The ‘Practice’ of Dentistry

One of the best days in the dental office is when someone comes in and wants services from you. It likely means you have formed a relationship with them — that they trust you — and that makes you feel pretty good about yourself. You are doing work that you love on someone who trusts you — and they pay you (this is like dental utopia).

Yet even with all that, so many things can go wrong, and most of the time, they do. This is something I know from personal experience, and I’m going to tell you about it now.

So we all know that the cementation appointments have the least risk/reward in dentistry. Margins can be open, the veneers can be too short, embrasure spaces can be too open or closed, the bite can be wrong, the color can be too gray or too yellow — oh my gosh, I am getting stressed out just typing this!

And, then, let’s say you do like the finished product and cement them in. The patient is numb, so they can’t appreciate the beauty of your work; they might even be disappointed when they look at them for the first time. And if they do like them, there is a good chance that you cemented them in even though you didn’t think they were perfect.

“I thought they were too white.” “Did you see the corner of distal line angle on No. 7? It was rounded and the distal line angle of No. 10 was straighter!” “They had an existing crown on No. 7 that we just couldn’t match just right.” We are critical to the point where we can’t be satisfied. (Am I the only one that sabotages my own happiness? Please tell me I am not.)

But I digress. Back to the story.

Two weeks ago, I had a 25-year-old come in to get veneers on her front eight teeth. She saved for about five years for the procedure, and the appointment went great on all fronts. She was so happy from the beginning, and I was thrilled to be able to help her with this — I mean, I was thrilled to have the skill to change someone’s life.



We had a great time. We did some minimal preps; I took impressions and made her some very nice temps. A couple weekslater, it was time to cement the veneers in. She was so excited about this appointment, but I was a bit reserved because I know the risk/reward is not in my favor.

We removed the temps and tried them all in. I liked about 80 percent of them — and that’s good. Changes needed to be made, but there’s an American Academy of Cosmetic Dentistry lab a mile from my office, so if I ever need adjustments, I can quickly run them over. After the changes, they were ready to be cemented. I was pretty happy, which is rare.

Then came the question that will live in infamy: “Doctor, what cement would you like to use?”

Now, this is why our profession sucks sometimes. There are about 40 answers to that question. Some dentists use warmed resin for this; some use flowable. Some use resin cements, which have about four or five categories.

I looked at my assistant and told her that we have been using that “new and improved stuff” that has been working well. It was a self-adhesive dual cured cement.

Remember when I told you that I minimally reduced the preps and all the margins were on enamel. Come to find out, that self-etch adhesive resin cement doesn’t work that well on enamel. I picked the wrong cement.

Oh man, the cementation went great. It was so easy to use, and after we polished, the veneers were awesome! Show quality. So much so that after she left, I even said, “Man, those turned out nice.”

It was about three hours later, as I was coming home from my son’s baseball practice, when I got the dreaded text: “One of my veneers have come off.” Three hours after that: “Another one of my veneers just came off.”

The next day — which was already full — I had to fit the patient into the schedule in order to cement the eight veneers all over again. Yes, I said all of them. By the time she came in they had all fallen out. My technician removed all of the cement, and they were good as new.

This time, we used the old tried-and-true cement. You know, the one that has about a four-minute working time. I prepared the veneers and the teeth and began to put them on. After I put them all in, I started to remove the cement from the first one, and then the next one and so on. I was getting a little antsy, though, because the material was getting pretty hard at this point.

I got cement everywhere. I began to floss, having my assistant holding down adjacent veneers, and I have to tell the patient that this is going to get a little rough, because for some, it’s hard to get the floss through.

Once I finally finished, I was a mess, but the patient was happy about getting new teeth. I finished polishing the beauties and then took take her to the front desk. I apologized to her for the inconvenience, yet she was still excited, smiling from ear to ear.

Then, for me, the doubt crept in. Did I use the right cement, will they come off again?

I was relieved but worried that they may come off again.



For the next six months, I will think of this patient often, probably cringe, and then hope that things don't fail. The same will happen next year, and it probably won’t be until the five-year mark that I might be able to take a deep breath and think of the procedure as a success.

Success and failure — it is what the “practice of dentistry” is all about. We are all our own biggest critics. We take responsibility for things we are responsible for, and we take responsibility for things we are not responsible for. And I know I am not alone in feeling this way.

Work is always busy, life at home with my family is always busy, but I try to have perspective — and so should you.

We have great jobs and great lives. Sometimes, we’re just moving too fast to realize this. Most days, I still feel as if my head is on a swivel. I still feel like, one day, I am going to finally get this. I still feel like it will all come together soon.

But until then, I will just keep on “practicing.”

John Gammichia, DMD, FAGD