveal some common occlusal discrepancies, but these usually are not sufficient to justify the severity of the symptoms reported by these unfortunate patients. For instance, the teeth about which they complain are rarely mobile or tender to percussion and usually respond within normal ranges to extensive pulp testing. There are usually no compelling radiographic changes, such as widened periodontal ligaments or radiolucent periapical areas visible, even on close examination of good quality radiographs. The teeth are of normal colour with no signs of discharging sinuses or apical tenderness. These patients will, however, insist that they have significant discomfort, general unease with their bite, or pain problems, or that they have a serious disability with their functioning elsewhere, sometimes in areas far from their mouth. Some of the descriptions Figure 2. Case 1: Tools used. Hand tools only. of these problems can sound bizarre, eg 12 DentalUpdate January 2017 RestorativeDentistry

back problems or balance problems, or Range of treatments offered for geographical locations. Phantom bite postural, or eye problems, or a combination PBS patients will often have had many of these of symptoms, but wherever these problems The interventions by different so-called ‘occlusal splints’ (which would be are, they are all, according to the patient, dentists depend very much on the kind more accurately called ‘occlusal devices’ as being caused by problems of their ‘bite’ or of clinician to whom they present. The they do not actually splint the occlusion) ‘occlusion’. treatments attempted can range from and/or studies casts and diagrams and, if One early clue that they occlusal splint therapy and/or occlusal requested to do so, will happily show these might have PBS is that these patients are equilibration, to orthodontics of various at consultation with any new clinician. superficially knowledgeable about dentistry types, through to extensive crown and The plaster models are and occlusal terminology, often using dental bridgework or combinations of any or all sometimes dated and carefully packaged jargon terms (eg ‘interferences’ or ‘slides’ or of these treatments. Orthognathic surgical and kept safely stored by the patient. ‘group function’) to describe their problems. Sometimes the ‘best study casts’ or ‘study approaches have also been involved in some The real diagnostic clues lie in models’, allegedly containing the key to cases. taking the history very carefully, preferably solving their occlusal problems, are referred It is not unusual to find that a in a structured way, (possibly using the to almost reverently and of them being kept bewildering array of occlusal devices, of questionnaire recommended in this article) ‘in a safe place’. widely differing designs and used in different with both eyes and ears being wide open Phantom bite patients will arches, have been used as part of diagnosis and being ‘fully present’ throughout the readily explain who took these plaster study or treatment, usually by different dentists, consultation. casts and describe which devices were sometimes over many years and in different made for them, when and by whom they were constructed, as well their immediate, sometimes beneficial, results. However, usually, they conclude these prolonged explanations with something like ‘the benefits had only been temporary’. A larger than usual case series (12) is presented below. These demonstrate most of the key clinical signs on presentation as well as outlining the considerable difficulties faced by many clinicians and their teams when managing

Figure 4. Case 1: Photographs taken by the patient herself, highlighting the occlusal contacts that she had marked herself and that she ‘knew needed to be ground down’. Apparently she did Figure 3. Case 1: Computer-generated scans of her study models made by the patient herself with this with a Dremel DIY drill because ‘no dentist detailed measurements ‘of her bucco-lingual discrepancies of the LR7’. could see what needed to be done’.

January 2017 DentalUpdate 15 RestorativeDentistry

these patients’ various frustrating and time- She presented with a bound, dental treatment could result in secondary consuming problems. Three clinical cases are beautifully illustrated, report prepared symptoms associated with any occlusal presented in detail with a brief discussion by herself. This included multiple graphic treatment. She was told ‘that she had done a to demonstrate the key clinical features. images, drawings and photographs of the great job with her own occlusal adjustments’ For reasons of brevity, other cases are things having been used by her to correct and, as she was almost free from symptoms, summarized. her apparently ‘disturbed bite’. She had to leave things as they were and to get on shown this collection to the consultant with her life as well as she could. Her father, Case reports orthodontist and maxillofacial surgeon, as who attended with her, seemed very relieved well as four of the more recent dentists, one with the diagnosis and the proposed plan. PBS Case 1 of whom had acceded to her request to The patient was offered onward referral for History supply her with dental articulating marking supportive ‘medical help’ but she declined Ms PBS1, a 28-year-old female, materials. this. presented with a three-year history of Her symptoms remained, While she was attentive and problems which began after a crown was eventually leading her to believe that her polite during this consultation and declined fitted on her lower right second molar. Over incorrect/heavy bite was causing pain that the offer of a review appointment, she may the course of the next four years she saw had previously been attributed to a blocked well have continued to carry on her search 11 dentists, an orthodontic specialist, two gland in her palate and to sinus infection. for someone else to cure her ‘incorrect bite’. registered specialist prosthodontists and She then saw an ENT consultant and had her three restorative consultants in different allegedly blocked gland removed, but she PBS Case 2 parts of the UK. continued to experience pain. History She reported pain initially as She attributed her malpositioned Ms PBS2 presented with a being associated with her root-filled lower lower right molars to her sunken appearance history of seeing at least 20 dentists over right second molar immediately after the under her cheek bones. the previous six years. This list included tooth was crowned. Apparently, this was After two years of self-treatment, eight very experienced general dental quickly ruled out as the cause of her pain she reported in her beautifully illustrated practitioners, from different parts of the and instead her partially erupted wisdom dental journal ‘there is nothing more that I country, several restorative consultants, tooth was deemed to be the cause of her can do. Professional help needed.’ two private practice ‘occlusion’ experts, two symptoms. Following the extraction of her She was offered Botox injections orthodontic specialists and one orthodontic lower right wisdom tooth she developed into her masticatory muscles by one consultant. a dry socket, but also had inferior alveolar consultant oral and maxillofacial surgeon to She complained initially of a nerve damage with paraesthesia to the right help to manage her chronic myofascial pain, fractured lower left first molar that she side of her face. which she declined. reported was restored with ‘a Cerec crown’. After six months, she was She then saw a prosthodontist However, once fitted, she felt that this crown prescribed Pregabalin which controlled the who recommended reversible treatment was ‘undersized and had a sharp profile.’ Two nerve pain, but she continued to report pain only, namely the provision of a Michigan months later, the opposing tooth, the upper from her lower right second molar. Following splint. She was then referred to a restorative left first molar, was also crowned, allegedly a further six months of pain, she was seen consultant in a different hospital who due to a crack. on a facial pain clinic, where the diagnosis of described her as ‘acutely dentally aware’ and Ms PBS2 then saw a second trigeminal neuropathic pain was made, but described her in the letter to her dentist as dentist who apparently informed her that she was ‘still 100% positive that there were having ‘atypical odontalgia’. issues with her bite’. the contact between the two crowns was She was referred to a GDC minimal and the left lower 6 crown was then registered specialist orthodontist who Presentation to one of the authors replaced with a porcelain-fused to metal identified a premature contact on the upper Refusing to accept the diagnosis crown to ‘increase the occlusal contacts’. right second molar and recommended it given by that particular restorative She then felt that the new crown to be eliminated to correct her occlusal consultant, she was then referred by a was ‘too bulky bucco-palatally’ (her words), problems. The patient described ‘complete different dentist to a different restorative causing tongue and cheek biting, as well as relief to have the diagnosis confirmed and consultant in his practice, where she ‘spacing between the occlusal aspects of that ‘the bite was the cause’ of her ongoing attended with her bound and beautifully these teeth’. problems. Although she was advised to see coloured dental journal, multiple study She subsequently saw a series of her dentist to have the occlusal adjustments models and radiographs (Figures 5a−c). 17 generalists or dental specialists. Some of carried out, she decided that she had lost these were at the suggestion of a corporate all trust in that dentist. Instead, she decided Management body. Different occlusal devices were to carry out the occlusal adjustments at She was diagnosed with PBS, prescribed. One of those recommended home herself. She used her technical skills in based on the detailed history, and the nature dentists ‘tried to correct the occlusal graphic design to colour code serial pictures of the condition was discussed at length problems by replacing the crowns together, of her posterior teeth (Figures 2−5). with her. She was advised that any further in order to establish the correct occlusion’. 16 DentalUpdate January 2017 RestorativeDentistry

