Pediatric patient management: Moving beyond "old school" techniques with Dr. David Johnson

In this episode of A Tale of Two Hygienists , hosts David Torres and Jessica Atkinson sit down with veteran pediatric dentist Dr. David Johnson to explore how the specialty has shifted away from the restrictive "old school" management techniques of the past.

Dr. Johnson shares his journey from an Oregon ranch to a 23-year career in pediatric dentistry, emphasizing that success with children relies more on psychology than clinical speed. The conversation covers the vital role of the dental team in setting the tone for a visit, how to effectively manage "helicopter parents," and why creating a sense of patient control is the best way to prevent adult dental phobias.

Key topics discussed in this episode:

• The evolution of management: Why "hand-over-mouth" and papoose boards are being replaced by positive affirmation and advanced sedation options.

• Effective phraseology: Real-world examples of how to explain complex procedures (like high-speed suctions and handpieces) using child-friendly analogies.

• Clinical updates: A look at the Hall Technique for primary molars and why Septocaine has changed the game for local anesthesia in pediatric patients.

• Trauma and prevention: How to handle the "Friday afternoon emergency" and why prevention in the primary dentition dictates the oral health trajectory of a lifetime.

Whether you are a seasoned RDH or a dental assistant considering hygiene school, this episode offers practical insights into making the pediatric chair a place of comfort rather than conflict.

Episode transcript

David Torres:

Welcome back, listeners, to A Tale of Two Hygienists podcast. We are your host, David Torres, and my amazing partner in crime co-host, Jessica Atkinson.

I'm wondering what kind of crime we're going to commit. Hopefully nice. I mean, I don't know, but as just a saying that I just kind of thought about and I thought of you. So for me, trying to get fluoride back in the water where it's been banned, that could be the crime.

Jessica Atkinson:

Dun, dun, dun! Well, you heard it here first. And today we're going to be talking in this episode of 525 to what I consider one of the best doctors that have an amazing beard. Doctor Johnson , you just want to tell us a little bit more about that?

I would love to. So you guys can see Doctor David Johnson, but he does have a pretty epic beard. He has entered his Santa Claus era and I have known him for—we just talked about this—over 20 years. Probably we're going to say around 20; we're not going to date each other too much.

But when we were talking, I said, let's do an interactive bio. So I had the blessed opportunity to work for Doctor David Johnson as a pediatric dental assistant . And this was when I was deciding to become a dental hygienist. And he was pivotal, integral, a big part of my decision to make dentistry part of my professional life through the long haul.

So thank you. I appreciate that. And I want him to tell us a little bit about where he went to school, a few of his accolades—which he has some; this is not a place to be humble. So tell a little bit about your professional bio and then I'll let you jump in with, you know, how on days we had cancellations, he would teach me some self-defense. So watch out everybody, I'm real good!

Dr. David Johnson:

Well, I'm honored to be here for it. I have a utmost respect for hygienists and working with hygienists in the current place that I work. You guys, to me, are like specialists , just like any other specialists, because everything from people on the back... Yeah, I cannot scale off calculus to save my life! So, you know, so thankful for hygienists.

But I'm honored to be here. Okay, so I guess you want undergrad, dental school?

Jessica Atkinson:

Yeah.

David Torres:

I want, I want maybe the time when you're like a teenager and you woke up in the middle of the night and you're like, " Dentistry. This is my life ," okay? Did we all have that?

Early life and the path to dentistry

Dr. David Johnson:

Well, to be honest, I grew up in Oregon. I grew up—most of them are pretty poor now—the east side in the desert, high desert family. My grandfather started a ranch farm. I kind of grew up working on the farm. I had no interest in anything except continuing on in that. I kind of wanted to be a rancher, raise cattle and stuff like that.

And then I got in, you know, in the high school, and I'm like, I got to get out of this town. Small town of 1,200 people.

Jessica Atkinson:

How long?

Dr. David Johnson:

It's called Vale, and it's about probably about an hour and 20 minutes from Boise, Idaho. So we're really far side. So I went to school. I did my undergrad down in Utah. My older brother was down there at BYU, and when I first started, I was doing a lot of research in microbiology, immunology, and I wanted to get a PhD and teach in research.

And I realize, you know, it's pretty tough to make a decent living. I mean, you can do okay, I guess it depends where you're at. And so I was gonna go into medicine. Dentistry was not on my radar. I had no interest in working with teeth.

