High-Risk Occlusion: Diagnostic Truths vs. Night Guard Defenses
A clinical masterclass on distinguishing active attrition from past destruction, mapping structural biomechanical failures, and correcting pathway wear patterns directly at the chair.
The Reality of Tooth Wear: Why You Can't Outsmart Nature
Every dentist faces this scenario: a patient sits in the chair with significantly worn, flattened, or shortened teeth, and the immediate instinct is to schedule them for a night guard or map out a complex smile makeover. But before touching a handpiece, you have to answer a crucial diagnostic question: Is this damage a cold case from ten years ago, or is the patient's bite actively destroying their teeth right now?
Distinguishing between active and inactive wear changes everything about how you treat a patient. Think of inactive wear like an old scar—if a patient has lost two millimeters of enamel but their bite has remained completely stable for twenty years, you are looking at historical damage, not a current disease. However, if their teeth are visibly getting shorter within a five-year window, the destructive process is aggressive and ongoing.
This is where Dr. John Kois shares a foundational rule taught at the Kois Center: *You cannot improve on nature.* If a patient's natural teeth could not withstand the functional forces of their own jaw pathways, any beautiful porcelain crowns or composite veneers you place will meet the exact same fate. Unless you identify and correct the underlying pathway issue breaking the teeth down, your restorations are bound to fail.
This reality is also why the classic reflex to prescribe a night guard needs to be re-evaluated. Teeth do not typically crack or chip while a patient is asleep; structural damage happens during the day while chewing, speaking, and living. A night guard is excellent for relieving nighttime muscle tension, but it does not fix a daytime functional pathway problem. True restorative success requires addressing the dynamic physics of the bite directly at the source.
Mapping the Three Red Flags of a High-Risk Occlusion
In this episode of the Dental Digest Podcast, Dr. John Kois joins host Dr. Melissa Seibert to share the practical, chairside clinical protocols used to identify high-risk patients, simplify jaw mechanics, and prevent premature porcelain failures.
How to Identify a High-Risk Case Before You Restore
Evaluating an occlusal environment requires looking far beyond basic visual wear facets. Dr. John Kois identifies a high-risk patient using three clear, simple criteria that every clinician can look for during a comprehensive exam:
1. Active Attrition: Structural enamel loss or flattening that the patient has actively noticed changing within the last five years.
2. Loaded Muscle Symptoms: Signs of neuromuscular fatigue that you cannot see with your eyes but must ask about directly, including chronic daytime clenching, morning muscle tightness, unexplained tension headaches, or mobile teeth.
3. An Unstable Joint Foundation: A temporomandibular joint structure that cannot be easily guided into a predictable reference position. If the joint assembly is unstable or painful when loaded, the foundation for planning your entire restorative case is compromised.
The Posture Mistake: Stop Adjusting Bites While Patients Lay Flat
A very common mistake occurs during the final delivery of crowns or bridges. Adjusting a patient’s bite while they are laying entirely flat in the dental chair introduces an immediate positioning error. The flat, supine position is a sleeping posture—it is not the natural head position humans use when they eat, chew, or speak.
To eliminate post-operative sensitivity and unexpected porcelain fractures, try adjusting your restorations while the patient is reclined at a 45-degree angle. Once those marks are cleared, sit the patient fully upright and have them use thin articulating paper to check their dynamic pathways in a natural, functional posture.
Why Your Verbal Cues Matter at the Chair
The exact words you use when checking articulation directly dictate how hard a patient bites. Telling a patient to "bite down" instantly signals their elevator muscles to clamp together with maximum, unnatural force, which often causes the jaw to shift and creates false-positive marks on your articulating paper. Instead, refine your language to clear, gentle cues like "tap softly" or "close gently." This simple shift allows you to capture an accurate, unforced reference position without muscle guarding getting in the way.
Digital Jaw Tracking: Incorporating Real Chewing Pathways
Traditional dental articulators are strictly limited to mimicking straight, robotic movements. However, advanced digital jaw tracking technologies—like those researched extensively at the Kois Center—allow clinicians to record a patient's true, three-dimensional chewing envelope. While this advanced equipment represents a calculated investment depending on your specific office case mix, its primary value lies in capturing real-world physiological data for full-mouth rehabilitations, ensuring your porcelain and implant restorations harmonize perfectly with the patient's natural jaw movements.
Clinical Takeaways
- Differentiate Wear Activity: Always determine if structural attrition is active or historical by assessing visible dental changes over a strict five-year timeline before planning treatment.
- Screen for Muscle Dysfunction: Actively interview patients regarding daytime clenching, chronic headaches, and morning tension, as severe neuromuscular overload cannot be diagnosed by sight alone.
