The provision of clear aligner treatment by general dental practitioners in England: a mixed-methods study

The provision of clear aligner treatment by general dental practitioners in England: a mixed-methods study | 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 Research The provision of clear aligner treatment by general dental practitioners in England: a mixed-methods study Ama Johal, Ghofran Ghofran Badabaan, Ryan McMeekin, Fiorella Colonio-Salazar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7509774/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Aim This study explored the training and working experiences of general dental practitioners (GDPs) in England in providing clear aligner treatment (CAT) to adult patients. Materials and methods A unique mixed methods approach was adopted, including an online questionnaire and one-to-one semi-structured interviews of GDPs across England providing CAT. Quantitative data were analysed descriptively using MS Excel and qualitative data using framework methodology. Results One-hundred completed surveys were received, and 16 interviews were conducted. Most GDPs reported having attained aligner certification (n = 86) and nearly one-third (n = 31) gained some theoretical knowledge of CAT but highlighted key shortcomings of the training courses, which need addressing. GDPs felt confident in treating mild or moderate malocclusion traits and expressed several reasons for choosing a specific CAT and digital scanner and provider. Those GDPs qualified more than 10 years could apply complex treatment mechanics. Laboratory-made fixed retainers were of higher preference following CAT, especially in complex malocclusions with high risk of relapse. Conclusion GDPs’ limited understanding and diverse practices in CAT provision, suggest the need for policy makers to review the undergraduate dental curriculum and for educators to ensure the inclusion of theoretical and practical aspects of CAT, together with the ongoing support of specialist in orthodontics. Health sciences/Health care/Dentistry/Orthodontics Introduction The increased demand for adult orthodontic treatment has seen an exponential rise in the use of more aesthetic appliance choices, amongst which there has been a corresponding increase in the popularity of clear aligner treatment (CAT). 1 The reported advantages of CAT include: better aesthetics; their removable nature; and range of tooth movements permissible. 1 In contrast, they require optimal wear adherence; removal for eating and notable limitations with challenging malocclusions. 2 , 3 CAT treatment has been portrayed to general dental practitioners (GDPs) as being relatively straightforward to undertake, with an unprecedented increase in their provision. 4 However, GDPs often graduate with limited training in orthodontic diagnosis and mechanotherapy and often acquire a variable level of training and experience in CAT. 4 Two surveys compared levels of experience between orthodontists and general dentists. 4 , 5 They found that orthodontists received more CAT training and were treating more cases than dentists, with the latter group expressing a lack of confidence after their initial certification course. 4 Interestingly, GDPs expressed greater confidence in treating more severe complexities of malocclusion with CAT. 4 , 5 Apart from performing interproximal enamel reduction (IPR), significant differences were observed in the use of all other auxiliaries, with GDPs less likely to use elastics and extractions. 5 More recently, d'Apuzzo et al. 3 highlighted GDP's lack of experience, as their reasoning for not undertaking CAT. A recent study reported that orthodontic tooth movement predictability via CAT was frequently overestimated by GDPs; thus, provision of future training for enhanced CAT efficacy with attention to CAT mechanics, cases requiring extractions, and troubleshooting governance has been emphasised. 6 Given the lack of evidence into the level of training and experience of GDPs providing CAT to adult patients, adopting a prospective mixed-methods approach would be invaluable to gaining a deeper and much need understanding, given their growing popularity of this treatment. The aim of the present mixed-methods research study was to explore the training and working experiences of GDPs, who were both less and more than 10 years qualified, and working in a private dental setting in England, in providing CAT for adult patients. Materials and methods This study adopted a sequential explanatory mixed-methods design. 