Infiltrating Resin Combined with Composite Resin to Cure Whole-mouth Dental Caries After Orthodontic Treatment: A Case Report

Infiltrating Resin Combined with Composite Resin to Cure Whole-mouth Dental Caries After Orthodontic Treatment: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Infiltrating Resin Combined with Composite Resin to Cure Whole-mouth Dental Caries After Orthodontic Treatment: A Case Report Jiyuan Zuo, Yizhou Chen, Qining Guo, Xiaobin Fu, Fengyuan Zhang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8309543/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives This study aimed to evaluate the aesthetic efficacy of the combination of composite resin Ceram.X duo and infiltrating resin Icon to cure severe caries after orthodontic treatment. Methods The treatment for a 14-year-old girl, who had been found caried white spot lesions and cavities on her every tooth, was divided into two parts – filling cavities with composite resin Ceram.X duo and masking white spot lesions with infiltrating resin Icon. After treatment, she was followed up for 30 months. Results The optical improvement can be observed significantly right after the treatment, and remains stable for at least 30 months. Conclusions The combination of composite resin Ceram.X duo and infiltrating resin Icon showed good therapeutic effect on severe dental caries after orthodontic treatment. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Key points Patients received orthodontic treatment have a higher risk of developing caries which affects multiple teeth. For this widespread decay, a treatment that is both minimally invasive and aesthetically improved should be found. The combination of composite resin and infiltrating resin has good therapeutic effect on severe orthodontic treatment-caused dental caries. Introduction Malocclusion is the third most common oral disease after caries and periodontal disease, whose prevalence is 56% worldwide. 1 For children, studies have demonstrated that malocclusion can affect aesthetic appearance, psychosocial well-being, and social interactions in the long term. Therefore, orthodontic treatment is necessary. However, patients received orthodontic treatment have a higher risk of developing caries. 2 Orthodontic-related caries has its own characteristics. It often affects multiple teeth in the mouth, and can be divided into initial stage decay, moderate decay, and extensive decay according to their severity. 3 In the initial stage decay, it appears as white spot lesions caused by demineralization, and generally there is no obvious formation of cavities. The existence of caried white spot lesions is a common complication in orthodontic patients. On average, such decalcifications are found in 30%‒70% of patients during orthodontic treatment. 4 The incidence rate of new carious lesions that developed during orthodontic treatment was 45.8%, with a prevalence rate of 68.4% in patients under orthodontic treatment. 5 Since the higher prevalence rate for orthodontic patients, doctors tried to prevent the initiation or inhibit the progress of such orthodontic-related white spot lesions with fixed appliances with coating agents such as sealants and other bonding materials. 6 Some doctors tried to restore aesthetics of such orthodontic-related white spot lesions with infiltrating resin Icon, and achieved good treatment results. 7 Extensive decay shows obvious caries cavity formation, often accompanied by hard enamel white spot lesions. If left untreated, caries often deteriorates in a progressive manner. In this case report, we describe a treatment combined infiltrating resin with composite resin to cure whole-mouth dental caries with both carious cavity formation and white spot lesions after orthodontic treatment. Case report A 14-year-old female was referred to our hospital with complaints of carious cavities and white spots on her every tooth after orthodontic treatment. She started the orthodontic treatment 3 years ago, and had worn orthodontic retainers for 1 year (Fig. 1 ). When the treatment was finished, fast progressing caries damages and white spot lesions could be seen on every one of her teeth. Clinical examination revealed caries on the labial surfaces and incisal margins of upper and lower anterior teeth, and on the occlusal cusps and buccal surfaces of upper and lower posterior teeth (Fig. 2 ), with no clinical symptoms, no heat and cold sensitivity, no percussion pain, no loosening. The whole-mouth gingiva was red and swollen, BOP (+), PD = 1 ~ 3. The diagnosis was rampant caries and chronic gingivitis. After reviewing the benefits and risks with the patient and her parents, we planned to fill all caries damages with composite resin (Ceram.X duo, Dentsply Sirona, Germany) and repair white spot lesions with infiltrating resin (Icon, DMG, Germany) after supragingival scaling. The time-consuming filling treatment would be divided into 5 visits and her occlusion would be divided into 5 parts - upper anterior teeth, left upper posterior teeth, left lower teeth, right lower teeth, and right upper posterior teeth. Shade A2 was selected after shade selection of