RESEARCH AND EDUCATION
SECTION EDITOR
LOUIS J. BOUCHER
“Phantom bite”: Classification and treatment
Joseph J. Marbach, D.D.S.,* John R. Varoscak, D.D.S.,** R. Terry Blank, D.D.S.,*** and
P. Lund, M.A.***
Columbia University, School of Public Health and School of Dental and Oral Surgery, New York, N.Y.
If
I?hantom bite” (PB) is a term coined to describe a
single hypochondriacal delusion on the part of patients
that their dental occlusion is abnormal.‘** The delusion
is sustained, often for many years, and is rarely
amenable to symptom-directed treatment, for example,
occlusal adjustment or prosthodontic restoration of the
occlusion. PB patients are intensely involved with and
superficially knowledgeable about details of dental
anatomy, physiology, and restorative dentistry. At
consultation they frequently present numerous radio-
graphs of their teeth, diagnostic casts, and, lately,
various plastic intraoral devices for inspection and
evaluation. A skilled and carefully conducted history
will reveal a long succession of dental treatments, most
frequently of short duration because the patient de-
cided not to continue treatment with the dentist after
the first or second visit. Occasionally, patient-doctor
relationships last for an extended period of time. More
rarely still, dental treatment may even progress to the
finished restoration before the patient invariably rejects
and terminates treatment. This article will show that
PB patients follow a consistent pattern that the dentist
may learn to identify. Because these patients are a
source of great frustration, financial loss, and potential
litigation, early identification of such patients is valu-
able to the dentist.
MONOSYMPTOMATIC
HYPOCHONDRIACAL PSYCHOSIS
Recently, attention has been focused on a number of
disorders described by the general term monosymptom-
atic hypochondriacal psychosis (MHP).’ MHP is a
psychotic disorder characterized by a hypochondriacal
delusion the central feature of which is an erroneous
and unshakable belief in a distorted body image. A
review was recently published of some of the more
*Clinical Professor, Division of Sociomedical Sciences, and Director,
Pain Research Unit, School of Public Health.
**Clinical Associate Professor, Division of Stomatology, School of
Dental and Oral Surgery.
***Clinical Assistant Professor, Division of Stomatology, School of
Dental and Oral Surgery.
556
common modes of presentation of MHP.4 Manifesta-
tions of MHP include delusional body-image distor-
tions such as in anorexia nervosa, wherein patients
perceive themselves as overweight, even after undergo-
ing life-threatening weight loss. Dermatologists are
familiar with those patients who persist in the delusion
of parasitosis, an erroneous belief that their skin is
infested with a parasite.
DYSMORPHOPHOBIA
Dysmorphophobia is the belief in OSprimary com-
plaint of a cosmetic defect, usually a sense of ugliness,
in a person of normal appearance.5 This disorder is
considered to be due to neurotically determined factors
in contrast to the psychotic basis of MHP.6 Dysmor-
phophobia ranges from a belief in a sense of mild
unattractiveness to ugliness of the body part in ques-
tion. Frequently, the patient seeks treatment to correct
the supposed deformity. Not surprisingly, the face and
its components (teeth, nose, mouth, eyes, ears, and
chin) make up a large percent of structures for which
patients seek and undergo cosmetic susgery.5
To our knowledge these are no reports of patients
seeking cosmetic dental procedures viewed from the
perspective of a dysmorphophobic complaint. Certainly
some PB patients fall into this category. The two
standard complaints of dental treatment voiced by these
patients are that the “bite is off” and “the teeth don’t
look sight.” Indeed, our own early work on the subject
concentrated on the former complaint with little atten-
tion to the latter one.‘,’
Given the opportunity, PB patients will talk endless-
ly about the shape, color, and size of crowns. They will
produce irrelevant pictures taken from magazines OS
newspapers. Unrealistic demands are made for
improvement in appearance based on the appearance of
a celebrity. Characteristically, dysmorphophobics sase-
ly connect these demands with improved function,
which can lead to extreme departure from biomechan-
ical principles should the dentist attempt to follow the
patient’s demands.
