Dentistry has become increasingly digital, yet occlusion is still often evaluated subjectively. But why? Although every practice deals with remakes, adjustment appointments, and bite-related callbacks, research published in the National Library of Medicine reported a concerning variation in callbacks appointment; some clinicians had virtually none while others exceed 40%.¹ 

Dr. Robert B. Kerstein , DMD, is a prosthodontist and digital occlusion specialist with more than 40 years of experience, spoke with DentistryIQ to explain why occlusion is one of dentistry's least measured disciplines and the barriers that have slowed adoption. 

Why do you think occlusion has remained one of the last areas of restorative dentistry to resist objective measurement? 

“Occlusion is a fractured science, with different thought leaders advancing differing, unproven biomechanical beliefs based on visual assessments of bite alignment and articulating paper markings. Many clinicians are still taught that these methods measure the occlusion, even though they cannot objectively measure force or timing. None of these belief systems involve measuring the bite surfaces when opposing teeth contact during chewing, but instead focus on the how the jaw is positioned against the skull.” 

According to Dr. Kerstein, occlusion is a neurological science, not a biomechanical one. The differing belief systems do not account for how the teeth neurologically “talk” directly to the brain and their role in guidinghead and neck muscles to chew, swallow, and carry food down into the stomach.  Therefore, he believes it is difficult for many dental professionals to consider how true occlusal measurement helps patients function much more comfortably. 

“What’s disheartening about this ongoing resistance to measure the occlusion is that patients are condemned to treatments that are subjective, highly error prone and can be more invasive than necessary, while potentially leaving them with severe symptoms that unmeasured bite treatments do not resolve. It’s a dangerous premise to resist or reject new learnings and treatment options and only focus on preferences. These choices reflect poorly not only on the provider but can ultimately be dangerous for patients.” 

What exactly are the educational and workflow barriers that have slowed adoption of objective occlusal measurement? 

The philosophical issues raised previously are by far the most significant barrier, according to Dr. Kerstein—but additional barriers that have slowed adoption include:  

1. Learning curves: “Most dentists are trained to use articulating paper, which appears to make bite analysis simple because clinicians interpret ink mark size and shape to guide adjustments. Since this approach is already embedded in dental education and daily practice, many clinicians see little reason to learn a more sophisticated technology. In contrast, using technology like the T-Scan, effectively requires specialized training, not just in collecting high-quality occlusal data, but also in analyzing force and timing measurements and translating those findings into precise, computer-guided adjustments. While dentists can attend didactic courses, truly developing these skills requires hands-on clinical mentorship. The familiarity and perceived simplicity of using articulating paper often outweigh the motivation to adopt a more objective approach, despite research showing dentists select the wrong ink marks for adjustment 88–95% of the time² because the marks themselves do not objectively measure occlusion.” 

2. Costs: “Articulating paper is very inexpensive, costing just cents per sheet, whereas occlusion technology is a greater investment as the dentist has to purchase the physical technology as well as the additionaltraining required to use it properly.” 

What are some of the biggest misconceptions dentists have about bite-related problems, and how have those misconceptions affected patient outcomes?

“The biggest misconception is the most important one, which is that dentists are incorrectly taught that the paper mark ink method works well to diagnose the health of a functioning occlusion. In actuality, using the subjective paper mark diagnosis to adjust the bite causes TMJ problems after treatment, which often can’t be solved for the patient by the same dentist who created the problem with unmeasured bite adjustments. This a definite, widespread problem in dentistry that is not be addressed by academia or the various governing bodies (like the ADA) for patient safety and well-being. Unfortunately, most patients are unaware that going to a dentist may result in them leaving the same day with a new bite problem they did not have when they sat down to have new fillings or to have a crown installed. 

Another huge misconception is that TMD is a psychological disorder that is brought on by life’s stresses. That is completely unfounded in science. TMD is a neurologically caused bite problem where excessive back tooth friction during chewing aggravates the many muscles associated with chewing and swallowing food.  