So, sign up, take the MCAT, and then about, oh, few weeks before the MCAT, I decided I don't want their hours. I don't want to work 60 to 80 hours a week. And then the thought just came in: What about dentistry? So I bought—I just remember for the dental exam—that I bought a $24 book at the college bookstore and I studied for like two weeks and I did pretty well on it and got into several schools, and especially the one I wanted to go to, which was Oregon Health Sciences, because I was from Oregon so I would get in-state tuition.

And yeah, so, you know, I wasn't planning on specializing. I was just going to be a family dentist, which is great, you know, love GPs and what they do. And in about two weeks, my fourth year, two weeks before the deadline to apply to pediatrics, I decided I'm going to be a pediatric dentist .

Before that, I really didn't want to, you know, it wasn't on my radar and I wasn't like, you know, I had a great GPA, but I wasn't in the top ten at Oregon. I was close to the top ten, but because I wasn't planning on specializing, you know, you kind of have to aim for those top ten and it hurts that...

So anyway, I applied. It kind of all worked out for me, I guess. I was pretty lucky. I interviewed at some residencies and I interviewed at University of Nebraska Medical Center , which was the second pediatric dental residency in the U.S. that was started. It was a great placement.

Jessica Atkinson:

Yeah.

Dr. David Johnson:

At the time, the director—I love the director. And so when I did match—you guys know what match is, right?

Jessica Atkinson:

Yeah.

David Torres:

So for those who may not be familiar, tell us a little bit about what match looks like.

The residency match process

Dr. David Johnson:

Yeah. So match is when you have the match—any residency medical or dental—you place where you interview, you rank your schools and then the schools or the hospitals will rank the applicants. And so if a place has three positions open and you place it as your number one and you're in their top three, you'll go there.

Anyway, so I got into University of Nebraska Medical Center. Interestingly, I almost after a year was going to go back and go to a med school. My director was going to help me because I loved anesthesia. We had to do a rotation through anesthesia and kind of glad I didn't, but finished there.

My wife and I didn't know where we wanted to practice. She wanted to go to California, I wanted to go to Santa Fe, New Mexico, and we ended up in Utah as a fallback plan and kind of built... Yeah, it's in the middle and it's great. It's grown; it's kind of nuts now, but...

And the practice—had my own practice for 23 years and then an group bought my practice; I worked for them for a year. And now I'm working on the Wind River Reservation . So that's it in a nutshell.

David Torres:

So question about you. Is your wife a dentist? Did you guys meet in school?

Dr. David Johnson:

No, we met in undergrad, but she has a degree in social work. Not a dentist, which I mean, has a part in dentistry. A little bit of social work for...

Jessica Atkinson:

Yeah. Oh, yeah. I know about those social aspects for sure. I'm curious about when you were at OHSU, in your beginning time of becoming a dentist, how much interaction did you actually have with the pediatric population?

Pediatric rotations in dental school

Dr. David Johnson:

So, I mean, the first two years, not much. I mean, but the third and fourth year, half a day a week, we would work with pediatric patients. So our whole class had some. Every school is different. So some schools would have a two-week rotation like at University Nebraska-Lincoln—the students will rotate through pediatric dentistry for two weeks.

We had it every week for the third and fourth year for a half a day. And so I kind of like it that way because, you know, every week you're dealing with kids. And my favorite thing about pediatric dentistry—I'm not going to lie—the dentistry is pretty easy. The actual what we do... I mean, you know, you're asking a pediatric dentist, you can put a crown on a tooth in like three minutes, but it's the management .

And I love the management and helping kids work through these things so when they're adults, they're not terrified to go to the dentist because the dentist kind of sucks, I'm not going to lie, you know? So that's really the main reason why I went in. We had the dentistry; I want to say the management, the psychology of it. I love that aspect of it.

David Torres:

But did you know that this was like a calling for you, or you just kind of like, you had a passion about being able to help with the trauma in dentistry?

The psychology of patient management

Dr. David Johnson:

So as far as the management, it's kind of something that I developed not only in dental school... I started as, you know, when you have a whole class working on kids and this kiddie's losing it, crying over here, it's like, you know, you can approach it in a way that the child thinks they're in control , which gives them some comfort.

And you can, you know, I'm big on positive affirmations. I have little tricks I've learned over the years. I think I kind of just... maybe it was my personality, but I was able to learn things as I continued practicing. So passion, definitely. Now, when it began, probably a little bit guessing. You do have a little natural knack for it.

Jessica Atkinson:

I also think that the management of the pediatric patient has a wide range of potential applications. Meaning when I was your dental assistant, we never strapped a kid to a board. I never saw a kid being papoosed, I never saw a situation where we took those kind of approaches.