Dentists are not the only practitioners consulted by
dysmorphophobics. Plastic surgeons are requested to
APRIL 1983 VOLUME 49 NUMBER 4
PHANTOM BITE
correct all manner of dysmorphic delusions concerning
ugliness of facial features, and urologists are asked to
perform mutilating genital surgeries5 Each medical
specialty can describe its own version of MHP
patients.
RELATION OF MHP TO PSYCHIATRY
Most MHP patients escape psychiatric scrutiny.
Munro,4 a psychiatrist, notes that few patients seek
psychiatric treatment and this gives the impression that
such patients are uncommon. However, psychiatric
referral by other clinicians is impractical because it is
generally rejected by the patient, who harbors a
somatic delusion. If the patient knew it were a delu-
sion, it would cease to be one. Because the delusion is
generally not secondary to any other psychiatric illness,
the patient’s personality and, in particular, cognition
remain intact. These people act and conduct themselves
in an otherwise reasonable way. Of course, the delusion
takes its toll as these patients endlessly insist on the
instituting of inappropriate treatment procedures.
Nevertheless, no matter how many times failure results
from such treatment, PB patients do not gain insight
into this problem and do not seek psychiatric help.
DIAGNOSTIC FEATURE OF PB
Although the diagnostic features of PB patients have
been described, a brief review is appropriate.‘,* These
patients are frequently classified as temporomandibu-
lar joint patients even though they rarely complain of
pain unless they believe that the report of pain will
elicit attention from the dentist. In contrast, the
patient’s attention is focused on the complaint that his
or her occlusion is not correct and the belief that dental
treatment will accomplish correction. Unlike compul-
sive behavior wherein the sufferer often strongly resists
the impulse to act and recognizes that the activity is
senseless, PB patients are convinced of the validity of
their complaints.
PHENOMENOLOGY OF MHP-PB
The phenomenology of the PB patient with MHP is
presented. Because less is known about dysmorphopho-
bia, it is not discussed under phenomenology.
Age at jkst presentation. As described by other
investigators, patients range from 20 to 80 years of age
with the mean age in the 40s. This range may be a
socioeconomic phenomenon for PB patients frequently
report the onset of their special behavior in later
adolescence and early adulthood, as do patients suffer-
ing from obsessional neurosis.
Sex distribution. In agreement with other investiga-
tions of MHP. the sex distribution of PB was found to
THE JOURNAL OF PROSTHETIC DENTISTRY
be about equally divided. This is in sharp contrast to
myofascial pain-dysfunction (MPD) patients, who are
predominantly women, but not unlike the equal sex
distribution reported to undergo cosmetic rhino-
plasty.’
Nationality. Virtually all groups are represented by
PB patients, including those from Southeast Asia and
the traditional F,ar East.
Socioeconomic status. Economic considerations pro-
vide a unique perspective from which to study the PB
patient. Complex and repetitive dental treatment is
costly. Thus, a hierarchical system of PB patients
naturally develops along economic dimensions. At the
lower economic end of the spectrum of PB patients are
those who choose to have teeth extracted and seek
treatment with numerous new dentures or, at the very
least, endless denture adjustments. At the high econom-
ic end of the spectrum of PB patients are those wealthy
and driven enough to undergo repetitive, extensive
restoration of their natural occlusion. In the middle are
the vast majority of PB patients trapped between
economic constraints and uncontrollable impulse.
These unfortunalte patients not only suffer a great deal,
but perhaps more than those in the other two economic
groups inflict suffering on their treating dentists.
Under economic pressures they engage in activities
normally reserved for the dishonest. They do not pay
their bills, they sue, and they spread untruths about
their dentists. They are caught between the delusion
that the right occlusal theory or the right articulator
will solve their agony and the knowledge that it is
beyond their economic scope to receive these treat-
ments. Such diliemmas produce desperate people. The
dentist should not underestimate the intensity and
extent of the suffering involved.
Duration of illness. Most PB patients have been ill
for many years. In our experience the duration of
illness is generally equal to their age minus 10 to 20
years.