a

January 2017 DentalUpdate 17 RestorativeDentistry

b

SET 4 CASTS – CROWN REMOVED The casts do not interlock as before. The bite is either correct on the left or right side, throwing the opposing side back teeth out of alignment.

CONCLUSION The small shift in the position of the UR6 tooth is throwing my bite out of alignment. I now fully understand the orthodontist's concern with regard to correcting the position of the UR6/7, risking of movement of the other teeth and causing more problems.

18 DentalUpdate January 2017 RestorativeDentistry

c

Figure 5. (a−c) Case 1: Multiple patient images with her descriptions, including study casts and her written observations on these.

January 2017 DentalUpdate 19 RestorativeDentistry

Her patient journey continued Presentation to one of the authors PBS Case 3 with another dentist who supplied her with She was referred by a dentist, History a NTISS device (Nociceptive Trigeminal who worked for a corporate body, apparently Mr PBS3, a 29-year-old male Inhibition Suppression System) and she was as a result of the multiple complaints that patient complained that his bite was causing told that her problems were now definitely had been received. She presented with him severe neck and shoulder problems. He related to her temporo-mandibular joints. several dated study models, carefully kept was adamant that this was a direct result of However, after a period of use, she felt that in dental model boxes and also with a an occlusal filling that had been placed in his ‘this device only worsened her open bite’ series of pantographic style tracings that upper right first molar two years prior to him which, considering the design of this, was had been carried out in various practices being seen at one hospital. not surprising. over the years. She also had results of ‘TMJ He reported that he had had a The patient subsequently joint vibration analysis’ that had been done ‘change in the enamel after a filling in the previously, along with multiple periapical developed ‘a unilateral posterior open bite’ upper right six’ and that then his ‘bite felt and panoramic radiographs. (her words) and she described herself as wrong.’ Her clinical examination revealed ‘having a slide with a movement to the He believed that his teeth were no occlusal contacts being present from left after the initial contact’ which she felt ‘locked in’ and that his ‘jaw pulled to the the upper left second premolar all the way significantly affected her speech and overall right causing postural problems.’ On several around to the upper right first premolar. function. occasions, he referred to the impact of However, the pre-treatment study casts One of the dentists and one of his dental problems on his daily life and showed very clearly that there had been the consultants who assessed this lady felt functions and that ‘this filling had ruined even occlusal contacts on all of the teeth that ‘they could not treat her condition because his life’ because his ‘group function was no prior to the various bits of dental treatment. it was not within their area of expertise’. This longer the same.’ angered her a lot and enhanced her belief He also felt that his ‘shim stock that ‘the whole of the dental profession was Management holds’ had changed over the previous two incompetent’. The diagnosis of ‘phantom years. During this time period, he had seen She reported that several hours bite’ was made, explained and discussed eight general dental practitioners and, from of her days were spent researching on at length. Ms PBS2 was informed that the the history, which he repeated at length to the internet for various treatment options occlusion had indeed changed considerably various clinicians, secretaries, receptionists, to correct her bite. Given her research since the first crown had been placed, or to anyone else who would listen to him, background, which included her having as judged from her original study casts. he had had numerous discussions with these a PhD, she was adamant that there was The patient was told that her bite would dentists over the telephone, as well as going a treatment ‘out there that she had not probably never return to the original to see them in their practices. found yet’ that could cure her bite problems asymptomatic one, which was something His treatment ranged from and ‘she was willing to try everything and that the patient found very difficult to replacement of the filling to ‘adjustment anything to get the right bite’. acknowledge as being the case or to accept of his opposing tooth to correct the bite’. After several more consultations that expressed view. However, the patient felt that his bite was with various dental professionals, and the It was explained, very gently, never quite right again. use of different occlusal devices, she saw one that the problem was not mainly dental He subsequently saw five restorative consultant in his private practice, and that the reason for this change in different restorative consultants in three who offered a non-destructive approach the occlusion was due, in part at least, to separate London hospitals. using direct resin composite to build-up her the patient’s insistence on seeing various He had an MRI scan as well as a teeth that were not in contact due to trying dentists and having more and more complex cone-beam CT scan done of his temporo- to stabilize her occlusion. However, the dental treatment at her specific request. As mandibular joints ‘to assess these for any patient felt that ‘the bite was fundamentally expected, this diagnosis was rejected by pathology’. All of the special investigations incorrect’ and did not want more teeth to the patient and her partner immediately. that were carried out were negative. be built-up into this wrong position, and An offer to refer her on to an appropriate Mr PBS3 reported he had been therefore that treatment option was rejected, specialist psychiatrist for diagnosis and apparently quite angrily, by her. treatment and help was also rejected researching his condition on the internet and Further searches on the internet immediately. Further time consuming felt that he ‘probably needed TMJ surgery to and further consultations ensued with explanations over some hours proved futile. fix his problem’. different dental laboratories, using computer Subsequent to this consultation scanning modelling. On that basis, she some further serious harassment by the patient Clinical presentation to the authors had two crowns replaced and temporarily ensued. This unpleasant harassment of various Examination revealed bilateral cemented for her ‘to assess the changes in people and of the clinician who diagnosed masseteric tenderness on palpation and her bite’, which she did using a microscope phantom bite only stopped following a legal left temporalis tenderness. There were that she had bought and used to do this at injunction to prevent it continuing. The no obvious abnormalities detected in his her home on a very regular basis. outcome therefore remains unknown to occlusion, with no evidence of non-working these authors. side interferences or of premature contacts. 20 DentalUpdate January 2017 RestorativeDentistry

