General anesthesia in dental treatments: where and how?

Abstract

Background

Patients with physical and/or mental disabilities exhibit higher caries activity and more treatment needs compared with the general population. Thus, the number of patients awaiting dental treatment under general anesthesia (GA) is far from negligible. Factors such as disabilities, presence of comorbidities, underlying medical conditions, and potential drug interactions render these patients a high-risk group for GA. Consequently, meticulous planning is essential when scheduling dental treatment under GA. The objective of the present research was to gather the opinions of anesthesiologists and dentists regarding the prompt treatment of dental patients requiring GA in institutions that offer optimal conditions for patient safety.

Methods

Data were collected using a 28-item questionnaire developed by the researchers based on a literature review and interviews with both dentists and anesthesiologists involved in dental procedures under GA. The survey was administered online via Google Forms.

Results

Nearly all respondents (95.0%) believed that having an in-house operating room would increase their work efficiency and such a facility would meet their expectations. When asked why having an in-house operating room would enhance efficiency, the most common reasons cited were the ability to schedule more surgery days, better communication from working with the same anesthesia team, and the elimination of time lost due to transfers between hospitals. Anesthesiologists stated that the most frequently encountered issues when admitting patients in operating rooms within the faculty of dentistry were the absence of another anesthesiologist in emergencies (46.7%) and difficulty in reaching a consultant physician when needed (20.0%). Furthermore, 79.2% of anesthesiologists expressed that they would not prefer to work in an operating room dedicated solely to dental patients.

Conclusion

As a result, dentists and anesthesiologists, the two most important members of the team performing dental treatments within GA, prefer to perform the procedures within their own institutions. Considering the high number of patients waiting for dental treatment under GA, the establishment of operating rooms within dentistry can make a positive contribution to the health system by eliminating the hesitations of anesthesiologists.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06638-3.

Background

Dentists treat their patients in the dental units of their facilities, and treatments are generally performed under local anesthesia. However, for some patients who are unable to tolerate dental treatment, sedation or general anesthesia (GA) may be required. The most common indications for sedation or GA include mental or psychological disorders that impede patient cooperation, multiple comorbidities, cases of jaw surgery requiring complex and prolonged procedures, pediatric patients, and individuals with autism [1]. Patients with physical and/or mental disabilities exhibit higher caries activity and more treatment needs compared with the general population [2]. Consequently, the number of patients awaiting dental treatment under GA is far from negligible. The management of these patients requires an operating room equipped with the necessary medical technology as well as an anesthesia team that includes an anesthesiologist. Because these infrastructural and staffing requirements cannot be met in all dental treatment settings—or because in institutions where these conditions are fulfilled, dentists do not have sufficient operating room slots—the number of patients awaiting GA is steadily increasing.

According to the American Society of Anesthesiologists (ASA) Closed Claims Project, which comprises standardized summary data on anesthesia malpractice claims collected from 35 professional liability carriers that insure approximately half of the anesthesiologists in the United States, significantly higher rates of postoperative complications have been observed in dental treatments performed under GA compared to outpatient procedures [3]. Studies in the literature have reported that approximately 45% of patients presenting for dental treatment require GA due to autism, intellectual disabilities, or other circumstances in which patient cooperation is unachievable. Factors such as disabilities, presence of comorbidities, underlying medical conditions, and potential drug interactions render these patients a high-risk group for GA. The reported rate of anesthesia-related complications in these patients is 20–30%. Furthermore, considering that most patients receiving dental treatment under GA are either children or individuals unable to fully express themselves, prompt intervention is likely to improve the quality of daily life for both the patients and their families. In light of these considerations, meticulous planning is essential when scheduling dental treatment under GA [4, 5].

Dental procedures conducted under GA require specialized equipment, state-of-the-art facilities, and a team of well-trained professionals to manage potential intraoperative and postoperative complications [3]. In addition to the necessity for dental treatment under GA to be performed by a professional team in fully equipped facilities, healthcare providers’ perceptions of their work environment also influence the quality of care delivered [6]. Moreover, to provide higher quality services and enhance patient satisfaction, it is crucial to ensure that the personnel are content with their working conditions [7]. In this context, studies that assess the demands, needs, and challenges encountered by staff may serve as guidance for healthcare decision-makers in designing effective healthcare services [8]. To the best of our knowledge, there is no study in the literature addressing the perspectives of anesthesiologists and dentists collaborating on the settings and conditions under which dental treatments under GA are provided. This study aimed to fill that gap and contribute to the existing literature.

