Dental Treatments under General Anesthesia at the Pediatric Dentistry of Pusan National University Dental Hospital from 2014 to 2023

Article information

J Korean Acad Pediatr Dent. 2025;52(1):35-45

Publication date (electronic) : 2025 February 21

doi : https://doi.org/10.5933/JKAPD.2025.52.1.35

Yuri Jeong¹, Jonghyun Shin^1,2, Soyoung Park^1,2, Taesung Jeong^1,2, Eungyung Lee^,1,2

¹Department of Pediatric Dentistry, Dental Research Institute, Pusan National University Dental Hospital, Yangsan, Republic of Korea

²Department of Pediatric Dentistry, School of Dentistry, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea

Corresponding author: Eungyung Lee Department of Pediatric Dentistry, School of Dentistry, Dental and Life Science Institute, Pusan National University, 49, Busandaehak-ro, Mulgeum-eup, Yangsan, 50612, Republic of Korea Tel: +82-55-360-5180 / Fax: +82-55-360-5174 / E-mail: eungyung@pusan.ac.kr

Received 2024 September 27; Revised 2024 October 21; Accepted 2024 October 29.

Trans Abstract

Introduction

Invasive dental treatments may induce anxiety and fear in pediatric and adolescent patients due to associated sounds, odors, pain, instrumentation, and the overall atmosphere of the treatment environment [1]. In cases of severe fear and anxiety that disrupt the progression of dental treatment, behavioral management strategies may be utilized [2,3], including psychological methods, physical restraints, sedation using pharmacological agents, and general anesthesia. However, more advanced behavioral management strategies are required for patients with severe dental anxiety or infeasible communication, as with young children or individuals with disabilities [4].

General anesthesia prevents patient movement during dental treatment, thereby eliminating reliance on patient cooperation and facilitating the delivery of high-quality dental care. Furthermore, it enables implementation of a comprehensive treatment of all necessary procedures in a single session, and as the treatment was performed in an unconscious patient, it does not evoke dental anxiety [5,6]. This approach minimizes the risk of psychological distress in patients and promotes a positive long-term relationship between the clinician and patient [7].

Consequently, the use of general anesthesia for dental treatment in pediatric and adolescent populations has attracted attention, with related reports being actively disseminated both domestically and internationally [6,8-10]. According to studies reported in Republic of Korea, there has been a discernible upward trend in the frequency of dental treatment performed under general anesthesia since 2013 [10,11]. Similarly, research conducted internationally has indicated a sustained increase in the demand for general anesthesia beginning in the 2000s [12,13].

However, there have been few studies reporting on the status of general anesthesia for dental treatment in pediatric and adolescent patients in Busan and Gyeongnam regions since 2018. Several noteworthy developments have occurred since 2018, warranting a renewed investigation. First, the number of specialized healthcare professionals, including pediatric dentists and anesthesiologists, in the Department of Pediatric Dentistry at the Pusan National University Dental Hospital has markedly increased, which significantly enhanced the department’ s capacity to safely and effectively administer dental treatments under general anesthesia. This expansion has strengthened the infrastructure necessary for delivering high-quality care to pediatric and adolescent patients requiring complex and invasive dental procedures.

Second, the perception of general anesthesia substantially shifted within both the public and medical communities. Historically, general anesthesia was only predominantly indicated for severe cases or patients with significant behavioral management challenges. However, the necessity and safety of general anesthesia, particularly in pediatric and adolescent populations, have been broadly accepted in recent years. Nowadays, general anesthesia is widely acknowledged to mitigate psychological distress and facilitate a more positive treatment experience. Consequently, the demand for dental procedures conducted under general anesthesia has increased, underscoring the importance of further research in this area.

This study aimed to comprehensively analyze the current state of general anesthesia in pediatric dental treatments at the Pusan National University Dental Hospital from 2014 to 2023. We examined long-term trends, characterized patient profiles and treatment types, and compared care patterns between patients with and without disabilities. This analysis provides insights into optimizing healthcare systems for administering dental treatments under general anesthesia, especially for individuals with disabilities, and ultimately informing the development of effective policies to improve oral health outcomes for pediatric and adolescent populations.

Materials and Methods

This study adhered to the Declaration of Helsinki and was approved by the Institutional Review Board of Pusan National University Dental Hospital (IRB approval number: PNUDH-2023-11-006-001).

This study retrospectively analyzed ten years of data, from January 2014 to December 2023, on patients who underwent dental procedures under general anesthesia at the Department of Pediatric Dentistry of Pusan National University Dental Hospital. A total of 1,214 patients were evaluated, accounting for 1,238 general anesthesia events. Data were extracted from electronic medical records, focusing on preanesthetic evaluations, anesthesia records, and surgical records. The variables analyzed included patient demographics (gender, age), American Society of Anesthesiologists (ASA) physical status classification, medical history, residence, specifics of treatment and locations, total anesthesia and procedural durations, aggregate treatment costs, actual patient expenditures, and the frequency of general anesthesia applications (including repeat procedures) throughout the study period.

