The paradoxes of phantom bite syndrome or occlusal dysaesthesia (‘dysesthesia’)

PBS Case 1

Presentation to one of the authors

Refusing to accept the diagnosis given by that particular restorative consultant, she was then referred by a different dentist to a different restorative consultant in his practice, where she attended with her bound and beautifully coloured dental journal, multiple study models and radiographs (Figures 5a–c).

PBS Case 2

PBS Case 3

Case 4

Complained of her ‘bite being too heavy at the front’ and this caused her postural problems and vision disturbances. Saw a GDP multiple times, two restorative consultants and an oral maxillofacial surgeon for consultation. Treatment involved splint therapy, full mouth rehabilitation, occlusal equilibration and then further splint therapy followed by rehabilitation as ‘the bite was not quite right’. She had an MRI of the TMJs done. No treatment resolved her bite symptoms. Clinical examinations revealed many different occlusal positions, with her currently preferred posturing one being very strange indeed. She attempted suicide 3 days after being told that she had phantom bite syndrome, which was her third attempt at committing suicide and which resulted in her being sectioned. Apparently she recovered from that acute episode of depression. Overall, it was estimated that she attended over at least 90 appointments with various clinicians.

Case 5

Presented complaining of ‘trigeminal neuralgia’ (patient's own words) which ‘caused his whole body to pull to the right’. He felt sure that ‘correcting his bite would re-align his body and improve his quality of life’. He reported that the symptoms began after a wisdom tooth extraction under local anaesthetic. He was seen by his GDP, a specialist prosthodontist, a number of restorative consultants and an oral and maxillofacial surgery consultant. His treatment included splint therapy, occlusal equilibration, multiple root canal treatments, re-root canal treatment, and extractions under local anaesthetic following ‘failed’ root canal treatment. Special investigations including a cone beam CT scan and MRI of the TMJ, all of which had negative findings. He was seen for over 50 appointments with no resolution of his symptoms. Clinical examination revealed nothing particularly untoward about his occlusion. The patient was eventually informed of the diagnosis being of phantom bite, which he refused to accept or to be referred for psychiatric evaluation.

Case 6

A 67-year-old patient presented with ‘jaw juddering attacks’ lasting 2–3 minutes once a week which caused her bite problems. She reported her tongue getting trapped at night due to her bite disturbance. She had seen her GDP and two other restorative consultants, as well as five junior members of staff over multiple appointments before being diagnosed with phantom bite syndrome. She wrote 25 letters to one of the authors repeating that all her various problems in her back, neck, knees and shoulders were all caused by her ‘bite juddering’. She refused any psychiatric input, or even to try a Michigan splint to see if her symptoms would improve, because her friend had told her that she needed ‘full bite correction’ to cure her. Her oral hygiene was dreadful in spite of multiple demonstrations of oral hygiene techniques. She refused any treatment that was not going to involve full bite rehabilitation because ‘her friend had read on the internet that her problem could only be dealt with properly with full mouth rehabilitation’.

Multiple formal complaints ensued.

Case 7

Patient presented complaining of ‘bite problems which started after 3 crowns were placed in the lower left quadrant’. She reported nasal problems, headaches and sinusitis, along with clicking jaw, neck and shoulder pain, blurred vision and vomiting, all of which, apparently, had been caused by her crowns having been placed incorrectly. Overall, she was seen by 6 general dental practitioners, 1 oral and maxillofacial surgery consultant, 3 consultant rheumatologists, 2 physiotherapists, 2 private dentists, 1 ENT surgeon, 7 general medical practitioners, 1 ophthalmologist, 1 specialist dentist and 1 restorative consultant. During this time, over £10,000 was spent to attempt to ‘correct her bite problems’. She underwent 3 crown replacements, adjustments of the crowns, root canal treatment, occlusal equilibration, 3 MRI scans, 1 facial CT scan and 1 TMJ arthroscopy. All of her dental and head and neck investigations were unsuccessful in managing her symptoms. She said that she was feeling suicidal but refused to accept the diagnosis of phantom bite or to be referred for urgent psychiatric help.