Based on the aforementioned considerations, the objective of this study was to gather the opinions of anesthesiologists and dentists regarding the prompt treatment of dental patients requiring GA in institutions that offer optimal conditions for patient safety. In addition, the study aimed to identify the challenges encountered by healthcare professionals in their respective institutions, with the goal of determining measures to enhance both patient safety and operational efficiency.

Materials and methods

Study design

This research was designed and implemented as a descriptive cross-sectional study.

Data collection instruments and procedures

Data were collected using a 28-item questionnaire developed by the researchers based on a literature review and interviews with both dentists and anesthesiologists involved in dental procedures under GA (12 items for anesthesiologists and 16 items for dentists). The questionnaire was developed by the authors specifically for this study to assess the experiences and perspectives of anesthesiologists and dentists regarding dental treatments under general anesthesia. It was originally created and administered in Turkish, and an English version was produced solely for publication purposes without undergoing a formal back-translation process.

Content validity was assessed by one anesthesiologist and three dentists, each of whom independently rated the items using a 4-point Likert scale. Each item was evaluated using a four-point Likert scale (1 = not appropriate, 4 = completely appropriate). The Content Validity Index (CVI) was calculated by dividing the number of experts who rated each item as “appropriate” or “completely appropriate” by the total number of raters. Items with a CVI below 0.80 were revised accordingly. Based on their evaluations, the Content Validity Index (CVI) was calculated and found to be acceptable. The questionnaire consisted of independent items designed to capture distinct dimensions of clinical practice and institutional experiences. For this reason, internal consistency testing such as Cronbach’s alpha was not conducted, as the items were not part of a single unified scale. Furthermore, the survey included open-ended questions, for which internal consistency analysis is not applicable.

The survey was administered online via Google Forms. Participants were recruited through snowball sampling, whereby anesthesiologists and dentists forwarded the online survey to their colleagues.

Participants

The study included 120 anesthesiologists and 120 dentists who voluntarily agreed to participate. Each participant could proceed to the remaining questions of the survey only after answering “Yes” to the first question, which asked whether they voluntarily agreed to participate in the study.Inclusion criteria were defined as follows: dentists must be performing dental treatments under GA and anesthesiologists must be administering GA for dental procedures.

Descriptive statistical analyses of the demographic characteristics (age, gender, and professional experience) of the participating dentists and anesthesiologists are presented in Table 1.

Table 1.

Descriptive statistics of the participants

	Dentists (n = 120)	Anesthesiologists (n = 120)
	Mean (SD)	Mean (SD)
Age	33.39 (7.66)	39.56 (8.69)
	f (%)	f (%)
Gender
Female	69 (57.5)	62 (51.7)
Male	51 (42.5)	58 (%48.3)
Professional Experience
1–5 years	48 (40.0)	30 (25.0)
6–10 years	33 (27.5)	30 (25.0)
11–15 years	13 (10.8)	30 (25.0)
≥ 16 years	26 (21.7)	30 (25.0)

Note: SD = Standard deviation

As shown in Table 1, the mean age of the dentists was 33.39 years, while that of the anesthesiologists was 39.56 years. Among the dentists, 69 were female and 51 were male; among the anesthesiologists, 62 were female and 58 were male. Regarding professional experience, majority of the dentists (40%) had 1–5 years of experience, whereas the anesthesiologists’ professional experience was evenly distributed across the four defined categories (25% each).

Ethical considerations

The study was approved by the Necmettin Erbakan University Dentistry Non-Drugs And Medical Devices Research Ethics Committee on November 28, 2024 (KONYA/TURKEY) (2024/507).Participation in the study was voluntary. Participants provided informed consent prior to completing the survey. They were also informed of their right to withdraw from the study at any stage.

Statistical analysis

Data were analyzed using IBM SPSS Statistics 23.0. Descriptive statistics, including frequency, percentage, arithmetic mean, and standard deviation, were used to analyze the data.

Power analysis

In this study, a power analysis was conducted based on a significance level of 5% (α = 0.05), a statistical power of 80% (1-β = 0.80), and a medium effect size (Cohen’s d = 0.5). The required minimum sample size for comparing two groups was calculated as 32 participants per group. Since the study included a total of 240 participants (120 dentists and 120 anesthesiologists), the achieved power was calculated to be above 97%. These results indicate that the sample size was sufficient and that the findings are statistically reliable.

Results

Within the scope of this study, findings regarding operating room location preferences, challenges encountered, and reasons behind these issues for dental patients treated under GA—as reported by the dentists—are presented in Table 2.

Table 2.

