Patient experiences with clear aligners: a scoping review

Abstract

Introduction

Clear aligner therapy (CAT) is an aesthetic alternative to fixed appliance therapy (FAT). An understanding of patient experiences with CAT can enable clinicians to educate patients, manage expectations, and identify potential barriers to effective treatment. A scoping review was undertaken to map and synthesise the available evidence on patient experiences with CAT.

Methods

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The PubMed (MEDLINE), Embase, Scopus, Web of Science and Dentistry & Oral Sciences Source databases and grey literature were searched. Data collation and synthesis was presented in descriptive and tabular formats.

Results

The initial search yielded 541 articles following removal of duplicate studies. 37 studies met the selection criteria and were scoped in the present review. The studies identified included cross-sectional, longitudinal, prospective, and randomised clinical trials reporting on patient experiences with CAT associated with Oral Health-Related Quality of Life (OHRQOL) and satisfaction. The impacts of CAT on OHRQOL with relevance to pain was the most frequently evaluated aspect, followed by speech, satisfaction, eating, anxiety, and sleep.

Conclusions

CAT patients report satisfaction with the aesthetics of the appliance however can expect transient negative effects on OHRQOL, pain, anxiety, and speech after commencing treatment. Further longitudinal research using validated qualitative tools focussing on CAT is required.

Registration

This review was registered in the Open Science Framework database (DOI: xx)

Introduction

Clear aligner therapy (CAT) involves the provision of a series of removable thermoplastic trays that incrementally shift the teeth of orthodontic patients into a pre-planned position. CAT has gained in popularity since the introduction of Align Technology’s Invisalign aligner system in the late 1990s [1]. In Australia, a recent survey found that 93.13% of orthodontists provided CAT as an orthodontic treatment option [2]. In the United Kingdom and Republic of Ireland, 77.3% of orthodontists surveyed reported offering CAT [3]. A total of 65% of survey respondents in the United States and Canada reported using CAT in their practice [4]. Aligner companies claim greater comfort and reduced treatment times with CAT [5]. Other purported advantages include aesthetics, improved periodontal health and reduced chairside time [6]. However, CAT is a compliance-dependent treatment modality. A retrospective study of compliance with CAT observed that only 36% of patients fully adhered to the prescribed wear time [7]. Therefore, gaining insight into patient experiences with CAT is essential to identify possible barriers to compliance.

Patient experiences are the sum of all interactions that influences patients’ perception of treatment received throughout the continuum of care [8]. These experiences shape patients’ understanding and satisfaction with their treatment and are a reflection of both the personal and interpersonal aspects of care received [8]. Ultimately, a comprehensive understanding of patient experiences is crucial for clinicians to align patient expectations with the realities of treatment, further facilitating the informed consent process [9].

In recent years, there has been an increasing demand for the output of qualitative research in healthcare. This is further reinforced by the need to consider patient values and not just the quantitative measurement of clinical outcomes relevant to health professionals [10]. Qualitative research allows the exploration of subjective aspects of healthcare and behavioural contexts which are central to patient-clinician interactions and optimising treatment outcomes [11, 12]. Systematic reviews have been undertaken in relation to patient experiences with CAT [13–18]. However, these studies indicate the generally low to moderate levels of evidence available in this area. Moreover, studies have generally not tended to encompass the full range of patient-reported experiences with CAT but have focussed on a single domain such as pain or speech [13, 14, 16]. Additionally, these systematic reviews have drawn on information from a limited number of studies answering a specific question that predominantly concentrated on comparing CAT with FAT. Given the potentially broad landscape of the current evidence-base, there is a need for a more comprehensive perspective on this topic to clarify the key relevant themes which can be challenging within the constraints of a systematic review. Furthermore, unlike systematic reviews that are typically quantitative in nature, the qualitative nature of the scoping review methodology is appropriate for the exploration of literature on patient-reported experiences with CAT [19]. The inclusive nature of scoping reviews, without the need for these studies to meet the often-strict criteria required in systematic reviews, further facilitates the mapping out of these key concepts on a broader level. Scoping reviews can also help identify deficiencies in the literature to guide further research and can act as a precursor to further systematic review(s) [20]. Considering these key elements pertinent to the scoping review methodology, a scoping review was undertaken to collate and synthesise the evidence in relation to patient experiences with CAT.