7 The training and working experiences of GDPs in providing CAT to adult patients were explored quantitatively and qualitatively; firstly, by means of a questionnaire survey and secondly, one-to-one semi-structured interviews. Ethical approval was granted by the Research Ethics Committee, Queen Mary University London, UK (QMERC23.032) and all participants provided written informed consent. Quantitative research study A cross-sectional quantitative study including a self-developed online survey questionnaire administered to a convenient sample of 100 GDPs, of all genders from across England, working in a private practice setting and providing CAT to adult patients. The GDPs undergoing formal orthodontic training or those with no previous experience of CAT for adults were excluded from this study. The GDPs were selected from those registering to undertake further free online training webinars in CAT and treatment planning support and mentorship from Specialist Orthodontists, through an independent organization called 32Co (London, UK). They are a registered private UK company that provide free registration and educational webinars, offering a range of commercially available clear aligner materials to GDPs. The 32Co organisation arranged access to the database (register list) of GDPs, who were recruited by the research team (AJ, RM and GB). Self-completion of the online survey questionnaire implied consent. The survey questionnaire was developed by the research team (AJ, GB, FCS) and administered online using HubSpot (Cambridge, MA, USA), with the assistance of 32Co. The survey was meticulously revised and refined by an experienced professional in the field (AJ), in addition to referring to similar surveys published in previous studies, 3 , 4 , 5 to optimise the formulated survey questions. It was piloted and any necessary modifications undertaken prior to adoption. The survey questionnaire included two parts: The first part explored the level of training gained and experiences of GDPs in providing CAT to adult patients; their use and understanding of the treatment mechanics in CAT; their choice of CAT provider and use of retention following CAT (see supplementary Table 1). The second part assessed seven different malocclusions, in respect of their suitability for treatment with CAT. The cases were presented in the form of a series of intraoral photographs (frontal view, right buccal view, left buccal view, maxillary occlusal view, and mandibular occlusal view; see supplementary Fig. 1). Email reminders were sent to potential participants to complete the online surveys following Dillman's et al. 8 approach. The data were coded and computerised using MS Excel. Random checks were carried out for typological errors during data entry. All statistical tests were executed using Statistical Package for the Social Sciences (SPSS), version 24 (IBM® SPSS® Statistics, 2016). Descriptive statistical analysis was performed. Qualitative research study A qualitative research study was undertaken with a sub-sample of GDPs who had completed the quantitative study. This consisted of semi-structured interviews to explore issues arising from the survey questionnaire in more depth. The study design was reported in line with the consolidated criteria for reporting qualitative research. 9 The sample was purposively selected to include GDPs of both gender and years since qualification (1–10 years & >10 tears qualified). This provided an opportunity to gain a greater insight in their views on their training and working experiences in CAT provision to adult patients. The sample size was based on ‘data saturation’, which was achieved when no new themes were elicited from the last 2 interviews. 10 , 11 GDPs were provided with an information and informed written consent obtained prior to the start of the interviews for those choosing to participate. A topic guide was developed by the research team (AJ, FCS and GB) and used to standardise data collection. The guide was created in line with previous research, prior professional experience, the research objectives, and following initial analysis of the survey questionnaire responses. The guide was piloted to assess its scope and clarity, 12 enabling further revisions and refinements. The findings from this pilot exercise were excluded from the data analysis. The CAT training and experience; digital scanning; used mechanics; choice of CAT provider and retention planning were explored in turn. One-to-one semi-structured interviews were carried out by a single researcher (GB), after being formally trained and observed by an experienced qualitative researcher (FCS). Interviews were undertaken online, using the Microsoft Teams (Redmond, USA) platform, in a quiet private space and at mutually convenient times within agreed office hours. Data were audio-recorded using a digital audiotape (WS-831, Olympus Corporation) and fieldnotes. The 50–70-minute interviews were transcribed verbatim by a confidential service (Essential Secretary Ltd, Farnborough, UK) without the inclusion of any personally identifiable data. Microsoft Excel was used to organise the qualitative data, facilitating analysis. A matrix-based approach, Framework methodology, was used to analyse the qualitative data. 11 , 3 – 15 This approach enables data analysis in a structured way around the key questions in the topic guide and comparison within and across participant groups. Specifically, data are transcribed, read, and reread by the research team, with subsequent coding of the data to permit development of major themes. 