Case 8

Patient had multiple crowns placed in a general dental practice. She then had a full mouth rehabilitation done by a consultant in a teaching hospital which was followed by a Michigan splint. Apparently, she had had about 100 appointments for various crowns to be replaced and for occlusal adjustments to be done over a 5-year period. She then had another full rehabilitation done but using metal and composite on the occlusal aspects for ‘ease of bite adjustment’. Eventually she made a formal complaint because, although she was relatively free of symptoms at that stage, apparently the consultant in charge at that time did not want to change these crowns for ‘new permanent crowns with the correct bite to finish her case’.

Case 9

Patient attended her GDP for 2 crowns and 3 veneers. When she complained after these were fitted she was referred to another dentist for ‘problems with the bite’ and fees were refunded. The crowns and veneers were replaced but things got no better. Fees were refunded. She was referred to a maxillofacial department and subsequently then saw 3 more dentists ‘to replace the replacements’ along with fitting of ‘a brace’ to reposition her bite. The patient attended one of the authors with a box full of models and a big red folder with about 50 pages of letters with dates and the names of different dentists and what they had done, along with copious notes about what ‘needed to be done to correct her bite problems’.

The box of models that she had with her was carefully presented. This box contained the original cast, the original cast with a denture, a diagnostic wax-up, a putty index of the diagnostic wax-up, one master cast of the preparations for one remake, as well as an uncut copy of a second cast with the re-prepared, now minimal remaining cores.

The patient was on Amitriptyline and Zopiclone, which apparently had helped a little.

An explanation was given about phantom bite syndrome and the patient was advised not to have further replacement dentistry. An offer to get her doctor to refer her for specialist psychiatric input was somewhat reluctantly accepted and the patient was then referred back to her doctor, with details of the phantom bite condition, for onward referral.

Case 10

Patient attended with multiple medical problems including cardiac and central nervous system (CNS) problems as well as several autoimmune conditions, including Hashimoto's thyroiditis and systemic lupus erythematosus. She had multiple allergies and was taking various medications. She blamed her CNS and heart problems on the extensive dental rehabilitation work which she had done in 2007.

She had seen multiple GDC registered specialist endodontists for very competent endodontic treatment after this prosthodontic treatment, as well as having had multiple CT scans.

She had had a number of extensive oral rehabilitations done which apparently ‘helped for a while but then the symptoms returned’. She had seen various other experts in various fields, including two pain specialists.

Examination showed extensive high quality restorations, including an implant following some bone grafting and many root-filled teeth without periapical areas. Soft tissues and TMJ examinations revealed no abnormalities and a diagnosis of phantom bite syndrome was made. This was explained to her in detail and the patient was offered onward referral for psychiatric input, but this was declined.

Case 11

The patient had some wisdom teeth removed and then had a maxillary hard occlusal device made which produced a ‘relatively comfortable bite for 17 years’. ‘She had a filling done which precipitated problems’. This included ‘trigeminal neuralgia in her face’, which she referred to as ‘TN’ throughout the consultation as well as ‘pain in her temporomandibular joints’. She then had occlusal adjustments, root fillings, multiple re-root fillings and an extraction of the previously re-root filled lower second molar. She had multiple copies of radiographs with her and various study casts. She had seen quite a number of ‘occlusion experts’, one of whom made her a Tanner device with multiple adjustments being done to this. She felt strongly that ‘if only she could have her bite built back up again then her whole body alignment would improve’. A consultant maxillofacial surgeon and a specialist radiologist concluded after multiple examinations that there was no jaw joint pathology present. A number of other well-known academics had seen her in various UK cities, as well as some pain experts.

She had with her a Lucia jig, a NTISS device, a Tanner device, as well as a couple of Michigan type splints. These had helped for a while but none as much as the first hard upper splint had done.

A diagnosis of phantom bite syndrome was made and gently explained in detail over a couple of hours, with her reiterating her convictions about ‘her problems all being caused by her occlusion’. An offer of referral for expert psychiatric help was refused.

Case 12

The patient presented having had a number of major occlusal rehabilitations carried out. She had had multiple extended veneers and all-ceramic crowns done, followed by remakes of these, many subsequent root fillings and re-root fillings and eventually extractions. She had two implants after two of the re-root filled teeth were extracted.

There were root fillings present in two of the lower incisors, as well as in the lower left second premolar, lower left first molar, upper left second molar, the lower right first premolar, lower right first molar and lower right second molar.