Diagnosis and management consultant’s home ever again, with the threat surgery will, if undertaken, only bring more The diagnoses of PBS and of obtaining a legal injunction. disappointment to both the patient and the possible TMD (myofascial pain) were made. On different occasions he was orthognathic11 team and the patient will A hard maxillary Michigan style occlusal escorted by the police from at least one probably prove to be unhappy with that splint was constructed for him to wear to general dental practice after demanding outcome too. manage his TMD symptoms and apparently ‘more occlusal treatment’. He was physically In summary, the amount of his pain improved for a short period of time. carried out from a different hospital’s time spent by multiple general dental However, he still remained focused and very restorative department by their hospital practitioners, restorative consultants and/ concerned ‘about his occlusal problems’. security after showing up demanding or others in attempting to manage the The patient reported that he had very little ‘treatment for his bite’. His attendance unrealistic goals of these patients with sleep at night because his occlusion was patterns became more disruptive to various dental procedures can be not only extremely worsening and he frequently attended or different hospital departments and dental time consuming and wasteful of valuable called reception, demanding to be seen practices. and scarce resources, but also prove to be urgently to ‘correct the occlusion problems’ After prolonged discussions with frustrating and futile, while also being likely and to get his study models. two more restorative consultants in a third to lead to exhausting complaint procedures His pattern was to go to different hospital, the patient eventually accepted of various types. practices and restorative departments referral for a psychiatric evaluation, but that without any appointments and to spend was something that he was extremely bitter Summary of other cases hours telling any clinician, nurse or secretary about. who would listen to him about ‘his bite’, Case 4 After various psychiatric using dental terminology such as ‘group Complained of her ‘bite being evaluations, his GMP prescribed Resperidone function’, ‘occlusal interferences’, ‘slides’ and too heavy at the front’ and this caused her and Olanzapine. These well-known anti- ‘shim stock holds’. postural problems and vision disturbances. psychotic drugs are often used separately, Despite his numerous Saw a GDP multiple times, two restorative or in combination, to treat schizophrenia complaints about his occlusion, further consultants and an oral maxillofacial surgeon and bipolar disorder. Predictably enough, clinical examination by different specialists for consultation. Treatment involved splint he discontinued the medication after 4 and generalists revealed no significant therapy, full mouth rehabilitation, occlusal days because he felt that he could not abnormalities in his occlusion. He had been equilibration and then further splint tolerate them. He also stopped seeing the advised early on by one consultant that therapy followed by rehabilitation as ‘the psychiatrist after three sessions ‘because he he had ‘phantom bite syndrome’. It was bite was not quite right’. She had an MRI felt it was not worth his time’. suggested to him at the time of the phantom of the TMJs done. No treatment resolved He became increasingly bite diagnosis that he should cease his her bite symptoms. Clinical examinations antagonistic towards the restorative search for further expert opinions about his revealed many different occlusal positions, consultant who had made the original occlusal problems and that he should get his with her currently preferred posturing one phantom bite diagnosis at his first doctor to get him support and medication being very strange indeed. She attempted appointment with him and who had forecast from the psychiatric department of an suicide 3 days after being told that she had the likely problems that would happen. appropriate hospital. He objected strongly phantom bite syndrome, which was her third In spite of being treated courteously, over to this advice and, predictably enough, he attempt at committing suicide and which very many hours, by various consultants, in sought advice from other dental consultants resulted in her being sectioned. Apparently different hospitals and by various general in different hospitals. she recovered from that acute episode of dentists in their practices, he then pursued Mr PBS3 frequently became depression. Overall, it was estimated that she extremely aggressive and confrontational multiple time consuming formal complaints, attended over at least 90 appointments with within different hospital restorative with the help of an advocate, all the way to various clinicians. departments, often returning to different the Ombudsman. Eventually, after multiple hospitals without an appointment, Case 5 unpleasant incidents, restraining orders were demanding to see whichever restorative Presented complaining of taken out against the patient by at least two consultant was available and sometimes ‘trigeminal neuralgia’ (patient’s own words) demanding that he be given ‘his study hospitals. which ‘caused his whole body to pull to models that would fix his occlusal issues’. the right’. He felt sure that ‘correcting his He also attended one Prognosis bite would re-align his body and improve consultant’s home twice, both times The prognosis is poor. Patients his quality of life’. He reported that the unannounced on a Friday night, proffering usually continue to seek different dental symptoms began after a wisdom tooth some study models and repeating his history treatment from someone new and may extraction under local anaesthetic. He was in detail in the hall to the consultant’s eventually progress to surgical options seen by his GDP, a specialist prosthodontist, wife, as well as demanding that occlusal to correct their perceived occlusal a number of restorative consultants and an adjustment should be done there and then. disharmonies. oral and maxillofacial surgery consultant. His He was ‘strongly advised’ not to visit that Orthodontics followed by jaw treatment included splint therapy, occlusal January 2017 DentalUpdate 23 RestorativeDentistry