- Correct the Pathway: Address structural restrictions in the dynamic chewing envelope instead of utilizing a night guard as a universal defense for daytime porcelain fractures.
- Modify Patient Posture: Always evaluate and adjust final restorative occlusion at a 45-degree recline, followed by a vertical, upright posture test to match real-world mastication.
- Use Non-Threatening Verbiage: Replace the instruction to "bite down" with "tap lightly" to prevent muscle guarding and eliminate false-positive marks on your articulating paper.
Chapters & Timestamps
| Timestamp | Topic Covered in Episode |
|---|---|
| [00:00] | Reading Articulating Paper: Identifying False Positives, Smears, and Superficial Marks |
| [04:15] | The Chair-Position Trap: Why Supine Occlusal Adjustments Fail Real-World Chewing Pathways |
| [09:30] | Refining Verbal Cues at the Chair: How Language Precision Prevents Muscular Guarding |
| [14:12] | Active vs. Inactive Attrition: The Critical Five-Year Diagnostic Framework |
| [19:45] | The Laws of Nature: Why Active Attrition Predictably Destroys Ceramic Restorations |
| [24:20] | Mapping the Three Structural Markers of a True High-Risk Occlusal Environment |
| [29:05] | The Night Guard Fallacy: Why Nighttime Appliances Fail to Prevent Daytime Chipping |
| [33:40] | Digital Jaw Tracking Technology: Clinical Indications for Full-Mouth Rehabilitation |
| [38:15] | Articulator Limitations vs. Real Envelopes of Function in Contemporary Dentistry |
| [42:10] | The Four Levels of Clinical Learning: Skepticism, Questioning, Agreement, and Commitment |
Dr. John Kois
DMD, MSD · Founder, The Kois Center
Dr. John Kois is a prosthodontist, internationally recognized educator, and founder of the Kois Center, whose work has reshaped how dentists approach diagnosis, treatment planning, and occlusion. With advanced training in both periodontics and prosthodontics, he maintains a private practice limited to prosthodontics, is an affiliate professor at the University of Washington School of Dentistry, and is past president of both the American Academy of Restorative Dentistry and the American Academy of Aesthetic Dentistry. Through decades of clinical practice, research, and teaching at the Kois Center, he has helped redefine what predictable, comprehensive dentistry actually looks like.
The Kois CenterDr. Melissa Seibert
DMD, MS, FAGD, ABGD
Creator and host of the Dental Digest Podcast — the #1 clinical dental podcast worldwide and a top 1% global podcast. Dr. Seibert is a former active-duty U.S. Air Force dentist, internationally sought-after speaker, Key Opinion Leader, and published author in top dental journals. She is passionate about equipping general dentists with high-level, evidence-based clinical skills.
Publications & SpeakingStudies & Resources
- The Kois Center — Seattle, WA · restorative dentistry continuing education
- Kois Center research output — led by Dr. Marta Revilla-León, Director of Research
- Modjaw and contemporary jaw tracking technology — clinical applications
- Primary occlusal traumatism — clinical recognition and management
- The four levels of learning — skepticism, quizzical, agreement, commitment
- Part 1 of this series — Rethinking Occlusion with Dr. John Kois
Full Episode Transcript
Dr. Melissa Seibert: Welcome to the Dental Digest Podcast — a show with a mission of enabling you to stay on the cutting edge of evidence-based dentistry. I'm your host, Dr. Melissa Seibert. This is Part 2 of our two-part series with Dr. John Kois — a prosthodontist and internationally recognized educator whose work has reshaped how dentists approach diagnosis, treatment planning, and occlusion. Through decades of clinical practice, research, and teaching at the Kois Center, he has helped redefine what predictable, comprehensive dentistry actually looks like.
Dr. Seibert: You've talked about how articulating paper is a medical device — and with any medical device, there can be false positives and negatives. When you're actually having the patient chew on the articulating paper, what are you looking for?
Dr. John Kois: The hard part in the chewing envelope is always going to be where the paper smears or shows a false positive. After a while you learn to judge by how faint or deliberate the mark is. But to make it easy — when I finish even single restorations, even anterior, I sit the patient up and ask them to chew on the paper. I remove any blue streaks or smudges on my restorations. Because what I'm getting at is that even in single-tooth dentistry, it's not enough to eliminate pre-contacts and the traditional right-working / left-working interferences. The physiology piece is what they do when they sit up and chew and eat and speak. So under no circumstances can I have interferences in that regard.
Dr. Kois: Dentists have to learn to treat even individual crowns the way people actually use them — chewing, speaking, coming into MIP. That's how we close the gap between being in the chair and being at home using their teeth. For example: I think it's a mistake to adjust single crowns with the patient laying all the way back. That's a sleeping position. That's not where you use your teeth. So I adjust at 45 degrees back — about 120 — and then before they leave, I sit them up and have them chew on the paper.