The findings drawn from this review will offer clinicians a broad understanding of patient-reported experiences with CAT and highlight treatment-related factors that are significant from the patients’ perspective. Knowledge of these patient perspectives of CAT can guide clinicians in engaging in more meaningful communication with patients addressing their expectations and concerns. Ultimately, this supports the provision of patient-centred care and can help foster the patient-orthodontist relationship.

Materials and methods

The present review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews [21]. It was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [22]. A review question was developed based on the scoping review mnemonic PCC (Population, Concept, Context), equivalent to the PICOS mnemonic used in systematic reviews (Population, Intervention, Comparison, Outcome, Study Design) [21]. Table 1 outlines the inclusion and exclusion criteria for publications in the present review based on the PCC [21].

Participants

All adult patients (≥18y) treated with CAT.

Concept

Patient-reported experiences with CAT.

Context

Patients undergoing treatment with CAT, with no restriction on geographic location.

Review question

The review question was ‘What are the patient-reported experiences with CAT?’

Search strategy

The search strategy aimed to comprehensively map the existing literature. PubMed (MEDLINE), Embase, Scopus, Web of Science and Dentistry & Oral Sciences databases were searched on 29 July 2024. Supplementary Table I shows the search terms used for each database. The reference lists of studies included in this scoping review were also reviewed to identify additional studies. The American Journal of Orthodontics and Dentofacial Orthopedics (AJODO), European Journal of Orthodontics (EJO), Angle Orthodontist, Australasian Orthodontic Journal, Journal of the World Federation of Orthodontists, Seminars in Orthodontics, Progress in Orthodontics and Journal of Orthodontics were also hand-searched to identify further relevant studies.

Study screening

All studies identified from the search were uploaded into Covidence (Covidence, Vic, Aus) for screening. Covidence is an online platform used to facilitate the screening and extraction of data for systematic and scoping reviews. After duplicates were removed, two reviewers (xx & yyy) screened the titles and abstracts to evaluate their eligibility based on the selection criteria. All sources meeting the inclusion criteria were retrieved for full-text review, which was conducted by two reviewers (xx & zz). This led to further exclusion of sources that did not meet the inclusion criteria. The reasons for exclusion of these sources were documented and can be found in Supplementary Table II.

Data extraction

Data were extracted into a data extraction tool in Microsoft Excel (Microsoft Corporation, Redmond, WA). Details related to the participants, concept, context, study design and key findings relevant to the review question were recorded. Following this, the extracted data were synthesised and presented in tables. The date were organised by treatment modality, study methodology, qualitative tool for analysis, time-point of analysis, key findings, and the corresponding patient experience.

Results

Study inclusion

Figure 1 shows that a total of 37 studies met the selection criteria and were included in this scoping review.

Characteristics of included studies

Characteristics of study location

Table 2 shows that the largest number of relevant studies were conducted in Europe (n = 13; 35.14%), with Spain (n = 6; 16.22%) [23–28] being the country in which studies were most commonly undertaken.

Characteristics of journal publication and study type

The majority of studies were published in orthodontic-based journals (n = 20; 54.05%) [6, 29–47]. The AJODO was the journal which reported most studies (n = 5; 13.51%) [30, 36, 38–40], followed by the EJO (n = 3; 8.11%) [33, 34, 42] and Progress in Orthodontics (n = 3; 8.11%) [43, 46, 47]. Three studies were published in general dentistry journals [25, 28, 48], 13 studies in other scientific journals [23, 24, 26, 27, 49–57], and one was a post-graduate thesis [58]. The investigations comprised prospective observational studies (n = 25; 67.57%) [6, 23–28, 31–34, 37–43, 45, 46, 49, 50, 54, 56, 57] and cross-sectional studies (n = 12, 32.43%) [29, 30, 35, 36, 44, 47, 48, 51–53, 55, 58]. Of the prospective studies, five [26–28, 40, 49] were longitudinal with patients followed for time periods ranging 3 mo from commencing treatment through to the end of treatment and four [34, 41, 54, 56] were randomised clinical trials. Fig. 2 shows that there has been an increase in the number of relevant publications in recent years.

Characteristics of samples

All studies involved adult populations involving patients over 18 years of age. Sex was specified in all apart from four studies [45, 50, 52, 54]. Where sex was specified, females comprised the greater number of participants in all studies.