equilibration, multiple root canal treatments, physiotherapists, 2 private dentists, 1 ENT be done to correct her bite problems’. re-root canal treatment, and extractions surgeon, 7 general medical practitioners, The box of models that she had under local anaesthetic following ‘failed’ 1 ophthalmologist, 1 specialist dentist with her was carefully presented. This box root canal treatment. Special investigations and 1 restorative consultant. During this contained the original cast, the original cast including a cone beam CT scan and MRI of time, over £10,000 was spent to attempt to with a denture, a diagnostic wax-up, a putty the TMJ, all of which had negative findings. ‘correct her bite problems’. She underwent index of the diagnostic wax-up, one master He was seen for over 50 appointments with 3 crown replacements, adjustments of cast of the preparations for one remake, as no resolution of his symptoms. Clinical the crowns, root canal treatment, occlusal well as an uncut copy of a second cast with examination revealed nothing particularly equilibration, 3 MRI scans, 1 facial CT scan the re-prepared, now minimal remaining untoward about his occlusion. The patient and 1 TMJ arthroscopy. All of her dental cores. was eventually informed of the diagnosis and head and neck investigations were The patient was on Amitriptyline being of phantom bite, which he refused unsuccessful in managing her symptoms. and Zopiclone, which apparently had to accept or to be referred for psychiatric She said that she was feeling suicidal but helped a little. evaluation. refused to accept the diagnosis of phantom An explanation was given bite or to be referred for urgent psychiatric about phantom bite syndrome and the Case 6 help. patient was advised not to have further A 67-year-old patient presented replacement dentistry. An offer to get her with ‘jaw juddering attacks’ lasting 2−3 Case 8 doctor to refer her for specialist psychiatric minutes once a week which caused her Patient had multiple crowns input was somewhat reluctantly accepted bite problems. She reported her tongue placed in a general dental practice. She and the patient was then referred back to getting trapped at night due to her bite then had a full mouth rehabilitation done her doctor, with details of the phantom bite disturbance. She had seen her GDP and by a consultant in a teaching hospital condition, for onward referral. two other restorative consultants, as well as which was followed by a Michigan splint. five junior members of staff over multiple Apparently, she had had about 100 Case 10 appointments before being diagnosed appointments for various crowns to be Patient attended with multiple with phantom bite syndrome. She wrote 25 replaced and for occlusal adjustments to medical problems including cardiac and letters to one of the authors repeating that be done over a 5-year period. She then central nervous system (CNS) problems as all her various problems in her back, neck, had another full rehabilitation done but well as several autoimmune conditions, knees and shoulders were all caused by her using metal and composite on the occlusal including Hashimoto’s thyroiditis and ‘bite juddering’. She refused any psychiatric aspects for ‘ease of bite adjustment’. systemic lupus erythematosus. She had input, or even to try a Michigan splint to see Eventually she made a formal complaint multiple allergies and was taking various if her symptoms would improve, because her because, although she was relatively free medications. She blamed her CNS and friend had told her that she needed ‘full bite of symptoms at that stage, apparently heart problems on the extensive dental correction’ to cure her. Her oral hygiene was the consultant in charge at that time did rehabilitation work which she had done in dreadful in spite of multiple demonstrations not want to change these crowns for ‘new 2007. of oral hygiene techniques. She refused any permanent crowns with the correct bite to She had seen multiple GDC treatment that was not going to involve full finish her case’. registered specialist endodontists for very bite rehabilitation because ‘her friend had competent endodontic treatment after this read on the internet that her problem could Case 9 prosthodontic treatment, as well as having only be dealt with properly with full mouth Patient attended her GDP had multiple CT scans. rehabilitation’. for 2 crowns and 3 veneers. When she She had had a number of Multiple formal complaints complained after these were fitted she was extensive oral rehabilitations done which ensued. referred to another dentist for ‘problems apparently ‘helped for a while but then the with the bite’ and fees were refunded. The symptoms returned’. She had seen various Case 7 crowns and veneers were replaced but other experts in various fields, including Patient presented complaining of things got no better. Fees were refunded. two pain specialists. ‘bite problems which started after 3 crowns She was referred to a maxillofacial Examination showed extensive were placed in the lower left quadrant’. She department and subsequently then saw 3 high quality restorations, including an reported nasal problems, headaches and more dentists ‘to replace the replacements’ implant following some bone grafting and sinusitis, along with clicking jaw, neck and along with fitting of ‘a brace’ to reposition many root-filled teeth without periapical shoulder pain, blurred vision and vomiting, her bite. The patient attended one of the areas. Soft tissues and TMJ examinations all of which, apparently, had been caused by authors with a box full of models and a big revealed no abnormalities and a diagnosis her crowns having been placed incorrectly. red folder with about 50 pages of letters of phantom bite syndrome was made. Overall, she was seen by 6 general dental with dates and the names of different This was explained to her in detail and the practitioners, 1 oral and maxillofacial surgery dentists and what they had done, along patient was offered onward referral for consultant, 3 consultant rheumatologists, 2 with copious notes about what ‘needed to psychiatric input, but this was declined. 24 DentalUpdate January 2017 RestorativeDentistry

Case 11 problems all being caused by her occlusion’. dysaesthesia, or as occlusal dysesthesia, The patient had some wisdom An offer of referral for expert psychiatric help which is the American spelling) is usually teeth removed and then had a maxillary was refused. described as being a rare condition. hard occlusal device made which produced However, based on various conversations a ‘relatively comfortable bite for 17 years’. Case 12 with some older dentists, there will be at ‘She had a filling done which precipitated The patient presented least some readers of this article who will problems’. This included ‘trigeminal neuralgia having had a number of major occlusal remember having seen, or tried to treat, in her face’, which she referred to as ‘TN’ rehabilitations carried out. She had had one or more patients who roughly match throughout the consultation as well as multiple extended veneers and all-ceramic the description of this problem. The cases ‘pain in her temporomandibular joints’. crowns done, followed by remakes of these, described above report the lengths some She then had occlusal adjustments, root many subsequent root fillings and re-root of these patients will go to in order to get fillings, multiple re-root fillings and an fillings and eventually extractions. She had someone to correct their perceived bite extraction of the previously re-root filled two implants after two of the re-root filled issues or ‘problems with their occlusion’ or lower second molar. She had multiple teeth were extracted. bite. copies of radiographs with her and various There were root fillings present One major paradox of this study casts. She had seen quite a number of in two of the lower incisors, as well as in the condition is that these sorts of patients ‘occlusion experts’, one of whom made her lower left second premolar, lower left first are unwilling to accept that they have got a Tanner device with multiple adjustments molar, upper left second molar, the lower phantom bite syndrome (PBS) (or occlusal being done to this. She felt strongly that ‘if right first premolar, lower right first molar dysaesthesia/dysesthesia) and usually deny only she could have her bite built back up and lower right second molar. even the possibility of that diagnosis being again then her whole body alignment would She had got mainly all-ceramic correct, or of them needing any psychiatric improve’. A consultant maxillofacial surgeon help. However, their previous and their crowns present on her teeth, including and a specialist radiologist concluded after subsequent behaviour, which can include two on the implants. She was still unhappy multiple examinations that there was no persistent and vindictive complaints, usually with her bite, in spite of having worn Tanner jaw joint pathology present. A number of confirm the phantom bite diagnosis as being devices and maxillary hard occlusal splints other well-known academics had seen her correct. before, during and after her extensive in various UK cities, as well as some pain For instance in PBS2, as ceramic-based reconstructions (Figure 6). experts. described above, in an average patient She was strongly advised against further She had with her a Lucia jig, a with a ‘dentistogenically’ induced unilateral speculative dental interventions in view of NTISS device, a Tanner device, as well as a posterior open bite, a direct bonding the probability of phantom bite syndrome couple of Michigan type splints. These had technique using composite could probably being the root cause of her ongoing helped for a while but none as much as the be utilized to try to address the functional problems. first hard upper splint had done. issues and hopefully ‘stabilize the occlusion’. A diagnosis of phantom bite However, in cases of PBS, unfortunately, syndrome was made and gently explained Discussion this treatment approach would not be in detail over a couple of hours, with her Phantom bite syndrome at all predictable because these patients reiterating her convictions about ‘her (also now known sometimes as occlusal are always trying to find their elusive ‘final comfortable bite’. As this preferred ideal position for ‘their bite’ varies enormously, sometimes in very weird ways, with the preferred jaw positions demonstrated being far away from any recognizable or traditional reproducible position, that is probably not going to be realistically achievable by any dental professional in any predictable way.