11 An analytic framework is then developed and tested. The research team (FCS, GB and AJ) regularly met during data collection and analysis to discuss and agree on the emerging themes, and any disagreement was discussed and resolved jointly. Results Participant characteristics One hundred completed surveys were available for analysis. Just over half of the total respondents were male (n = 55) and were greater than 10 years qualified (n = 55). Sixteen participants were purposively sampled and completed the semi-structured interviews. Nine GDPs were male, all working in private practice in England. GDPs’ learning experience of CAT training courses Overall, 86 GDPs had attained certification, with the majority (n = 77) attending 1–4 days of training in total. Only 31 GDPs felt the course met their needs in terms of theoretical understanding. Similar distributions were observed in terms of performing IPR, case selection, trouble shooting, patient monitoring and pricing. Only GDPs who were more than 10 years qualified reported a high degree of satisfaction with use of auxiliaries, though only a few (n = 14) reported they felt were adequately trained. The majority (n = 71) of GDPs reported feeling a need for further training in all aspects of CAT provision (see supplementary Table 1). When exploring further through semi-structured interviews, the perceived usefulness of webinar series based CAT training courses, with specialist orthodontists,, the GDPs reported gaining a better understanding of the theoretical background of CAT, ranging from the biology of tooth movement, functionality of CAT in correcting malocclusion, diverse clinical techniques, through the benefits and limitations of the treatment, and to how to undertake clinical assessment. Some went further and reported that the acquired knowledge enhanced their diagnostic skills, ability to select clinical cases and confidence in providing CAT. “...They [training facilitators at 32Co] discuss modifying molar relationships. I felt like that really gave me a lot more confidence in diagnosing patients” (GDP F5,<10 years since qualification ) Moreover, GDPs, irrespective of the number of years since qualification, highlighted some key “features of the training courses” that were of clear benefit to their understanding and confidence in providing CAT, such as learning mode, training duration, content, training facilitators, cost and access to appropriate learner-support elements (see supplementary Table 2). GDPs’ working experience in providing CAT Reasons for selecting CAT provision The variety of reasons influencing GDPs decision to provide CAT is presented in supplementary Table 3, ranging from patients’ preferences, compliance and expectations, through case complexity to cost. A similar theme “patient-related factors” also arose from the interviews; GDPs perceived high demand for CAT related to patients’ preferences for a cosmetic and comfortable solution. Furthermore, GDPs echoed the importance of CAT in the success of other dental treatment outcomes and/or retreatment, motivating them to perform this treatment in their practices. “I just wanted to improve the outcome of restorative cases, and orthodontics was one of the ways to do that. Basically, if you need to do veneers, or if you want to treat wear cases, many times those teeth are in the wrong place, that's why they are worn away. Many patients also have had orthodontics before and it's relapsed, and orthodontics can sometimes be one of the first steps in enabling them to have a better form function and anatomy and the shape of the teeth…” (GDP M11, >10 years since qualification ) From the interviews, it was also found that “clinician-related factors” influenced decision. GDPs with less than 10 years qualified, expressed motivation to perform CAT for continuing developing professionally and broadening their scope of practice. For others, delivering CAT to their patients results in job satisfaction: “...Actually, you get a good degree of satisfaction from doing it. Because you’ve transformed that patient into what they wanted...” (GDP M3 >10 years since qualification ) “Oral health care service-related factors” were discussed broadly by GDPs, who qualified more than 10 years. They felt motivated to provide CAT due to the high perceived demand for CAT and the lack of specialist practices in their local area. Another reason was the effect of competition and how this interacts with patients as consumers, as well as the remuneration opportunity. “Any specialist practices are at least half an hour, or more away, and people aren’t always that willing to travel. It's more inconvenient for them... So