Background: The extubation phase in pediatric general anesthesia (GA), particularly in children at risk for perioperative respiratory adverse events (PRAEs), poses significant challenges. This study aimed to compare the effects of sevoflurane and propofol induction on respiratory complications during emergence in pediatric dental patients at risk for PRAEs. Methods: In this retrospective cohort study, 221 children aged 2–15 who underwent elective dental rehabilitation under GA were analyzed. Patients were assigned to induction with either sevoflurane (n=130) or propofol (n=91). All patients were extubated while awake. The primary outcome was the incidence of respiratory complications, including laryngospasm, bronchospasm, desaturation (SpO₂ <95%), airway obstruction, and severe coughing, during emergence and recovery. Risk factors for PRAEs were assessed using a modified ISAAC questionnaire. Results: Respiratory complications were significantly more frequent in the sevoflurane group (32%) compared to the propofol group (11%). Serious adverse events were observed only in the sevoflurane group (6%). Although oxygen desaturation occurred more often in the sevoflurane group (21 vs. 8 cases), the difference was not statistically significant (p=0.1557). Demographic characteristics and distribution of most risk factors were similar between groups, though eczema-related factors were more common in the sevoflurane group. Conclusion: Propofol induction was associated with a lower incidence of respiratory complications during awake extubation in pediatric dental patients at risk for PRAEs. This study is the first to support propofol as the preferred induction agent for this high-risk population, enhancing post-awake extubation respiratory safety.