The root of the problem is mental illness and not dental disease. The ‘dental’ management of these patients should probably therefore be limited to patient information and sympathetic discussion about the difficulties of the condition, as well as an offer of onward referral for psychiatric input. Figure 6. A DPT of a patient who had extensive dental treatment done on previously intact teeth by The structured phantom bite different dentists, over long periods, with the apparent aim to ‘correct the bite and to get a perfect questionnaire (see below) should be completed smile’. by patients in their own time, at their home, 26 DentalUpdate January 2017 RestorativeDentistry

and this will provide a suitable record as well as Bite Syndrome' or a 'Somatoform Symptom Different explanations for helping to alert the clinician early on about the Disorder' may have overlapping features phantom bite have been proposed. probable real problems and hopefully enable similar to those with body dysmorphic Klineberg suggested that occlusal hyper- the clinician to refer appropriately. disorder (BDD), a term applied to those awareness could be the cause of the individuals with a normal appearance who condition.12 He suggested that a lack of The Diagnostic and Statistical Manual (DSM) present requesting treatment because they adaptability to occlusal changes resulted in ’ 11 Classification of Mental Disorders of the believe that they have a ‘defect. the condition. 13 American Psychiatric Association (APA) In 1985, Marbach considered Phantom bite was originally Costs of treatment for phantom bite syndrome the psycho-social factors involved in why described by Marbach in 19762 as a mono- Patients with this condition seem these patients fail to adapt to dental symptomatic hypochondriacal syndrome, to be of above average intelligence and treatment. He found that many of the complaints were incurable. Interestingly, he a term which has since been deprecated often highly articulate and literate. Some can found that they were also not terminal with by subsequent iterations of the American afford to have extensive private treatment regards to the dentition. These patients Psychiatric Association (APA) Classification of and detailed investigations in an effort to are chronic sufferers, with their ongoing Mental Disorders. satisfy their perceived needs for their bite or dentistry becoming an illness maintenance In terms of APA classification, ‘occlusion’ to be treated. system. He warned that ‘prolonged dental previous versions of ‘Phantom Bite Patients from different social intervention and palliation can result in Syndrome’ (PBS) would probably have been groups can become a repetitive burden on the emergence of symptoms secondary to categorized under ‘Medically Unexplained different NHS hospital departments and treatment’. These secondary symptoms, or Symptoms’ (MUS), or as a 'Somatoform regularly move to different ones if they can, side-effects, are sometimes more destructive Disorder' in their fourth Diagnostic and particularly if they are frustrated in their than the disease the treatment was intended Statistical Manual of Mental Disorders (DSM− quest for their ‘bite’ or ‘occlusal’ desired to palliate. IV−TR 2000).7 treatment being denied to them by one Root fillings following elective In the 2013 DSM V classification, clinician, department or hospital. extensive ceramic crown preparations, which it would probably now come under ‘Somatic Phantom bite patients often are sometimes done to achieve the desired Symptom Disorder’,8 which is abbreviated intersperse their hospital visits with an occlusal contacts, are not uncommon. to SSD. Characteristics of SSD are somatic unknown number of contacts with general This is often because the pulps in the symptoms that are very distressing to a dental practitioners (GDPs). Unless that previously intact teeth get no warning of patient and/or that result in significant GDP contacts the appropriate clinician the unprovoked air rotor attack opening disruption of functioning, as well as or hospital(s), there may well be no real millions of their previously healthy dentinal excessive and disproportionate thoughts, knowledge of the overall number of these tubules. This physical assault is often feelings and behaviours regarding those patient visits. An estimate of the three most followed by a period of microleakage due to symptoms. To be diagnosed with SSD, the ‘frequent flyers’ in this series is that they each poor temporization of the cut teeth, thereby individual must be persistently symptomatic, had well over a 100 visits to various clinicians allowing easy bacterial ingress down the which typically means for at least 6 months. in different locations. This conservative freshly opened tubules directly to the pulp, Once the diagnosis is confirmed estimate does not include the costs of the especially near the pulp horns or gingival by a specialist psychiatrist, preferably one time involved with dealing with their time margins.14 The resultant pulpitic symptoms who is familiar with these sorts of problems, consuming telephone calls and/or letters can then lead to pain of variable severity and then selective serotonin re-uptake inhibitors to secretaries and reception desks, often difficulty of interpretation, and eventually (SSRIs) or other appropriate antidepressant followed by complaints to different people to root fillings through the extensive or other drugs and/or cognitive behavioural and organizations. restorations with unpredictable outcomes. therapy, or some combination of these As a result of the different If there are further ongoing complaints, treatments can be prescribed as appropriate. and often extensive dental treatments, then eventually extractions of the previously If the treatment suggested is accepted by these patients become educated in dental intact teeth are done, sometimes followed patients, this probably represents their terminology and various ‘dental occlusion by implant-retained restorations. best chance of a possible solution to their philosophies’.9 They then often use this new Dental treatment in cases of longstanding problems, as opposed to found knowledge to persuade any new, phantom bite syndrome almost always someone continuing to provide speculative, and usually initially sympathetic, clinician promotes the illness, as opposed to curing unpredictable, irreversible, biologically to undertake the next course of speculative it. In a delusional condition such as this, expensive dental treatment to ‘improve or treatment based on one or other of these patients’ seemingly unshakeable belief correct the bite’, which often seems, based mutually contradictory occlusal treatment about the cause of their dental problems on this selection of 12 cases but also on philosophies.9 Given the benefits of the will not be overcome by replacing a filling, others, to have been futile and to have been detailed history and enough experience of a crown or bridge with fastidious detail undertaken, at least partly, at the repetitive the condition, coupled with the 20:20 vision to occlusal contacts, nor by altering the insistence of the patient. of hindsight, at least some of this might be occlusal contour of the restorations, nor by Some patients with 'Phantom considered to be inappropriate treatment. even more extensive occlusal treatments. January 2017 DentalUpdate 27 RestorativeDentistry