She had got mainly all-ceramic crowns present on her teeth, including two on the implants. She was still unhappy with her bite, in spite of having worn Tanner devices and maxillary hard occlusal splints before, during and after her extensive ceramic-based reconstructions (Figure 6). She was strongly advised against further speculative dental interventions in view of the probability of phantom bite syndrome being the root cause of her ongoing problems.

The Diagnostic and Statistical Manual (DSM) Classification of Mental Disorders of the American Psychiatric Association (APA)

Phantom bite was originally described by Marbach in 1976²as a mono-symptomatic hypochondriacal syndrome, a term which has since been deprecated by subsequent iterations of the American Psychiatric Association (APA) Classification of Mental Disorders.

In terms of APA classification, previous versions of ‘Phantom Bite Syndrome’ (PBS) would probably have been categorized under ‘Medically Unexplained Symptoms’ (MUS), or as a ‘Somatoform Disorder’ in their fourth Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR 2000).⁷

In the 2013 DSM V classification, it would probably now come under ‘Somatic Symptom Disorder’,⁸ which is abbreviated to SSD. Characteristics of SSD are somatic symptoms that are very distressing to a patient and/or that result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings and behaviours regarding those symptoms. To be diagnosed with SSD, the individual must be persistently symptomatic, which typically means for at least 6 months.

Once the diagnosis is confirmed by a specialist psychiatrist, preferably one who is familiar with these sorts of problems, then selective serotonin re-uptake inhibitors (SSRIs) or other appropriate antidepressant or other drugs and/or cognitive behavioural therapy, or some combination of these treatments can be prescribed as appropriate. If the treatment suggested is accepted by patients, this probably represents their best chance of a possible solution to their longstanding problems, as opposed to someone continuing to provide speculative, unpredictable, irreversible, biologically expensive dental treatment to ‘improve or correct the bite’, which often seems, based on this selection of 12 cases but also on others, to have been futile and to have been undertaken, at least partly, at the repetitive insistence of the patient.

Some patients with ‘Phantom Bite Syndrome’ or a ‘Somatoform Symptom Disorder’ may have overlapping features similar to those with body dysmorphic disorder (BDD), a term applied to those individuals with a normal appearance who present requesting treatment because they believe that they have a ‘defect’.¹¹

Costs of treatment for phantom bite syndrome

Patients with this condition seem to be of above average intelligence and often highly articulate and literate. Some can afford to have extensive private treatment and detailed investigations in an effort to satisfy their perceived needs for their bite or ‘occlusion’ to be treated.

Patients from different social groups can become a repetitive burden on different NHS hospital departments and regularly move to different ones if they can, particularly if they are frustrated in their quest for their ‘bite’ or ‘occlusal’ desired treatment being denied to them by one clinician, department or hospital.

Phantom bite patients often intersperse their hospital visits with an unknown number of contacts with general dental practitioners (GDPs). Unless that GDP contacts the appropriate clinician or hospital(s), there may well be no real knowledge of the overall number of these patient visits. An estimate of the three most ‘frequent flyers’ in this series is that they each had well over a 100 visits to various clinicians in different locations. This conservative estimate does not include the costs of the time involved with dealing with their time consuming telephone calls and/or letters to secretaries and reception desks, often followed by complaints to different people and organizations.

As a result of the different and often extensive dental treatments, these patients become educated in dental terminology and various ‘dental occlusion philosophies’.⁹ They then often use this new found knowledge to persuade any new, and usually initially sympathetic, clinician to undertake the next course of speculative treatment based on one or other of these mutually contradictory occlusal treatment philosophies.⁹ Given the benefits of the detailed history and enough experience of the condition, coupled with the 20:20 vision of hindsight, at least some of this might be considered to be inappropriate treatment.

Different explanations for phantom bite have been proposed. Klineberg suggested that occlusal hyper-awareness could be the cause of the condition.¹² He suggested that a lack of adaptability to occlusal changes resulted in the condition.

In 1985, Marbach¹³ considered the psycho-social factors involved in why these patients fail to adapt to dental treatment. He found that many of the complaints were incurable. Interestingly, he found that they were also not terminal with regards to the dentition. These patients are chronic sufferers, with their ongoing dentistry becoming an illness maintenance system. He warned that ‘prolonged dental intervention and palliation can result in the emergence of symptoms secondary to treatment’. These secondary symptoms, or side-effects, are sometimes more destructive than the disease the treatment was intended to palliate.