Findings on the perspectives of dentists

	f	%
Type of institution receiving cases in need of anesthesia
Faculty of Dentistry	19	15.8
Faculty of Medicine	58	48.3
State hospitals	8	6.7
Oral Dental Health Center (ODHC)	9	7.5
Private hospitals	26	21.7
Perceived adequacy of equipment specific to dentistry in the institution the dentist is receiving the cases
Fully equipped	54	45.0
Partially adequate	56	46.7
Inadequate	10	8.3
Level of communication with the anesthesia team
Very good	39	32.5
Good	48	40.0
Moderate	27	22.5
Inadequate	6	5.0
Most common difficulty experienced with the anesthesia team
Communication problems	33	27.5
Time management	64	53.4
Case planning	13	10.8
Emergency management	10	8.3
Most common problem faced in the operating room
Lack of equipment	16	13.3
Staff shortage	21	17.5
Time management	38	31.7
Communication with the surgical team	13	10.8
Procedural differences	32	26.7
Preference for performing surgeries in their own institution’s operating room
Yes	91	75.9
No	10	8.3
Already operates in their institution	19	15.8
Perceived adequacy of allocated surgery days in external hospitals the dentist is receiving cases
Adequate	50	41.7
Inadequate	70	58.3
Feeling like a part of the team when operating in external hospitals
Yes	37	30.8
No	83	69.2
Discomfort in working with a different anesthesia team each time in external hospitals
No discomfort	30	25.0
Yes, I feel uncomfortable	90	75.0
Perceived impact of having an in-house operating room on work efficiency
Increases efficiency	114	95.0
No effect	6	5.0
Expectation that an in-house operating room would meet their needs
Meets expectations	114	95.0
No effect	6	5.0

Note: f = Frequency

As seen in Table 2, majority of the participating dentists performed surgical dental procedures in medical faculty hospitals (48.3%), followed by private hospitals (21.7%). Regarding the adequacy of dental equipment at their institution, 45% rated it as fully equipped, whereas 46.7% found it partially adequate. Only 5% of dentists rated their communication with the anesthesia team as inadequate. The most common difficulties encountered with the anesthesia team were time management (53.4%) and communication (27.5%). The most common problems encountered by dentists in operating rooms were time management (31.7%) and procedural differences (26.7%). Majority of the dentists stated that they would prefer to perform surgeries in their own institution (75.9%) and found the number of surgery days allocated to them in external hospitals insufficient (58.3%). Majority of the dentists (69.2%) did not feel like a part of the team when working in external hospitals, and 75% of the dentists expressed discomfort in working with a different anesthesia team each time. Nearly all dentists (95.0%) believed that having an in-house operating room would increase their work efficiency and such a facility would meet their expectations. When asked why having an in-house operating room would enhance efficiency, the most common reasons cited were the ability to schedule more surgery days, better communication from working with the same anesthesia team, and the elimination of time lost due to transfers between hospitals (Fig. 1).

Fig. 1.

Reasons for dentists’ preference to operate in their own institutions

As part of the objective of the present study, the findings regarding anesthesiologists’ preferences for the location of operating rooms for dental patients treated under GA and the reasons for these preferences are presented in Table 3.

Table 3.

Findings on the perspectives of anesthesiologists

	f	%
Location where dental treatment cases are operated
At the hospital where I work	85	70.8
Outside the organization where I work	35	29.2
Opinion on which institution’s operating room should be used for dental cases
Faculties of dentistry	11	9.2
Fully equipped hospitals (Medical Faculty/State Hospitals/Private Hospitals)	105	87.5
ODHC	4	3.3
The age group most frequently anesthetized for dental treatment
0–3	7	5.8
4–10	94	78.4
11–17	7	5.8
≥ 18	12	10.0
Most common problem encountered in patients undergoing dental treatment
Difficult airway	35	29.2
Complications related to nasal intubation (bleeding, etc.)	38	31.7
Problems due to comorbidities (seizures, arrhythmia, etc.)	20	16.6
Problems occurring in the recovery room (bleeding, agitation, etc.)	27	22.5
Feeling of professional comfort when receiving cases in operating rooms established in dental faculties
Feels comfortable	14	11.7
Does not feel comfortable	106	88.3
Most common issue encountered when admitting patients in operating rooms within the faculty of dentistry
Absence of another anesthesiologist in case of emergency	56	46.7
Lack of equipment	17	14.1
Difficulty in reaching a consultant physician when needed	24	20.0
Lack of an intensive care unit	23	19.2
Preference for working in an operating room dedicated solely to dental patients
Would like to work	25	20.8
Would not like to work	95	79.2

