Characterizing General Anesthesia Use in Dental Procedures for Patients with Behavioral Conditions: A Preliminary Phenotype

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I. Background

In the United States, more than 107 million adults and 36 million children received dental services in 2021, representing a total dental expenditure of $127 billion [1]. In the same year, 22.8% of adults and 27.7% of children had a diagnosed mental, behavioral, or developmental disorder [2-3]. Dental care under general anesthesia (GA) is often necessary for individuals who are unable to tolerate routine dental procedures due to severe dental disease, complex medical comorbidities, or behavioral and developmental challenges [4]. Studies consistently show that patients with conditions such as autism spectrum disorder (ASD), intellectual disability, epilepsy, and developmental delay are at significantly increased risk of receiving dental care under GA in hospital-based settings [5-6]. Barriers such as uncooperative behavior, cognitive limitations, and anxiety complicate in-office dental management and necessitate deeper sedation or full anesthesia [7-8]. In many cases, GA becomes the only viable method to deliver comprehensive oral care, especially in hospital settings. Despite its clinical necessity, the use of GA is associated with access issues, including cost, provider availability, and institutional capacity, creating disparities for those most in need [9-10].

The literature shows that GA is commonly used in dentistry to treat extensive caries or dental trauma [6,11]; patients with cognitive or behavioral impairments, including ASD, epilepsy, and genetic syndromes [12,13]; and very young children who are unable to tolerate procedures in conventional settings [14,15]. GA use ranges from 6–20% in pediatric dental patients in hospital settings depending on clinical presentation and access to care [7,9]. Common procedures performed under GA include multiple extractions, restorations, and comprehensive oral rehabilitation [7, 11]. Despite generally favorable clinical outcomes and high parental satisfaction, significant challenges, including the availability of anesthesia-trained dental providers, high costs, and institutional limitations, persist within the public health systems [6, 9,16].

There is currently no published OHDSI phenotype that identifies patients receiving dental procedures under GA, particularly those with neurodevelopmental or behavioral conditions. This lack of a standardized phenotype limits the ability to conduct robust, multicenter observational studies that explore utilization patterns, comorbidities, and treatment outcomes in this population. Moreover, GA is documented using procedure and drug codes in varying ways across systems. CPT codes alone often fail to distinguish whether a procedure was performed by a general dentist, oral surgeon, or another specialist. Many standard GA drugs (e.g., propofol) are also used in non-dental surgical contexts, complicating efforts to isolate relevant exposure events without a clear framework. Developing a standardized OHDSI phenotype for dental GA use can bridge these gaps and facilitate real-world evidence generation across EHR and claims databases.

II. Research Purpose

The purpose of this work is to develop a standardized phenotype to identify patients receiving dental procedures under GA in hospital settings, with a focus on those who have behavioral, neurodevelopmental, or neurological conditions.

This phenotype is designed to:

  • · Enable consistent identification of this patient population across OMOP-standardized EHR and claims databases.
  • · Support characterization studies describing demographics, comorbidities, and treatment patterns.
  • · Facilitate comparisons across institutions and geographic regions to evaluate utilization trends and potential disparities in access to dental GA care.
  • · Provide a foundation for future analytic use cases, including population-level estimation and patient-level prediction, once validated in multiple datasets.

By establishing a reproducible and clinically meaningful cohort definition, this phenotype aims to support research on hospital-based dental GA use, inform evidence-based policy discussions, and improve care delivery for populations that require anesthesia-assisted dental treatment.

III. Characterization Use Case

This work is currently aligned with OHDSI’s characterization analytic use case.

The aim is to describe patients receiving dental care in hospital settings, with or without general anesthesia, focusing on those with behavioral, neurodevelopmental, or neurological conditions. The characterization includes:

  • · Demographics: age, gender, index year.
  • · Conditions: neurodevelopmental, neurological, behavioral, and other comorbidities.
  • · Drug exposures: general anesthetics, supplementary medications, and supportive therapies such as antiemetics.

The goal at this stage is to profile and understand the composition of this population, examining utilization trends, prevalence of relevant diagnoses, and co-occurring health conditions.