General character traits. Our experiences are in
accord with those of Munro.4 He states: “There are
high frequencies of nonmarriage, separation, and
divorce (especially among the men) and in married
patients of both sexes the reproduction rate is below
average.” The husbands of many of the women demon-
strate a complete belief in their wife’s delusion. One
investigation of MHP has placed this incidence of folie
i deux at 2570.’
Munro+ found that although his MHP patients were
of a lower&an-average socioeconomic group, this
finding may be an artifact of his psychiatric practice.
He states that sophisticated paranoid patients do not
readily consult psychiatrists. Our experience supports
557

this view. In addition, PB patients are generally of
above average income and educational level.
Rachman and Hodgson8 reviewed the literature on
the relationship of intelligence and obsessional patients.
They conclude that obsessional patients who share
many traits with MHP patients as a group appear to
be of above average intelligence. The theoretical and
practical significance of these findings is important to
the dentist.
Prognosis. The pessimism that pervades the psychi-
atric literature with regard to MHP and dysmorpho-
phobia as well as obsessions and compulsions should
not be ignored.gs’o Nevertheless, due to the paucity of
reports on PB patients there is little reliable informa-
tion about prognostic indicators and treatment meth-
ods. Our own long-term observations indicate that PB
patients remain remarkably constant over extremely
long periods of time. Marbach’ has personally observed
the same patient for 15 years, many more for about 10
years, and reported a patient he traced for 36 years of
unsuccessful psychiatric and dental treatment.
TREATMENT
This discussion of treatment will briefly review the
following approaches: (1) drug therapy, (2) psycho-
therapy, and (3) strategies to be used by the dentist.
Aspects of PB, MHP, and dysmorphophobia will be
discussed where appropriate.
Dnig therapy
Pimozide (Janssen, New Brunswick, N. J.) is the only
psychotomimetic drug shown to be successful in the
treatment of MHP. Pimozide is a nonphenothiazine
neuroleptic drug similar in structure to the buty
rophenones such as haloperidol. Positive changes in
behavior have been noted within a week. Furthermore,
there is a reduction in the intensity and preoccupation
with the delusion. Reports of up to 4% years of successful
maintenance on pimozide are encouraging. However,
pimozide is not available in the United States. Perhaps if
pimozide becomes available, we shall reattempt drug
therapy. For the present, with the generally unsuccessful
results gleaned from the occasionally compliant PB
patient, drug therapy appears impractical.
Psychotherapy
Many investigators have commented on the lack of
successin dealing with MHP by traditional interpreta-
tive psychotherapy.6 The patients are reluctant to seek
such care, especially after reinforcing the somatic
delusion with various surgeries. Andreasen and Bar-
dach,” a psychiatrist and otolaryngologist, respectively,
558
MARBACH ET AL
state: “Patients request procedures such as facelifts for
what they inaccurately perceive as sagging chins or
wrinkled foreheads, mandibular augmentation for
‘weak’ jawlines that recede only in the insecure young
male patient’s imagination, or elevation of the eye-
brows to make the patient look more optimistic and
‘less like a criminal.’ . . . . A few (of these dysmorpho-
phobics) may actually have very minor ‘defects,’ but
their concern is disproportionate to the degree of the
defect.”
Patients who have unrealistic expectations regarding
their appearance as well as those who believe that life’s
problems can be solved in narcissistic ways are poor
candidates for psychotherapy. They lack insight, the
elementary tool of the treatment.
MHP, dysmorphophobia, and
dental treatment
The dentist should be certain of the diagnosis. Once
one is familiar with the presentation of the PB patient,
the identification is not difficult. A careful history and
thorough clinical examination are necessary. Neverthe-
less, an exaggerated emphasis on the unrealistic com-
plaints acts to reinforce the patient’s symptoms. Gould
and Gnagg,lz a dermatologist and psychiatrist, respec-
tively, report that the initial contact is the time to gain
the confidence of the patient. They state: “Eventually a
referral of a psychiatrist may be accepted. However,
many patients will never accept such a referral. Here
the dermatologist may need to alter his usual expecta-
tions and hopes for successful treatment. He will have
to be satisfied with a program that supports a burden-
some patient who is in desperate need of help.”