It is important that patients understand that TMD can be successfully treated, but they must see a DTR (Disclusion Time Reduction) trained dental professional to get appropriate TMD therapy. Multiple studies show that DTR therapy stops clenching and grinding and often eliminates symptoms like tension headaches and increased cortisol levels, without resorting to temporary fixes like appliances, night guards or even Botox.” 

Can you share a case where objective occlusal data fundamentally changed a diagnosis or treatment outcome in a way traditional methods likely would not have? 

“That’s a very easy moment to remember. In 1984, when I was first trying to understand the original T-Scan device (a digital occlusal analysis system that records the timing and force of a patient's bite), I was working with a patient at Tufts dental school who complained about an upper right painful back tooth. I used the T-Scan to record her bite forces and, sure enough, there was very high force of contact that the T-Scan found on her upper right first molar, close to her cheek. When I marked that tooth with articulating paper to isolate that forceful contact, a very small ink mark was visible near her cheek, but there were other bigger and darker markings on other parts of that same first molar. In this soon-to-be eye-opening moment, T-Scan found the problem of high force contact, but articulating paper left a very small ink mark. 

Without the T-Scan most dentists (including me in 1984) would have assumed the forceful contact was where there were large ink markings, while also thinking the pinpoint contact was a “light force” contact. But because I was trying to understand the first ever bite computer, I adjusted that very small ink mark the T-Scan data said was the problem. When the patient checked her bite comfort by tapping her teeth together a few times, she looked up and said “wow! That’s so much more comfortable! Thank you!”  

And that’s when I realized fundamentally, that the articulating paper and ink “size” force concepts were false, because the high force wasn’t where there was lots of ink.  We dentists are taught to discount the light marks and adjust the big ones. But T-Scan often detects high forces in small markings, and treating those contacts quickly resolves bite problems that weren’t being solved for patients without T-Scan detection.  

That was a fundamental early moment in my 42 years of T-Scan implementation, which led to the development of the “T-Scan-guided” objective bite adjustment method. Since then, I have had the privilege of publishingmany papers with fellow authors that have continued to solidify these findings and prove that ink mark size is incapable of accurately reporting differing bite force levels.” 

If a dentist reading this interview wanted to reduce remakes or unnecessary chair time, what's the first change you would recommend they make in their workflow? 

“It’s very simple, as an advocate who’s championed the technology for over four decades, I believe that any dentist reading this article should learn to use digital occlusion technology as the final step in their digital workflow. A 2024 publication showed T-Scan reduced implant mechanical complications from 25% (articulating paper used to install the implant restorations) down to 1.8% (T-Scan 10 used to install the implant restorations).³ It’s very clear that subjective use of paper and ink is a huge problem in daily dental practice, yet it can often go unchecked.” 

Conclusion 

Occlusion may be one of the last frontiers in dentistry's digital workflow, but Dr. Kerstein argues that relying on subjective bite assessment comes at the cost of unnecessary remakes, callbacks, and patient discomfort. As restorative dentistry continues to embrace digital precision, objectively measuring occlusion could help clinicians improve treatment predictability, reduce chair time, and deliver more consistent long-term outcomes. 

References:  

1. McCracken MS, Litaker MS, Gordan VV, Karr T, et al. Remake rates for single-unit crowns in clinical practice: findings from The National Dental Practice-Based Research Network. J Prosthodont. 2019;28(2):122-130. doi:10.1111/jopr.12995

2. Goud SS, Thumathi P, Poovani SK, Radke J, Kerstein RB. A prospective single arm study of salivary cortisol changes in muscular temporomandibular disorders patients following computer-guided occlusal adjustments. J Prosthet Dent. 2026 ;136(1):187-195. doi:10.1016/j.prosdent.2026.02.031 

3. Implant complications after installation with traditional vs digital occlusal indicators. Tekscan. February 2024. https://www.tekscan.com/resources/articles-research/implant-complications-after-installation-traditional-vs-digital