In one of his presentations at Spear Summit 2020, Dr. Frank Spear spoke to Spear Visiting Faculty members on the topic of the “emotional stages in learning.”

Dr. Spear concisely outlined four stages and provided insight as to the growth and transition that occurs as we move through those various stages. The four stages are:

  • Unconscious Incompetence: the “You don't know what you don't know” or “You only know what you know”
  • Conscious Incompetence: the “Ah-ha”
  • Conscious Competence: the “whole is greater than the parts”
  • Unconscious Competence: “It's automatic” or you “see and feel” the possibilities and the outcome.

These concepts and stages are well-documented and studied in educational and psychology literature. Learning does not occur without emotional connection and a subsequent change in action or understanding.

While Dr. Spear related these stages of learning to us as dentists and mentors, the same stages can be applied to the learning and understanding that occurs within our patients. I believe that “Facially Generated Treatment Planning” directly relates to emotional awareness and understanding. Growth and change occur in both the dentist and patient through the application of FGTP concepts.

The four stages Frank referred to are normal and expected emotions experienced through as we grow and develop the understanding and skills of our profession. I want to highlight the first stage, “Unconscious Incompetence,” in this article. I will share a recent experience with a new patient as an example.

'Unconscious Incompetence' in the dental practice

Leni, a referral patient who complained about the black triangle between her two front teeth.

The patient above was new to my practice. Leni, 57, was referred from my collaborative surgical specialist. The patient's chief complaint was the “ugly 'black triangle'” between her two front teeth.

Leni was referring to the loss of papilla height gingival to the contact point between her two maxillary central incisors. As noted in the image above, a “black triangle” is obvious. But the additional information to her chief complaint was that the recent ceramic restorations on her maxillary centrals were remade twice to close the black triangle!

The image above is one of the images captured during Leni's initial comprehensive examination in my office. As you can see, an interproximal papilla deficiency remained. As a matter of fact, there was a small piece of cement that remained on the mesial of tooth #8. The patient did not want it removed because it reduced some of the space. She was disappointed with the outcome from the previous dentist's treatment and was searching for an improved solution.

In this brief outline of Leni's referral, I have directed your attention to the papilla between her maxillary central incisors. As we know from basic patient interaction, it is important to focus and address our attention to the patient's chief complaint. That is how most of us were taught in our treatment planning education. Clearly, this patient was justified in her “black triangle” complaint.

Look at the image again. What do you see? What do you notice? What catches your eye?

Uneven gingival margins of central incisors? Reverse smile line? “Black margins” at gingival of existing crowns? Worn teeth? Erosion? Gingival recession? Uneven occlusal plane? These concerns, and others, comprise the “problem list” required to be addressed and corrected. In one image alone, so much information is gleaned. Photography is integral to treatment planning success. Observation is important.

Spear Resident Faculty member Dr. Gary DeWood says, “If it doesn't look right, it probably isn't right!” This holds true for not only the patient in this “black triangle” case but for every patient. Many aspects of this image alone, do not look like we expect them to appear. And it is important that clinicians review images, thoroughly, when initiating the treatment planning process.

The images are the key factor in Leni' case, especially with discussing the emotional stages of learning. In reference to the above image, the patient and her previous dentist were at the level of “Unconscious Incompetence,” meaning the only awareness for both was the existing “black triangle” between the maxillary central incisors.

The other disparities were not noticed and were not part of the concern or discussion between them. The treatment (ceramic veneers) was aimed solely at solving that issue. Again, two attempts were made without success and approval by the patient. Frustrating? Yes! Costly with chair time and laboratory fees? Yes! Loss of patient trust? Yes!

There is, of course, fault directed at the dentist for promising the patient that the problem would be solved and was subsequently never achieved after two attempts. But the reality was that the dentist was “unconscious” as to the many other factors to be considered. She “did not know what she did not know.” She was “incompetent” in her ability to recognize and treat the entire condition presented. She aimed her treatment to what she saw and utilized her limited abilities to provide a restorative solution.