However, that does not stop some dentists In 2007, Reeves and Merrill16 angry with all their various dentists’ sharing in the delusion that it will do so, described an apparently similar condition to previous failures which did not resolve particularly if adequate fees are available, ‘Phantom Bite Syndrome’ as being one they the occlusal problems as they perceive and/or when the patient initially flatters the termed ‘Occlusal Dysesthesia’ and stated them. dentist with compliments about the dentist’s that it was a somatoform disorder that 11. They become litigious against the reputation for greater occlusal knowledge should be described under the psychiatrists’ dentist(s) who they perceive as having and occlusal expertise. In some ways, this Diagnostic and Statistical Manual IV (DSM IV, caused them harm. could be described as a version of the 2000). They suggested cognitive behavioural This description sounds a lot ‘folie a deux’, with both the patient and the therapy should be undertaken by the like the much earlier named ‘Phantom Bite dentist being deluded, at the beginning of appropriate specialists. They described Syndrome’. their relationship at least. Sadly, this ‘mutual occlusal dysesthesia as having the following adoration’ relationship only lasts until the characteristics: Psychiatric issues of phantom bite/occusal patient declares the dentist’s treatment 1. The patient’s complaints are often of long dysesthesia. Somatic symptom disorders a failure and then goes to someone else standing and reported to have occurred (which were previously classified as to try to solve their ongoing problems, as a consequence of procedures ranging somatoform disorders) or complains to some supposed higher from simple fillings through to extensive These are characterized by ‘authority’ or to some allegedly unbiased restorations, orthodontics or oral surgery. symptoms affecting different parts of the regulator − neither of whom know anything 2. Reassurance by the dentist does not body, usually beginning at age 30 and much about these difficult problems − often reduce patient’s concerns or distress. extending over many years.8 The incidence leaving a clinician to puzzle about how, or 3. Being referred to a ‘TMJ expert’ or of patients presenting in general medical why, things went so badly wrong. ‘Occlusion’ expert increases patients’ practice with somatization has been put at Describing these patients as somatic preoccupation and reinforces just under 9%, with three-quarters of those having ‘obsessive compulsive tendencies’ their erroneous conviction that they reported to be women.7 is understandable, but possibly inaccurate have a serious illness as a result of their ‘Somatization’ involves the in purely psychiatric terms, as patients with occlusion. patient presenting with symptoms whose true obsessive-compulsive-disorders are 4. An occlusal dysesthesia patient often cause cannot be identified and it is often usually defined as having ‘an unwanted misinterprets the reason for the referral. associated with stress, anxiety or other intrusive thought, doubt, image or urge that repeatedly enters the mind. The person They believe that the dentist believes that psychological factors. usually regards the intrusion as unreasonable the problem is very serious and is merely Typical complaints include or excessive and tries to resist them'. In other asking the ‘expert’ to confirm this. double vision, fainting, abdominal pain, words, they have some insight into their 5. Patients misinterpret their physical bowel problems or extremely painful problems. In phantom bite syndrome cases, sensations regarding their occlusion menstruation. These complaints are often patients are usually oblivious about their as well as other health-related presented in a dramatic and exaggerated delusion and they lack insight into their communications. manner. The patient may visit many condition. Indeed, as Marbach observed 6. The patient’s perception of occlusal healthcare providers, sometimes several originally, if they developed insight into it, abnormalities persists in spite of multiple simultaneously, and undergo numerous it would cease to be a psychotic delusion attempts to adjust the patient’s occlusion. diagnostic procedures, unnecessary and therefore would not be included in that 7. No dental or pharmaceutical treatment treatments and even surgery. category of mental disorders. has been effective in eliminating Most of these patients are Jagger and Korszun, in an article the unhappiness about the ‘bite’ or anxious and/or depressed and many have reviewing three cases, noted that phantom ‘occlusion’. Occlusal splints, occlusal difficulty in their personal relationships. bite was a rare and difficult to treat disabling adjustments, orthodontics, oral surgery They are rarely completely free of symptoms, condition, which could not be cured by or orthognathic surgery of various other in spite of frequent medical attention. occlusal treatments and irreversible occlusal types do not solve patients’ perceptions The repeated, unnecessary diagnostic treatments and therefore that these should of their problem. procedures or surgery can add to their be avoided.15 Instead, they recommended 8. Repeated failures merely reinforce real suffering. Depression has been found that, if possible, patients be referred for patients’ convictions that there is a to be highly correlated with somatoform psychiatric diagnosis and help. They deemed serious illness and that this is all due to disorders. Versions of these conditions are the prognosis to be poor for symptom their occlusion. well recognized in different medical circles, elimination, but not necessarily for patients’ 9. They persist in seeking multiple opinions with one version, described by Briquet as overall functioning and well-being. In their and make unreasonable demands for long ago as 1859, being termed ‘Briquet’s view, further research into the condition their occlusal ‘problems’ to be sorted syndrome’. was required but, in the meantime, it was out, often presenting with monologues In summary, ‘phantom suggested that emphasis should be placed detailing their current problems and past bite syndrome’/occlusal dysaesthesia on patients building their adaptive coping treatment failure(s). (‘dysesthesia’) probably meets most of the skills. 10. They are usually dissatisfied and often criteria for a somatic symptom disorder, 28 DentalUpdate January 2017 RestorativeDentistry