Root fillings following elective extensive ceramic crown preparations, which are sometimes done to achieve the desired occlusal contacts, are not uncommon. This is often because the pulps in the previously intact teeth get no warning of the unprovoked air rotor attack opening millions of their previously healthy dentinal tubules. This physical assault is often followed by a period of microleakage due to poor temporization of the cut teeth, thereby allowing easy bacterial ingress down the freshly opened tubules directly to the pulp, especially near the pulp horns or gingival margins.¹⁴ The resultant pulpitic symptoms can then lead to pain of variable severity and difficulty of interpretation, and eventually to root fillings through the extensive restorations with unpredictable outcomes. If there are further ongoing complaints, then eventually extractions of the previously intact teeth are done, sometimes followed by implant-retained restorations.

Dental treatment in cases of phantom bite syndrome almost always promotes the illness, as opposed to curing it. In a delusional condition such as this, patients' seemingly unshakeable belief about the cause of their dental problems will not be overcome by replacing a filling, a crown or bridge with fastidious detail to occlusal contacts, nor by altering the occlusal contour of the restorations, nor by even more extensive occlusal treatments. However, that does not stop some dentists sharing in the delusion that it will do so, particularly if adequate fees are available, and/or when the patient initially flatters the dentist with compliments about the dentist's reputation for greater occlusal knowledge and occlusal expertise. In some ways, this could be described as a version of the ‘folie a deux’, with both the patient and the dentist being deluded, at the beginning of their relationship at least. Sadly, this ‘mutual adoration’ relationship only lasts until the patient declares the dentist's treatment a failure and then goes to someone else to try to solve their ongoing problems, or complains to some supposed higher ‘authority’ or to some allegedly unbiased regulator – neither of whom know anything much about these difficult problems – often leaving a clinician to puzzle about how, or why, things went so badly wrong.

Describing these patients as having ‘obsessive compulsive tendencies’ is understandable, but possibly inaccurate in purely psychiatric terms, as patients with true obsessive-compulsive-disorders are usually defined as having ‘an unwanted intrusive thought, doubt, image or urge that repeatedly enters the mind. The person usually regards the intrusion as unreasonable or excessive and tries to resist them’. In other words, they have some insight into their problems. In phantom bite syndrome cases, patients are usually oblivious about their delusion and they lack insight into their condition. Indeed, as Marbach observed originally, if they developed insight into it, it would cease to be a psychotic delusion and therefore would not be included in that category of mental disorders.

Jagger and Korszun, in an article reviewing three cases, noted that phantom bite was a rare and difficult to treat disabling condition, which could not be cured by occlusal treatments and irreversible occlusal treatments and therefore that these should be avoided.¹⁵ Instead, they recommended that, if possible, patients be referred for psychiatric diagnosis and help. They deemed the prognosis to be poor for symptom elimination, but not necessarily for patients' overall functioning and well-being. In their view, further research into the condition was required but, in the meantime, it was suggested that emphasis should be placed on patients building their adaptive coping skills.

In 2007, Reeves and Merrill¹⁶ described an apparently similar condition to ‘Phantom Bite Syndrome’ as being one they termed ‘Occlusal Dysesthesia’ and stated that it was a somatoform disorder that should be described under the psychiatrists’ Diagnostic and Statistical Manual IV (DSM IV, 2000). They suggested cognitive behavioural therapy should be undertaken by the appropriate specialists. They described occlusal dysesthesia as having the following characteristics:

This description sounds a lot like the much earlier named ‘Phantom Bite Syndrome’.

Psychiatric issues of phantom bite/occusal dysesthesia. Somatic symptom disorders (which were previously classified as somatoform disorders)

These are characterized by symptoms affecting different parts of the body, usually beginning at age 30 and extending over many years.⁸ The incidence of patients presenting in general medical practice with somatization has been put at just under 9%, with three-quarters of those reported to be women.⁷

‘Somatization’ involves the patient presenting with symptoms whose cause cannot be identified and it is often associated with stress, anxiety or other psychological factors.

Typical complaints include double vision, fainting, abdominal pain, bowel problems or extremely painful menstruation. These complaints are often presented in a dramatic and exaggerated manner. The patient may visit many healthcare providers, sometimes several simultaneously, and undergo numerous diagnostic procedures, unnecessary treatments and even surgery.