anterior and posterior teeth respectively, and correspondingly, enamel resin E2 and dentin resin D2 (Ceram.X duo, Dentsply Sirona, Germany) was chosen (Fig. 3 A). It could be seen that the pupil line and the oral line of the patient were parallel and perpendicular to the middle line, and the curve of the incisal margin was consistent with the curve of the lower lip (Fig. 3 B①). The highest points of the cervical margins were basically symmetric. The ratio of width to length of 11 and 21 was asymmetrical, the mesial incisal angles were defective, and the tooth axis were not parallel. In order to obtain a more beautiful dentition, digital smile design (DSD) for patient was made between two visits (Fig. 3 B②). Diagnostic wax-up and lingual guide plate were made referring to DSD (Fig. 3 C). At the second visit, the patient’s upper anterior teeth were minimally-invasively grinded to remove softened decayed tissues but retained hard white spot lesions with small ball-shaped drill and ultrasonic tip (Fig. 3 D). As showed in Fig. 3 E①②③, the lingual and incisal enamel of 22 and 23 was filled with the help of lingual guide plate, followed by filling the dentin part ( Fig. 3 E④) and next the labial surfaces (Fig. 3 E⑤⑥) step by step. 12 and 13 were treated in the same procedure described above (Fig. 3 F, G), and the enamel defect in lingual and labial surfaces of 11 and 21 was filled (Fig. 3 H). When filling was finished, the repaired teeth were adjusted and polished with polisher and polishing paste (Fig. 3 I, J). All work was done under microscope. In the following visits, the rest divisions of her occlusion were grinded as mentioned above (Fig. 4 A, B). Enamel resin was used to fill missing enamel, and dentin resin was used to fill missing dentin (Fig. 4 C). Polishing was done as mentioned above. To lightened the white spots, infiltration treatment was carried out 1 week after filling (Fig. 5 ). Isolated all the teeth with rubber dam, the surfaces of teeth were micro-grinded and cleaned with fluorine-free grind paste (Fig. 6 A). Then the teeth were acid etched with 15% hydrochloric acid for 2 minutes (Fig. 6 B), rinsed for 30 seconds, and dried with blowing gun (Fig. 6 C). All teeth were dried with 99% ethanol for 30 seconds following with blowing gun (Fig. 6 D) before coating infiltrating resin. 3 minutes later, redundant resin was removed with dental floss, and every surface of teeth was photocured for 40 seconds (Fig. 6 E). Most of the white spots disappeared after the infiltration treatment, but some stubborn spots still remained on the labial surfaces of the upper central incisors. Hence a local treatment of this area was carried out as the same method mentioned above (Fig. 6 F). Significant effect could be seen before (Fig. 2 ) and right after the treatment (Fig. 7 A). The patient was called back 8 months (Fig. 7 B), 12 months (Fig. 7 C) and 30 months (Fig. 7 D) after the treatment, the therapeutic effect was steady without recurrence (Fig. 8 ). Discussion Patients under orthodontic treatment is in high-caries-risk. Therefore, a thorough management of dental caries is needful for these patients. However, there are no studies that have elaborated what treatments should be chosen in cases of different severity of orthodontic-related caries, especially how to preserve the dental tissue as much as possible and obtain good aesthetic effect in the case of severe caries of whole occlusion. According to Caries management by risk assessment (CAMBRA), to prevent dental caries, the patients are recommended to do as followed: (1) Fluoride varnish applied in the clinic at the time of the clinical visit and get X-ray exam, reapplied every 6 to 12 months. (2) Brushing with high fluoride (5000 ppm F) toothpaste instead of regular fluoride toothpaste, at least twice daily, plus counseling on reducing between-meal snacking of fermentable carbohydrates. (3) Rinse for one minute once daily for one week each month with a chlorhexidine gluconate mouthrinse (0.12%). This should be done at least one hour apart from the fluoride toothbrushing, preferably last thing at night before bed. (4) Take xylitol gum 4 times a day. (5) Get pit and fissure sealing. 2 These advices should be emphasized to patients before orthodontic treatment, and be repeated through the whole treatment. Recent studies have found that using mobile phone application also improved oral hygiene of orthodontic patients and reduce the risk of caries. 8 If carious white spot lesions are found during or after orthodontic treatment, but carious cavity has not formed yet, fluoride treatment, remineralization treatment and infiltration treatment are all acceptable choices. Nowadays, with the development of oral materials, many products can be used for such treatments. Acidulated phosphate fluoride gel (APF-gel) and fluoride varnish are widely used in fluoride treatment, and CPP-ACP is generally used in remineralization treatment. It has been proved that the effect of infiltration treatment is better than that of fluoride and remineralization. 