Characteristics of appliances evaluated

Studies largely evaluated patient experiences with CAT in comparison to other orthodontic appliances, primarily with labial fixed appliances [FA] (n = 18, 48.65%) [25, 27, 28, 32, 34–38, 40–44, 53, 55–57], with lingual fixed appliances (LFA) (n = 10, 27.02%) [23, 24, 26, 30, 33, 45, 46, 49, 51, 54], or with direct-to-consumer (DTC) aligners (n = 2, 5.41%) [48, 58]. Patient experiences with CAT alone were examined least frequently (n = 8, 21.62%) [6, 29, 31, 39, 47, 48, 50, 52]. Table 3 shows that Invisalign (Align Technology, Santa Clara, CA) was the most frequently prescribed CAT system (n = 20, 54.05%) [6, 23–25, 27–29, 31–33, 36–41, 43, 49, 53, 55] among the studies in the present review.

Characteristics of qualitative tool used

Various qualitative tools were employed to evaluate patient experiences with CAT. The key features of these are outlined in Supplementary Table III.

Questionnaires were the most frequently used tool except in four studies that used tools such as a daily diary [38, 41] or semi-structured interviews [30, 58]. The qualitative tools used in the studies included in this scoping review are presented in Table 4. A total of 16 studies used validated instruments to measure the patient’s Oral Health-Related Quality of Life (OHRQOL). The Oral Health Impact Profile-14 (OHIP-14) was most commonly used [6, 23, 25, 26, 28, 34, 42, 47, 56]. The OHIP-14 consists of 14 questions gauging the impact of treatment on OHRQOL. This was followed by the OHRQOL questionnaire in four studies [33, 49, 53, 57], the Dental Impacts on Daily Living Index (DIDL) in two studies [36, 39] and the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) in one [46]. The OHRQOL and WHOQOL-BREF both evaluate aspects related to OHRQOL such as pain, oral symptoms and psychological well-being. The Dental Impacts on Daily Living Index (DIDL) was used to evaluate how treatment interferes with daily life across domains such as appearance, pain and eating. Pain was evaluated as part of a questionnaire in 20 studies [23, 24, 28, 29, 31, 33, 34, 39, 40, 42, 45–47, 49, 51–53, 55–57]. Other studies evaluated pain using the Visual Analogue Scale (VAS) alone [6, 27, 32, 42, 43], in combination with a daily diary [38, 41], or as part of a semi-structured interview [30, 58]. The VAS involves patients marking their pain level along a linear scale, enabling visual reflection of the patient’s pain experience. The McGill Pain Questionnaire (MPQ), which evaluates sensory, functional, and emotional aspects of pain was used in two studies [23, 24]. Anxiety was measured using the State-Trait Anxiety Inventory (STAI) [25, 42] or the Self-Rating Anxiety Scale (SRAS) [6]. Both of these tools involve a series of questions that patients answer on a Likert scale.

Patient satisfaction was measured as part of the Patient Satisfaction Questionnaire (PSQ) in two studies [36, 39]. One study used sleep-specific questionnaires including the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale to measure the impact of treatment on sleep quality [35]. Thirteen (35.14%) studies [28, 29, 31, 37, 44, 45, 47, 48, 50–52, 54, 55] included in this scoping review appeared to have used qualitative tools that were not validated. Two studies [28, 47] used the validated OHIP-14 tool in combination with a non-validated questionnaire.

Review findings

An overview of the studies can be found in Table 5 while key relevant findings are outlined in Supplementary Table IV. Pain and OHRQOL were the most frequently explored patient experiences reported by the studies. Various other dimensions of OHRQOL including speech, eating, anxiety, psychosocial factors and sleep were also investigated (Fig. 3).

OHRQOL

Pain

OHRQOL encompasses how oral health can influence an individual’s overall physical and psychosocial well-being [59]. It is the outcome of complex interrelationships between oral health conditions, social factors, contextual factors and systematic health [60]. Sixteen studies [25, 26, 28, 31, 33, 34, 36, 39, 42, 46, 47, 49, 53, 55–57] in the present review evaluated OHRQOL in relation to CAT. The consensus from the findings from these studies was that the most significant decline in OHRQOL was observed in the first 2 days of treatment, which correlated with pain levels peaking in the first 24 hours following appliance insertion [6, 23, 42, 47, 56]. Pain was found to reduce by the end of the first week of treatment according to six studies [6, 33, 38, 42, 56, 57]. Overall, pain and analgesic use was reportedly lower in patients undergoing CAT compared with FA [27, 28, 32, 34, 42, 43, 45, 46, 55, 56]. CAT patients utilised the terms ‘dull pain’ or ‘pressure-like pain’ to describe their pain experience [53]. Most pain was reportedly localised to the anterior maxillary and mandibular dento-alveolar regions [24, 28]. Various reasons have been posed to explain why patients experience pain with CAT. Some of these reported reasons for pain included gingival pressure, tongue irritation, tray deformation and gingival swelling related to third molars or poor oral hygiene [43, 47].