expand the services that we were offering at the practice...” (GDP M1, >10 years since qualification ) GDPs’ experience and confidence in CAT provision Whilst GDPs who were more than 10 years of qualified, had undertaken more CAT cases, similar numbers of cases (1–10 cases) had been undertaken in the past year in both groups of GDPs. All GDPs had provided CAT to adults, with only a third (n = 33) being confident in treating teenagers (see supplementary Table 3). Most GDPs reported treating more “mild” or “moderate” malocclusion traits, including crowding, simple tipping movements, mild class II and III posterior corrections, and rotational corrections. GDPs across both groups revealed less confidence in treating more severe complexities of malocclusion involving severe crowding, class II and III corrections, deep overbites and open bites, and bilateral posterior crossbites. Most GDPs (58%) felt more confident in prescribing extractions with their preference for a premolar extraction (see supplementary Table 4). Supplementary Fig. 1 illustrates the findings of the GDPs’ evaluation of treatment complexity and confidence with CAT for seven different malocclusion traits, before and after further training. Overall, the following trends were observed: the assessment of case complexity changed in similar degrees for both groups; a greater reported confidence in treating the following occlusal traits: overbite; crossbite; crowding correction; anterior open bite correction; overjet reduction and median diastema closure. Similar responses around working experiences in CAT provision were reported in the semi-structured interviews. The varied experience and opportunities that GDPs had in CAT provision alongside the ongoing development of “self-awareness” notably influenced their confidence in selecting cases and patients and managing varying malocclusion traits. Having recently completed a 4-week webinar training course with specialist orthodontists, GDPs felt they better recognised their abilities and limitations. As such, they were able to make decisions on patient care ethically and to learn about one’s responsibilities to prevent patient harm and practice dentistry safely. “So, to keep myself like clinically safe and then not over promise and not be able to deliver things to patients.” (GDP F9,<10 years since qualification ) Furthermore, as part of the training course and regardless of the level of confidence, their “access to ongoing specialist support” using different channels (e.g. a dedicated online platform; web portal; email correspondence), particularly in case selection, treatment planning and advice received from specialist orthodontists enabled GDPs to deliver CAT with further confidence and achieve a successful treatment outcome. “I think there's only one reason behind why I feel confident now to treat it (malocclusion)...because I've got a specialist orthodontist at 32Co helping me with the treatment planning...” (GDP F14,<10 years since qualification ) Digital scanning in CAT provision Most GDPs (n = 73) reported having used a digital scanner for treatment planning for CAT. However, over a quarter of GDPs (n = 27) remained impression-based, with those GDPs who were more than 10 years qualified, expressing less confidence with digital scanning or planning software (see supplementary Table 5). From the semi-structured interviews, it emerged that confidence in using digital scanning was related to the familiarity with digital scanners and support from providers. “I think confidence comes with practice, so, that’s what you need to do, is just practice with it really and the more you practice, that’s how the confidence comes” (GDP F4,>10 years since qualification ) Exploring the influential factors for digital scanner adoption through interviews, some “enablers” and “barriers” emerged from the data analysis. Regarding the enablers , the manufacturers’ reputation and ongoing support were highly valued by GDPs due to the perceived high-quality service provided and the opportunity to access further training and access to advice. “I wanted something that was going to have good backup, good support... I wanted it to be a kind of well recognized brand and company. I'm the practice owner as well... also, do provide good training” (GDP M1,>10 years since qualification ) Digital scanner features were also key in decision-making. Some found that their chosen digital scanners offered greater accuracy, avoided repeat remakes and undesirable gag reflexes, as well as eliminating the risk of postal damage with conventional impressions. Others valued the perceived clinical efficiency in reduced chairside time. Moreover, the ease of use, quick turnaround of scans, ease of communication with the laboratory and patient and no space consumption with digital storage were also highly valued. “It's easier to communicate, digitally, with someone, specialist or a laboratory, because then they can look at the scan in 3D and they can give better advice. Obviously, it doesn't consume any space in the clinic, so that's amazing” (GDP M11,>10 years since qualification ) “ What I really like is the high definition, the quality of the animation and the picture. Because this is my selling point! Then I meet my patients face to face, we discuss all the details of the treatment, clear view where the attachments are placed, where the IPR [interproximal enamel reduction] will be done, how much IPR. So, patient knows all the details of the treatment.