9, 10 Infiltration treatment is a new technique to prevent early caries from developing by using new resin material – infiltrating resin. The fluidity of low viscous resin permeates into the porous structure of the demineralized enamel driven by capillary forces and prevent the diffusion of nutrients and the progression of caries. Resin blocking and filling micropores form a barrier in the caries, replacing the loss of hard tissue caused by demineralization, enhancing the enamel structure and acid resistance, preventing the surface disintegration of enamel and the formation of cavities. 11 When carious cavities form, decayed dental tissue should be removed if the patient’s situation is severe, for example, all the teeth get carious cavities and white spot lesions like the case we reported, a combination of infiltrating resin and composite resin is recommended. As we showed above, composite resin was used to fill cavities, and infiltrating resin is for white spot lesions. In this way, more dental tissue was able to be retained, and better aesthetic effect can be obtained. What’s more, it is worth emphasizing that although grinding decayed dental tissue is inevitable, the minimally invasive principle should be kept in mind (Fig. 9 ). If conditions permit, it is recommended to operate under a microscope. Conclusion Patients who are taking or have taken orthodontic treatment have higher risk of caries, so scientific caries management is necessary. In different stages of dental caries, different treatments are suggested. In this case, we filled the decayed cavities with composite resin, while evanishing white spot lesions with infiltrating resin. This combined method showed good therapeutic effect on severe dental caries after orthodontic treatment. Abbreviations BOP Bleeding on Probing PD Periodontal Probing DSD Digital Smile Design CAMBRA Caries management by risk assessment APF-gel Acidulated phosphate fluoride gel CPP-ACP Casein Phosphopeptide-Amorphous Calcium Phosphate Declarations Ethics approval and consent to participate The treatment protocol described in this case report was performed in accordance with the principles of the Declaration of Helsinki. Ethical approval was not required for this single case report in accordance with local and national guidelines. Informed consent for participation in the clinical treatment and relevant examinations was obtained from the patient and her legal guardians. Consent for publication Consent for publication Written informed consent was obtained from the patient’s legal guardian for the publication of this case report and any accompanying images. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing Interest The authors declare no conflicts of interest. Funding This research was funded by Guangdong Basic and Applied Basic Research Foundation (No.2022A1515011266, No.2019A1515011289), National Natural Science Foundation of China (No. 81700950), Medical Scientific Research Foundation of Guangdong Province of China (A2022322). Authors’ contributions JY.Z and YZ.C contributed equally to this work. JM.Z and YY.K participated in the study design; JM.Z, JY.Z, QN.G, XB.F and FY.Z performed the clinical treatment and data acquisition; JY.Z and YZ.C wrote the manuscript; JY.Z, YZ.C, QN.G, XB.F, and FY.Z participated in data collection and literature review; JM.Z and YY.K revised the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Lombardo G, Vena F, Negri P, Pagano S, Barilotti C, Paglia L, Colombo S, Orso M, Cianetti S. Worldwide prevalence of malocclusion in the different stages of dentition: A systematic review and meta-analysis. Eur J Paediatr Dent. 2020; 21 : 115-122. Featherstone J, Crystal YO, Alston P, Chaffee BW, Doméjean S, Rechmann P, Zhan L, Ramos-Gomez F. Evidence-Based Caries Management for All Ages-Practical Guidelines. Front Oral Health. 2021; 2 : 657518. Pitts NB, Ekstrand KR. International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol. 2013; 41 : e41-e52. Julien KC, Buschang PH, Campbell PM. Prevalence of white spot lesion formation during orthodontic treatment. Angle Orthod. 2013; 83 : 641-647. Sundararaj D, Venkatachalapathy S, Tandon A, Pereira A. Critical evaluation of incidence and prevalence of white spot lesions during fixed orthodontic appliance treatment: A meta-analysis. J Int Soc Prev Community Dent. 2015; 5 : 433-439. Kamber R, Meyer-Lueckel H, Kloukos D, Tennert C, Wierichs RJ. Efficacy of sealants and bonding materials during fixed orthodontic treatment to prevent enamel demineralization: a systematic review and meta-analysis. Sci Rep. 2021; 11 : 16556. Wierichs RJ, Langer F, Kobbe C, Abou-Ayash B, Esteves-Oliveira M, Wolf M, Knaup I, Meyer-Lueckel H. Aesthetic caries infiltration - Long-term masking efficacy after 6 years. J Dent. 2023; 132 : 104474. Davoodi NS, Tayebi A, Rahimipour K, Zarei M, Mozaffari A, Mirzadeh M, Mousavi R, Bayat N. Efficacy of a mobile phone application for the improvement of oral hygiene of patients undergoing fixed orthodontic treatment : A randomized controlled clinical trial. J Orofac Orthop. 2025; 86 : 81-88. Aref NS, Alrasheed MK. Casein phosphopeptide amorphous calcium phosphate and universal adhesive resin as a complementary approach for management of white spot lesions: an in-vitro study. Prog Orthod. 