So give me a little bit of perspective on, as a dental student in both residency—you know, your specialized schooling—and before, what was appropriate or accepted and then how that evolved into what you prefer.

Moving away from old school techniques

Dr. David Johnson:

Yeah. So dental school, I mean, it's a little different. We did have pediatric dentists that would come in, but it wasn't a... There's something to be said for environment. And like when Jess worked with me, basically our staff was so well trained that you guys basically managed the kids before I even got in the room. They're in the chair, they're comfortable. You know, we put nitrous on, they're watching the show, listening to the show.

Dental school, we didn't have that. We never held kids down in dental school. My residency, I learned all of it. We call them old school techniques . We papoosed kids. We did hand-over-mouth in my residency. You know, that was back in the late '90s. But all of us that kind of went back directly, you know, learned those techniques. None of us really that I know personally practice that way anymore.

David Torres:

I was going to say, was there ever a positive experience where like that worked really well? Putting that hand over the mouth—that was a good thing, glad we did that?

Dr. David Johnson:

No. Absolutely not. You know, to me, I look at it as trauma. And trauma is not a success psychologically, and the child feels like they have no control over the situation. You know, there's voice control, intimidation. I learned all those techniques. And I think that's why we have a lot of really nervous patients as adults today. And, you know, it's just not a good way to practice.

And, but I'll give credit, I think, like I taught at Primary Children's, which is Utah's, you know, level one trauma center for kids. I taught there for ten years, the residents. Well, the new director is fantastic. He's been there, probably, I don't know, 12, 14 years now. And they don't papoose kids.

Sedation and anesthesia options

We do have now, compared to when I was a resident, there's more options. So obviously, traditionally you would have, you know, nitrous oxide, right? Kind of the first. And then you had an oral sedation. And then you would have the operating room. Now there's an in-between.

So you, you know, you still have—obviously I use nitrous all the time. I never really found oral sedation worked very well. Sometimes if you give some Valium at the right dose with nitrous, it works pretty well.

Jessica Atkinson:

The cocktail, if you will.

Dr. David Johnson:

Yeah. I mean, you can do liquid Valium, but normally the kiddie cocktail is your like chloral hydrate, Vistaril. They're stronger sedatives, so they're out more. I just found that the kids were crying the whole time anyway, so I never use that in private practice.

I did in my residency, but now we have in-office IV situations with in-office intubation and then the operating room. So those kids that are like 8 or 9 that have their first molars or kind of need a lot of work and they're stressed out... you know, I would bring in a nurse anesthetist—and Jess probably remembers that—and, you know, we would get the work done.

It's definitely safer now because the nurse anesthetist or anesthesiologist—depends where you're at—the one I use towards the end of my private practice days, he had a full anesthesia machine. And he would use sevoflurane, put the kids out when the parents are there, and then after the kids are asleep, parents would go out in the waiting room. He'd put an IV in and he'd intubate.

So it was more of an operating room, like a surgical suite. And you had less of those side effects like ketamine... I mean, kind of went, yeah. And less issues with respiration and airways closing off and stuff like that. So pediatric dentistry has improved a lot, especially in the management side in my opinion.

I mean, there's obviously still risks doing that. There's risk in the operating room. I mean, there's risks to the local patient. Yes, with local. But I think the in-office sedation is a nice in-between. So parents don't have to pay a $5,000 operating room bill and oral sedation or Valium and nitrous—or nitrous just doesn't quite work.

Managing the parents

David Torres:

Doctor, did you mention really managing the kids, right? Yeah. What about the parents? What are some of those communication settings that you have where you have that one parent that is just hovering over your shoulder asking you a bunch of questions, including how long you've been doing this, all that stuff. How do you manage that?

Jessica Atkinson:

And to be fair, you looked really young 20 years ago! "How long have you been doing this?"

Dr. David Johnson:

Yeah, I'll be honest. You're not just managing the kid; you are managing the parents . And when I trained, we didn't let parents back. That was kind of the old school approach, but I was the type that: Listen, if a kiddo starts to lose it, I want the parent in the room to know, you know, we're not hurting the child, right?

And you do get that sixth sense over time. It's like, this is going to be a struggle. So before you even start or you just put the topical on... a five-year-old or six-year-old... actually the easiest age to work on is about 4 to 5, honestly. In my career, I have only been bitten by an eight-year-old!