Dr. Kois: When I was younger, if a patient said "could you sit me up and check my bite sitting up?" — I'd think they were the crazy ones. Then I realized there were too many of them. They were teaching me something. I started to really enjoy OCD patients, because when I'd say "bite up and down," an OCD patient would say, "how hard should I bite?" That's a great question. I should have been saying "tap up and down" or "close up and down." My language needed to be refined. We're working with a range of humanity that isn't a robot. Education is a gap-closer — from what we learned in school to what we actually need to do as complete clinicians.
Dr. Seibert: An integral part of what you teach is helping dentists recognize high-risk cases. What are the hallmarks of a high-risk occlusal case?
Dr. Kois: What dentists react to every day are visual things — wear on the teeth, and the patient gets labeled a bruxer. But there are people with significant attrition in their 40s and 50s who tell me, "I wore my teeth out — they've looked like this for the last 20 years." I used to think they were lying. Now I realize what I'm seeing with my eyes is often previous disease activity, not current. So with that in mind — active attrition. Patients who say their teeth are getting shorter, even in the last few years. That tells me the process is active. And I can say: "Mr. Jones, if your teeth are getting shorter, the process is active. If we don't fix what you did to your natural teeth, you'll do to the new restorations what you did to what nature gave you. And I can't improve on nature."
Dr. Kois: So number one is recognizing that broken-down teeth that are still active are higher risk — they've not adapted yet. The patient sees visible change in the last five years.
Dr. Kois: Number two: actively symptomatic patients — squeezing, clenching, AM discomfort, daytime discomfort, headaches, mobility. You have to ask about muscles, because you can't see muscle dysfunction. There can be active or inactive wear without symptoms. Symptomatic patients are signaling that the muscle system is overloaded, or that the joint can't load properly — which means you won't get a reference position for the jaw. That collapses the first of the Three Ps before you've even started.
Dr. Kois: If the jaw isn't right, the teeth don't fit right, and the pathway isn't right — we won't be successful in the rehab. The symptoms stay. They chip the porcelain. And dentists' default solution is a night guard, which is only helpful for nighttime problems. I ask dentists: if you think everyone's a bruxer, how many of your patients wake up with porcelain in their mouth? Where does all that chipping happen? Patients say, "I was eating. It just chipped." Why would we think a night guard is a magical saving grace for everyone? We have to treat why you think they need a night guard in the first place — most of the time, we can fix it.
Dr. Seibert: A big part of what you do is research at the Center. Are you implementing systems like Modjaw? Is jaw tracking something you'd recommend dentists learn more about?
Dr. Kois: A couple of levels to unpack. Yes, the Center is research-heavy — we have four different jaw trackers, multiple intraoral scanners, and Marta, our Director of Research, has a PhD in digital dentistry and spearheads everything. I don't think any teaching center in the world has put out more research than we have in the last two to three years. But beyond that: jaw tracking is incredible technology that might not be right for every practice, depending on case mix and return on investment. From a diagnostic perspective, I don't think the technology is fully there yet — we have patients with significant jaw issues that the trackers can't pick up. The real value of jaw tracking is for bigger cases. There isn't a pathway or an envelope of function on any analog or virtual articulator on the planet — all they have is excursive movements. Jaw tracking gives us one of the few opportunities to incorporate a physiologic movement into restoration design. So yes — for big cases, the potential is definitively there for more predictable outcomes.
Dr. Seibert: What are you doing to bring your curriculum online? Is it true you have your own GPT now?
Dr. Kois: Our first course is already in an online module. We also have a virtual reality version that was nominated for an award as one of the best CE applications for VR. And we have a Kois Center GPT — a chatbot trained only on the research integrated in our manual, so it's not corrupted by rogue internet content that AI normally scrapes. We're moving slowly into online overall because the people who take the online version and then come to the Center tell us how different the in-person experience is. Online is great for learning traditional steps. But learning how to think doesn't transform as easily onto an online platform — at least I haven't been able to do that as successfully.
Dr. Kois: I'll close with what I call the four levels of learning. The first is skepticism — and I applaud anyone listening, because to grow you have to be comfortable being in search of incompetence. Realizing you've been doing something incompletely is what drives improvement. The second level is quizzical — the things being said make enough sense that you want to ask questions, and the answers feel evidence-based. The third is agreement — most dentists get to this point; we share common ground. But the real issue is the fourth: commitment. That's when you apply the learning. Information is free. Knowledge is cheap. Wisdom is priceless — and that's what we're all after.