2022; 23 : 10. Giray FE, Durhan MA, Haznedaroglu E, Durmus B, Kalyoncu IO, Tanboga I. Resin infiltration technique and fluoride varnish on white spot lesions in children: Preliminary findings of a randomized clinical trial. Niger J Clin Pract. 2018; 21 : 1564-1569. Paris S, Bitter K, Krois J, Meyer-Lueckel H. Seven-year-efficacy of proximal caries infiltration - Randomized clinical trial. J Dent. 2020; 93 : 103277. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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11:38:28","extension":"xml","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":46198,"visible":true,"origin":"","legend":"","description":"","filename":"5335323d8eb94290b78c9b528a3b53231structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/7fbd1f706f92c76523db5e0c.xml"},{"id":100394971,"identity":"d1515a15-8fbd-47c2-b2c9-d3b4e2cb0b20","added_by":"auto","created_at":"2026-01-16 11:35:30","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51691,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/b5437b4065f247c647b41e13.html"},{"id":100395074,"identity":"9f3189e7-13bc-4c68-ab93-e4768bbbe921","added_by":"auto","created_at":"2026-01-16 11:36:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2428253,"visible":true,"origin":"","legend":"\u003cp\u003eDigital photographs of patient’s teeth (A) before orthodontic treatment, (B) 2 years after orthodontic treatment, (C) 1 year after wearing retainer.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/ae77ee4448c478529891b469.png"},{"id":100395416,"identity":"e2f2ce9a-cedf-4428-a24c-24759aa7f052","added_by":"auto","created_at":"2026-01-16 11:39:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2878827,"visible":true,"origin":"","legend":"\u003cp\u003eTotal dental condition of the patient at the time of presentation.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/f546e4d655f702a71d14ba80.png"},{"id":100395148,"identity":"c22d1b6e-56e0-4c1d-8363-b4396e3fd921","added_by":"auto","created_at":"2026-01-16 11:38:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3031101,"visible":true,"origin":"","legend":"\u003cp\u003eFilling process of upper anterior teeth. (A) Shade selection. (B) Digital smile design (DSD). (C) Diagnostic wax-up and lingual guide plate. (D) Comparison ① before and ② after removal of decayed tissue. (E) Filling process of 22 and 23. (F) Filling process of 12. (G)Filling process of 13. (H) Filling process of 11 and 21. (I) Polishing. (J) Upper anterior teeth after polishing.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/60cec6ce3e37e57d31188c1d.png"},{"id":100395063,"identity":"8551dc41-ad9e-4fb5-b686-73429021624c","added_by":"auto","created_at":"2026-01-16 11:36:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2446771,"visible":true,"origin":"","legend":"\u003cp\u003eFilling process of the rest of teeth. (A) Teeth before grinding. ①Right upper posterior teeth, ②left upper posterior teeth, ③ left lower posterior teeth, ④right lower posterior teeth before removing decayed tissues. (B) Teeth after grinding. ①Right upper posterior teeth, ②left upper posterior teeth, ③ left lower posterior teeth, ④right lower posterior teeth after removing decayed tissues. (C) ①②Right upper posterior teeth, ③left upper posterior teeth, ④⑤left lower posterior teeth, ⑥⑦right lower posterior teeth after filling.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/2c9433b6d8f6769b5112892c.png"},{"id":100395316,"identity":"56a40c1b-1ab2-48cd-9abc-6cdd62dd803d","added_by":"auto","created_at":"2026-01-16 11:38:48","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2306646,"visible":true,"origin":"","legend":"\u003cp\u003eDigital photographs of (A) maxillary and (B) mandibular teeth 1 week after filling.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/c13bca47a28d34b790bb0ab1.png"},{"id":100395840,"identity":"a0843db2-37a6-493c-ad6f-059c028612d0","added_by":"auto","created_at":"2026-01-16 11:39:27","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":2769342,"visible":true,"origin":"","legend":"\u003cp\u003eInfiltration progress. (A) Micro-grinding and cleaning.(B) Etching with 15% hydrochloric acid. (C) Drying with blowing gun. (D) drying with 99% ethanol. (E) All teeth ①④coating infiltrating resin and ②photocuring. ③⑤⑥After photocuring. (F) 11 and 21 ①before retreatment, ②etching with 15% hydrochloric acid, ③coating infiltrating resin and ④after retreatment.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/ec5a841c79245b2690577184.png"},{"id":100395412,"identity":"7429e0bd-c7d5-4916-9212-a23d913222a3","added_by":"auto","created_at":"2026-01-16 11:39:01","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":970751,"visible":true,"origin":"","legend":"\u003cp\u003eDigital photographs of patient’s teeth (A) right after infiltration treatment, (B) 8 months after infiltration treatment, (C) 12 monthsafter infiltration treatment, (D) 30 months after infiltration treatment.