Most of these patients are anxious and/or depressed and many have difficulty in their personal relationships. They are rarely completely free of symptoms, in spite of frequent medical attention. The repeated, unnecessary diagnostic procedures or surgery can add to their real suffering. Depression has been found to be highly correlated with somatoform disorders. Versions of these conditions are well recognized in different medical circles, with one version, described by Briquet as long ago as 1859, being termed ‘Briquet's syndrome’.

In summary, ‘phantom bite syndrome’/occlusal dysaesthesia (‘dysesthesia’) probably meets most of the criteria for a somatic symptom disorder, or of a somatoform disorder. In this instance, it usually presents with excessive preoccupation with recurring complaints which, in patients' persistent view, is being caused by their bite or occlusion being incorrect.

Reeves and Merrill noted that such patients indulge in ‘dentist shopping’ for occlusal treatment and this search for a bite solution is of such long duration and intensity that this impairs their normal social and occupational life.¹⁶ Such searches for a dental solution incur expenses estimated at more than six times the average. That figure excludes the amount of income that they lose due to lost work when seeking or having treatment.

However, as this is a mental health issue rather than a dental health issue, until the somatoform disorder is addressed with some combination of medical, behavioural or pharmaceutical treatments, virtually all types of dental treatments, even sophisticated occlusal ones, are very likely to fail.

Specialist orthodontists' familiarity with phantom bite syndrome

In 2011, Ligas et al¹⁷ carried out a survey of 4,000 orthodontists in America. Only 337 completed the survey and only 50% of this group were familiar with the term ‘phantom bite’. However, many reported seeing patients with ‘phantom bite’ types of complaints. It would appear that the awareness amongst this group of this phantom bite phenomenon, or of its various versions, such as occlusal dysesthesia, needs to be raised in order to detect these patients early on, thereby preventing unnecessary treatment of a condition that will not resolve with orthodontic or elaborate, often irreversible, subsequent dental treatment.

Warning signs of phantom bite or occlusal dysaesthesia being the possible diagnosis

In this context, there are many dentists with strong views about occlusion. The dental literature is replete with descriptions of various occlusal philosophies purporting to be the correct one.⁹ Many orthodontists worship Edward Angle's classification as being vitally important and many strive to produce Angle Class 1 occlusions where possible. Some prosthodontists are fans of mutually protected occlusion, while others prefer canine guided occlusion, or unilateral group function. Makers of complete dentures aspire to provide ‘bilaterally balanced occlusion’.

However, a more rational approach involves recognizing that dental occlusion changes as a result of the time of day, conscious jaw posturing and muscle tension.

Premature contacts are common in most patients and these are generally tolerated. Some problems, eg temporomandibular dysfunction, which have often been attributed to occlusal discrepancies, are now viewed as being multi-factorial with stress, anxiety, depression and gender being important risk factors, but these usually resolve themselves without aggressive dental adjustment in the majority of cases.

Can the paradoxes be resolved?

Not predictably, sadly. Phantom bite syndrome or occlusal dysaesthesia has a protracted and poor prognosis. Dentistry in its various guises is very unlikely to cure patients' perceived occlusal problems in a predictable way, but it can do irreversible damage, and it is therefore important to try to detect the condition early on, in order to prevent inappropriate and/or dentally destructive, or unstable, over-treatment of these very difficult, trying and challenging patients.

A structured history should be taken and a detailed summary should be made, preferably using the patient's own sentences, phrases and terms to report their main complaints. Sadly, the national health remuneration system does not encourage clinicians to do this nor does it allow adequate time for these time consuming tasks to be undertaken thoroughly.

A questionnaire has been developed for patients to complete in their own time and in private which should help to alert clinicians to the possibility of the patient having this condition and save them surgery time trying to work out what is probably going on. A copy of this is available to be downloaded FREE from info@martinkelleher.co.uk

Early referral, preferably to a psychiatrist, if they will attend, or at least to a dental hospital for sympathetic explanations is probably a sensible first step. However, many of these patients do not generally accept psychiatric support or medication and, paradoxically, some complain very strongly if this is suggested, even gently, to them.

