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Occlusal Dysesthesia: a Topical Narrative Review

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Occlusal Dysesthesia: a Topical Narrative Review Journal o f Oral Rehabilitation Journal of Oral Rehabilitation 2015 42; 779–785 Review Occlusal dysesthesia: a topical narrative review † ‡ † M. MELIS* &K.H.ZAWAWI *Private Practice, Cagliari, Italy, Craniofacial Pain and Headache Center, School of ‡ Dental Medicine, Tufts University, Boston, MA, USA and Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia SUMMARY Occlusal dysesthesia (OD) is a disorder them were considered relevant to the topic. This characterised by the sensation of uncomfortable article reviews the epidemiology, taxonomy and bite with no obvious occlusal discrepancy. It is etio-pathophysiology, symptomatology, diagnosis usually associated with emotional distress and is and treatment of OD, with special relevance to elicited by dental occlusal procedures. Multiple issues of clinical importance and dental therapy. dental treatments are often provided to try to Any dental treatment must be avoided in patients resolve the symptoms, but the outcome is usually with OD, because the results could be inadequate dissatisfying for the dentist and disappointing for and it usually worsens the symptoms. the patient. To summarise the specific features of KEYWORDS: occlusal dysesthesia, phantom bite, OD, a PubMed search was carried out looking for topical review, dental treatment, diagnostic all papers related to the topic. The references from criteria the studies selected and from review articles were also examined for further relevant papers. A total Accepted for publication 5 May 2015 of 138 articles were first identified, of which 18 of conditions (5, 6). The aim of this article was to review Introduction the epidemiology, taxonomy and etio-pathophysiol- Occlusal dysesthesia (OD) is a disorder characterised ogy, symptomatology, diagnosis and treatment of OD. by the sensation of uncomfortable bite with no obvi- A special relevance was given to issues of clinical ous occlusal discrepancy, usually associated with emo- importance and dental therapy. tional distress (1, 2). Based on patients’ self-reports, the onset almost always begins after a dental proce- Materials and methods dure involving a change of the bite, such as occlusal adjustment, orthodontic, prosthodontic and restor- To summarise in a narrative review the specific fea- ative treatments (1, 3). In 1976, Marbach (4) tures of OD, a literature search was carried out to try described for the first time such condition using the to find all relevant articles written on the disease. A term ‘phantom bite’. He explained the disease as a PubMed search was performed on the 15th of Janu- variation of the phantom phenomenon, such as phan- ary 2015 using the following key words: ‘occlusal dys- tom limb and phantom tooth, and stressed the fact esthesia’, ‘phantom bite’, ‘occlusal neurosis’, ‘positive that these patients undergo numerous dental treat- occlusal sense’, ‘positive occlusal awareness’, ‘occlusal ments and occlusal adjustments trying to achieve the hyperawareness’, ‘uncomfortable bite’ and ‘uncom- goal of a ‘correct bite’ (4). Following that report, fortable occlusion’. The terms were searched as ‘All many other articles were published on the topic, Fields’, and a total number of 138 references were examining the features of those patients and found. After evaluating the titles and abstracts, 120 frequently associating the disease with psychiatric publications were eliminated because they were not © 2015 John Wiley & Sons Ltd doi: 10.1111/joor.12309 780 M. MELIS & K. H. ZAWAWI For the same reason, the neurological mechanisms through which OD develops are not clear, but a few hypotheses have been made. These hypotheses fall within three major categories: psychopathologic aetiology, neuromatrix theory and altered dental proprioception. Psychopathologic aetiology Marbach et al. (8, 17) identified the disease as a men- Fig. 1. Flowchart of the literature search. tal disorder described by the term monosymptomatic hypochondriacal psychosis (MHP), where the sole symptom is the feeling of abnormal bite. Monosymp- related to occlusal dysesthesia, and 18 articles were tomatic hypochondriacal psychosis is described as a selected. The references of the articles retrieved where somatic type of delusional disorder and is defined as then examined to search other relevant papers, and an erroneous conviction of bodily disease, abnormal- additional 4 articles were found. Thus, a total of 22 ity or alteration (8, 17). The fifth edition of the diag- articles were included in the review (Fig. 1). The full nostic and statistical manual of mental disorders text of those selections was obtained. The results of (DSM)-V, published in 2013, does not use the term those papers are displayed