Cognitive and cortical alteration with full mouth rehabilitation in a group of children

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There are links between cognitive function and symptoms, including mental slowness, memory issues, and attentional impairment. Thus, getting thorough dental treatment could enhance mental wellness. When a child needs extensive dental work, or exhibits acute situational anxiety, whole-mouth rehabilitation under general anesthesia (GA) is one therapeutic alternative. Aim of the work: This study looked at changes in cognition and the brain's function in children who had extensive dental rehabilitation while under general anesthesia. Materials and methods : Thirty uncooperative, healthy male and female children, ages six to twelve, with various dental issues, were enrolled in the study. Before the treatment, one week later, and three months later, their pain was assessed using the Wong-Baker Faces Pain Rating Scale (WBFPS) as well as Face, Legs, Activity, Cry, and Consolability (FLACC). Assessments of cognitive function using the Digit Span Subtest (DS) and Electroencephalogram (EEG) were also evaluated. The data collection was statistically analyzed . Results: All children showed a significant improvement regarding pain when evaluated by themselves or their parents after dental procedures at 1 week and 3 months later. Also, there were improvements in cognitive functions after dental procedures. Conclusion : The research findings indicate that full mouth rehabilitation under general anaesthesia improved pain as well as cognitive and brain functions in children. Clinical Relevance : severe dental pain in addition to the child's negative behavior interferes with routine dental visits and also with different brain and cognitive functions, so whole mouth rehabilitation under GA may be able to address these issues. cognitive functions cortical alterations full mouth rehabilitation pain scale general anesthesia Figures Figure 1 Figure 2 1. Background It has been clearly shown that poor oral care has a negative biological, psychological, and social impact on aesthetics and communication (1). Children who have oral pain suffer terrible consequences, such as lack of sleep, stunted growth, behavioural issues, and poor academic performance (2, 3). Dentalgia, or toothache (TA), is pain in the dental pulp and/or periodontal tissues brought on by dental or non-dental diseases (4). Since pain is essentially defined as a personal experience, a variety of pain assessment tools (self-report and observational scales) have been utilized. The Faces Pain Scale (FPS) by Bieri et al. and the Numerical Rating Scale (NRS) by von Baeyer et al. are two widely used scales that demonstrate self-reporting of acute procedural, postoperative, or disease-related pain (5, 6). Children with postoperative conditions can use observational scales to gauge their level of pain, such as FLACC (Face, Legs, Activity, Cry, and Consolability), and in preverbal children and children who are unable to comprehend a self-report scale (7). Pain is linked to reduced cognitive function. Studies have shown that individuals who are suffering from chronic pain, acute pain, or experimental pain perform worse cognitively (8–12). Patients with severe pain have poorer cognitive performance than those with mild to moderate pain (13). Attentional impairment, memory problems, and mental slowness are often reported as signs associated with cognitive function. Therefore, receiving comprehensive dental care may improve brain health. Full mouth rehabilitation under general anaesthesia (GA) is a treatment option for children who require substantial dental work, display severe situational anxiety, emotional or cognitive immaturity, or are in a medically fragile state (14). It has various advantages, including high-quality restorative and preventative dental care that is safe, effective, and convenient. (15). The American Academy of Pediatric Dentistry (AAPD) asserts that only GA can be used to treat a specific patient population that may not tolerate conventional dental therapy (16, 17). Most dental GA candidates are young children who have early childhood caries (ECC), a common health issue, but who are otherwise in good health and completely uncooperative children (18–21). The relationship between oral health problems in children, including dental pain, and brain function is not well understood. So, this study was directed to investigate cognitive and cortical alterations in children subjected to comprehensive dental rehabilitation under general anaesthesia before and after treatment. 2. Patients and methods 2.1. Patients’ rights: The Faculty of Dentistry at Tanta University's Research Ethics Committee granted approval for this study under the reference number (R-PED-11-22-11). Along with the agreement of the children above the age of 8, the present study's goal was explained to the parents, and they gave their informed consent in accordance with the ethical guidelines outlined in the Declaration of Helsinki and its subsequent revision.. 2.2. Sample size calculation The sample size was calculated using G Power version 3.1.9.2 (22). Adopting a power of 80% (b = 0.20), and level of significance of 5% (α error accepted = 0.05), to detect a standardized effect size (g) of 0.3, the minimum required sample size was found to be 25 patients (23, 24). After adjustment for a dropout rate of 10%, the sample size was increased to 30 patients (25). 2.3. Participants This study was conducted as a single-arm clinical trial. The study enrolled 30 child patients, male and female, with multiple oral problems aged 6 to 12 years, recruited from the outpatient’s clinic of the pediatric dentistry clinic, Faculty of Dentistry, Tanta University. These children are classified as completely uncooperative, cannot tolerate routine dental treatment, and need full-mouth oral rehabilitation under general anaesthesia. Inclusion criteria : Uncooperative normal healthy (ASA I) child that needs comprehensive dental treatment under general anaesthesia and suffers from pain and other dental problems. Exclusion criteria : The presence of substantial neurological impairment, or head injury. Current or previous psychotic episodes. Intellectual disabilities. 2.4. Procedures and methods of data collection: The whole procedure of full mouth rehabilitation will be performed in the pediatric anaesthesia unit of the public service center, Faculty of Dentistry, Tanta University. The participants were subjected to the following : History Taking General and Neurological Examinations: To exclude any physical or neurological disorder. Pain evaluation scales, psychological scales, and EEG at baseline, one week after completion of dental rehabilitation, and after 3 months of follow up. 2.5. Pain evaluation: Children's suffering was measured using the Wong-Baker Faces Pain Rating Scale (WBFPS). Each child used the WBFPS to measure his pain. The child received the scale and was asked to select three times. The first one prior to anaesthesia procedures, and two times, one week and three months following general anaesthetic procedures (26) (Fig. 1 ). The accompanying parent was asked to rate their child's pain tolerance and behaviour using a behavioural/observational pain scale while they were present in the clinic and at home prior to the anaesthesia procedure and 1 week and 3 months after GA procedures. The parents used the Face, Legs, Activity, Cry, and Consolability Measure (FLACC), which was translated into Arabic, to evaluate their children (27) (Table 1 ). Table 1 FLACC scale for pain assessment from child behaviour (score 0–10) Behavior 0 1 2 Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting, back and forth, tense Arched, rigid or jerking Cry No cry (awake or asleep) Moans or whimpers; occasional complaint Crying steadily, screams, sobs, frequent complaints Consolability Content, relaxed Reassured by touching, hugging or being talked to, distractible Difficult to console or comfort 2.6. Cognitive function assessment: The Arabic version of the Stanford-Binet Intelligences Scale is used to assess IQ for each subject (28). Wisconsin Card Sorting Task (WCST): This is used to test the executive functions (29). Trail-Making Test (TMT) or Trails A & B: Part A of this test is a measure of processing speed, whereas the TMT-B is used to assess the ability of set shifting and cognitive flexibility (part of executive functioning). We used the Arabic version of this test (30). Digit Span Subtest (DS) This IQ test was administered as a component of the WAIS. A mixed array of digits had to be repeated by the subject, first in the same order (ahead span) and then in the opposite direction (backward