Patients were categorized into three groups according to their medical history: “nondisabled” for those without systemic conditions, “disabled” for individuals with either severe dental disabilities, such as those diagnosed with autism or cerebral palsy, or other systemic medical conditions, such as heart disease or lung conditions, and a “combined” category for patients with both severe dental disabilities and other systemic medical conditions. We conducted a distributional analysis across these categories, examining age distribution, frequency of patients undergoing multiple general anesthesia, anesthesia and treatment durations, average total costs versus actual payments made by patients, and the distribution of treatment modalities.

Dental procedures performed under general anesthesia were stratified into OP 1 comprising restorative treatments for dental caries; OP 2 surgical treatments (such as extraction of supernumerary teeth, removal of odontomas, surgical exposure of impacted teeth, and frenectomy); and OP 3 orthodontic interventions (installation of space maintainers and orthodontic appliances). OP 1 procedures included pulp therapies, prefabricated crown restorations (utilizing stainless steel and zirconia crowns), composite resin fillings, glass ionomer fillings, and routine primary tooth extractions.

Furthermore, an annual analysis of the frequency and nature of treatments, aggregate treatment expenditures, and patient-paid costs was performed to determine temporal trends in dental care delivered under general anesthesia.

Variables were summarized by frequency and percentage for categorical data and mean ± standard deviation for numeric data. Group differences were tested using the chi-squared test or Fisher’s exact for categorical data and the independent t test or Mann-Whitney U test for numeric data as appropriate. To check if its distribution is normal, we used Shapiro-Wilk’s test.

All statistical analyses were carried out using SPSS 29.0 statistical software (IBM Corp., Armonk, NY, USA). We considered p values less than 0.05 as statistically significant.

Results

Tables 1 and 2 show the results of the investigation into the gender and age of patients who received dental treatment under general anesthesia. Among the 1,214 patients, 833 were male (68.6%) and 381 were female (31.4%). The ages ranged from 2.7 to 20.9 years. All instances, including repeated ages, were considered patients who were treated under general anesthesia multiple times. Of the 1,238 general anesthesia procedures, the mean age of patients was 7.2 ± 2.2 years, with the largest age group being 6 ‒ 10 years (67.1%).

Table 1.

Gender distribution of the patients

Table 2.

Age distribution of the patients

The physical classification system of the American Society of Anesthesiologists revealed that the general health status of patients at pretreatment was predominantly ASA Class I, with 938 patients (77.3%), followed by ASA Class II with 238 patients (19.5%) and ASA Class III with 37 patients (3.0%, Table 3).

Table 3.

Preoperative physical status of the patients

The residential distribution of patients who visited for dental treatment under general anesthesia was as follows: Gyeongsangnam-do, 601 patients (49.6%); Busan, 484 patients (39.7%); Ulsan, 114 patients (9.4%); Gyeongsangbuk-do, 12 patients (0.9%); and Daegu, 3 patients (0.3%, Fig. 1).

Fig 1.

Residential distribution of patients who received dental treatment under general anesthesia.

The distribution of patients according to medical status is presented in Table 4. Among the total patient cohort, 793 individuals (64.1%) were nondisabled without medical history. A total of 445 patients had disabilities, comprising 157 (12.6%) with severe dental disabilities only, 218 (17.6%) with other medical conditions only, and 70 (5.7%) with both severe dental disabilities and other medical conditions.

Table 4.

Medical condition of the patients

In Table 5, the dental treatment characteristics under general anesthesia were compared between nondisabled and disabled patients. The mean age of nondisabled and disabled patients was 6.84 (range: 2.9 ‒ 12.1) years and 7.80 (range: 2.7 ‒ 20.9) years.

Table 5.

Comparison of dental treatments under general anesthesia between nondisabled and disabled patients

The number of multiple general anesthesia cases was higher in the disabled group (35 cases) compared to the nondisabled group (10 cases), and this difference was statistically significant (p < 0.0001).

The mean duration of anesthesia and treatment for the disabled group were longer than for the nondisabled group. Moreover, the total treatment cost and actual patient payments tend to be higher for disabled patients (p < 0.0001).

The treatment types varied significantly between the two groups. The frequency of OP 2 was the highest in the nondisabled group, comprising 513 cases (64.7%), followed by OP 1, comprising 152 cases (19.2%). However, in the disabled group, OP 1 was the most frequent, comprising 303 cases (68.1%), followed by OP 2 comprising 74 cases (16.6%). It was statistically significant (p < 0.0001).