Anxiety and psychosocial factors

Studies [6, 42] evaluating anxiety in CAT and FA patients found that anxiety levels closely mirrored pain levels, peaking in the first 1–2 days from commencing treatment. At 2 weeks, anxiety levels decreased in both CAT and FA patients. However, less anxiety was reported in CAT patients [42]. However, at 1 month following the start of treatment, there were no significant differences between the two groups [25, 42]. The number of additional aligner trays needed during the refinement phase was also correlated with higher levels of anxiety [6]. Minimal negative psychological impacts with CAT were observed in seven investigations [26, 30, 31, 36, 46, 55, 57]. Four studies [26, 46, 55, 57] reported significantly more positive psychological impacts in patients undergoing CAT treatment compared with FA. Another study [30] that assessed patients’ experiences with CAT, FA, and LFA treatment found that CAT and LFA patients experienced minimal impact on their social interactions, while FA patients felt restricted in their social interactions. However, on completion of treatment, one study [36] reported comparable levels of psychosocial improvements in both FA and CAT patients. Overall, the OHRQOL was found to improve by the end of treatment regardless of the appliance used [26].

Speech

Speech is a complex interplay of motor and sensory functions. CAT can disrupt tongue positioning and airflow, commonly resulting in misarticulation [16]. Speech impediments with CAT alone was the primary focus of two studies [37, 50]. Another study [44] compared the effects of both CAT and FA on speech. Six additional studies reported on the effects of CAT on speech as a secondary focus with CAT alone [31], in comparison with FA [53, 56, 57], or both FA and LFA [33, 45, 49]. Seven of the studies [31, 33, 44, 45, 53, 56, 57] investigating the effects of CAT on speech used questionnaires to gather data while three [37, 49, 50] utilised a mixed methods approach. Upon commencing CAT, patients noted immediate speech alterations that improved over time [31, 37, 50]. The reported time taken for patients to adapt to speech disturbances with CAT ranged from 4 days [33] and 1 week [57], to 3 months [49]. One study [37] reported that speech alterations did not return to pre-treatment levels at 2 months from commencing treatment. Furthermore, studies [33, 45, 49] comparing CAT, FA and LFA observed that LFA patients experience the most significant speech disturbances and extended adaptation time. However, studies [37, 44, 53] comparing speech with CAT and FA demonstrated that more CAT patients experienced greater limitations with speech. One study [56] found that FA patients experienced more difficulties with pronunciation compared to CAT patients. However, patients in the FA group were prescribed transpalatal arch and Nance appliances which may have influenced the findings.

Eating

Eating disturbances have been reported to varying extents with orthodontic appliances during treatment [30, 31, 33, 36, 39, 45, 49, 51, 53, 56, 57]. This was evaluated with CAT alone [31, 39], in comparison with FA [36, 53, 56, 57], LFA [49], or FA and LFA [30, 33, 45, 51]. One study [30] reported that all patients undergoing treatment with either CAT, FA or LFA experienced the need to modify dietary habits on commencing treatment. CAT patients in this study [30] reported a reduced tendency to snack due to the need to remove the appliance when eating. However, six studies [36, 45, 49, 53, 56, 57] reported that FA patients were found to experience more pronounced disturbances whilst eating compared to CAT patients. FA patients in one study [30] reported needing to restrict the types and amount of food they were consuming compared to CAT patients due to concerns of food trapping and staining of their appliance. Patients in this study also reported taking longer to finish their meals with FA and LFA [30]. Two studies [33, 49], evaluating CAT, FA and LFA patients, observed that LFA patients experienced greater disturbances when eating. Reported disturbances to eating included reduced chewing ability, food enjoyment and taste compared to FA and CAT patients [33]. However, the findings from one study [49] observed that at 3 months into treatment, the differences in eating disturbances were found to be negligible between patients with different appliances.

Sleep

Sleep was the primary focus of one study [35], and was further reported in four additional investigations [33, 41, 49, 57]. Any sleep disturbances experienced by patients were found to improve within the first week of treatment [41]. No significant differences in sleep disturbances were found between CAT and FA patients in three studies [35, 41, 57]. However, LFA patients were found to experience comparatively greater sleep disturbances [33, 49].