Starting with characterization ensures that the logic and scope of the phenotype are well-understood and clinically meaningful before applying it to population-level estimation or patient-level prediction.

IV. Phenotype Definition

This phenotype identifies patients who received dental procedures performed by general dentists in a hospital setting, as defined by a curated list of CPT procedure codes validated by clinical experts. It is designed to support the study of dental care in individuals with behavioral, neurodevelopmental, or neurological conditions, including the subset who undergo procedures with general anesthesia.

The phenotype can be applied to OMOP-standardized electronic health record or claims data to:

  • Capture a clinically relevant population for dental and anesthesia research.
  • Enable descriptive characterization of demographics, comorbidities, drug exposures, and procedure types.
  • Facilitate cross-database comparison and reproducibility through standardized code sets.

V. Logic Description

The phenotype is implemented as two separate but linked JSON cohort definitions, both of which are shared in this post.

Cohort Definition – The main cohort captures patients who received dental procedures performed by general dentists in a hospital setting. Inclusion is based on the curated list of CPT procedure codes validated by Johns Hopkins dentists. The cohort definition does not require general anesthesia (GA) for inclusion, allowing for capture of both GA and non-GA dental procedures.

Cohort Characterization – Once the main cohort is generated, the characterization step describes the population by:

  1. Demographics: age, gender, index year.
  2. Clinical characteristics: dental-related, behavioral, neurodevelopmental, neurological, and other comorbid conditions.
  3. Drug exposures: general anesthetics, medications used during or after anesthesia, and supportive medications.

The figure below illustrates this workflow, showing how the cohort definition feeds into the characterization to produce descriptive statistics that can be compared across databases.

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By structuring the logic this way, the phenotype allows researchers to first define a precise, validated dental care population and then characterize it in depth, capturing GA utilization, comorbidity patterns, and demographic trends.

VI. Limitations

This phenotype has several limitations that may affect precision and generalizability. First, the absence of CDT codes in the OMOP vocabulary limits the ability to capture many outpatient dental procedures, particularly those performed in non-hospital settings. Coding practices in dental EHRs also present challenges, as billing codes may not fully reflect the detailed clinical documentation found in notes, leading to potential misclassification. In addition, CPT codes do not specify provider type, creating the possibility of including procedures performed by specialists rather than general dentists, and some relevant CPT codes—such as 41899 (“unlisted procedure, dentoalveolar structures”)—are too broad to provide meaningful clinical detail. Conditions of interest, including behavioral, neurodevelopmental, and neurological diagnoses, may be miscoded, or unrelated to the need for general anesthesia, which could bias interpretation. Drug exposure data are not definitive indicators of GA use, as some medications recorded may have been administered for moderate sedation rather than full general anesthesia. Finally, pediatric validation is limited because current clinical reviewers do not treat children, reducing the ability to fully assess accuracy for that subgroup.

VII. Next Steps

The next stage of this work is to validate and refine the phenotype through broader testing in the OHDSI network.

Two JSON files, the cohort definition and cohort characterization, are attached to this post for community use. Researchers are encouraged to run these on their OMOP-standardized databases and share:

  • Summary results (demographics, conditions, drug exposures)
  • Feedback on logic, code lists, or potential refinements
  • Observations about data availability and coding variations in their systems

Planned next steps include running Cohort Diagnostics, exploring PheValuator for internal validation, and incorporating community feedback to prepare the phenotype for potential submission to the OHDSI Phenotype Library.

Community participation will be essential to improving specificity, ensuring reproducibility, and expanding applicability across care settings and patient populations.