Applying the designation of “Unconscious Incompetence” is not meant to be demeaning or disrespectful. It is simply defining where the individual is at that particular period in their learning. An individual in this emotional stage “does not know what they don't know.” They can only address situations or conditions in which they are aware.

Of course, we do not expect our patients to understand or comprehend the technical aspects related to the appearance by which they present. Patients focus on those things that “catch their eye,” create pain or discomfort, or create inability to function with comfort. Our patients remain unconscious to many related aspects surrounding esthetics, function, structure, biology (ESFB) of the teeth. Most are incompetent to provide guidance as to their awareness or objective. Old photos and drawings can aide the patient conversation and interaction around proposed treatment or direction.

It is up to clinicians to create that awareness for patients. It is up to us to create consciousness around what we see in their presentation features. Facially Generated Treatment Planning provides the system and the pathway to help our patients understand deficiency and consequences of not initiating treatment. FGTP helps them see possibility in creating optimum oral health.

Consciousness and competence

The dentist failing to solve Leni's problem led to self-awareness that she was not capable of providing predictable treatment outcome. As she became aware, she transitioned to the state of “Conscious Incompetence.”

The dentist realized she did not know what to do to correct the problem. That is, she ascertained that Leni needed to be referred to gain an acceptable solution to her problem(s). This “ah-ha moment” resulted in the referral of Leni to my practice. The dentist realized that Leni's condition required the evaluation and care from someone more extensively versed in esthetic restoration. This dentist, who practices close to my office, offered to refund Leni.

As frustrating as these situations may be, this awareness and action of referral and refund restored Leni's trust in dentistry. In a thank you referral letter to this dentist, I commended her for her actions related to Leni's treatment and, in an effort to raise her competence, referred her to Dr. Bob Winter's Spear Digest article, “Closing the Infamous Black Triangle.” She was grateful for my supportive gesture.

As I stated earlier, patients have a level of “unconsciousness” regarding their dental condition and presentation. Most come with “tunnel vision” regarding their concerns and objectives, as they “only see what they see.” For Leni, it was the black triangle that dominated her attention.

Following the photographic “tour of her oral cavity,” I asked Leni what bothered her most of what she observed in the above image. Her reply was “I don't like any of it!” That response indicates that her level of awareness (and consciousness) had been significantly raised. This new knowledge and consciousness could help her identify her concerns and direct treatment.

Leni's mouth with Facially Generated Treatment Planning template applied.

With the application of FGTP principles and templates, I had a structured and educational conversation with Leni regarding her treatment plan. Due to the extent of her dental concerns and needs, a staged or phased approach was designed and outlined for her. While her primary focus was the esthetic correction of her maxillary teeth, the comprehensive discussion helped her realize the importance of function, structure and biology in establishing a predictable and long-lasting outcome.

By applying the evaluation and planning of FGTP, we may convert the unconscious (unaware of present condition) and incompetent (unable to identify and verbalize) patient into an enlightened and educated partner in directing care and treatment.

Leni's situation provided insight into the power of FGTP. Her story is one that each of us experiences daily in our practice. Our job, our role, is to help patients, and other dentists, realize that remaining “unconscious” relative to a deficiency in oral health is neither healthy nor productive.

Knowledge and awareness improve competence and when competence is increased, self-confidence follows. Dentistry provides the ability to change the lives of our patients. When we move from “unconsciousness” to “consciousness” and become cognizant of possibility, we can achieve great things for our patients and for ourselves.


Howell, W. S. "Conscious and competence. The empathic communicator, University of Minnesota." (1982).

Cannon, Hugh M., Andrew H. Feinstein, and Daniel P. Friesen. "Managing complexity: applying the conscious-competence model to experiential learning." Developments in Business Simulation and Experiential Learning: Proceedings of the Annual ABSEL Conference. Vol. 37. 2014.


Commenter's Profile Image Alex F.
January 5th, 2021
Great article!
Commenter's Profile Image Gary R.
March 27th, 2024
Another great article Jeff! This will be passed on many times... Thank you