or of a somatoform disorder. In this and treatments including the failures damage, and it is therefore important to try instance, it usually presents with excessive of traditional conservative occlusal to detect the condition early on, in order preoccupation with recurring complaints treatments, eg Michigan splints or Tanner to prevent inappropriate and/or dentally which, in patients’ persistent view, is being devices. destructive, or unstable, over-treatment of caused by their bite or occlusion being 4. Patients expressing anger about previous these very difficult, trying and challenging incorrect. dentists’ failures ‘to get their bite right’ patients. Reeves and Merrill noted that or of having had dental treatment, A structured history should be such patients indulge in ‘dentist shopping’ which looks reasonably satisfactory, but taken and a detailed summary should be for occlusal treatment and this search for a is nonetheless getting blamed by the made, preferably using the patient’s own bite solution is of such long duration and patient for all their problems, often in sentences, phrases and terms to report their intensity that this impairs their normal social remoter parts of their body. main complaints. Sadly, the national health and occupational life.16 Such searches for a 5. Patients who are overly praising about remuneration system does not encourage dental solution incur expenses estimated at your reputation for knowledge about clinicians to do this nor does it allow more than six times the average. That figure occlusion, or overly ingratiating or adequate time for these time consuming excludes the amount of income that they manipulative, about your great clinical tasks to be undertaken thoroughly. lose due to lost work when seeking or having skills, in the hope of them getting A questionnaire has been treatment. treatment from you for their ‘bite’ developed for patients to complete in However, as this is a mental health problems. their own time and in private which should issue rather than a dental health issue, until In this context, there are help to alert clinicians to the possibility the somatoform disorder is addressed with many dentists with strong views about of the patient having this condition and some combination of medical, behavioural or occlusion. The dental literature is replete save them surgery time trying to work out pharmaceutical treatments, virtually all types with descriptions of various occlusal what is probably going on. A copy of this is of dental treatments, even sophisticated philosophies purporting to be the correct available to be downloaded FREE from info@ occlusal ones, are very likely to fail. one.9 Many orthodontists worship Edward martinkelleher.co.uk Angle’s classification as being vitally Early referral, preferably to a Specialist orthodontists’ familiarity with important and many strive to produce psychiatrist, if they will attend, or at least to a phantom bite syndrome Angle Class 1 occlusions where possible. dental hospital for sympathetic explanations In 2011, Ligas et al17 carried out Some prosthodontists are fans of mutually is probably a sensible first step. However, a survey of 4,000 orthodontists in America. protected occlusion, while others prefer many of these patients do not generally Only 337 completed the survey and only canine guided occlusion, or unilateral group accept psychiatric support or medication 50% of this group were familiar with the function. Makers of complete dentures aspire and, paradoxically, some complain very term ‘phantom bite’. However, many reported to provide ‘bilaterally balanced occlusion’. strongly if this is suggested, even gently, to seeing patients with ‘phantom bite’ types However, a more rational them. of complaints. It would appear that the approach involves recognizing that dental awareness amongst this group of this occlusion changes as a result of the time of Drugs used for phantom bite phantom bite phenomenon, or of its various day, conscious jaw posturing and muscle The use of the drug Pimozide was versions, such as occlusal dysesthesia, needs tension. suggested in the original Marbach report to be raised in order to detect these patients Premature contacts are (1978) but it is lacking scientific support.2 early on, thereby preventing unnecessary common in most patients and these are A very small study in Japan18 treatment of a condition that will not generally tolerated. Some problems, eg described a case series of treating phantom resolve with orthodontic or elaborate, often temporomandibular dysfunction, which bite with the serotonin re-uptake inhibitor irreversible, subsequent dental treatment. have often been attributed to occlusal Milnacipran for four weeks. The paper discrepancies, are now viewed as being showed 5 out of the 6 patients taking Warning signs of phantom bite or occlusal multi-factorial with stress, anxiety, depression the medication reported a significant dysaesthesia being the possible diagnosis and gender being important risk factors, but improvement, with a visual analogue scale 1. Patients reporting severe problems these usually resolve themselves without improvement in their occlusal discomfort ‘caused by their bite’ or using the term aggressive dental adjustment in the majority in half of them. It was reported that the ‘occlusal problems’ that do not make of cases. improvement was independent of the anti- much dental sense but yet seem to be depressant effect. It was suggested that overly disabling to the patient. Can the paradoxes be resolved? Milnacipran might be helpful in managing 2. Patient showing hugely increased focus Not predictably, sadly. Phantom this condition, but the authors stressed that on some aspect of ‘their bite’ which is bite syndrome or occlusal dysaesthesia has further long-term studies should be carried way in excess of what would normally be a protracted and poor prognosis. Dentistry out.12 expected. in its various guises is very unlikely to cure A 2015 a Japanese study of 3. Patient giving a very detailed history of patients’ perceived occlusal problems in a 130 patients reported on the incidence many previous ‘occlusal’ or ‘bite’ problems predictable way, but it can do irreversible of psychiatric co-morbidities, as well as 30 DentalUpdate January 2017 RestorativeDentistry