VIII. References

  1. Agency for Healthcare Research and Quality. Dental Utilization and Expenditures, U.S. Civilian Noninstitutionalized Population Aged 2 and Older, 2019-2021. Medical Expenditure Panel Survey (MEPS) Statistical Brief #555. Published February 2024. Dental Utilization and Expenditures, U.S. Civilian Noninstitutionalized Population Aged 2 and Older, 2019-2021

  2. Stransky ML, Becerra-Culqui TA, Danielson ML, Cottengim C, Kogan MD, Schieve LA. Trends in Diagnosed Mental, Behavioral, and Developmental Disorders Among US Children Aged 3–17 Years, 2016–2021. Prev Chronic Dis. 2024;21:E38. doi:10.5888/pcd21.240142. Accessed July 30, 2025. Trends in Mental, Behavioral, and Developmental Disorders Among Children and Adolescents in the US, 2016–2021

  3. Substance Abuse and Mental Health Services Administration. 2021 National Survey on Drug Use and Health (NSDUH) Release. Published January 4, 2023. Accessed July 30, 2025. 2021 NSDUH Annual National Report | CBHSQ Data

  4. Ghezzi EM, Chávez EM, Ship JA. General anesthesia protocol for the dental patient: emphasis for older adults. Spec Care Dentist. 2008;28(5):152-158. https://doi.org/10.1111/j.1754-4505.2000.tb00011.x

  5. Britt M, Piña F, Kim A, Goldsmith D, Shariff J. Third Molar Extractions in Patients With Developmental Disabilities. Oral Surg Oral Med Oral Pathol Oral Radiol . 2024;137(1):e57-e58. Redirecting

  6. Delfiner A, Myers A, Lumsden C, Chussid S, Yoon R. Characteristics and Associated Comorbidities of Pediatric Dental Patients Treated under General Anesthesia. J Clin Pediatr Dent. 2017;41(6):482-485. https://doi.org/10.17796/1053-4628-41.6.12

  7. Ă–zkan A, Ozkan N, Cildir S, Sandalli N. Retrospective Evaluation of Dental Treatment Performed under General Anaesthesia. Turk J Anaesthesiol Reanim . 2015;43(5):332-336. https://doi.org/10.5152/tjar.2015.82542

  8. Kuroda I, Fujita A, Okumura Y, et al. Intravenous Sedation in a Patient With Sotos Syndrome and Intellectual Disability: A Case Report. Cureus . 2024;16(12):e76555. Intravenous Sedation in a Patient With Sotos Syndrome and Intellectual Disability: A Case Report | Cureus

  9. Marinho MA, Ramos FCT, Cardoso AL, Silva-Junior GO, Faria MDB, Bastos LF, Dziedzic A, Picciani BLS. Dental Treatment under General Anesthesia in Patients with Special Needs Provided by Private and Public Healthcare Services—A Retrospective, Comparative Study. Healthcare. 2022; 10(6):1147. https://doi.org/10.3390/healthcare10061147

  10. Maes, M.S., Kanzow, P., Biermann, J. et al. Risk factors for repeated general anesthesia for dental treatment of adult patients with intellectual and/or physical disabilities. Clin Oral Invest 26, 1695–1700 (2022). Risk factors for repeated general anesthesia for dental treatment of adult patients with intellectual and/or physical disabilities | Clinical Oral Investigations

  11. Vermeulen M, Vinckier F, Vandenbroucke J. Dental General Anaesthesia: Clinical Characteristics of 933 Patients. ASDC J Dent Child . 1991;58(1):27-30.

  12. Acs G, Pretzer S, Foley M. Perceived Outcomes and Parental Satisfaction Following Dental Rehabilitation under General Anesthesia. Pediatr Dent . 2001;23(5):419-423.

  13. Gao F, Wu Y. Procedural sedation in pediatric dentistry: a narrative review. Front Med (Lausanne). 2023;10:1186823. Published 2023 Apr 26. Frontiers | Procedural sedation in pediatric dentistry: a narrative review

  14. Sheller B, Williams BJ, Hays K. Reasons for Repeat Dental Treatment under General Anesthesia for the Healthy Child. Pediatr Dent . 1997;19(5):386-390.

  15. Majewski RF, Snyder CW, Bernat JE. Dental emergencies presenting to a children’s hospital. ASDC J Dent Child. 1988;55(5):339-342.

  16. Špiljak B, Brailo V, Janković B, et al. Satisfaction of Parents and Caregivers with Dental Treatment of Children Under General Anesthesia in a Day Care Surgery Setting. Acta Stomatol Croat. 2022;56(4):376-386. https://doi.org/10.15644/asc56/4/4

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