The total anesthesia and treatment times during general anesthesia were categorized and analyzed according to the treatment type (Table 6). The average anesthesia and treatment durations for dental treatment under general anesthesia were 124 (range: 30 ‒ 375) min and 96 (range: 10 ‒ 345) min. The anesthesia and treatment durations were longest when OP 1 and 3 were performed concurrently and shortest in OP 2, which involved exclusively surgical procedures.

Table 6.

Duration of anesthesia and treatment according to the treatment type

Specifically, the number of dental treatments performed under general anesthesia and the total healthcare costs were categorized according to the treatment type annually. The distribution analysis of treatment counts revealed that only OP 1 and OP 3 were conducted from 2014 to 2017, whereas OP 2 was introduced in 2018. Since 2020, the proportion of OP 2 increased relatively, subsequently constituting the largest share among the treatment types (Fig. 2). Moreover, in the distribution of total healthcare costs, the proportion of OP 2 significantly increased since 2020; however, OP 1 consistently represented the highest percentage in the overall annual total healthcare costs (Fig. 3).

Fig 2.

Yearly distribution of the number of dental treatments under general anesthesia according to the treatment content. OP 1: restorative treatments for dental caries; OP 2: surgical treatments such as extraction of supernumerary teeth, removal of odontomas, surgical exposure of impacted teeth, and frenectomy; and OP 3: orthodontic interventions such as installation of space maintainers and orthodontic appliances.

Fig 3.

Yearly distribution of total medical costs for dental treatments under general anesthesia according to the treatment content. OP 1: restorative treatments for dental caries; OP 2: surgical treatments such as extraction of supernumerary teeth, removal of odontomas, surgical exposure of impacted teeth, and frenectomy; and OP 3: orthodontic interventions such as installation of space maintainers and orthodontic appliances.

The proportional distribution of each treatment type associated with dental caries management performed under general anesthesia was examined and presented by year (Fig. 4). The percentages of pulp treatment and stainless steel or zirconia crown restorations generally declined over time, whereas the proportion of resin fillings increased.

Fig 4.

Annual changes in the proportion of dental caries treatment types under general anesthesia.

Discussion

This study was conducted to evaluate the characteristics of patients who visited the Department of Pediatric Dentistry at Pusan National University Dental Hospital and received dental treatment under general anesthesia from January 2014 to December 2023, with the aim of analyzing long-term trends over the past decade.

The data analyzed in this study revealed that among the total of 1,214 patients, males constituted 68.6% while females accounted for 31.4%, indicating a relatively higher proportion of males. This finding aligns with that of Lee et al.’s study[4] in 2018 at the same institution, which reported a male-to-female ratio of 60.6% to 39.4%, as well as with previous studies on dental treatments utilizing general anesthesia published both domestically and internationally [14-16].

The age distribution analysis revealed that the mean age was 7.2 ± 2.2 years, with patients aged 6 ‒ 10 years constituting the largest group at 67.1%. In contrast, patients older than 16 years accounted for only 0.7% of the total study population. This finding aligns with the results observed in prior studies [4,17,18].

Annual data reveal a significant increase since 2019 in both the frequency of dental treatments under general anesthesia and associated medical expenses. This rise is attributable to an increase in the number of pediatric dentists at the Pusan National University Dental Hospital’ s Department of Pediatric Dentistry who are specifically trained to provide comprehensive care. Additionally, most patients were from Gyeongsangnam-do, closely followed by Busan. This distribution is likely attributable to the geographical accessibility of the Pusan National University Dental Hospital for these regions. As reported in a 2022 study by Lee et al. [19], this trend may also reflect the disparity in the number of dental clinics and pediatric specialty dental clinics relative to the land area in Gyeongsangnam-do and Busan.

Moreover, since 2020, the proportion of surgical procedures has surpassed that of dental caries treatments, and it continues to represent the largest category. However, dental caries treatments still account for the majority of medical expenses. This could be attributed to the fact that procedures such as the removal of supernumerary teeth or odontomas, which constitute the majority of surgeries, are covered by the national health insurance in Korea, whereas dental caries treatments, such as composite resin fillings or prefabricated crown restorations for primary teeth, are typically performed as out-of-pocket expenses.

Mo et al. [20] reported that the number of pediatric patients aged < 9 receiving pulp treatment has remained stagnant or shown a decreasing trend since 2017, whereas those aged 10 ‒ 14 years have exhibited a continuous decline in the number of such treatments since 2011. Additionally, until 2019, the frequency of restorative treatments, including light-cured composite resin fillings, has shown an increasing trend. In this study, analyzing the changes in specific treatment modalities for dental caries treatment conducted under general anesthesia, it was found that the proportion of pulp treatments and restorations using stainless steel or zirconia crowns has been decreasing over time, whereas the proportion of resin restorations has gradually increased. These findings may support the results of previous studies.

