The question of how to have situational awareness in dentistry is something we can examine through a historical lens. When a patient comes to us with certain expectations in mind, we may overlook our own instincts in favor of a quick, decisive victory, much like General Custer did during the Battle of the Little Bighorn, leading to failure in the end. Let's delve more into how you can hone your situational awareness in dentistry to avoid these outcomes.

Asking the Right Questions to Make the Best Decisions

Close up image of damaged tooth
Figure 1: Blue tooth

“Hey Doc, can you fix my blue tooth?” The image and situation that you are looking at above is a common request from many patients. Most patients who have a dark blue and unattractive tooth will ask to have the restoration replaced to improve the color and appearance. And most dentists will happily and readily jump in and correct the problem.

What are some of the treatment options available to correct this situation? It could be another amalgam restoration. In many parts of the world, amalgam is still a common and viable treatment material. A more likely replacement could be a MOD composite and a buccal composite. It also might be that a ceramic onlay restores the functional surface and a composite manages the buccal aspect. Of course, a ceramic crown would be an appropriate solution, as well.

View of a damaged tooth from above
Figure 2: Blue tooth.

Lots of restorative possibilities exist. The real question, however, is not what we use to restore the tooth, but should we restore it? For sure the ugly and unattractive tooth needs to be corrected. And the patient's request needs to be fulfilled. But there is an important scientific information processing theory that should be considered before we haphazardly fix the tooth. This theory is called situational awareness.

How to Have Situational Awareness

Situational awareness was identified as a complex problem-solving process during World War I. Oswald Boelke, father of the German fighter air force, realized the importance of gaining an awareness of the enemy before the enemy gained a similar awareness and devised methods for accomplishing this. This idea of separation between the human operators' understanding of system status and actual system status is at the crux of the definition of situational awareness.

Mica Endsley, a Ph.D. systems engineer, is credited with bringing this concept to the contemporary forefront in the airline safety industry. Her definition of situational awareness is: “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and a projection of their status in the near future." In simple terms, her definition is a three-part process for assessing a complex situation.

The three-part sequential definition is:





Information or data in the present environment

  • “This is what I have/see.”

 Comprehension and synthesis of the data to perform an action

  • “These are the  possibilities.”

Relating the information, making a judgment, and projecting an outcome

  • “This is my expected result from action.”


Although this scientific definition is helpful, practical usage and understanding of this process through a well-known story can validate and reinforce the concept and its application to dentistry.

Custer’s Last Stand: A Historical Perspective on Awareness

Most everyone is familiar with George Armstrong Custer. Custer graduated from West Point in 1861 and was promoted to brigadier general at age 23. As a cavalry leader, he fought in both the Civil War and American Frontier Wars. He was a well-respected leader and commander.

In the summer of 1876, Custer was assigned to Fort Abraham Lincoln in the Black Hills of South Dakota. The objective of the mission was to end the tensions and conflicts quickly and efficiently between the US government and the Plains Indians.

General Custer was young, enthusiastic, and impatient. He was anxious to complete his objective, get back to Washington, and advance his career. Patrol Scouts sent from the fort had uncovered a large encampment of Indians along the Little Bighorn River. The Calvary regiment was detached to intercept this encampment.

As the company moved along the riverbank in pursuit, Custer spotted a small band of Indians moving up a ravine. The eager and raring Custer wanted to end this turmoil as quickly as possible. After assessing the circumstances and scouting reports, he resolved that vanquishing the band would provide a “quick win” and teach a lesson to the Indian nation. As such he ordered his troops up the ravine in fast pursuit.

Of course, we know the ending to this story. Custer and his troops were met by Chiefs Sitting Bull, Crazy Horse, and approximately 3,500 warriors who annihilated the regiment in what is labeled as “Custer’s Last Stand”. It was an unfortunate end for a young and capable leader.

What is the moral of this story as it relates to situational awareness?

