Global trends in pediatric dental general anesthesia services: a bibliometric analysis of the most influential literature

2.1 Sources/databases and search strategy

For the bibliometric analysis, the Scopus (https://www.scopus.com) and Web of Science Core Collection (WoS-CC, http://www.webofknowledge.com) databases were utilized. Keywords were generated by combining frequently used free-text terms and Medical Subject Headings (MeSH) related to pediatric DGA.

The search strategy included the following terms: (“dentistry” OR “dental” OR “teeth” OR “tooth”) AND (“general anesthesia” OR “general anaesthesia” OR “hospital admission”) AND (“child” OR “childhood” OR “children” OR “pediatric” OR “paediatric”). The selection was limited to documents categorized as “research articles” or “case report/series”.

The search encompassed literature from database inception up to 22 May 2025. The search was restricted to English-language publications. A total of 1655 articles were found in the WoS database, and 3009 in Scopus. To manage duplicate records, datasets from both databases were merged, and duplicate removal was performed computationally using RStudio.

2.2 Eligibility criteria and study selection

Following deduplication, a rigorous manual screening of titles, abstracts, and full texts was conducted independently by two researchers. Discrepancies were resolved through discussion and consensus.

The inclusion criteria were as follows:

(1) Original research articles or case reports/series;

(2) Studies explicitly focused on comprehensive dental treatment or dental rehabilitation under general anesthesia;

(3) Pediatric populations (defined as individuals aged 0 to 18 years, including healthy children or those with special healthcare needs);

(4) Studies investigating DGA-specific outcomes (e.g., post-operative morbidity, OHRQoL, repeat DGA rates, or restorative outcomes under DGA).

While some bibliometric assessments exclude case reports to reduce heterogeneity, case reports and case series were included in the present analysis; as they provide important early evidence for identifying rare but serious adverse events and contribute to clinical knowledge in anesthetic practice [18].

The exclusion criteria were:

(1) Studies focusing primarily on adult populations (>18 years);

(2) Studies limited to sedation, premedication or nitrous oxide inhalation without general anesthesia;

(3) General anesthesia studies without a dental context;

(4) Broad pediatric dentistry topics where DGA was not the primary focus;

(5) Educational or administrative surveys unrelated to clinical outcomes.

2.3 Data extraction and bibliometric analysis

After applying the eligibility criteria, the remaining articles were ranked in descending order based on total citation counts in the Scopus database, and the top 100 most-cited articles were selected for analysis.

The final dataset comprising the 100 most-cited articles is presented in Supplementary Table 1 and was used for subsequent analyses. To provide a concise overview, the top 10 most-cited articles are highlighted in Table 1. While citation counts from both Scopus and WoS-CC are reported for comprehensiveness, all subsequent bibliometric mapping and quantitative network analyses were conducted exclusively using Scopus data due to its broader historical coverage of key pediatric journals. For each article, the following variables were extracted: citation count, publication title, year, journal name and impact factor, authorship details, country, institution, study type and research domain.

The primary outcome of this study was the citation count of each publication, used as an indicator of scientific influence. In cases where articles had equal citation counts, more recent publications were prioritized. If multiple authors were affiliated with the same institution, that institution received a single count. Likewise, when authors reported affiliations in more than one country, each country was counted once per article. To identify the study area, full-text articles were reviewed, and relevant concepts were extracted based on MeSH terms from PubMed. Analysis and visualizations were performed using the “biblioshiny” web interface of the “bibliometrix” package in RStudio 4.4.2. To assess relationships between citation counts, publication years, and journal impact factors, Spearman’s rank correlation coefficient was applied due to the non-normal distribution of bibliometric data. A p-value < 0.05 was considered statistically significant.