Unfortunately, the treatment rendered by the dentist
is different from that of the dermatologist, who gener-
ally can administer reversible treatment with oint-
ments. The dentist is requested by the patient to
prepare, move, and otherwise permanently alter teeth.
Dentists are in the unenviable position of determining
if they should commence treatment, thus committing
themselves to complete the agreed-upon treatment.
Few dentists should undertake prosthodontic or
cosmetic alteration of the dentition of a PB patient.
Assuming that the dentist does not wish to undertake
treatment of the PB patient, the following method of
proceeding is suggested.
1. After the examination the patient is told frankly
that treatment may not be successful. This is usually
enough to discourage the patient. In addition, the
patient should be requested to sign a disclaimer to this
effect. Few PB patients with their paranoid features
will sign such an agreement.
APRIL 1983 VOLUME 49 NUMBER 4
PHANTOM RITE
2. Dentists should not discuss the diagnostic impres-
sion with the patient’s relatives or bring a family
member into their confidence when they suspect PB. If
the dentist is right and the patient has MHP, the
spouse may greet the information with disbelief or
hostility. If the dentist is wrong, he or she will appear
to have made a serious and unsupportable accusation
regarding the patient’s sanity. Dentists should record
their impressions in the patient’s chart.
3. If dentists discover that they are treating a PB
patient only after therapy has begun, they should
attempt to limit the scope of treatment. Furthermore,
they should try to view the problem from the patient’s
perspective. The patient may feel sad and lack the
ability to communicate with the dentist. The patient
may fear that treatment will fail and his or her misery
will go unrelieved. Thus, the dentist should try to
perfect that aspect of the treatment that has been
started. Frustration on the part of the patient coupled
with kindness on the part of the dentist will frequently
result in a mutually agreed-upon termination of the
relationship.
4. Dentists should use only consultants in whom
they have confidence. Dentists should confide in the
patient’s general or specialist physicians only if they
are sure that they will honor the confidence. The
dentist should ask appropriate dental specialists to help
evaluate the patient. In short, the responsibility should
be shared.
5. The dentist should not try antianxiety drugs such
as diazepam or chlordiazepoxide. They will probably
only succeed in depressing the patient.13 The PB
symptoms must constantly be put in perspective. Frus-
tration should not influence the dentist into attempting
to satisfy the bizarre requests of the patient.
CONCLUSION
Currently, the best approach to the care and treat-
ment of PB patients is in the dentist’s familiarity with
the signs and symptoms of these syndromes. This is
especially important for those dentists interested in the
practice of prosthetic dentistry. The PB patient
presents problems for which there are no conventional
THE IOURNAL OF PROSTHETIC DENTISTRY
solutions. This situation is unusual for the dentist. If
the traditional problem-solving attitude of the dentist is
applied in such cases, the result is frequently worse
than the original situation. Nowhere in the practice of
dentistry is the admonition of Szasz’” more relevant:
“Don’t just do something, stand there!”
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2. hlarbach, J. J.: Phantom bite syndrome .\rn .] Psychiatry
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Giiteborg, Sweden, 1978.
4. Munro, A.: Monosymptomatic hypochondriac A psvrhosis. Br
J Hosp Med :!:34, 1980.
5, Hay, G G- Dysmorphophohia. Br .J Pwchiaq 116:399,
1970.
6. Riding, J., and Munro, A.: Pimozlde m the treatment of
monosymptomatic hypochondriacal psychosIs Arta Psychiatr
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7. Macgregor. F. C.. ‘Transformation and Idemit\: The Face .md
Plastic Surgery. New York, 1974. Quadrange The New York
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35
9. Rachman. S. J.. and Hodgson, R. J.: Obsessux and Compul-
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Il. .Indreasen, N. C., and Bardach. J.: Dvsnlorphophobia: Yymp-
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13. hlarbach, J. J., and Lund, P.: Drpresslon. anhedonta and
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14. Szasz, T S.. Pain and Pleasure, ed 7. New \ork. 1075, Baric
Books. Inc.. 11VII.
Rqtmnt reyud.\ to:
DR.JOSEPH J. MARBACH
115 E. 615~ ST.
NEW YORK. NY 10021
559