\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/b469c695a33947761dc720f1.png"},{"id":100395315,"identity":"1872c542-b0ce-46e1-b47f-5afa762c1d46","added_by":"auto","created_at":"2026-01-16 11:38:48","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":429244,"visible":true,"origin":"","legend":"\u003cp\u003eComparison between the patient’s teeth (A) before treatment and (B) 30 months after the treatment.\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/a0296862239bf9e6951d3d91.png"},{"id":100395583,"identity":"1df8f988-4296-4ad3-a136-415aa909b661","added_by":"auto","created_at":"2026-01-16 11:39:09","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":1632545,"visible":true,"origin":"","legend":"\u003cp\u003eProgressive minimally invasive prevention and treatment of caries after orthodontic treatment.\u003c/p\u003e","description":"","filename":"floatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/8c36b86c4dcbec0f913e7113.png"},{"id":102398305,"identity":"a705850c-067e-43ca-b048-bea13fe3b56f","added_by":"auto","created_at":"2026-02-11 10:22:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":19337451,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8309543/v1/a4f6054c-4c50-40e4-9090-7c8425f538d2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Infiltrating Resin Combined with Composite Resin to Cure Whole-mouth Dental Caries After Orthodontic Treatment: A Case Report","fulltext":[{"header":"Key points","content":"\u003cul\u003e\n \u003cli\u003ePatients received orthodontic treatment have a higher risk of developing caries which affects multiple teeth.\u003c/li\u003e\n \u003cli\u003eFor this widespread decay, a treatment that is both minimally invasive and aesthetically improved should be found.\u003c/li\u003e\n \u003cli\u003eThe combination of composite resin and infiltrating resin has good therapeutic effect on severe orthodontic treatment-caused dental caries.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eMalocclusion is the third most common oral disease after caries and periodontal disease, whose prevalence is 56% worldwide.\u003csup\u003e1\u003c/sup\u003e For children, studies have demonstrated that malocclusion can affect aesthetic appearance, psychosocial well-being, and social interactions in the long term. Therefore, orthodontic treatment is necessary. However, patients received orthodontic treatment have a higher risk of developing caries.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOrthodontic-related caries has its own characteristics. It often affects multiple teeth in the mouth, and can be divided into initial stage decay, moderate decay, and extensive decay according to their severity.\u003csup\u003e3\u003c/sup\u003e In the initial stage decay, it appears as white spot lesions caused by demineralization, and generally there is no obvious formation of cavities. The existence of caried white spot lesions is a common complication in orthodontic patients. On average, such decalcifications are found in 30%‒70% of patients during orthodontic treatment.\u003csup\u003e4\u003c/sup\u003e The incidence rate of new carious lesions that developed during orthodontic treatment was 45.8%, with a prevalence rate of 68.4% in patients under orthodontic treatment.\u003csup\u003e5\u003c/sup\u003e Since the higher prevalence rate for orthodontic patients, doctors tried to prevent the initiation or inhibit the progress of such orthodontic-related white spot lesions with fixed appliances with coating agents such as sealants and other bonding materials.\u003csup\u003e6\u003c/sup\u003e Some doctors tried to restore aesthetics of such orthodontic-related white spot lesions with infiltrating resin Icon, and achieved good treatment results.\u003csup\u003e7\u003c/sup\u003e Extensive decay shows obvious caries cavity formation, often accompanied by hard enamel white spot lesions. If left untreated, caries often deteriorates in a progressive manner.\u003c/p\u003e \u003cp\u003eIn this case report, we describe a treatment combined infiltrating resin with composite resin to cure whole-mouth dental caries with both carious cavity formation and white spot lesions after orthodontic treatment.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 14-year-old female was referred to our hospital with complaints of carious cavities and white spots on her every tooth after orthodontic treatment. She started the orthodontic treatment 3 years ago, and had worn orthodontic retainers for 1 year (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). When the treatment was finished, fast progressing caries damages and white spot lesions could be seen on every one of her teeth. Clinical examination revealed caries on the labial surfaces and incisal margins of upper and lower anterior teeth, and on the occlusal cusps and buccal surfaces of upper and lower posterior teeth (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with no clinical symptoms, no heat and cold sensitivity, no percussion pain, no loosening. The whole-mouth gingiva was red and swollen, BOP (+), PD\u0026thinsp;=\u0026thinsp;1\u0026thinsp;~\u0026thinsp;3. The diagnosis was rampant caries and chronic gingivitis. After reviewing the benefits and risks with the patient and her parents, we planned to fill all caries damages with composite resin (Ceram.X duo, Dentsply Sirona, Germany) and repair white spot lesions with infiltrating resin (Icon, DMG, Germany) after supragingival scaling. The time-consuming filling treatment would be divided into 5 visits and her occlusion would be divided into 5 parts - upper anterior teeth, left upper posterior teeth, left lower teeth, right lower teeth, and right upper posterior teeth.