Yeah, it's the older preteen, adolescent kids. They're the ones that have had a bad experience. You just kind of have to... because like I said, you're managing two people: the kiddo and the parent. And if it's done right, you know, you just talk to the parent as you're doing. I explain things in a non-threatening way to the kids, which helps.

Jessica Atkinson:

And some of your favorite phraseology for that?

Show-tell-do phraseology

Dr. David Johnson:

Yeah. So, you know, obviously with the topical I'm like, "Okay, I'm just going to brush your teeth. Now, this is some special toothpaste. It's going to start to feel really weird." And I lie a lot. It's easier to lie! And I say, "Okay, now..." once it starts to get numb, I'm like, "Okay, I'm going to work this toothpaste and you may feel me press just a little."

And if they start to move, you know, you can kind of see. It's like, "Oh, am I pushing too hard?" And they'll say, "Yeah." And then as far as, like, I do a lot of show-tell-do . So I'll show the kids. Like I'll say it's like going to the car wash. Here's the sprayer—I spray their hand at the high speed. This is the brush with the slow speed.

And then, you know, we clean your teeth really well, and then it's like getting a new paint on your car, and then we show the vacuum and I'll ask, "Have you seen your parents vacuum their car? This is what this is for."

And so I kind of word things in a way that, to me, doesn't sound threatening and it's on their level. And to be honest, most of the parents are really good. The ones I've seen, they just kind of sit back. It's the ones that will say, "Oh, I already told Johnny," or whoever, "we're going to... yeah, you're going to get a shot" or whatever.

And so they said... yeah, now we have to backpedal and try to start new. And normally we can come up with something. And one of the—in my opinion in my career—the greatest thing for dentistry is Septocaine . I think it is the most amazing local anesthetic because... like a miracle.

Jessica Atkinson:

Yeah.

Dr. David Johnson:

Because with Septocaine, honestly, any primary teeth, even extractions, I never have to block on the lowers. And even some permanent premolars with a Class II, I never have to block. Even some mesials of some 19 and 30, I can infiltrate and it works fantastic. So to me, Septocaine is like the greatest thing.

And I remember when it came out. Well, I remember when it came out in dental school, but we couldn't use it for anyone 12 and under per the FDA. Now it's, you know, for the older. So yeah. Good stuff.

Deciding on advanced management

Jessica Atkinson:

My question I have: When do you decide that this situation has now gotten to a point that we're going to be recommending either an in-office sedation or a hospital experience? Where do you know when that patient's in the chair that you're like, "Hey, this is where we're going to draw the line"? Is it how much work that needs to be done or how they're behaving?

Dr. David Johnson:

Yeah, I'll be honest. Kind of all the above. So I mean, obviously the first thing: if we can't get X-rays, probably not going to happen, right? A lot of it's the age. If it's going to take more than two visits... I've been surprised. Kids that are four and even younger for visits... you know, if it's going to take more than two visits, we talk about it. Does that make sense?

Jessica Atkinson:

Yeah.

Dr. David Johnson:

And some parents want us to try, and we do. And what I found: First visit, first two visits are great. It's by that fourth visit they're... and it depends on when they come in, morning or afternoon. Morning appointments are better for kids than afternoon when they're tired. But yeah, if there's 50% of the primary teeth that need work, we'll sedate them. Yeah. I mean, that's kind of a general mark for that.

David Torres:

Doctor Jay, what about emergencies? Like can you think about like an emergency that just always happens, like a chipped tooth? What are some of the things that you've noticed—like you can always count on a Friday afternoon this was, for all you know, happen.

Dental trauma and "razor scooters"

Dr. David Johnson:

Yeah, that's a great question. And I don't know if Jess remembers, but in my career, I've been in every holiday, Christmas thing. I think I was in one or two!

The bane of my practice is those stupid razor scooters —falling forward and chipping the teeth. Luckily, primary teeth, if they're chipped, you know, that's not a big deal. If they get knocked out—which is better—then we don't put them back in. It's the ones that are cracked to the nerve and we have to take it out, or it's an able incisor that we have to take out and the kiddie's four and you have to extract it there in the clinic. Those are the ones that are a little kind of a pain, you know, because this little kid is toothless for two years!

David Torres:

Yeah. Guys, I have a confession. I want to say this. I have three kids, Doctor Jay. My youngest, we have this tradition where before Christmas, every Friday, we watch a Christmas movie. And it just so happens—I know, right?—and it just so happens that on the Friday that it was basically Christmas Eve, I want to say, like 3 or 4 years ago when my youngest was a year, maybe more or maybe less...