span). While the latter was connected to working memory, the former was thought to be a measure of basic attention. The digit spread is defined as the maximum number of successfully repeated digits before failing twice. (31). Electroencephalogram (EEG) : While the EEG was being recorded, participants were told to close their eyes, refrain from thinking, and not move or tense their muscles. The Neurofax Nihon Kohden QP-110 AK was used to record EEGs from scalp locations that were arranged in accordance with the 10–20 international standard. For five minutes, each patient's resting EEG was collected in order to determine their baseline background activity. After digitizing the EEG, fast Fourier transformation (FFT) was carried out. A fast Fourier transform is an algorithm that computes the discrete Fourier transform of a sequence, or its inverse. Through the use of Fourier analysis, a signal's original domain—typically time or space—is transformed into a representation in the frequency domain, and vice versa. The frequency spectrum was split into 0.2 Hz bands, which were then compacted into the EEG frequency bands of beta (13.0–30 Hz), theta (4.0-7.9 Hz), alpha (8.0-12.9 Hz), and delta (1–3 Hz). This allowed for the calculation of EEG power. The Fast Fourier Transform (FFT) algorithm was utilized to analyze the frequency domain and determine the mean frequency (Hz), relative (%), and absolute (µV2/Hz) power densities inside each of the sub-bands (32). The following equations will be applied : Mean band frequency in Hz: beta and alpha at F3 (before sessions, the next day after applying for 10 sessions, after 1 and 3 months of follow-up) Absolute band power (log x) in µV2/Hz: beta and alpha at F3. Relative band power beta and alpha at F3. Absolute power was log transformed (log x), and relative power variables were transformed in order to normalize the distribution of the data. EEG frequency (Hz) indices were found to be normally distributed and thus did not require transformation (33). 2.7. Statistical Analysis: The descriptive statistics were calculated using SPSS version 21 (IBM Corp, New York, USA), in terms of number, frequency, mean, and standard deviations. T-test was used for scale variables, paired sample T-test was used for before and data. 3. Results As manifested in Fig. 2 , sixty child patients were assessed for eligibility, and thirty patients were excluded: twenty patients did not meet the inclusion criteria, and ten patients were not willing to join the research. Thirty children were recruited into the study at 1 week, and only 27 were followed up at 3 months, and three children withdrawn and dropped out of the study. For sex distribution, 57% of children were male, and 43% were female at the beginning of the study. The mean age was 9.2, ranging from 6 to 12 years old, with a mean ± SD of 9.2333 ± 2.01175 (Table 2 ). Table 2 Gender and age distribution among the included patients Sex (n = 30) Male Female N = 17 (57%) N = 13 (43%) Minimum Maximum Mean Std. Dev Age (n = 30) 6.00 12.00 9.2333 2.01175 3.1. Pain evaluation Before GA dental procedures, all children suffered from moderate to severe pain, with scores above average (5/10). This was cleared on both the WBFPS and FLACC scales taken from children and parents, with mean ± SD 7.9667 ± 1.18855 and 0.7000 ± .79438, respectively. As for WBFPS, comparisons of pain scores before and after GA procedures were analysed using the t-test. The pain scores significantly decreased after 1-week GA procedures for children. Most of the scores were mild to no pain (mean = 2.3667, p = 0.0). The pain scores showed a significant decrease after 3 months of GA procedures (mean = 0.3667), with almost no pain in all children in comparison to scores recorded before GA procedures and 1 week after (p = 0.0). (Table 3 ) Concerning FLACC scale, the t-test was used to compare pain scores before and after GA procedures. Children's pain scores dramatically dropped following a one-week GA operation. The majority of the scores (mean = 2.1000, p = 0.0) indicated minor to no pain. When compared to scores recorded prior to GA treatments and one week later, the pain scores indicated a considerable decrease after three months of GA procedures (0.4333), with nearly no discomfort in any child (p = 0.0). (Table 4 ) Table 3 Comparison of WBFPS before and after procedure Mean Std. Dev t test Sig. WBFPS before dental procedure 7.9667 1.18855 32.90 0.00* WBFPS after 1 week of dental procedure 2.3667 .99943 WBFPS before dental procedure 7.9667 1.18855 41.48 0.00* WBFPS after 3 months of dental procedure .3667 .61495 WBFPS after 1 week of dental procedure 2.3667 .99943 13.19 0.00* WBFPS after 3 months of dental procedure .3667 .61495 ∗Statistically significant at p < 0.05 Table 4 Comparison of FLACC scale before and after procedure Mean Std. Dev t test Sig. FLACC scale before dental procedure 7.7000 .79438 34.29 0.00* FLACC scale after 1 week of dental procedure 2.1000 .84486 FLACC scale before dental procedure 7.7000 .79438 45.83 0.00* FLAAC scale after 3 months of dental procedure .4333 .56832 FLACC scale after 1 week of dental procedure 2.1000 .84486 10.81 0.00* FLAAC scale after 3 months of dental procedure .4333 .56832 ∗Statistically significant at p < 0.05 3.2. Cognitive function evaluation Regarding cognitive functions, when comparing both group, there was a significant difference in all cognitive variables including digit forward, digit backward, processing speed, verbal IQ, WCST perseverative responses, WCST failure to maintain set (Table 5 ). Trail Making Test A and Trail Making Test B showed statistically significant differences before and after performing the dental procedure (Table 6 ). in performance IQ, total IQ, and Trail Making Test A (time). Also, MOCA statically analysis showed a significant increase in the cognitive functions after performing the dental procedure (Table 7 ). Table 5 Comparison of (digit forward, backward), processing speed and WCST results before and after the procedure. T test sig Digit forward before dental procedure Mean 3.7503 -3.80 0.001* Std. Dev 0.58445 Digit forward after dental procedure Mean 4.3222 Std. Dev 0.42459 Digit backword before dental procedure Mean 2.4399 -5.49 0.001* Std. Dev 0.74086 Digit backword after dental procedure Mean 3.4231 Std. Dev 0.71161 Processing speed before dental procedure Mean 81.5302 -4.23 0.001* Std. Dev 6.63907 Processing speed after dental procedure Mean 89.3979 Std. Dev 8.47644 WCST(PR) before dental procedure Mean 24.1736 2.065 0.048* Std. Dev 4.58539 WCST (PR) after dental procedure Mean 18.2369 Std. Dev 15.34025 WCST (FMS) before dental procedure Mean 7.3320 8.564 0.001* Std. Dev 2.11747 WCST(FMS) after dental procedure Mean 3.4328 Std. Dev 0.79709 Table 6 Comparison of trial make tests results before and after the procedure. Mean Std. Dev T test Sig. TMT A (Time) before dental procedure 54.0419 17.34324 2.90 0.002* TMT A (Time) after dental procedure 40.0893 17.41050 TMT A (Error) before dental procedure 5.2000 1.34933 2.84 0.008* TMT A (Error) after dental procedure 4.2884 1.09272 TMTB (Time) before dental procedure 126.6315 25.26646 7.87 0.001* TMTB (Time) after dental procedure 87.7218 12.63608 TMTB (Error) before dental procedure 8.5667 1.40156 3.28 0.003* TMTB (Error) after dental procedure 7.3716 1.13739 Table 7 Comparison of MOCA results before and after the procedure. Mean Std. Dev T test Sig. MOCA before dental procedure 24.06 1.284 -10.24 0.001* MOCA after dental procedure 27.60 1.566 Power ratios are a measure of EEG power that show variations in the power balance within each frequency band. The current investigation found a significant difference between the baseline values of alpha band relative power and mean log transformed alpha band power before and after any dental procedures (Table 8 ). Table 8 Comparison of EEG indices before and after the procedure. Mean Std. Dev T test sig Alpha range before dental procedure 9.9000 1.18467 1.30 0.23 Alpha range after dental procedure 9.5333 1.13664 Absolute alpha power before dental procedure 1.9581 .56419 -7.24 0.001* Absolute alpha power after dental procedure 2.8246 .24763 Relative alpha power before dental procedure 55.9002 20.92444 -4.24 0.001* Relative alpha power after dental procedure 75.4679 20.49183 4. Discussion Unfortunately, most of the published studies have focused on evaluating cognitive performance, neural correlates, and quality of life in older adults after oral rehabilitation. (34–37). While most paediatric studies have concentrated on oral health-related quality of life or pain after oral rehabilitation (38–40). Based on this, we aimed to explore this issue in the current study. The majority of children can receive dental care in a