3.1 Citation analysis and journal distribution

The complete list of the top 100 most-cited articles, ranked by their citation counts, is presented in Supplementary Table 1. To provide a concise overview, the top 10 most-cited articles from this dataset are detailed in Table 1. The 100 most-cited articles were published between 1972 and 2020, as illustrated in Fig. 1. Eighty-three articles were published between 2000 and 2020, with 2014 having the highest number of top-cited articles (n = 11), followed by 2000 (n = 8), and 2011 (n = 6). The oldest article, authored by Leagault et al. [19], was published in the Journal of the Canadian Dental Association in 1972. The most recent article was written by Wang et al. [20] published in Biomed Research International, in 2020. The average number of citations per article was 56.66. The most-cited article, published in 2000 by Almeida et al. [21] in Pediatric Dentistry, had 174 citations and assessed the susceptibility of children to the future development of caries following comprehensive treatment for early childhood caries under DGA. The least-cited article received 31 citations. A total of 100 most-cited articles were published across 37 different journals, all in English. Among these journals, 20 published only one top-cited article, while eight published two. The remaining nine journals, each publishing at least three top-cited articles, are presented in Table 2. Pediatric Dentistry had the highest number of top-cited articles (n = 16), followed by the International Journal of Paediatric Dentistry (n = 13) and Pediatric Anesthesia (n = 9).

Fig. 1.Annual distribution of the 100 most cited articles on dental general anesthesia in children. This figure was generated using the “biblioshiny” web interface of the “bibliometrix” package in RStudio 4.4.2.

To evaluate relationships between citation counts and publication characteristics, Spearman’s rank correlation coefficient was used. A statistically significant negative correlation was observed between citation counts and publication year (rs = −0.250, p = 0.014). No significant correlation was found between citation counts and journal impact factor (rs = −0.034, p = 0.741), nor between the publication year and impact factor (rs = 0.149, p = 0.148).

3.2 Author, institution, and geographical contributions

A total of 324 authors contributed to the 100 most-cited articles, including two single-authored publications. Regardless of their authorship position, the most frequently cited authors were Thomson WM, followed by Weinstein P, Amin MS and Hosey MT. Examples of their highly cited collaborative works include the studies by Anderson et al. [22], Berkowitz et al. [23], Amin et al. [24] and Hosey et al. [25]. The contributing countries were determined based on the affiliations of all authors. Overall, the articles originated from 20 different countries. The United States contributed the highest number of publications (n = 26) and total citations (n = 1141), followed by the United Kingdom and Canada. Authors and countries contributing at least three top-cited articles are presented in Table 3. The most productive institutions, each with at least four publications, are listed in Table 4. The University of Washington had the highest number of contributions, followed by the University of Glasgow and Toronto.

3.3 Keyword evolution and thematic analysis

A total of 149 different keywords were identified across the included publications. The most frequently occurring keywords were “general anesthesia” (n = 11), “early childhood caries” (n = 8), “children” (n = 7), “anesthesia” (n = 6), “child” (n = 6), “quality of life” (n = 5) (Fig. 2).

Fig. 2.Keyword co-occurrence network of the top 100 most-cited articles on pediatric dental general anesthesia, visualizing the most frequently used author keywords. The network was generated using the “biblioshiny” web interface of the “bibliometrix” package in RStudio 4.4.2.

Thematic analysis is presented in Fig. 3. The keyword groups “quality of life”, “follow up”, “pain”, “premedication” and “caries recurrence”, were identified as prominent and actively studied topics. “Dental care for children”, “general anesthesia”, “dental caries” are situated in the lower development features but higher relevance, suggesting they are fundamental and well-established topics with high importance. However, although there are publications on the subjects of “emergence delirium”, “emergence agitation”, it is noteworthy that they are less studied subjects than other subjects.

Fig. 3.Thematic map illustrating the development and relevance of key research topics within the top 100 most-cited articles on pediatric dental general anesthesia. The map was generated using the “biblioshiny” web interface of the “bibliometrix” package in RStudio 4.4.2.

4.1 Methodological trends and publication patterns

The inclusion of a study among the most-cited articles highlights its academic and clinical significance. This bibliometric analysis illustrates the evolution of research themes in DGA, with a focus on clinical outcomes, behavioral management strategies, and public health concerns. Regarding study design, most publications relied on observational approaches, whereas studies investigating premedication strategies more frequently employed randomized controlled trial (RCT) designs.

A statistically significant negative correlation observed between publication year, and citation counts reflects a well-known phenomenon, time-dependent citation bias. This phenomenon occurs because older publications inherently accumulate higher citation frequencies due to their extended duration of exposure within the scientific literature. Therefore, citation frequency should be viewed as an indicator of historical scholarly impact rather than a direct measure of current clinical superiority.

