Townie Casefile: When GERD Does the Damage

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Townie Casefile: When GERD Does the Damage 

A severe erosion case managed in a single sitting

Townie Casefiles spotlight exceptional case studies from our own community. Each article highlights real-world clinical techniques, decision-making strategies, and long-term outcomes from Townies who share their expertise on the Dentaltown message boards.

Case Highlights
Clinician: David Palmer, DDS

Laboratory: Jeff Bingham at Epic Labs

Patient: Adult male

Chief complaint: Severe generalized tooth wear.

Diagnosis: Severe acid erosion consistent with GERD; pulpal involvement on two upper molars and a bicuspid with decay into the pulp chambers.

Treatment: Root canal therapy, pin buildups, full-arch crown and bridge preparation, zirconia restorations; bite opened slightly.
An adult male patient presented to Dr. David Palmer with severe generalized tooth wear. The underlying cause was not bruxism, but acid erosion consistent with GERD. The extent of destruction was significant, with flattening of cusp anatomy throughout the dentition and structural compromise across multiple teeth (Figs. 1–2). Two upper molars and a bicuspid demonstrated pulpal involvement, with decay extending into the pulp chambers.

Study models were taken to evaluate the pre-treatment occlusion and establish a treatment plan (Figs. 3–4).
Townie Casefile: When GERD Does the Damage
Fig. 1
Townie Casefile: When GERD Does the Damage
Fig. 2
Townie Casefile: When GERD Does the Damage
Fig. 3
Townie Casefile: When GERD Does the Damage
Fig. 4


Endodontics and preparation
The appointment extended beyond six hours. Root canal therapy was completed on the three affected teeth, followed by pin buildups to establish a foundation for full-coverage restorations. With endodontic treatment complete, full-arch preparation was initiated along with an immediate bridge.

Establishing a reproducible bite was a key component of the case. The patient was guided into closure using soft wax in the molar regions, repeated until a consistent and reproducible position was achieved. Once verified, one side was replaced with a quick-setting bite registration material, followed by registration of the opposing side. The bite was checked multiple times to ensure the patient was not sliding into position.

Preparation was completed in a sequential, side-to-side approach. Molars and bicuspids on one side were prepared first. A bite registration was maintained on the unprepared side while a new registration was captured on the prepared side. The process was then repeated on the opposite side, allowing for a consistent reference throughout preparation. This sequencing provided a reproducible bite for laboratory fabrication.

Impregum impressions were taken and sent to a trusted laboratory for fabrication of all-zirconia restorations. The laboratory technician recommended opening the bite an additional 1–2 mm to achieve ideal central incisor length, which was approved. The anterior teeth were left slightly out of occlusion, with plans to restore the lower anteriors in a future phase to bring them into the new vertical, as reflected in the mounted models (Fig. 5).
Townie Casefile: When GERD Does the Damage
Fig. 5

Temporization and delivery
Temporization was completed without a diagnostic wax-up. Using the established bite as a reference, temporaries were fabricated by alternating sides and capturing impressions to create acrylic provisional restorations. Anterior temporaries were completed separately.

At delivery, occlusal adjustments were performed, followed by a secondary adjustment appointment one week later. Radiographs confirmed the extent of endodontic involvement and completed treatment (Figs. 6–7).
Townie Casefile: When GERD Does the Damage
Fig. 6
Townie Casefile: When GERD Does the Damage
Fig. 7


Results
Post-operative photos demonstrate restoration of incisal length, improved posterior support, and stabilization of the occlusion (Figs. 8–9). The primary restorative phase was completed in a single appointment. No occlusal guard was prescribed. The patient remains under medical management for GERD to address the underlying etiology.
Townie Casefile: When GERD Does the Damage
Fig. 8
Townie Casefile: When GERD Does the Damage
Fig. 9

What colleagues asked
The case generated discussion on the Dentaltown message board, particularly regarding bite registration in full-arch cases. Palmer described his sequential wax and bite material technique, which allows for reproducibility while maintaining reference points throughout preparation. A colleague noted this approach is sometimes referred to informally as “SYA bites.”

Questions were also raised regarding laboratory workflow. Although Palmer uses digital scanning and Dandy Lab for most crown and bridge cases, he elected to take traditional Impregum impressions and use a trusted lab for this case.

Additional discussion included consideration of a protective appliance with pH-modifying gel in cases involving ongoing acid exposure. While this was not prescribed in this case, it remains a consideration depending on patient management and compliance.


The takeaway
This case highlights the importance of distinguishing acid erosion from bruxism when evaluating severe wear. It also demonstrates that, with careful sequencing and occlusal management, complex erosion cases can be treated efficiently in a single, extended appointment.

View the full case study and join the conversation!

Great Dentists, Great Dentistry
Dr. David Palmer Dr. David Palmer, known as davidpalmer on the Dentaltown message boards, has been a member since 2000 and has contributed more than 52,000 posts. He practices in Lufkin, Texas, where he provides comprehensive general dentistry with advanced training in cosmetic dentistry and orthodontics. Known among Townies for his candid clinical discussions and willingness to take on challenging cases, Palmer regularly shares practical techniques and insights drawn from decades in practice. Outside the office, he stays active in youth sports and enjoys hunting, fishing, and time on the water—and has been known to turn a clinical discussion into offshore fishing talk when given the chance.

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