Drugs used for phantom bite

The use of the drug Pimozide was suggested in the original Marbach report (1978) but it is lacking scientific support.²

A very small study in Japan¹⁸ described a case series of treating phantom bite with the serotonin re-uptake inhibitor Milnacipran for four weeks. The paper showed 5 out of the 6 patients taking the medication reported a significant improvement, with a visual analogue scale improvement in their occlusal discomfort in half of them. It was reported that the improvement was independent of the anti-depressant effect. It was suggested that Milnacipran might be helpful in managing this condition, but the authors stressed that further long-term studies should be carried out.¹²

A 2015 a Japanese study of 130 patients reported on the incidence of psychiatric co-morbidities, as well as the psychopharmacological outcomes of treatment of PBS. There were four times more women than men in the study, with a mean age of 53 +/- 13 years They stated that only about one fifth of these patients had had severe psychiatric co-morbidities, such as schizophrenia, bipolar disorder or major depressive disorder. Forty patients (31%) showed good improvement with Mirtazapine, Amitryptilene or Aripiprazole.¹⁹

A 2015 review of the literature about occlusal dysesthesia by Melis and Zawawi found 18 articles which they considered to be relevant to the condition, including aetiology, diagnosis, classification and treatment. Their main conclusion was that irreversible dental treatment should be avoided because it usually worsened the condition.²⁰

Medico-legal implications

When phantom bite syndrome patients complain, or make a claim, the fair placement of appropriate blame, or responsibility, is often extremely difficult. In those cases where irreversible treatment has been done, which turns out not to have solved the patient's complaint, dentists should not be judged too harshly after the event by some probably previously poorly informed ‘authority’.

The truth is that there are often many complex factors involved, including the insistent patient demanding treatment and a dentist or specialist failing to recognize this rare condition early on. Many pious people have great wisdom, especially with the 20:20 benefit of hindsight. Patients and dentists are involved in varying proportions for these unhappy outcomes, including their biologic and financial consequences. In truth, many patients are at least as culpable as dentists in causing their own ongoing problems and costs.

Allegedly omniscient lawyers or regulators, most of whom have never met, or bothered to meet, any such difficult patients, because the condition is rare, can claim that the condition should have been recognized and dealt with better, but only with the benefits of seeing things after the event through their well-polished retrospectoscopes.

The harsh blame culture increasingly prevalent in modern society can mean that allegations can be made that the dentists who carried out extensive invasive treatment in these patients should carry all the blame for the ongoing problems or progression of the ‘Phantom Bite Syndrome’. That is spurious because most of these patients have demanded further extensive treatment. However, these claims can be difficult to defend, particularly if any obvious warning signs were repeatedly ignored, and it is alleged that some or all of the treatment done was inappropriate and/or undertaken largely for financial gain. That said, the high degree of intelligence of some of these patients, coupled with their ability to articulate their problems in a manipulative way in order to get clinicians, of different types or specialties, to treat them, means that they often become the real driving force in what attempts are made to try to correct their perceived ‘bite’ problems. Treating their perceived occlusal issues with mechanical dentistry means that the underlying psychiatric issues remain. However, because these patients lack insight, even after the failure of often elaborate dentistry, they often refuse psychiatric referral, because their firm belief remains that their problems really are purely dental and not mental.

Another paradox is that there does not seem to be much awareness of this specific phantom bite syndrome condition in the psychiatric or dental literature. Furthermore, even if patients do attend for psychiatric help, there is paradoxically little compelling scientific evidence of there being a swift or predictable cure by psychiatric intervention, pharmaceutical therapy, cognitive behavioural therapy (CBT) or any combination of these.

It appears that psychiatric treatment goals should be focused on re-directing beliefs away from ‘correcting the bite’ and towards coping with their current occlusion and how to focus on other aspects of their daily life. This approach can help reduce their fixation about ‘fixing’ their bite or their ‘occlusion’ or their other issues which they attribute to the problems caused by their allegedly problematic bite.

If, however, such patients do not get what they want done, they often become serial complainers to various patient advice and liaison offices, practice managers, practice owners, corporate bodies, or to regulatory authorities of various sorts.⁴ They can often easily manipulate the people handling the complaints early on that their previous dentists were incompetent, uncaring, ‘rude’ or negligent. Such complaints can result in even more time consuming quasi-judicial or disciplinary procedures, until eventually even those apparently omniscient complaint managers or regulators grow weary. They sometimes then accept what the clinician eventually making the diagnosis of ‘Phantom Bite Syndrome’ had told them early on about this unfortunate condition in these often extremely challenging patients.