\u003c/p\u003e \u003cp\u003eShade A2 was selected after shade selection of anterior and posterior teeth respectively, and correspondingly, enamel resin E2 and dentin resin D2 (Ceram.X duo, Dentsply Sirona, Germany) was chosen (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). It could be seen that the pupil line and the oral line of the patient were parallel and perpendicular to the middle line, and the curve of the incisal margin was consistent with the curve of the lower lip (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB①). The highest points of the cervical margins were basically symmetric. The ratio of width to length of 11 and 21 was asymmetrical, the mesial incisal angles were defective, and the tooth axis were not parallel. In order to obtain a more beautiful dentition, digital smile design (DSD) for patient was made between two visits (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB②). Diagnostic wax-up and lingual guide plate were made referring to DSD (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). At the second visit, the patient\u0026rsquo;s upper anterior teeth were minimally-invasively grinded to remove softened decayed tissues but retained hard white spot lesions with small ball-shaped drill and ultrasonic tip (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). As showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE①②③, the lingual and incisal enamel of 22 and 23 was filled with the help of lingual guide plate, followed by filling the dentin part \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE④) and next the labial surfaces (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE⑤⑥) step by step. 12 and 13 were treated in the same procedure described above (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eF, G), and the enamel defect in lingual and labial surfaces of 11 and 21 was filled (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eH). When filling was finished, the repaired teeth were adjusted and polished with polisher and polishing paste (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eI, J). All work was done under microscope.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the following visits, the rest divisions of her occlusion were grinded as mentioned above (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA, B). Enamel resin was used to fill missing enamel, and dentin resin was used to fill missing dentin (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC). Polishing was done as mentioned above.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo lightened the white spots, infiltration treatment was carried out 1 week after filling (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIsolated all the teeth with rubber dam, the surfaces of teeth were micro-grinded and cleaned with fluorine-free grind paste (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eA). Then the teeth were acid etched with 15% hydrochloric acid for 2 minutes (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eB), rinsed for 30 seconds, and dried with blowing gun (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eC). All teeth were dried with 99% ethanol for 30 seconds following with blowing gun (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eD) before coating infiltrating resin. 3 minutes later, redundant resin was removed with dental floss, and every surface of teeth was photocured for 40 seconds (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eE). Most of the white spots disappeared after the infiltration treatment, but some stubborn spots still remained on the labial surfaces of the upper central incisors. Hence a local treatment of this area was carried out as the same method mentioned above (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSignificant effect could be seen before (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and right after the treatment (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eA). The patient was called back 8 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eB), 12 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eC) and 30 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eD) after the treatment, the therapeutic effect was steady without recurrence (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePatients under orthodontic treatment is in high-caries-risk. Therefore, a thorough management of dental caries is needful for these patients. However, there are no studies that have elaborated what treatments should be chosen in cases of different severity of orthodontic-related caries, especially how to preserve the dental tissue as much as possible and obtain good aesthetic effect in the case of severe caries of whole occlusion.