The Ministry of Health and Welfare in South Korea defines “dentally-related individuals with severe disabilities” as those with severe and mild cerebral palsy, severe and mild epilepsy, severe autism spectrum disorder, mental disorders, severe intellectual disabilities, and severe physical disabilities [21]. Individuals with these conditions often find it challenging to maintain regular oral hygiene, and their lack of cooperation during dental treatment makes it difficult for them to seek care. Additionally, family members or caregivers frequently struggle to identify the symptoms exhibited by the patients, resulting in cases in which oral health issues progress to an advanced and severe state [10,22]. In such cases, the use of general anesthesia may be considered to efficiently and safely conduct high-cost, high-risk treatments under constrained conditions [22,23].

A statistically significant difference was observed in the rate of repeat general anesthesia between the nondisabled (1.3%) and disabled (7.9%) groups. This disparity underscores the increased complexity and potentially greater need for multiple treatment sessions in the disabled population [24]. The disabled group also experienced significantly longer anesthesia and treatment durations. Regarding treatment modality, while surgical procedures constituted 64.7% of treatments in the nondisabled group, restorative treatment for caries comprised 68.1% of treatments in the disabled group. This disparity likely reflects differences in oral hygiene practices and access to care. The nondisabled group, presumably exhibiting better oral hygiene, demonstrated a higher prevalence of invasive surgical procedures, such as removal of supernumerary teeth or surgical exposure of impacted teeth. Conversely, the disabled group, facing challenges in maintaining oral hygiene and accessing timely dental care, presented with a significantly higher proportion of restorative treatments for caries [14,25].

Furthermore, the total treatment cost and patient out-of-pocket expenses were higher for individuals with disabilities compared to those without disabilities. This difference might be attributable to the increased complexity of treatments for individuals with disabilities, often requiring additional equipment and personnel. This finding highlights the potential financial barrier to dental care for individuals with disabilities, potentially limiting their access to treatment and exacerbating oral health disparities.

The current criteria for defining severe dental disabilities are designed more for administrative convenience than to address the diverse needs of all individuals with disabilities. Therefore, policy adjustments are urgently needed to establish a comprehensive and effective dental care system catering to the unique requirements of patients with various disabilities. This shift should focus on a patient-centered approach and prioritize reducing high treatment costs, which are a significant barrier for many individuals with disabilities. Addressing these issues is crucial for facilitating access to dental care, mitigating oral health disparities, and developing a more equitable dental care system for all [26].

However, this study has inherent limitations. The retrospective nature of the analysis and the reliance on electronic medical records may limit the finding generalizability. Additionally, the study is confined to a single institution, which may not fully capture regional variations in treatment practices.

Future research should aim to broaden the scope of incorporating multiple institutions and exploring the long-term outcomes of patients who undergo dental treatment under general anesthesia. Such studies would yield more comprehensive data that could inform policy development and help establish best practices in pediatric dentistry.

The use of sedation or general anesthesia for dental treatment aims to deliver high-quality dental care to patients for whom conventional methods are not feasible [27,28]. When patients exhibit negative behavioral responses due to anxiety and fear or tend to make involuntary muscle movements during standard dental treatment, it can cause significant stress to the patient, their guardians, and the dental care providers, potentially adversely affecting future treatment processes [29]. Historically, perceptions of general anesthesia were more negative compared to psychological methods or pharmacological behavioral management techniques. However, the demand, interest, and a shift in perception toward dental treatments under general anesthesia have been increasing [5,30].

General anesthesia can be an effective behavioral management technique, particularly for pediatric and adolescent patients with severe anxiety or fear that hampers their ability to cooperate or for those with disabilities where outpatient treatment is limited [31]. It is also beneficial for the delivery of necessary treatments in a single session, minimizes the stress experienced by the patients in the dental clinic, and provides high-quality care in those requiring extensive treatment [4,32].

Furthermore, preventing dental caries is crucial for maintaining oral health, reducing the need for invasive procedures, and preventing the need for general anesthesia, which can involve additional risks and costs. Early intervention and regular dental check-ups play a crucial role in identifying dental caries at an early stage, thus making less-invasive treatments possible and reducing the need for advanced procedures under general anesthesia.

Conclusion

This study analyzed trends in dental treatments under general anesthesia at the Pusan National University Dental Hospital over the past decade, highlighting an increase in cases and changing perceptions toward this treatment method. Significant findings underscore the importance of continuous monitoring to align healthcare delivery with evolving patient needs, policy improvements, and treatment optimization. Emphasizing the unique needs of patients with disabilities, the study calls for equitable access to dental care. Future research should expand to multiple institutions and explore long-term patient outcomes to inform policy and best practices in pediatric dentistry.

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