traditional setting, but some patients can't get the standard behaviour control methods to work on them (41, 42). Children who receive dental care while under general anaesthesia benefit from immediate pain alleviation and full mouth rehabilitation completed in a single visit (42, 43). Since pain is a subjective sensation as opposed to a clinical diagnosis, self-report is the gold standard for assessing pain in children (44). In our study, pain was measured using a modified VAS that employed images of faces. The Wong-Baker scale, which has also been effectively utilized with children, and this modified version of the VAS have a good association, according to earlier research. The Wong-Baker scale, however, has been linked to overestimation of pain because apprehensive children who are not in pain might not choose a happy face on the scale (45). Furthermore, the unique qualities of every patient, their family history, and other relevant data for pain assessment make clinical decisions more difficult (46). When parents' views and judgments are included in the pain assessment, it may be more accurate than one that only considers the patient's experience and the clinician's observations because parents are aware of their child's typical pain reactions and appreciate contextual and systemic information (47). The fundamental behavioural categories in the FLACC pain assessment tool have been consistently linked to pain cognitively intact (48, 49). This tool has been assessed against a number of criteria in earlier studies of children during their early and later (i.e., in patient) surgical recovery phases (48–50). While some studies have shown variances, others have found that the parent and child's reported pain levels coincide (51–53). In the present study, there was no difference between parents’ and their children’s ratings. All of the children experienced moderate-to-severe pain prior to receiving dental operations. The WBFPS and FLACC scales, which are used to rate children and parents, both showed this to be apparent. This pain has significantly decreased after one week of evaluation. And there was another considerable decrease of pain score after 3 months of evaluation using both scales. These improvements were observed coincide with Prior research on parents' perceptions of their children's quality of life revealed that, following dental treatment under GA, pain reduction was the most important factor, followed by improvements in sleeping and feeding patterns (54, 55). Also, a study was done by Versloot and his colleagues (56) showed that Children who receive dental care have lower pain-related behaviours, which improves their quality of life. Our results revealed significant differences in all cognitive variables pre and post procedure, including digit forward, digit backward, processing speed, WCST perseverative responses, WCST failure to maintain set, Trail Making Test. Statistical analysis of the MOCA also showed a significant improvement in cognitive functions after the dental procedure. Despite studying different populations, Gu and coworkers (57) reported similar findings in their work. They found that poor periodontal status was strongly associated with worse global cognitive performance, especially in short-term memory and executive function for the aging population. Their study also demonstrated an association between oral health and global cognition. A previous Systematic review found the most consistent associations between oral health and the cognitive domains of learning/memory, complex attention, and executive function. Many studies found oral health predicted performance in these domains even after accounting for confounding factors (58). Electroencephalography (EEG) directly measures cortical activity involved in cognition and emotion. Therefore, EEG power spectral analysis is a valuable objective index of psychological state. In recent years, alpha, beta, and theta band powers have been used to evaluate psychological state. Alpha waves are prominent during resting wakefulness with eyes closed, while beta waves increase during concentration and mental effort (59). The current study showed significant difference regarding mean log transformed alpha band power and alpha band relative power at baseline before performing any dental procedure compared with after performing the dental procedure. Saikia et al. (60) analysed the influence of fixed dental prostheses on brain function. Cognitive function was assessed using a mental state questionnaire. EEG alpha wave power spectral density analysis was conducted pre-treatment, post-treatment. They demonstrated improved brain function in partially edentulous patients after rehabilitation. Changes in EEG can be explained by reduced imbalance in trigeminal proprioceptive signaling thereby improving performance on complex sensorimotor tasks and to increased prefrontal cortex activation (60). 5. Conclusion The research findings indicate that full mouth rehabilitation under general anaesthesia improved pain as well as cognitive and brain functions in children. Declarations Ethical approval and consent to participate. Ethical Approval for this study was obtained from the ethical committee (REC), Faculty of Dentistry, Tanta University; code (#R- PED-11-22-11) adhering to the 1964 Helsinki Declaration and any updates that have since been made. The parents of the patients were informed about the purpose of the study and provided written approval for the treatments to be carried out. Consent for publication: Not applicable Availability of Data and Materials On reasonable request, the datasets utilized and/or analyzed during the present study are accessible from the corresponding author. Competing interests The authors declared no conflict of interest relevant to this article. Funding There was no funding provided to the authors by any organizations. Authors’ contributions N.M.M. contributed to the study design, data collection, and writing the manuscript. O.A.R. participated in the study's design, data collection, and manuscript revision. M.S.H.K. collecting data and revising the manuscript. L.A.E. helped design the study, and explained the data. The final article had been reviewed and accepted by all authors. Acknowledgments: Not applicable References Emami E, de Souza RF, Kabawat M, Feine JS. 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J Clin Pediatr 2016;40(1):53-61. doi: 10.17796/1053-4628-40.1.53, PMID 26696108. Rane JV, Winnier J, Bhatia R. Comparative assessment of oral health related quality of life of children before and after full mouth rehabilitation under general anaesthesia and local anaesthesia. J Clin Diagn 2017;11(1):ZC23-6. doi: 10.7860/JCDR/2017/23699.9163, PMID 28274038. Guney SE, Araz C, Tirali RE, Cehreli SB. Dental anxiety and oral health-related quality of life in children following dental rehabilitation under general anesthesia or intravenous sedation: A prospective cross-sectional study. Niger J Clin 2018;21(10):1304-10. doi: 10.4103/njcp.njcp_150_18, PMID 30297563. Yildirim MD, Cantekin K. Effect of palonosetron on postoperative nausea and vomiting in children following dental rehabilitation under general anesthesia. Pediatr 2014;36(1):7E-11E. PMID 24717698. Anderson HK, Drummond BK, Thomson WM. Changes in aspects of children’s oral-health-related quality of life following dental treatment under general anaesthesia. Int J Paediatr 2004;14(5):317-25. doi: 10.1111/j.1365-263X.2004.00572.x, PMID 15330997. Harrison MG, Roberts GJ. Comprehensive dental treatment of healthy and chronically sick children under intubation general anaesthesia during a 5-year period. Br Dent 1998;184(10):503-6. doi: 10.1038/sj.bdj.4809675, PMID 9642869. Merskey H. Pain terms: a list with definitions and notes on usage. Recommended by the IASP subcommittee on taxonomy. Pain. 1979;6(3):249. PMID 460932. Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B. Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain. 2006;125(1-2):143-57. doi: 1016/j.pain.2006.05.006, PMID 16777328. Ranger M, Campbell-Yeo M. Temperament and pain response: a review of the literature. Pain Manag 2008;9(1):2-9. doi: 10.1016/j.pmn.2007.09.005, PMID 18313584. Kazak AE, Penati B, Waibel MK, Blackall GF. The Perception of Procedures Questionnaire: psychometric properties of a brief parent report measure of procedural distress. J Pediatr 1996;21(2):195-207. doi: 10.1093/jpepsy/21.2.195, PMID 8920153. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr 1997;23(3):293-7. PMID 9220806. Willis MH, Merkel SI, Voepel-Lewis T, Malviya S. FLACC Behavioral Pain Assessment Scale: a comparison with the child’s self-report. Pediatr 2003;29(3):195-8. PMID 12836995. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth 2002;95(5):1224-9. doi: 10.1097/00000539-200211000-00020, PMID 12401598. Chambers CT, Craig KD, Bennett SM. The impact of maternal behavior on children’s pain experiences: an experimental analysis. J Pediatr 2002;27(3):293-301. doi: 10.1093/jpepsy/27.3.293, PMID 11909936. Miller C, Newton SE. Pain perception and expression: the influence of gender, personal self-efficacy, and lifespan socialization. Pain Manag 2006;7(4):148-52. doi: 10.1016/j.pmn.2006.09.004, PMID 17145488. Loopstra C, Strodl E, Herd D. A qualitative analysis of how parents assess acute pain in young children. Health Psychol Open. 2015;2(1):2055102914566290. doi: 1177/2055102914566290, PMID 28070349: p. 2055102914566290. Acs G, Pretzer S, Foley M, Ng MW. Perceived outcomes and parental satisfaction following dental rehabilitation under general anesthesia. Pediatr 2001;23(5):419-23. PMID 11699167. Sachdev J, Bansal K, Chopra R. Effect of comprehensive dental rehabilitation on growth parameters in pediatric patients with severe early childhood caries. Int J Clin Pediatr 2016;9(1):15-20. doi: 10.5005/jp-journals-10005-1326, PMID 27274149. Versloot J, Veerkamp JS, Hoogstraten J. Dental Discomfort Questionnaire for young children following full mouth rehabilitation under general anaesthesia: a follow-up report. Eur Arch Paediatr 2006;7(3):126-9. doi: 10.1007/BF03262552, PMID 17140540. Gu W, Li J, Li F, Ho TE, Feng X, Wang Y, et al. Association between oral health and cognitive function among Chinese older adults: the Taizhou imaging study. BMC Oral Health. 2023;23(1):640. doi: 1186/s12903-023-03353-9, PMID 37670297. Nangle MR, Riches J, Grainger SA, Manchery N, Sachdev PS, Henry JD. Oral Health and cognitive function in older adults: a systematic review. Gerontology. 2019;65(6):659-72. doi: 1159/000496730, PMID 30904915. Bhavnani S, Lockwood Estrin G, Haartsen R, Jensen SKG, Gliga T, Patel V, et al. EEG signatures of cognitive and social development of preschool children–a systematic review. PLOS ONE. 2021;16(2):e0247223. doi: 1371/journal.pone.0247223, PMID 33606804. Saikia UP, Chander NG, Balasubramanian M. Effect of fixed dental prosthesis on the brain functions of partially edentulous patients – pilot study with power spectrum density analysis. Eur Oral 2020;54(3):114-8. doi: 10.26650/eor.20200032, PMID 33543115. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3854246","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268715566,"identity":"bb9a3a0d-c214-44aa-87e8-e32144155944","order_by":0,"name":"Nancy Mohamed Metwally","email":"data:image/png;base64,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","orcid":"","institution":"Tanta University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"Mohamed","lastName":"Metwally","suffix":""},{"id":268715567,"identity":"dff20b6a-65a6-4949-baa8-b9f72a005ce5","order_by":1,"name":"Osama Abd Allah Ragab","email":"","orcid":"","institution":"Tanta University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Osama","middleName":"Abd Allah","lastName":"Ragab","suffix":""},{"id":268715568,"identity":"e98cee67-f5c7-40db-8d70-db86db9d353f","order_by":2,"name":"Mostafa Shaaban Kandil","email":"","orcid":"","institution":"Tanta University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mostafa","middleName":"Shaaban","lastName":"Kandil","suffix":""},{"id":268715571,"identity":"b32c3fa4-7de1-4dd7-958f-89949bb32040","order_by":3,"name":"Lamis Ahmed Elghareb","email":"","orcid":"","institution":"Tanta University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lamis","middleName":"Ahmed","lastName":"Elghareb","suffix":""}],"badges":[],"createdAt":"2024-01-11 17:29:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3854246/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3854246/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50174479,"identity":"81c4992c-256f-4735-ab4d-b4a095a17734","added_by":"auto","created_at":"2024-01-25 16:12:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24719,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWong-Baker FACES Pain Rating Scale\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3854246/v1/b66b2f58866272753a6511a2.png"},{"id":50174478,"identity":"b078616c-acf3-420c-a1db-14595e134262","added_by":"auto","created_at":"2024-01-25 16:12:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40069,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT Flow chart diagram of participants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3854246/v1/11c566f748db8a1d20195c0d.png"},{"id":50175105,"identity":"534adb76-50d3-49ea-861a-4429da79eb7d","added_by":"auto","created_at":"2024-01-25 16:20:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":488150,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3854246/v1/8b02dab1-951f-4a83-b445-3db341134ee9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cognitive and cortical alteration with full mouth rehabilitation in a group of children","fulltext":[{"header":"1. Background","content":"\u003cp\u003eIt has been clearly shown that poor oral care has a negative biological, psychological, and social impact on aesthetics and communication (1). Children who have oral pain suffer terrible consequences, such as lack of sleep, stunted growth, behavioural issues, and poor academic performance (2, 3). Dentalgia, or toothache (TA), is pain in the dental pulp and/or periodontal tissues brought on by dental or non-dental diseases (4). Since pain is essentially defined as a personal experience, a variety of pain assessment tools (self-report and observational scales) have been utilized. The Faces Pain Scale (FPS) by Bieri et al. and the Numerical Rating Scale (NRS) by von Baeyer et al. are two widely used scales that demonstrate self-reporting of acute procedural, postoperative, or disease-related pain (5, 6). Children with postoperative conditions can use observational scales to gauge their level of pain, such as FLACC (Face, Legs, Activity, Cry, and Consolability), and in preverbal children and children who are unable to comprehend a self-report scale (7). Pain is linked to reduced cognitive function. Studies have shown that individuals who are suffering from chronic pain, acute pain, or experimental pain perform worse cognitively (8\u0026ndash;12). Patients with severe pain have poorer cognitive performance than those with mild to moderate pain (13). Attentional impairment, memory problems, and mental slowness are often reported as signs associated with cognitive function. Therefore, receiving comprehensive dental care may improve brain health. Full mouth rehabilitation under general anaesthesia (GA) is a treatment option for children who require substantial dental work, display severe situational anxiety, emotional or cognitive immaturity, or are in a medically fragile state (14). It has various advantages, including high-quality restorative and preventative dental care that is safe, effective, and convenient. (15). The American Academy of Pediatric Dentistry (AAPD) asserts that only GA can be used to treat a specific patient population that may not tolerate conventional dental therapy (16, 17). Most dental GA candidates are young children who have early childhood caries (ECC), a common health issue, but who are otherwise in good health and completely uncooperative children (18\u0026ndash;21).\u003c/p\u003e \u003cp\u003eThe relationship between oral health problems in children, including dental pain, and brain function is not well understood. So, this study was directed to investigate cognitive and cortical alterations in children subjected to comprehensive dental rehabilitation under general anaesthesia before and after treatment.\u003c/p\u003e"},{"header":"2. Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Patients\u0026rsquo; rights:\u003c/h2\u003e \u003cp\u003e The Faculty of Dentistry at Tanta University's Research Ethics Committee granted approval for this study under the reference number (R-PED-11-22-11). Along with the agreement of the children above the age of 8, the present study's goal was explained to the parents, and they gave their informed consent in accordance with the ethical guidelines outlined in the Declaration of Helsinki and its subsequent revision..\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Sample size calculation\u003c/h2\u003e \u003cp\u003eThe sample size was calculated using G Power version 3.1.9.2 (22). Adopting a power of 80% (b\u0026thinsp;=\u0026thinsp;0.20), and level of significance of 5% (α error accepted\u0026thinsp;=\u0026thinsp;0.05), to detect a standardized effect size (g) of 0.3, the minimum required sample size was found to be 25 patients (23, 24). After adjustment for a dropout rate of 10%, the sample size was increased to 30 patients (25).