the psychopharmacological outcomes of dentists who carried out extensive invasive early on that their previous dentists were treatment of PBS. There were four times treatment in these patients should carry incompetent, uncaring, ‘rude’ or negligent. more women than men in the study, with all the blame for the ongoing problems or Such complaints can result in even more a mean age of 53 +/- 13 years They stated progression of the ‘Phantom Bite Syndrome’. time consuming quasi-judicial or disciplinary that only about one fifth of these patients That is spurious because most of these procedures, until eventually even those had had severe psychiatric co-morbidities, patients have demanded further extensive apparently omniscient complaint managers such as schizophrenia, bipolar disorder or treatment. However, these claims can be or regulators grow weary. They sometimes major depressive disorder. Forty patients difficult to defend, particularly if any obvious then accept what the clinician eventually (31%) showed good improvement with warning signs were repeatedly ignored, making the diagnosis of ‘Phantom Bite Mirtazapine, Amitryptilene or Aripiprazole.19 and it is alleged that some or all of the Syndrome’ had told them early on about A 2015 review of the literature treatment done was inappropriate and/or this unfortunate condition in these often about occlusal dysesthesia by Melis and undertaken largely for financial gain. That extremely challenging patients. Zawawi found 18 articles which they said, the high degree of intelligence of some considered to be relevant to the condition, of these patients, coupled with their ability Conclusions to articulate their problems in a manipulative including aetiology, diagnosis, classification Possible phantom bite syndrome way in order to get clinicians, of different and treatment. Their main conclusion was patients should be identified early on if types or specialties, to treat them, means that irreversible dental treatment should be possible and managed very carefully as that they often become the real driving force avoided because it usually worsened the they do not respond at all well to dental 20 in what attempts are made to try to correct condition. treatment, no matter how skilfully this is their perceived ‘bite’ problems. Treating their performed. perceived occlusal issues with mechanical Medico-legal implications Phantom bite patients are highly dentistry means that the underlying When phantom bite syndrome resistant to being referred to psychiatrists psychiatric issues remain. However, because patients complain, or make a claim, the as they lack insight into their condition these patients lack insight, even after the fair placement of appropriate blame, or or behaviours and they usually remain failure of often elaborate dentistry, they responsibility, is often extremely difficult. resolutely convinced that if they could only often refuse psychiatric referral, because In those cases where irreversible treatment get someone competent enough to get their firm belief remains that their problems has been done, which turns out not to have their ‘bite right’ then all their symptoms and really are purely dental and not mental. problems would be solved. solved the patient’s complaint, dentists Another paradox is that there Dental practitioners, or other should not be judged too harshly after the does not seem to be much awareness of this specialists, who suspect that they might event by some probably previously poorly specific phantom bite syndrome condition be dealing with such a problem should get informed ‘authority’. in the psychiatric or dental literature. such patients to complete a phantom bite The truth is that there are often Furthermore, even if patients do attend for questionnaire. One questionnaire that can many complex factors involved, including psychiatric help, there is paradoxically little be helpful can be downloaded free from the insistent patient demanding treatment compelling scientific evidence of there being [email protected] and once this and a dentist or specialist failing to recognize a swift or predictable cure by psychiatric is completed it can provide an appropriate this rare condition early on. Many pious intervention, pharmaceutical therapy, record as well as helping to identify patients people have great wisdom, especially with cognitive behavioural therapy (CBT) or any who might suffer from phantom bite the 20:20 benefit of hindsight. Patients and combination of these. syndrome. dentists are involved in varying proportions It appears that psychiatric Once identified, these patients for these unhappy outcomes, including treatment goals should be focused on should be referred early on for specialist their biologic and financial consequences. In re-directing beliefs away from ‘correcting the management, within the secondary care truth, many patients are at least as culpable bite’ and towards coping with their current settings, preferably before embarking on as dentists in causing their own ongoing occlusion and how to focus on other aspects extensive dental treatment that will probably problems and costs. of their daily life. This approach can help not resolve the patient’s underlying mental Allegedly omniscient lawyers reduce their fixation about ‘fixing’ their bite illness condition. or regulators, most of whom have never or their ‘occlusion’ or their other issues which met, or bothered to meet, any such difficult they attribute to the problems caused by patients, because the condition is rare, their allegedly problematic bite. References can claim that the condition should have If, however, such patients do 1. Marbach JJ. Phantom bite. Am J Orthod been recognized and dealt with better, not get what they want done, they often 1976; 70: 190−199. but only with the benefits of seeing things become serial complainers to various 2. Marbach JJ. Phantom bite syndrome. Am J after the event through their well-polished patient advice and liaison offices, practice Psychiatry 1978; 135: 476−479. retrospectoscopes. managers, practice owners, corporate 3. Marbach JJ, Varoscak JR, Blank RT, Lund P. The harsh blame culture bodies, or to regulatory authorities of various Phantom bite: classification and treatment. increasingly prevalent in modern society can sorts.4 They can often easily manipulate J Prosthet Dent 1983; 49: 556−559. mean that allegations can be made that the the people handling the complaints 4. Kelleher M. Regulators and regulations: January 2017 DentalUpdate 31 RestorativeDentistry

who will guard the guards? (or ‘Quis 9. Shillingburg HT. Fundamentals of Fixed revisited. Br Dent J 2004; 197: 241−243. custodiet ipsos custodes’ as old Juvenal Prosthodontics 4th edn. Chapter 2: 16. Reeves JL, Merrill RL. Diagnostic and used to say). Dent Update 2015; 42: Fundamentals of occlusion. London, Berlin: treatment challenges in occlusal 406−410. Quintessence Books, 2008. dysesthesia. J Calif Dent Assoc 2007; 35: 5. Hara ES, Matsuka Y, Minakuchi H, Clark GT, 10. Marbach JJ. Orofacial phantom pain: 198−207. Kuboki T. Occlusal dysesthesia: a qualitative theory and phenomenology. J Am Dent 17. Ligas BB, Galang MT, BeGole EA et systematic review of the epidemiology, Assoc 1996; 127: 221−229. al. Phantom bite: a survey of US aetiology and management. J Oral Rehabil 11. Cunningham SJ, Feinmann C. Psychological orthodontists. Orthodontics (Chic) 2011; 12: 2012; 39: 630−638. assessment of patients requesting 38−47. 6. Tsukiyama Y, Yamada A, Kuwatsuru R, orthognathic surgery and the relevance 18. Toyofuku A, Kikuta T. Treatment of Koyano K. Bio-psycho-social assessment of body dysmorphic disorder. (PMID: phantom bite syndrome with milnacipran of occlusal dysaesthesia patients. J Oral 9884781). Br J Orthod 1998; 25: 293−298. − a case series. Neuropsychiatr Dis Treat Rehabil 2012; 39: 623−629. 12. Klineberg I. Occlusion: Principles and 2006; 2: 387−390. 7. Diagnostic and Statistical Manual of Mental Practice. Oxford: Butterworth Heinemann, 19. Watanabe M, Umezaki Y, Suzuki S Disorders (DSM−IV−TR) Section 10 4th edn. 1991. et al. Psychiatric comorbidities and Arlington, VA, USA: American Psychiatric 13. Marbach JJ. Psychosocial factors for failure psychopharmacological outcomes of Association, 2000. to adapt to dental prostheses. Dent Clin phantom bite syndrome. J Psychosom Res 8. Diagnostic and Statistical Manual V. Section North Am 1985; 29: 215−233. 2015; 78: 255−259. 1.2.9. Arlington, VA, USA: American 14. Kelleher M. Porcelain pornography. 20. Melis M, Zawawi KH. Occlusal dysesthesia: Psychiatric Association, 2013. ISBN 978-0- Fac Den J 2011; 2: 134−141. a topical narrative review. 89042-554-1. 15. Jagger RG, Korszun A. Phantom bite J Oral Rehab 2015; 42: 779−785.

With 95% of dental care in the UK provided With 21 active regions across the UK and in the primary dental care setting, FGDP(UK) with members around the globe, membership of provide dental professionals with education and FGDP(UK) is available to all dentists, dental surgeons training opportunities to enhance patient care. and dental care professionals.

For information on how to become a member, For information on how visit www.FGDP.org.uk to become a member, visit www.FGDP.org.uk

95%

32SM8136 Dental HalfUpdate page advert (january issue) Dental Update 4 PRINT.indd 1 13/12/2016January 09:572017