Sir, further to Messrs Jagger and Korszum (BDJ 2004, 197: 241) and letters from Mew (BDJ 2004, 197: 660) and Veale and Chapman (BDJ 2005, 198: 2) it would appear to me that the patients are suffering from a type of 'Habitual Subconscious Clenched Swallowing'. I have classified this condition in order of complexity into five classes:

  1. 1

    Clenched tongue thrust swallow with normal cusp contact, no mandible deviation, without or with mandible protrusion, no tongue support.

  2. 2

    Clenched tongue thrust swallow with no cusp contact, no mandible deviation, with mandible protrusion with tongue support.

  3. 3

    Clenched tongue thrust swallow with premature cusp contact, no mandible deviation, with tongue support.

  4. 4

    Clenched tongue thrust swallow with premature cusp contact, with mandible deviation, no tongue support.

  5. 5

    Clenched variable tongue thrust swallow, with variable cusp support, variable mandible deviation, mandible protrusion and variable tongue support.

The symptoms Mew describes appear to fit into the most complex, Class 5. Unfortunately Veale and Chapman in their psychiatric discussion reveal no dental or medical histories in their cases. The cases I treated had in addition, puckering of the orbicularis oris, posturing of the mandible, tension headaches, reduced hearing and the inability to 'pop' their ears when swallowing. They did not exhibit hypersensitive gagging, as I believe tongue pressure was exerted mainly around the dental arches.

They were treated by swallowing relaxation1 to reduce the frequency and strength of their variable tongue thrust in their 'subconscious' habitual clenched swallowing which reduced their 'bite' awareness. I believe that tongue thrust is the muscular protagonist to the clenching muscles (including the lips) which attempt to resist, balance and adapt to this swallowing pressure, so every time the patient subconsciously clench swallows it influences tooth position. This produces the 'scalloping' of the tongue and sometimes of the cheeks, which is in fact indentation caused by the excessive tongue and cheek pressure on the teeth (dents), not by 'scallops' (an unfortunate term which distracts from the cause).

With careful clinical examination and using this classification, it is possible to predict symptoms for each patient, also tongue shape and indentation will indicate if and where there is any premature cusp contact. Reducing the strength of the clenching by relaxing the patient's swallow reduces the patient's awareness of their occlusion and gives them a simple strategy to control their idiosyncrasy. Thence, further to rebuild normal adaptable swallowing movements for saliva, through to bulky solids. The obsessive compulsive attitude of some 'occlusal specialists' when treating these patients' occlusal irregularities often makes the clenched swallowing worse!

It would appear that this had happened in the three cases in 'Phantom Bite Revisited' as each had been referred for psychiatric treatment, maybe as a last resort, it is easy to 'blame' a condition we do not understand. The case of a 'Dental Phobic with Pronounced Aversion to Rubber Gloves' being treated by Swallowing Relaxation in Two Appointments2 illustrates a simple behavioural treatment for habitual sub conscious clenched swallowing: (Class 1) Similarly swallowing relaxation should be contemplated before complex restorative procedures and more so before psychiatric diagnosis and therapy. The restoration of adaptable swallowing following swallowing relaxation treatment allows these patients to follow more normal lives.

The functional differences of subconscious habitual clenched swallowing will be affected by the number and position of the teeth present, size and position of the dental arches, size, posture and position of the tongue, and the force of the thrust initiating the swallowing movement. I found that the main interconnecting conditions with Stress, Tongue Thrust and Habitual Subconscious Clenched Swallowing were:

Class 1:

  1. 1

    Puckering of orbicularis oris, hypersensitive gagging, inability to 'pop' ears by swallowing, reduced hearing, persistent cough.

  2. 2

    Mandible protrusion, puckering of orbicularis oris, hypersensitive gagging, sharp anterior teeth, pronounce sibilants with anterior teeth, indigestion, 'lump in the throat' sensation, persistent cough.

Class 2:

  • Puckering of orbicularis oris, hypersensitive gagging, posturing of mandible, sharp anterior teeth, pronounce sibilants with anterior teeth, air swallowing, indigestion.

Class 3:

  • Hypersensitive gagging.

Class 4:

  • Puckering of orbicularis oris, hypersensitive gagging, posturing of mandible, sharp anterior teeth, pronounce sibilants with anterior teeth, tension headaches, inability to 'pop' ears, indigestion, 'lump in throat', allergies, persistent cough.

Class 5:

  • Puckering of orbicularis oris, posturing of mandible, tension headaches, inability to 'pop' ears, reduced hearing.

Tension headaches occurred when there was no tongue support, premature cusp contact with mandible deviation. Careful clinical examination of the tongue and inner cheek indentations will often reveal the pressure points causing bite instability.