Note: f = Frequency

As shown in Table 2, it is observed that 70.8% of the participating anesthesiologists operated on surgical dental cases at the hospital where they work, while 29.2% performed surgeries outside their institution. Majority of the participating anesthesiologists (87.5%) stated that dental cases should be operated on in fully equipped hospitals. Anesthesiologists reported that the most frequently anesthetized age group for dental treatment was 4–10 years (78.4%) and that the most common issues encountered in dental treatments were complications related to nasal intubation (bleeding, etc.) (31.7%) and difficult airway (29.2%). Regarding their professional comfort in operating rooms established in dental faculties, majority of the participating anesthesiologists (88.3%) reported that they did not feel comfortable. Anesthesiologists stated that the most frequently encountered issues when admitting patients in operating rooms within the faculty of dentistry were the absence of another anesthesiologist in emergencies (46.7%) and difficulty in reaching a consultant physician when needed (20.0%). Furthermore, 79.2% of anesthesiologists expressed that they would not prefer to work in an operating room dedicated solely to dental patients. An open-ended question was posed to the anesthesiologists who stated that they would not prefer to work in such an operating room, asking for their reasons. Their responses included the absence of another physician when needed, concern that working with a single type of case would lead to professional stagnation, and risk associated with being the sole anesthesiologist.

Discussion

GA administration in dental treatments requires careful management due to the high prevalence of various genetic syndromes, chronic diseases, and mental retardation among these patients. Anesthesia management strategies should be meticulously planned according to patient-specific needs, and the procedure should be conducted in a fully equipped operating room by experienced professionals [9]. A study investigating mortality associated with dental treatments under anesthesia reported that > 50% of deaths occurred in children aged 2–5 years, often following moderate sedation administered by dentists [10]. Another study analyzing cases of sedation and GA in dental clinics between 1996 and 2015 documented three deaths and one severe complication [11]. These findings highlight the critical importance of anesthesia management and a fully equipped surgical environment for dental procedures requiring GA [9]. Consistent with previous research, anesthesiologists and dentists participating in the present study also reported that due to the presence of comorbidities and the age range of these patients prompting extra care and attention, they preferred to perform these procedures primarily in well-equipped medical faculty hospitals.

In dental treatments performed under GA, effective teamwork is key to delivering optimal dental care [7]. Among the dentists participating in the present study, 69.2% reported that when treating patients outside their institutions, they did not feel like a part of the team, and 75% expressed discomfort working with a different anesthesia team each time. However, team coordination is crucial for risk prevention and ensuring high-quality patient care [12]. Furthermore, 95% of the participating dentists stated that performing procedures in their own institution’s operating rooms would improve both their workflow efficiency and professional satisfaction. Considering the high number of patients awaiting dental treatment under GA, providing dentists with access to an operating room within their own institutions may enhance both efficiency and workplace satisfaction.

A retrospective study analyzing 3,661 patient records reported that majority of the patients requiring GA for dental treatment were between the ages of 3 and 6 years [13]. In line with previous studies, the anesthesiologists participating in the present study reported that 78.3% of the patients receiving GA for dental treatment in an operating room setting were children aged 4–10 years.

When asked about the safest institutional settings for performing dental treatments under GA, 87.5% of participating anesthesiologists indicated that procedures should be conducted in fully equipped hospitals. Additionally, 88.3% of anesthesiologists reported feeling professionally unsafe when managing cases in operating rooms within dental faculties. When asked why they preferred not to administer anesthesia in dental faculty operating rooms, 40% cited the absence of another anesthesiologist to assist in emergencies, 16.7% pointed to the lack of other relevant medical specialists when needed, and 15.8% expressed concern about the absence of an active intensive care unit. These concerns align with findings from previous studies. A retrospective study analyzing the records of 1,536 pediatric patients aged 1–14 years undergoing dental treatment reported that among 407 patients with systemic diseases or disabilities, 27 required postoperative intensive care, with an average stay of 1.22 days [14]. As patients requiring GA for dental treatment often have comorbid conditions or special needs, they should undergo thorough preoperative evaluation and comprehensive consultations. Procedures should be conducted in fully equipped, technologically advanced operating rooms, and patients should be followed up by experienced teams [15].