\u003c/p\u003e \u003cp\u003eAccording to Caries management by risk assessment (CAMBRA), to prevent dental caries, the patients are recommended to do as followed: (1) Fluoride varnish applied in the clinic at the time of the clinical visit and get X-ray exam, reapplied every 6 to 12 months. (2) Brushing with high fluoride (5000 ppm F) toothpaste instead of regular fluoride toothpaste, at least twice daily, plus counseling on reducing between-meal snacking of fermentable carbohydrates. (3) Rinse for one minute once daily for one week each month with a chlorhexidine gluconate mouthrinse (0.12%). This should be done at least one hour apart from the fluoride toothbrushing, preferably last thing at night before bed. (4) Take xylitol gum 4 times a day. (5) Get pit and fissure sealing.\u003csup\u003e2\u003c/sup\u003e These advices should be emphasized to patients before orthodontic treatment, and be repeated through the whole treatment. Recent studies have found that using mobile phone application also improved oral hygiene of orthodontic patients and reduce the risk of caries.\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIf carious white spot lesions are found during or after orthodontic treatment, but carious cavity has not formed yet, fluoride treatment, remineralization treatment and infiltration treatment are all acceptable choices. Nowadays, with the development of oral materials, many products can be used for such treatments. Acidulated phosphate fluoride gel (APF-gel) and fluoride varnish are widely used in fluoride treatment, and CPP-ACP is generally used in remineralization treatment. It has been proved that the effect of infiltration treatment is better than that of fluoride and remineralization.\u003csup\u003e9, 10\u003c/sup\u003e Infiltration treatment is a new technique to prevent early caries from developing by using new resin material \u0026ndash; infiltrating resin. The fluidity of low viscous resin permeates into the porous structure of the demineralized enamel driven by capillary forces and prevent the diffusion of nutrients and the progression of caries. Resin blocking and filling micropores form a barrier in the caries, replacing the loss of hard tissue caused by demineralization, enhancing the enamel structure and acid resistance, preventing the surface disintegration of enamel and the formation of cavities.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhen carious cavities form, decayed dental tissue should be removed if the patient\u0026rsquo;s situation is severe, for example, all the teeth get carious cavities and white spot lesions like the case we reported, a combination of infiltrating resin and composite resin is recommended. As we showed above, composite resin was used to fill cavities, and infiltrating resin is for white spot lesions. In this way, more dental tissue was able to be retained, and better aesthetic effect can be obtained. What\u0026rsquo;s more, it is worth emphasizing that although grinding decayed dental tissue is inevitable, the minimally invasive principle should be kept in mind (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e). If conditions permit, it is recommended to operate under a microscope.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePatients who are taking or have taken orthodontic treatment have higher risk of caries, so scientific caries management is necessary. In different stages of dental caries, different treatments are suggested. In this case, we filled the decayed cavities with composite resin, while evanishing white spot lesions with infiltrating resin. This combined method showed good therapeutic effect on severe dental caries after orthodontic treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBOP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bleeding on Probing\u003c/p\u003e\n\u003cp\u003ePD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Periodontal Probing\u003c/p\u003e\n\u003cp\u003eDSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Digital Smile Design\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCAMBRA \u0026nbsp; \u0026nbsp; Caries management by risk assessment\u003c/p\u003e\n\u003cp\u003eAPF-gel \u0026nbsp; \u0026nbsp; \u0026nbsp; Acidulated phosphate fluoride gel\u003c/p\u003e\n\u003cp\u003eCPP-ACP \u0026nbsp; \u0026nbsp; \u0026nbsp;Casein Phosphopeptide-Amorphous Calcium Phosphate\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe treatment protocol described in this case report was performed in accordance with the principles of the Declaration of Helsinki. Ethical approval was not required for this single case report in accordance with local and national guidelines. Informed consent for participation in the clinical treatment and relevant examinations was obtained from the patient and her legal guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication Written informed consent was obtained from the patient’s legal guardian for the publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by Guangdong Basic and Applied Basic Research Foundation (No.2022A1515011266, No.2019A1515011289), National Natural Science Foundation of China (No. 81700950), Medical Scientific Research Foundation of Guangdong Province of China (A2022322).