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Participants\u003c/h2\u003e \u003cp\u003eThis study was conducted as a single-arm clinical trial. The study enrolled 30 child patients, male and female, with multiple oral problems aged 6 to 12 years, recruited from the outpatient\u0026rsquo;s clinic of the pediatric dentistry clinic, Faculty of Dentistry, Tanta University. These children are classified as completely uncooperative, cannot tolerate routine dental treatment, and need full-mouth oral rehabilitation under general anaesthesia.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eUncooperative normal healthy (ASA I) child that needs comprehensive dental treatment under general anaesthesia and suffers from pain and other dental problems.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe presence of substantial neurological impairment, or head injury.\u003c/p\u003e \u003cp\u003eCurrent or previous psychotic episodes.\u003c/p\u003e \u003cp\u003eIntellectual disabilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Procedures and methods of data collection:\u003c/h2\u003e \u003cp\u003eThe whole procedure of full mouth rehabilitation will be performed in the pediatric anaesthesia unit of the public service center, Faculty of Dentistry, Tanta University.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe participants were subjected to the following\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cb\u003eHistory Taking\u003c/b\u003e \u003c/p\u003e \u003cp\u003eGeneral and Neurological Examinations: To exclude any physical or neurological disorder.\u003c/p\u003e \u003cp\u003ePain evaluation scales, psychological scales, and EEG at baseline, one week after completion of dental rehabilitation, and after 3 months of follow up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Pain evaluation:\u003c/h2\u003e \u003cp\u003eChildren's suffering was measured using the Wong-Baker Faces Pain Rating Scale (WBFPS). Each child used the WBFPS to measure his pain. The child received the scale and was asked to select three times. The first one prior to anaesthesia procedures, and two times, one week and three months following general anaesthetic procedures (26) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe accompanying parent was asked to rate their child's pain tolerance and behaviour using a behavioural/observational pain scale while they were present in the clinic and at home prior to the anaesthesia procedure and 1 week and 3 months after GA procedures. The parents used the Face, Legs, Activity, Cry, and Consolability Measure (FLACC), which was translated into Arabic, to evaluate their children (27) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFLACC scale for pain assessment from child behaviour (score 0\u0026ndash;10)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo particular expression or smile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOccasional grimace or frown, withdrawn, disinterested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequent to constant quivering chin, clenched jaw\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLegs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal position or relaxed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUneasy, restless, tense\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKicking or legs drawn up\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLying quietly, normal position, moves easily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSquirming, shifting, back and forth, tense\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eArched, rigid or jerking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo cry (awake or asleep)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMoans or whimpers; occasional complaint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCrying steadily, screams, sobs, frequent complaints\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsolability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContent, relaxed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReassured by touching, hugging or being talked to, distractible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifficult to console or comfort\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Cognitive function assessment:\u003c/h2\u003e \u003cp\u003eThe Arabic version of the Stanford-Binet Intelligences Scale is used to assess IQ for each subject (28).\u003c/p\u003e \u003cp\u003eWisconsin Card Sorting Task (WCST): This is used to test the executive functions (29).\u003c/p\u003e \u003cp\u003eTrail-Making Test (TMT) or Trails A \u0026amp; B: Part A of this test is a measure of processing speed, whereas the TMT-B is used to assess the ability of set shifting and cognitive flexibility (part of executive functioning). We used the Arabic version of this test (30).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDigit Span Subtest (DS)\u003c/strong\u003e \u003cp\u003eThis IQ test was administered as a component of the WAIS. A mixed array of digits had to be repeated by the subject, first in the same order (ahead span) and then in the opposite direction (backward span). While the latter was connected to working memory, the former was thought to be a measure of basic attention. The digit spread is defined as the maximum number of successfully repeated digits before failing twice. (31).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eElectroencephalogram (EEG)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eWhile the EEG was being recorded, participants were told to close their eyes, refrain from thinking, and not move or tense their muscles. The Neurofax Nihon Kohden QP-110 AK was used to record EEGs from scalp locations that were arranged in accordance with the 10\u0026ndash;20 international standard. For five minutes, each patient's resting EEG was collected in order to determine their baseline background activity. After digitizing the EEG, fast Fourier transformation (FFT) was carried out.\u003c/p\u003e \u003cp\u003eA fast Fourier transform is an algorithm that computes the discrete Fourier transform of a sequence, or its inverse. Through the use of Fourier analysis, a signal's original domain\u0026mdash;typically time or space\u0026mdash;is transformed into a representation in the frequency domain, and vice versa. The frequency spectrum was split into 0.2 Hz bands, which were then compacted into the EEG frequency bands of beta (13.0\u0026ndash;30 Hz), theta (4.0-7.9 Hz), alpha (8.0-12.9 Hz), and delta (1\u0026ndash;3 Hz). This allowed for the calculation of EEG power.\u003c/p\u003e \u003cp\u003eThe Fast Fourier Transform (FFT) algorithm was utilized to analyze the frequency domain and determine the mean frequency (Hz), relative (%), and absolute (\u0026micro;V2/Hz) power densities inside each of the sub-bands (32).\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe following equations will be applied\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eMean band frequency in Hz: beta and alpha at F3 (before sessions, the next day after applying for 10 sessions, after 1 and 3 months of follow-up)\u003c/p\u003e \u003cp\u003eAbsolute band power (log x) in \u0026micro;V2/Hz: beta and alpha at F3.\u003c/p\u003e \u003cp\u003eRelative band power beta and alpha at F3.\u003c/p\u003e \u003cp\u003eAbsolute power was log transformed (log x), and relative power variables were transformed in order to normalize the distribution of the data. EEG frequency (Hz) indices were found to be normally distributed and thus did not require transformation (33).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Statistical Analysis:\u003c/h2\u003e \u003cp\u003eThe descriptive statistics were calculated using\u003c/p\u003e \u003cp\u003eSPSS version 21 (IBM Corp, New York, USA), in terms of\u003c/p\u003e \u003cp\u003enumber, frequency, mean, and standard deviations. T-test was used for scale variables, paired sample T-test was used for before and data.