He, this kid thinks he's made out of rubber because he's always, like, bouncing around, right? So we are in—we have this projector—and so we are getting everybody to sit down and play the Christmas movie. And I was already in... it's like a day bed. I was already in the day bed and he was playing around with me, but I was getting distracted.

As I said, I have three kids, so there's a lot going on. My wife is making the popcorn, my oldest is controlling the TV, and I'm trying to tame my second. And Jacob is just like bouncing around the bed and I'm trying to catch him... he bounced off the bed.

Now I want you to picture me slow motion, trying to grab my kid by the back of his... hopefully he was wearing an easy-grab shirt. It was like a onesie. And so, like, I'm trying to, like, grab him. And if you can just slow down and measure it, the distance between the tip of my fingers and his onesie, it was probably like five millimeters or a dental probe. And I missed it and just bounced off the bed, chipped his front tooth.

My wife and I are hygienists. Do you know the emotional toll that it takes for two dental hygienists to find out that their kid broke their tooth? And of course, it happens at the worst time. So that's what type of medical emergency—or dental emergency rather—happens, because it happened to me in those two teeth. I'd like to be the first thing to catch anything, you know, not your hands, but your teeth and your mouth.

But I think that these kinds of things happening that are pediatrics... I mean, not a lot of adults come in having chipped eight and nine as many as children. I would imagine I should probably pull the numbers on that. But in my own personal experience, I have seen more children have frontal facial injuries than an adult, and maybe because it's so frequent, do you think this is one of the reasons why pediatric dentistry was a specialty, why it was not just, "Okay, you got a half Thursday in your third and fourth year with pedes, you're good to go"?

The importance of primary teeth

Dr. David Johnson:

Yeah. I think definitely baby teeth are different. And I know that sounds weird, but, like, there have been changes in treatment. So when I was in my residency, when I first started practicing up until about 2014, if it was a deep decay, we would just do a pulpotomy—take out the top part of the nerve.

Now, I haven't done a pulpotomy since probably 2018. Now, if there's a bombed-out first molar and the kids aren't in pain, I don't even clean out the decay. I just prep it and put a crown on it. And it's a technique called the Hall Technique . And it has like a 97% success rate where the pulpotomy you're probably about 75% in the ballpark of that.

But I think that having my experience in dental school with kids, it's different than permanent teeth. And the management is different than adults. Although where I work, sometimes I have to help out and see adults. In my career, I treat them like kids. I know that sounds bad, but I explain everything well! I mean, I just, I explain it like kids and I tell them, "Hey, I'm one of the pediatric dentists and I talk to you like you're five. I'm sorry. I just want to explain it."

And I'll be honest, the adults really appreciate it. I'm like, "You like that? I've explained what I'm doing." So then they know and they're like, "Yeah, absolutely." I think it gives the patients, you know, like I said, they feel like they're in control rather than just going to the dental chair—you sit back, you have no idea what the dentist is doing.

You know, I had to get a root canal myself not too long ago. I know, hey, it's... I'm airing my dirty laundry! But anyway, my buddy—and I know what the process is—I had an endodontist do a root canal on 15. And I kind of knew what was going on. And I was like, "Oh, he's done, thank goodness," and he's just starting! And he's a good buddy of mine and I know the profession so he didn't really explain it, but I think patients who have no background in dentistry, I think they do appreciate that.

And I think with kids, you know, it's easy for general dentists—and again, this is no disrespect for general dentists—it's easier to work on an adult than it is on a kid in a lot of ways. Not just the bit, but also how to address the primary teeth. I mean, the good thing is they're all going to fall out eventually, so I guess that's one positive thing. But you know, those primary second molars, they'll have them until they're age 12.

And so it's easier... that's what I love about hygiene—it's prevention . Hygiene is prevention. And that's what you get. And pediatric dentistry is prevention as well. And if we can prevent a lot of these issues, it's so much better for the patient.

Jessica Atkinson:

So like—I mean, I think that's a really good place to end this one of two episodes. Don't worry, we're having Doctor Johnson back because we've got a lot more to talk about. But to end on the note of prevention is key , and prevention is where the power is to really change the trajectory of not only dental experiences when they're young, but throughout the lifespan of a person is prevention.

So we are so glad you came. So good to see you. And I'm excited to talk some more about pediatric dentistry and what you're doing now.

Dr. David Johnson:

Okay. Thank you. It's been a blast. This is great. Thank you.

David Torres:

Doctor Jay, we'll see you at the next one. Okay. Thank you.

Dr. David Johnson:

Oh, you're welcome.

This transcript was generated and lightly edited by AI tools.