  1. Perception: Custer was given accurate and critical data from his scouts that indicated extensive opposition.

  2.  Interpretation: Custer’s interpretation was skewed by his desire for a quick finish to the turmoil and an expeditious return to Washington.

  3. Prediction: The decision was to attack and squelch the uprising without further delay.

The application and integration of situational awareness is that all available data provided is analyzed completely and all considerations should be reviewed before proceeding to a predicted outcome.

Custer's Last Stand resulted from his improper and inaccurate interpretation of the surrounding data. The waring Indians were in much greater numbers than Custer estimated. By jumping in to chase the band in the ravine, the hurried misjudgment resulted in a catastrophic outcome for both he and his troops.

Clinical dentistry can have similarities to both situational awareness concepts and Custer's Last Stand. The tooth needs restoration. It is unattractive, structurally compromised, and functionally weak. As such, consideration must also be given to the surrounding circumstances. Knowing how to have situational awareness in this patient's presentation means associated data must be evaluated and weighed to create a predictable and successful outcome.

Using Facially Generated Treatment Planning to Improve Outcomes

Application of the principles of facially generated treatment planning is key to the evaluation and integration of comprehensive treatment and success. Using templates and employing parameters of esthetics, function structure, and biology, outlines a thorough assessment and provides greater possibility for the projection of a predictable outcome.

Data: pretreatment templates
Figure 3: Data: pretreatment templates.

FGTP Template application provides insight as to where concerns exist. Pre-treatment condition templates provide the perception data that is needed to gain perspective of the surroundings. As an example of data gathering, the adjacent canine and anterior teeth exhibit incisal wear patterns consistent with parafunctional jaw movement. Multiple large and deficient fillings, along with numerous craze lines, create concerns for both an esthetic appearance and functional longevity.

 Interpretation: Possibility for outcome
Figure 4: Interpretation: Possibility for outcome.

Analysis (or interpretation in the situational awareness world) plays out with the templates of the proposed or expected contours. As visualized with the template design, tooth length, contour, and tooth proportion create a more pleasing symmetry. These proposal templates provide insight as to what restorative direction could be taken. Templates uncover challenges and difficulties discovered in the process of analysis.

Prediction: Projection of outcome
Figure 5: Prediction: Projection of outcome.

Prediction is the final aspect of applying situational awareness concepts to complex conditions. The templates provide a directional perspective that allows for a “preview” of what may be possible with a projected or predicted outcome. Overall esthetics are improved. Increasing tooth length and shape provides functional contours that provide for longevity and predictability. Observing the bigger picture incorporates all concerns or quandaries that could lead to restoration demise if these contributions are ignored, and the blue tooth is restored alone.

Complete maxillary restoration
Figure 6: Complete maxillary restoration.

Completing a comprehensive restorative process for this patient has eliminated the leaking fillings, corrected the ragged incisal edges, and created an esthetic and functional result that has a beautiful appearance. Additionally, improved function and stability can be expected to last for many years. The patient is very pleased with her appearance and is happy that her blue tooth is no longer visible. Comprehensive planning and execution create exceptional outcomes that carry long-term predictability and satisfied patients.

Knowing how to have situational awareness is important as it relates to complex environments, circumstances, and systems. The scientific importance of this theory is proven. Application of these ideas results in greater safety and improved system outcomes by implementing the key aspects of perception, interpretation, and prediction. Facially generated treatment planning is the dental corollary to situational awareness. George Custer’s demise occurred because he misinterpreted data and subsequent disastrous projections. Poor comprehensive treatment planning may result in non-ideal restorative outcomes. Angry, dissatisfied, and frustrated patients create stress and anxiety for both them and the clinician. Relationships can be strained beyond resolution. Patients may leave the practice and provide negative feedback. This is an effective “Custer’s Last Stand” for dental practices.

Jeffrey Bonk, D.D.S., is a member of Spear Resident Faculty.


Commenter's Profile Image Gary R.
March 18th, 2024
Great job parallelling a history lesson with treatment planning Dr. Bonk! Thank you for another great article!