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eAs manifested in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, sixty child patients were assessed for eligibility, and thirty patients were excluded: twenty patients did not meet the inclusion criteria, and ten patients were not willing to join the research. Thirty children were recruited into the study at 1 week, and only 27 were followed up at 3 months, and three children withdrawn and dropped out of the study. For sex distribution, 57% of children were male, and 43% were female at the beginning of the study. The mean age was 9.2, ranging from 6 to 12 years old, with a mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD of 9.2333\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01175 (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGender and age distribution among the included patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;17 (57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;13 (43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.2333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.01175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Pain evaluation\u003c/h2\u003e \u003cp\u003eBefore GA dental procedures, all children suffered from moderate to severe pain, with scores above average (5/10). This was cleared on both the WBFPS and FLACC scales taken from children and parents, with mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD 7.9667\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18855 and 0.7000\u0026thinsp;\u0026plusmn;\u0026thinsp;.79438, respectively.\u003c/p\u003e \u003cp\u003eAs for WBFPS, comparisons of pain scores before and after GA procedures were analysed using the t-test. The pain scores significantly decreased after 1-week GA procedures for children. Most of the scores were mild to no pain (mean\u0026thinsp;=\u0026thinsp;2.3667, p\u0026thinsp;=\u0026thinsp;0.0). The pain scores showed a significant decrease after 3 months of GA procedures (mean\u0026thinsp;=\u0026thinsp;0.3667), with almost no pain in all children in comparison to scores recorded before GA procedures and 1 week after (p\u0026thinsp;=\u0026thinsp;0.0). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eConcerning FLACC scale, the t-test was used to compare pain scores before and after GA procedures. Children's pain scores dramatically dropped following a one-week GA operation. The majority of the scores (mean\u0026thinsp;=\u0026thinsp;2.1000, p\u0026thinsp;=\u0026thinsp;0.0) indicated minor to no pain. When compared to scores recorded prior to GA treatments and one week later, the pain scores indicated a considerable decrease after three months of GA procedures (0.4333), with nearly no discomfort in any child (p\u0026thinsp;=\u0026thinsp;0.0). (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of WBFPS before and after procedure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBFPS before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.9667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.18855\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e32.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBFPS after 1 week of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.3667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.99943\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBFPS before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.9667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.18855\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e41.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBFPS after 3 months of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.3667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.61495\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBFPS after 1 week of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.3667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.99943\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e13.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBFPS after 3 months of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.3667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.61495\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026lowast;Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of FLACC scale before and after procedure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFLACC scale before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.7000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.79438\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e34.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFLACC scale after 1 week of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.84486\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFLACC scale before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.7000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.79438\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e45.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFLAAC scale after 3 months of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.4333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.56832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFLACC scale after 1 week of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.84486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e10.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFLAAC scale after 3 months of dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.4333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.56832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026lowast;Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Cognitive function evaluation\u003c/h2\u003e \u003cp\u003eRegarding cognitive functions, when comparing both group, there was a significant difference in all cognitive variables including digit forward, digit backward, processing speed, verbal IQ, WCST perseverative responses, WCST failure to maintain set (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Trail Making Test A and Trail Making Test B showed statistically significant differences before and after performing the dental procedure (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). in performance IQ, total IQ, and Trail Making Test A (time). Also, MOCA statically analysis showed a significant increase in the cognitive functions after performing the dental procedure (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of (digit forward, backward), processing speed and WCST results before and after the procedure.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003esig\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDigit forward before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.7503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e-3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.58445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDigit forward after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.3222\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42459\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDigit backword before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.4399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e-5.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.74086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDigit backword after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.4231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.71161\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProcessing speed before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.5302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e-4.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.63907\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProcessing speed after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89.3979\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.47644\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWCST(PR) before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.1736\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e2.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.048*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.58539\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWCST (PR) after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.2369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.34025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWCST (FMS) before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e8.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.11747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWCST(FMS) after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.4328\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.79709\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of trial make tests results before and after the procedure.