There is a risk of encountering significant complications in dental treatments performed under deep sedation and GA. These complications may include life-threatening anaphylaxis, cardiac issues, and airway problems [16]. The anesthesiologists participating in the present study reported that the most frequently encountered complications in patients undergoing dental treatment under GA were nasal intubation-related bleeding (31.7%), difficult airway (29.2%), and agitation-related recovery room complications (22.5%). The findings regarding complications observed in dental treatments under GA are consistent with the existing literature but diverge in specific aspects. Wang et al. conducted a study on 200 patients treated under GA and identified epistaxis as the most common complication. Additionally, postoperative complications, such as desaturation, postoperative nausea and vomiting, hypothermia, and agitation, were also observed [17]. In a study by Demir et al., the most frequently reported postoperative complications following dental treatments under GA were sore throat (52.05%), nausea (50.68%), and oral bleeding (41.09%) [18]. In another study evaluating cases undergoing dental treatment under GA, Akpınar reported that bradycardia was the most frequently observed postoperative complication, while difficult intubation was the rarest [19].

Among the 120 anesthesiologists participating in the present study, 79.2% stated that they did not wish to work in operating rooms dedicated exclusively to dental procedures. When asked about their reasons in an open-ended question, they cited the absence of other medical specialists when needed, challenges of being the sole anesthesiologist, and lack of case variety. Moreover, the risk profile of patients undergoing dental treatment under GA was also noted as a factor influencing their decision not to work in such institutions.

The present findings can be interpreted through the lens of systems-level healthcare delivery models, particularly those that emphasise integrated care and cross-institutional coordination. Integrated care frameworks posit that colocating complementary services (e.g., dentistry and anaesthesiology) within a single organisational entity reduces fragmentation, improves communication, and shortens patient pathways, thereby enhancing overall efficiency and safety [20, 21]. Similarly, theories of networked or hub-and-spoke hospital design suggest that decentralising low-risk procedures to satellite units—while retaining rapid access to high-acuity resources—optimises resource utilisation and staff satisfaction [22]. Our data show that dentists overwhelmingly prefer in-house operating theatres, citing time efficiency, stable equipment access, and improved team communication. These preferences align with the core principles of integrated-care and hub-and-spoke models, supporting the notion that establishing operating rooms within dental faculties is not merely a logistical convenience but a systems-level solution that can streamline care pathways, reduce inter-institutional transfers, and ultimately improve patient outcomes.

Limitation

The present study highlights critical considerations regarding the institutional setting for performing dental treatments under anesthesia; however, it has certain limitations. The main limitation is that the sample consisted only of anesthesiologists and dentists who were reached online via Google Forms, while other potential participants were not included in the study. Since participants were recruited through a snowball sampling approach, the sample may not fully represent the broader population of anesthesiologists and dentists involved in dental procedures under general anesthesia. Therefore, the findings should be interpreted with caution and may not be generalizable to all clinical settings. Additionally As the English version of the questionnaire was prepared post hoc for publication without undergoing a back-translation process, this may limit the ability of international researchers to replicate or adapt the instrument reliably in future studies.

Conclusions and recommendations

In conclusion, the two most essential members of the team performing dental treatments under GA—dentists and anesthesiologists—prefer to conduct procedures within their own institutions. However, patients requiring dental treatment under GA are still predominantly treated in hospitals outside dental faculties, such as university, state, or private hospitals. Although dentists reported maintaining good communication with anesthesia teams when working outside their own institutions, they also expressed discomfort and a lack of sufficient surgical time allocation. Considering the high number of patients awaiting dental treatment under GA, the establishment of operating rooms within dental faculties could contribute positively to the healthcare system. However, this study also revealed that majority of the anesthesiologists do not want to work in operating rooms dedicated solely to dental cases due to various concerns. If operating rooms are to be established in dental faculties, measures should be taken to address these concerns to alleviate the hesitations of anesthesiologists.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

TÇ: Writing review & editing, Writing original draft, Visualization, Methodology, Investigation, Data curation, Conceptualization.ŞNM: Writing review & editing, Supervision.AÖS: Visualization, Editing, Supervision.YDF: Editing, Supervision.

Funding

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets analyzed in our study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Necmettin Erbakan University Dentistry Non-Drugs And Medical Devices Research Ethics Committee on November 28, 2024 (KONYA/TURKEY) (2024/507). I declare and undertake that I have read the current versions of the Declaration of Helsinki and the Good Clinical Practice Guide and the Good Laboratory Practice Guide, that the study was conducted in accordance with the Declaration of Helsinki, and that all units and personnel participating in the study have been informed about the study. Informed consent to participate was obtained from all participants. Each participant could proceed to the remaining questions of the survey only after answering “Yes” to the first question, which asked whether they voluntarily agreed to participate in the study.

Consent for publication

Not applicable.

Informed consent

Ethics committee approval and informed consent have been obtained. Documents have been uploaded.

Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.