Satisfaction

Questionnaires [31, 36, 39, 47, 52–54, 57] and semi-structured interviews [30, 58] were used in ten studies to evaluate patient satisfaction with CAT. Greater satisfaction with the aesthetics of aligners compared to FA was frequently expressed by patients [30, 47, 53, 54, 57]. One study [47] reported that 90.7% of patients who had previously undergone treatment with FA reported greater satisfaction with CAT. The authors speculated that this was associated with reduced intensity and shorter duration of pain with the appliance [47]. A cross-sectional survey [51] of 175 patients reported that 82.9% rated their satisfaction with treatment as ‘eight out of ten’. These findings corresponded with those of another study [31] that utilised a questionnaire across eight appointments, which found that 84% of patients were ‘very satisfied’ with the results achieved thus far. Two studies [36, 39] reported that the ‘doctor-patient’ relationship demonstrated a strong positive correlation with satisfaction while pain and discomfort, most commonly food packing between teeth, were major sources of negative sentiments. Despite these associations, no single factor was found to have any statistically significant correlation with satisfaction levels, indicating the multi-factorial nature of patient satisfaction [36, 39].

Direct-to-consumer aligners

Patient experiences related to DTC aligners were the primary focus of one study [48], while patient experiences with DTC aligners were compared to CAT and FA in another investigation [58]. One study [48] surveyed the experiences of individuals undergoing treatment with DTC aligners and found that 87.5% of respondents were satisfied with their treatment while 6.6% reported experiencing complications severe enough to warrant seeking a dentist. Most respondents noted that cost and convenience were their major reasons for seeking DTC aligners over in-office CAT. Patients who were seeking treatment for the correction of ‘bite issues’ were reportedly less satisfied with their treatment [48]. Lower expectations of treatment outcome were also reported by patients electing to undergo treatment with DTC aligners [58]. However, the inability to reach a dental professional, difficulties with aligner fit, insertion, and quality were additional concerns raised by patients undergoing treatment with DTC aligners [58].

Discussion

This scoping review was conducted to map and synthesise the existing evidence surrounding patient experiences with CAT. The increasing global use of CAT as a treatment modality to manage malocclusions highlights the relevance of this review. A survey of orthodontists in North America reported that orthodontists in the younger generations felt that CAT would overtake FA as the primary treatment modality used to manage malocclusions in the future [61]. Patients are also reportedly willing to pay more for aesthetic appliances [62]. The increasing uptake of CA usage worldwide is further reflected in the projected rise in the market size of CA, valued at USD 2.9 billion in 2020, with an expected increase to USD 11.6 billion by 2027 [63]. The findings from this review highlighted a range of study types utilising different qualitative tools to evaluate patient-reported experiences with CAT including OHRQOL, specifically in relation to pain, psychosocial factors, speech, eating, sleep and overall satisfaction. The upward trend of studies reporting on this area in recent years is similarly reflected in a previous bibliometric study [64] of CAT publications between 2002–22. Given the increasing body of evidence and the breadth of the available studies on this topic, a scoping review methodology was considered most appropriate to answer the objectives of this review as it would enable the inclusion of a broad range of studies.

Key patient experiences evaluated with CAT in this review included OHRQOL and satisfaction. Overall, OHRQOL with CAT was found to decline in the early phase of treatment for patients, which was found to correlate with pain that tended to peak in the first day following initial aligner insert [6, 23, 24, 38, 42, 43, 57]. These findings aligned with the outcomes of studies [65–67] that have identified the impact of pain on OHRQOL during the initial phase of treatment with FA. Another finding was that FA patients experienced greater pain and consumed more analgesics during the first week of treatment compared to CAT patients [32, 41]. Reduced pain levels with CAT are purportedly the result of more intermittent forces provided by removable appliances in comparison to FA. This enables the re-organisation of tissues before re-application of compressive forces [41, 68]. The findings of the review also observed that anxiety paralleled pain levels [6, 42] and that CAT patients reported less psychosocial impacts compared to FA patients [26, 30, 46, 55, 57]. In correspondence with these findings, a 2013 study also recognised that anxious patients tended to favour CAT and LFA over labial FA due to their ‘concealed’ nature [69].