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMT A (Time) before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54.0419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.34324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMT A (Time) after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.0893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.41050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMT A (Error) before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.34933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.008*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMT A (Error) after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.2884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.09272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMTB (Time) before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e126.6315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.26646\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMTB (Time) after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87.7218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.63608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMTB (Error) before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.5667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.40156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMTB (Error) after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.3716\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.13739\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of MOCA results before and after the procedure.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMOCA before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-10.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMOCA after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.566\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePower ratios are a measure of EEG power that show variations in the power balance within each frequency band. The current investigation found a significant difference between the baseline values of alpha band relative power and mean log transformed alpha band power before and after any dental procedures (Table \u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of EEG indices before and after the procedure.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003esig\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlpha range before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.9000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.18467\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlpha range after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.5333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.13664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsolute alpha power before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.9581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.56419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-7.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsolute alpha power after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.8246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.24763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelative alpha power before dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55.9002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.92444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-4.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelative alpha power after dental procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75.4679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.49183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eUnfortunately, most of the published studies have focused on evaluating cognitive performance, neural correlates, and quality of life in older adults after oral rehabilitation. (34\u0026ndash;37).\u003c/p\u003e \u003cp\u003eWhile most paediatric studies have concentrated on oral health-related quality of life or pain after oral rehabilitation (38\u0026ndash;40). Based on this, we aimed to explore this issue in the current study.\u003c/p\u003e \u003cp\u003eThe majority of children can receive dental care in a traditional setting, but some patients can't get the standard behaviour control methods to work on them (41, 42). Children who receive dental care while under general anaesthesia benefit from immediate pain alleviation and full mouth rehabilitation completed in a single visit (42, 43). Since pain is a subjective sensation as opposed to a clinical diagnosis, self-report is the gold standard for assessing pain in children (44).\u003c/p\u003e \u003cp\u003eIn our study, pain was measured using a modified VAS that employed images of faces. The Wong-Baker scale, which has also been effectively utilized with children, and this modified version of the VAS have a good association, according to earlier research. The Wong-Baker scale, however, has been linked to overestimation of pain because apprehensive children who are not in pain might not choose a happy face on the scale (45). Furthermore, the unique qualities of every patient, their family history, and other relevant data for pain assessment make clinical decisions more difficult (46). When parents' views and judgments are included in the pain assessment, it may be more accurate than one that only considers the patient's experience and the clinician's observations because parents are aware of their child's typical pain reactions and appreciate contextual and systemic information (47). The fundamental behavioural categories in the FLACC pain assessment tool have been consistently linked to pain cognitively intact (48, 49). This tool has been assessed against a number of criteria in earlier studies of children during their early and later (i.e., in patient) surgical recovery phases (48\u0026ndash;50). While some studies have shown variances, others have found that the parent and child's reported pain levels coincide (51\u0026ndash;53). In the present study, there was no difference between parents\u0026rsquo; and their children\u0026rsquo;s ratings. All of the children experienced moderate-to-severe pain prior to receiving dental operations. The WBFPS and FLACC scales, which are used to rate children and parents, both showed this to be apparent. This pain has significantly decreased after one week of evaluation. And there was another considerable decrease of pain score after 3 months of evaluation using both scales. These improvements were observed coincide with Prior research on parents' perceptions of their children's quality of life revealed that, following dental treatment under GA, pain reduction was the most important factor, followed by improvements in sleeping and feeding patterns (54, 55). Also, a study was done by Versloot and his colleagues (56) showed that Children who receive dental care have lower pain-related behaviours, which improves their quality of life.\u003c/p\u003e \u003cp\u003eOur results revealed significant differences in all cognitive variables pre and post procedure, including digit forward, digit backward, processing speed, WCST perseverative responses, WCST failure to maintain set, Trail Making Test. Statistical analysis of the MOCA also showed a significant improvement in cognitive functions after the dental procedure.\u003c/p\u003e \u003cp\u003eDespite studying different populations, Gu and coworkers (57) reported similar findings in their work. They found that poor periodontal status was strongly associated with worse global cognitive performance, especially in short-term memory and executive function for the aging population. Their study also demonstrated an association between oral health and global cognition.\u003c/p\u003e \u003cp\u003e A previous Systematic review found the most consistent associations between oral health and the cognitive domains of learning/memory, complex attention, and executive function. Many studies found oral health predicted performance in these domains even after accounting for confounding factors (58).\u003c/p\u003e \u003cp\u003eElectroencephalography (EEG) directly measures cortical activity involved in cognition and emotion. Therefore, EEG power spectral analysis is a valuable objective index of psychological state. In recent years, alpha, beta, and theta band powers have been used to evaluate psychological state. Alpha waves are prominent during resting wakefulness with eyes closed, while beta waves increase during concentration and mental effort (59).\u003c/p\u003e \u003cp\u003eThe current study showed significant difference regarding mean log transformed alpha band power and alpha band relative power at baseline before performing any dental procedure compared with after performing the dental procedure.\u003c/p\u003e \u003cp\u003eSaikia et al. (60) analysed the influence of fixed dental prostheses on brain function. Cognitive function was assessed using a mental state questionnaire. EEG alpha wave power spectral density analysis was conducted pre-treatment, post-treatment. They demonstrated improved brain function in partially edentulous patients after rehabilitation. Changes in EEG can be explained by reduced imbalance in trigeminal proprioceptive signaling thereby improving performance on complex sensorimotor tasks and to increased prefrontal cortex activation (60).