and discussed in the MHP, but describes the delusional disorder as charac- following sections. terised by the presence of one or more delusions with the duration of 1 month or longer. Delusions are ‘fixed beliefs that are not amenable to change in the Epidemiology light of conflicting evidence’, and their content can OD is generally considered a rare condition (7), embrace different subjects. One of these subjects is although no precise data on its prevalence and inci- the somatic type, which applies when the central dence in the population have ever been reported (8). theme of the delusion regards bodily functions or sen- However, in a survey of patients with temporoman- sations, as in the case of patients with OD (18). dibular disorders (TMD), over 30% reported some bite Marback also hypothesises that some of these discomfort, and about 10% reported uncomfortable patients might suffer from dysmorphophobia [the bite almost all of the time (9, 10). It seems to be dif- new edition of the DSM-V uses the new term body ferently distributed between the genders with higher dysmorphic disorder (18)], which is defined as a belief female prevalence (1, 3, 11–14), similarly to the in or a primary complaint of a cosmetic defect (8, 17). higher female prevalence of TMD that sometimes are However, this is limited to the patients with OD who comorbid with the disease (2, 8, 15, 16). However, also complaint of the fact that ‘the teeth don’t look such female preponderance is not reported in all the right’, in addition to the complaint of bite discomfort, studies (8, 17). The age of the patients can vary and patients with OD rarely complaint about appear- widely from 20 to 80 years with a mean age of 40– ance of their teeth, they rather focus their attention 50 years (1, 8, 11, 14). First onset of the symptoms on tooth contacts. occurs at the mean age of 45 years, with mean time Clark and Simmons support Marback’s belief of a of symptoms duration of 6 years (1). In a survey by psychologic aetiology of OD (9, 16). They mention Watanabe et al. (14), among 130 patients over 70% the possibility of the occurrence of the psychotic dis- reported that symptoms developed after a dental order termed MHP or the neurotic disorder termed treatment. dysmorphophobia, as reported by Marback, but pro- posed a major role of a somatoform disorder to explain OD symptoms. Similarly, Reeves and Merrill Taxonomy and etio-pathophysiology classify OD as a somatoform disorder (6), as described There is no official classification of OD, because there by the DSM-IV (19). Again, the new edition of the is no agreement on its aetiology and characteristics. DSM-V modifies the diagnosis of somatoform disorder © 2015 John Wiley & Sons Ltd OCCLUSAL DYSESTHESIA 781 into somatic symptom disorder (18). It is characterised tioning Klineberg’s book (15, 23), where it is called by the presence of one or more somatic symptoms ‘iatrogenic dysproprioception’ caused by changes in that are distressing or result in significant disruption dental occlusion. This event needs a new adaptation of daily life, causing excessive thoughts, feelings or or relearning of new mandibular movements and per- behaviours related to it (18). Specifically, in the case ception (15, 23). However, a recent study by Baba of OD, such somatic symptom is represented by bite et al. (12) compared the perceptive and discriminative discomfort. Conversely, a psychopathological aetiology abilities of patients with OD and healthy subjects is not supported by another study that described 5 using three tests: (i) thickness discrimination test patients with OD and only one of them was diag- using occlusal registration foils, (ii) thickness discrimi- nosed with somatoform disorders (13), and by a nation test using bite block and (iii) mouth opening recent study where <50% of the subjects displayed reproducibility test (12). While patients with OD dis- psychiatric disorders (14). However, in the former played better thickness discrimination ability than study, the criteria used to reach the diagnosis were controls (8 micron vs. 14 micron), such difference not provided, while in the latter, the patients were was not statistically significant, and the rest of the evaluated based on the clinical records and the refer- tests showed no difference between the groups (12). ral letters of the patients psychiatrists. Similar results were obtained more recently by Tsu- kiyama et al. (5), who displayed similar ability of interdental thickness discrimination between patients Neuromatrix theory with OD and a control group. Therefore, the hypothe- In 1996, Marbach revised his interpretation of the sis that an altered interdental thickness discrimination pathophysiology of OD using Melzack’s theory of the ability is responsible for the development of OD can- neuromatrix (20–22). According
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