Issues regarding speech and eating disturbances with CAT were additional findings of this review. Speech alterations were considered transitory during the early stages of treatment with CAT while eating difficulties were minimal [36, 37, 41]. LFA patients experienced more negative impacts on speech, eating and sleep when compared to CAT and FA [33, 49]. This was perhaps unsurprising as LFA results in significant reduction of intra-oral space and restriction of tongue movement, both of which contribute to sound and speech distortion. However, regardless of the appliance used, all patients undergoing treatment experienced temporary speech alterations on commencing treatment [37, 44, 45]. This agrees with findings from a study [70] not included in this review which indicated that by the end of the first month of treatment, patient-reported speech disturbances improved to baseline levels in both CAT and FA groups. With regards to eating, the minimal impact of CAT on eating disturbances is expected, as aligners can be removed before meals.

Satisfaction with CAT has been reported in terms of the aesthetics of the appliance itself and treatment progress [30, 31, 53]. The importance of appliance aesthetics on patient satisfaction has been previously highlighted in studies [71, 72] not included in this review. Patients who expressed minimal concern with their appearance in social settings showed a strong correlation with appliance acceptance and compliance [72]. The importance of appliance aesthetics, especially among adult patients, is further highlighted by the perception that metal FA are typically associated with children and adolescents [71]. This is particularly relevant to CAT as it is predominantly undertaken in adult populations. The finding that doctor-patient relationships play a key role in patient satisfaction [36, 39] is also in line with previous studies that have highlighted this association [73–77].

Studies [48, 58] reporting on patient experiences with DTC aligners are limited. DTC aligners are favoured by some patients because of cost and convenience [48]. These findings corresponded with the findings of two studies [78, 79] not included in this review that surveyed the demographics and motivating factors for individuals that would be interested in undergoing treatment with DTC aligners. However, the lack of oversight by a dental professional with DTC aligners raises significant concerns regarding its safety and effectiveness.

Overall, the findings from this scoping review highlight that while CAT typically causes less discomfort than FA, temporary disturbances in speech and eating can be expected early in treatment. These findings emphasise the importance of educating patients and managing their expectations, particularly during the early phases of treatment.

Limitations

This scoping review is not without its limitations. The exclusion of studies published in languages other than English may have restricted the comprehensiveness of the results. Moreover, the exclusion of patients under 18 years old limit the relevance of the findings to adult populations. However, CAT is primarily favoured by adult populations as they demonstrate a preference for aesthetic appliances such as CAT and LFA rather than labial FA [80, 81]. While studies published prior to the year 2000 were also excluded, this was not thought to limit the comprehensiveness of the search given that publications related to contemporary CAT would have only emerged after the commercial release of Invisalign in 1999. Furthermore, despite efforts to ensure the search terms for this scoping review comprehensively covered the available relevant literature, variations in the terminology utilised may have also limited the ability to capture further relevant studies in this review. Moreover, in accordance with the PRISMA-ScR guidelines [22], a critical appraisal of the studies included in this scoping review was not conducted. As such, the findings from this study should be interpreted with caution. A further consideration is that CAT can be used in conjunction with auxiliaries such as elastics and temporary anchorage devices, or as part of a hybrid approach with FA, or in combination with orthognathic surgery. Whilst the inclusion of these approaches were outside the scope of this review, this may be an area for future investigation given that these factors may also influence the patient’s comfort, aesthetic perception and satisfaction with treatment as indicated by studies outside of this review [82, 83].

Conclusion

CAT patients may experience transitory effects on OHRQOL, in relation to pain, anxiety, mastication and speech during the initial phase of treatment. Overall, patients report satisfaction with the aesthetics of clear aligners and treatment outcomes with CAT. Findings from this review highlight the responsibility of clinicians in informing patients about the potential for temporary pain and disturbances to speech and eating, particularly during the initial stages of treatment with CAT. Overall, the heterogenous nature of the studies included in this scoping review, involving the evaluation of patients with varying malocclusions at different stages of treatment and over varying time periods, underscores the need for further research to establish more robust conclusions. Furthermore, the short-term nature of most studies involving patients at the early phases of treatment reinforces the need for more longitudinal studies. Formal critiquing of the studies is also outside the scope of this review. However, the breadth of studies included in this review indicates the need for further research to better guide clinicians in providing patient-centred care. More studies using validated qualitative tools to evaluate patient experiences with CAT in isolation rather than in comparison with other orthodontic appliances could also allow for further in-depth studies to be conducted in this area in the future.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

Supported by the Australian Society of Orthodontists Foundation for Research and Education.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

References