\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe research findings indicate that full mouth rehabilitation under general anaesthesia improved pain as well as cognitive and brain functions in children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval and consent to participate.\u003c/p\u003e\n\u003cp\u003eEthical Approval for this study was obtained from the ethical committee (REC), Faculty of Dentistry, Tanta University; code (#R- PED-11-22-11) adhering to the 1964 Helsinki Declaration and any updates that have since been made. The parents of the patients were informed about the purpose of the study and provided written approval for the treatments to be carried out.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn reasonable request, the datasets utilized and/or analyzed during the present study are accessible from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no conflict of interest relevant to this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding provided to the authors by any organizations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN.M.M.\u003c/strong\u003e contributed to the study design, data collection, and writing the manuscript. \u003cstrong\u003eO.A.R.\u003c/strong\u003e participated in the study\u0026apos;s design, data collection, and manuscript revision. \u003cstrong\u003eM.S.H.K.\u003c/strong\u003e collecting data and revising the manuscript. \u0026nbsp;\u003cstrong\u003eL.A.E.\u003c/strong\u003e\u0026nbsp; helped design the study, and explained the data. The final article had been reviewed and accepted by all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEmami E, de Souza RF, Kabawat M, Feine JS. The impact of edentulism on oral and general health. Int J 2013; 2013: 498305. doi: 10.1155/2013/498305, PMID 23737789.\u003c/li\u003e\n\u003cli\u003eLow W, Tan S, Schwartz S. The effect of severe caries on the quality of life in young children. Pediatr 1999; 21(6):325-6. PMID 10509332.\u003c/li\u003e\n\u003cli\u003eJackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children\u0026rsquo;s school attendance and performance. Am J Public Health. 2011;101(10):1900-6. doi: 2105/AJPH.2010.200915, PMID 21330579.\u003c/li\u003e\n\u003cli\u003eRaab WH. Acute and chronic toothache. Dtsch Zahnarztl 1991;46(2):101-8. 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PMID 12836995.\u003c/li\u003e\n\u003cli\u003e Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth 2002;95(5):1224-9. doi: 10.1097/00000539-200211000-00020, PMID 12401598.\u003c/li\u003e\n\u003cli\u003e Chambers CT, Craig KD, Bennett SM. The impact of maternal behavior on children\u0026rsquo;s pain experiences: an experimental analysis. J Pediatr 2002;27(3):293-301. doi: 10.1093/jpepsy/27.3.293, PMID 11909936.\u003c/li\u003e\n\u003cli\u003e Miller C, Newton SE. Pain perception and expression: the influence of gender, personal self-efficacy, and lifespan socialization. Pain Manag 2006;7(4):148-52. doi: 10.1016/j.pmn.2006.09.004, PMID 17145488.\u003c/li\u003e\n\u003cli\u003e Loopstra C, Strodl E, Herd D. A qualitative analysis of how parents assess acute pain in young children. Health Psychol Open. 2015;2(1):2055102914566290. doi: 1177/2055102914566290, PMID 28070349: p. 2055102914566290.\u003c/li\u003e\n\u003cli\u003e Acs G, Pretzer S, Foley M, Ng MW. Perceived outcomes and parental satisfaction following dental rehabilitation under general anesthesia. Pediatr 2001;23(5):419-23. PMID 11699167.\u003c/li\u003e\n\u003cli\u003e Sachdev J, Bansal K, Chopra R. Effect of comprehensive dental rehabilitation on growth parameters in pediatric patients with severe early childhood caries. Int J Clin Pediatr 2016;9(1):15-20. doi: 10.5005/jp-journals-10005-1326, PMID 27274149.\u003c/li\u003e\n\u003cli\u003e Versloot J, Veerkamp JS, Hoogstraten J. Dental Discomfort Questionnaire for young children following full mouth rehabilitation under general anaesthesia: a follow-up report. Eur Arch Paediatr 2006;7(3):126-9. doi: 10.1007/BF03262552, PMID 17140540.\u003c/li\u003e\n\u003cli\u003e Gu W, Li J, Li F, Ho TE, Feng X, Wang Y, et al. Association between oral health and cognitive function among Chinese older adults: the Taizhou imaging study. BMC Oral Health. 2023;23(1):640. doi: 1186/s12903-023-03353-9, PMID 37670297.\u003c/li\u003e\n\u003cli\u003e Nangle MR, Riches J, Grainger SA, Manchery N, Sachdev PS, Henry JD. Oral Health and cognitive function in older adults: a systematic review. Gerontology. 2019;65(6):659-72. doi: 1159/000496730, PMID 30904915.\u003c/li\u003e\n\u003cli\u003e Bhavnani S, Lockwood Estrin G, Haartsen R, Jensen SKG, Gliga T, Patel V, et al. EEG signatures of cognitive and social development of preschool children\u0026ndash;a systematic review. PLOS ONE. 2021;16(2):e0247223. doi: 1371/journal.pone.0247223, PMID 33606804.\u003c/li\u003e\n\u003cli\u003e Saikia UP, Chander NG, Balasubramanian M. Effect of fixed dental prosthesis on the brain functions of partially edentulous patients \u0026ndash; pilot study with power spectrum density analysis. Eur Oral 2020;54(3):114-8. doi: 10.26650/eor.20200032, PMID 33543115.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cognitive functions, cortical alterations, full mouth rehabilitation, pain scale general anesthesia","lastPublishedDoi":"10.21203/rs.3.rs-3854246/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3854246/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e: Individuals in pain, whether severe or mild to moderate, perform less cognitively. There are links between cognitive function and symptoms, including mental slowness, memory issues, and attentional impairment. Thus, getting thorough dental treatment could enhance mental wellness. When a child needs extensive dental work, or exhibits acute situational anxiety, whole-mouth rehabilitation under general anesthesia (GA) is one therapeutic alternative.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim of the work:\u003c/strong\u003eThis study looked at changes in cognition and the brain's function in children who had extensive dental rehabilitation while under general anesthesia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods\u003c/strong\u003e: Thirty uncooperative, healthy male and female children, ages six to twelve, with various dental issues, were enrolled in the study. Before the treatment, one week later, and three months later, their pain was assessed using the Wong-Baker Faces Pain Rating Scale (WBFPS) as well as Face, Legs, Activity, Cry, and Consolability (FLACC). Assessments of cognitive function using the Digit Span Subtest (DS) and Electroencephalogram (EEG) were also evaluated. The data collection was statistically analyzed\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e All children showed a significant improvement regarding pain when evaluated by themselves or their parents after dental procedures at 1 week and 3 months later. Also, there were improvements in cognitive functions after dental procedures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The research findings indicate that full mouth rehabilitation under general anaesthesia improved pain as well as cognitive and brain functions in children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Relevance\u003c/strong\u003e: severe dental pain in addition to the child's negative behavior interferes with routine dental visits and also with different brain and cognitive functions, so whole mouth rehabilitation under GA may be able to address these issues.\u003c/p\u003e","manuscriptTitle":"Cognitive and cortical alteration with full mouth rehabilitation in a group of children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-25 16:11:56","doi":"10.21203/rs.3.rs-3854246/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-30T07:59:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-14T20:07:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8cfebc6e-8bc0-4555-a410-f662ae220369","date":"2024-02-11T13:16:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-11T13:10:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-02T17:33:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-01-23T06:47:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-23T06:46:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2024-01-11T17:20:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4506bc21-4b09-490c-a59d-8c5329198d9f","owner":[],"postedDate":"January 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-09T08:12:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-25 16:11:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3854246","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3854246","identity":"rs-3854246","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}