Most of the highly cited articles (n = 83) were published between 2000 and 2020, indicating a notable rise in scholarly interest in DGA. This trend is not merely a byproduct of time but likely reflects the growing clinical reliance on DGA in response to increasing treatment needs among children. Supporting this, previous studies have reported substantial increases in pediatric DGA. For instance, Broomhead et al. [26] reported a 24% rise in hospital-based tooth extractions among young children in England, attributed to limited access to dental care. Similarly, in Australia, DGA has become one of the most common reasons for preventable hospitalization in children [27].

Articles with over 100 citations are generally regarded as highly influential in shaping both research directions and clinical practices. The most cited article by Almeida et al. [21] in 2000, focused on long term caries susceptibility following DGA, whereas the second article by Lee et al. [28] in 2013, emphasized mortality risks associated with pediatric dental sedation and DGA. Together, these studies highlight a dual focus in the literature: clinical effectiveness of DGA, and patient safety.

Another noteworthy finding was the substantial scientific influence of case-based studies. Although big-data bibliometric analyses often favor large-scale observational studies or RCTs, our results demonstrate that well-documented case series can have a lasting impact on the field, particularly in relation to patient safety. For instance, the closed-claim analysis on anesthetic morbidity and mortality, ranked as the 22nd most-cited article in the dataset [29]. In areas such as anesthesia safety, where randomized trials are ethically difficult to conduct, case reports and case series provide essential early evidence guiding clinical awareness and safety protocols [18].

4.2 Geographical patterns and institutional dominance

The United States produced the highest number of top-cited articles, followed by the United Kingdom. However, relative to population size, the UK’s contribution appears comparatively greater. This may be partly explained by structural differences in healthcare system. The centralized nature of the UK’s National Health Service (NHS) facilitates systematic data collection and supports population-level dental public health strategies. In contrast, the US healthcare system is more fragmented, with research often driven by academic centers or regional clinical demands. Overall, these findings suggest how national healthcare policies and funding structures influence research priorities [30].

4.3 Clinical themes and research clusters

The thematic mapping analysis identified “caries recurrence”, “premedication”, “pain” and “quality of life” as prominent research clusters within the DGA literature. Among these, several studies have addressed the long-term sustainability of DGA outcomes, particularly the recurrence of ECC [31, 32, 33]. Notably, Almeida et al. [21] reported that 79% of ECC patients required additional restorative treatment, and 17% underwent repeat DGA within two years. Studies focusing on postoperative care remain relatively limited; however, available evidence suggests that factors such as parental oral hygiene compliance and adjunctive measures, including povidone-iodine application, may influence long-term outcome [34, 35].

There is a growing emphasis on patient-centered outcomes, particularly OHRQoL following treatment under DGA [22]. Beyond clinical success, DGA research increasingly explores the broader psychosocial impact on families, including parental satisfaction and decision-making processes [36, 37].

In addition, safety related clusters such as “emergence delirium”, “emergence agitation”, and “anesthesia complications” underscore a dual narrative in the field: maximizing restorative benefits while rigorously mitigating perioperative risks [28, 38]. Premedication strategies also remain a major research focus, with numerous randomized trials evaluating agents like midazolam, dexmedetomidine, and ketamine to optimize anxiety control and induction quality [39]. Additionally, the literature addresses broader public health concerns, including cost-effectiveness, service accessibility, and inequalities in care for underserved populations or children with special health care needs [40, 41].

4.4 Strengths and limitations

This study has several strengths. First, it employs a systematic and transparent methodology with clearly defined inclusion and exclusion criteria. Second, the combined use of the WoS-CC and Scopus databases allowed broader coverage of the literature and reduced the risk of omitting influential publications.

However, certain limitations should be considered. The searches were limited to English-language publications. In addition, citation counts differ significantly between databases. For example, although WoS-CC provides long-standing historical coverage, some influential journals such as Pediatric Dentistry were indexed only after 2004. Consequently, highly cited articles such as Almeida et al. [21], are absent from the WoS database. Although Scopus data were used for our primary mapping, database variations remain a methodological limitation of bibliometric studies. Finally, citation frequency primarily reflects scholarly attention rather than the methodological quality or contemporary clinical validity of individual studies.