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJY.Z and YZ.C contributed equally to this work. JM.Z and YY.K participated in the study design; JM.Z, JY.Z, QN.G, XB.F and FY.Z performed the clinical treatment and data acquisition; JY.Z and YZ.C wrote the manuscript; JY.Z, YZ.C, QN.G, XB.F, and FY.Z participated in data collection and literature review; JM.Z and YY.K revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLombardo G, Vena F, Negri P, Pagano S, Barilotti C, Paglia L, Colombo S, Orso M, Cianetti S. Worldwide prevalence of malocclusion in the different stages of dentition: A systematic review and meta-analysis. Eur J Paediatr Dent. 2020; \u003cstrong\u003e21\u003c/strong\u003e: 115-122.\u003c/li\u003e\n\u003cli\u003eFeatherstone J, Crystal YO, Alston P, Chaffee BW, Dom\u0026eacute;jean S, Rechmann P, Zhan L, Ramos-Gomez F. Evidence-Based Caries Management for All Ages-Practical Guidelines. Front Oral Health. 2021;\u003cstrong\u003e2\u003c/strong\u003e: 657518.\u003c/li\u003e\n\u003cli\u003ePitts NB, Ekstrand KR. International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol. 2013; \u003cstrong\u003e41\u003c/strong\u003e: e41-e52.\u003c/li\u003e\n\u003cli\u003eJulien KC, Buschang PH, Campbell PM. Prevalence of white spot lesion formation during orthodontic treatment. Angle Orthod. 2013; \u003cstrong\u003e83\u003c/strong\u003e: 641-647.\u003c/li\u003e\n\u003cli\u003eSundararaj D, Venkatachalapathy S, Tandon A, Pereira A. Critical evaluation of incidence and prevalence of white spot lesions during fixed orthodontic appliance treatment: A meta-analysis. J Int Soc Prev Community Dent. 2015; \u003cstrong\u003e5\u003c/strong\u003e: 433-439.\u003c/li\u003e\n\u003cli\u003eKamber R, Meyer-Lueckel H, Kloukos D, Tennert C, Wierichs RJ. Efficacy of sealants and bonding materials during fixed orthodontic treatment to prevent enamel demineralization: a systematic review and meta-analysis. Sci Rep. 2021; \u003cstrong\u003e11\u003c/strong\u003e: 16556.\u003c/li\u003e\n\u003cli\u003eWierichs RJ, Langer F, Kobbe C, Abou-Ayash B, Esteves-Oliveira M, Wolf M, Knaup I, Meyer-Lueckel H. Aesthetic caries infiltration - Long-term masking efficacy after 6 years. J Dent. 2023; \u003cstrong\u003e132\u003c/strong\u003e: 104474.\u003c/li\u003e\n\u003cli\u003eDavoodi NS, Tayebi A, Rahimipour K, Zarei M, Mozaffari A, Mirzadeh M, Mousavi R, Bayat N. Efficacy of a mobile phone application for the improvement of oral hygiene of patients undergoing fixed orthodontic treatment : A randomized controlled clinical trial. J Orofac Orthop. 2025; \u003cstrong\u003e86\u003c/strong\u003e: 81-88.\u003c/li\u003e\n\u003cli\u003eAref NS, Alrasheed MK. Casein phosphopeptide amorphous calcium phosphate and universal adhesive resin as a complementary approach for management of white spot lesions: an in-vitro study. Prog Orthod. 2022; \u003cstrong\u003e23\u003c/strong\u003e: 10.\u003c/li\u003e\n\u003cli\u003eGiray FE, Durhan MA, Haznedaroglu E, Durmus B, Kalyoncu IO, Tanboga I. Resin infiltration technique and fluoride varnish on white spot lesions in children: Preliminary findings of a randomized clinical trial. Niger J Clin Pract. 2018; \u003cstrong\u003e21\u003c/strong\u003e: 1564-1569.\u003c/li\u003e\n\u003cli\u003eParis S, Bitter K, Krois J, Meyer-Lueckel H. Seven-year-efficacy of proximal caries infiltration - Randomized clinical trial. J Dent. 2020; \u003cstrong\u003e93\u003c/strong\u003e: 103277.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8309543/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8309543/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the aesthetic efficacy of the combination of composite resin Ceram.X duo and infiltrating resin Icon to cure severe caries after orthodontic treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe treatment for a 14-year-old girl, who had been found caried white spot lesions and cavities on her every tooth, was divided into two parts \u0026ndash; filling cavities with composite resin Ceram.X duo and masking white spot lesions with infiltrating resin Icon. After treatment, she was followed up for 30 months.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe optical improvement can be observed significantly right after the treatment, and remains stable for at least 30 months.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe combination of composite resin Ceram.X duo and infiltrating resin Icon showed good therapeutic effect on severe dental caries after orthodontic treatment.\u003c/p\u003e","manuscriptTitle":"Infiltrating Resin Combined with Composite Resin to Cure Whole-mouth Dental Caries After Orthodontic Treatment: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 08:19:32","doi":"10.21203/rs.3.rs-8309543/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02457415-db7f-46ab-a914-5b02d1f87059","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T09:41:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 08:19:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8309543","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8309543","identity":"rs-8309543","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}