…” (GDP M8,>10 years since qualification ) “Barriers” to scanner adoption were discussed by GDPs, with those qualified more than 10 years, identifying their high cost as a primary deterrent, along with unrealistic plans being proposed: “ It’s mainly financial, because they’re super expensive, and we’re a small clinic, we have two chairs in the surgery. I mean definitely we wouldn’t have money to get one of those high end or whatever scanners!” (GDP F7, >10 years since qualification provision ) “I feel like Invisalign are sometimes a little ambitious. I'm wary of the amount of expansion and the amount of intrusion and extrusion that's planned. Clinicians need to understand the limits of that and sometimes what is planned is going to be very difficult to achieve clinically” (GDP M1,>10 years since qualification ) Selecting the CAT provider From the survey questionnaire, it was found that Invisalign (Align Technology®) was the commonest reported CAT provider amongst both GDP groups. Several reasons were reported including: the ease of use of the software planning tool; technical support; marketing; quality of the aligners and reported patient satisfaction and ongoing clinical training and educational resources (see supplementary Table 6). When exploring further the reasons for selecting a clear aligner provider through interviews, GDPs highlighted services provided after purchase, such as access to specialist orthodontist support including technicians and the quality of specialists’ response to GDPs concerns were valued by both groups for helping guide the management of their patients’ care. Some however acknowledged frustration with certain providers due to the lack of a specialist’s support and the depth of the answer that was provided. " The specialist support with 32Co is brilliant, it's like there's an instant messaging service built into the website. They get back within like a couple of hours! With others, I think the biggest thing was lack of support. It took a lot of time to get a response” (GDP F16,10 years since qualification ) Confidence in using the treatment mechanics in CAT As part of the planned CAT, a higher proportion of GDPs who were more than 10 years qualified, felt more comfortable with placing attachment; performing IPR; and using elastics and bite blocks. There also appeared to be a greater understanding of the reasons for performing IPR; the greater need for staging when 0.3-0.5mm was indicated and awareness of undertaking this in the presence of rotations. These longer qualified dentists also reported greater preference for alternative methods of space creation in the dental arch (see supplementary Tables 7 & 8). GPDs were asked in the interviews about factors that influenced their choice of treatment mechanics in CAT. Access to specialist support was commonly reported by GDPs. By engaging in iterative conversations with specialists for example at 32Co, GDPs felt they gained valuable knowledge in a wider variety of treatment mechanics they were previously unfamiliar with and refreshed their knowledge of areas they had not worked in previously. GDPs felt that this knowledge and support meant they could now manage their patients’ care in a more confident and informed manner. “Duo cases at 32Co, you get more support from an orthodontist, who's already familiar with the case and they'll give you some advice if things are going wrong. Or, if something is worrying you, you can just message them online” (GDP F6,>10 years since qualification ) As a result of the professional relationship with the specialists and technicians most felt confident and followed the providers’ prescription for treatment mechanics created by the specialists and technicians without the need to challenge the decisions. “I’m quite confident in doing IPR, I would only do it to a prescription that’s been provided by the lab tech, or by a specialist orthodontist at 32Co” (GDP M3,>10 years since qualification ) Selecting retainers following CAT Whilst both groups of GDPs used laboratory fabricated fixed retainers, those who were more than 10 years qualified, reported a higher use.. Both groups of GDPs frequently prescribed removable retainers in isolation and in smaller numbers in combination with fixed retainers (see supplementary Table 9). In the interviews, GDPs reported the following factors influenced their choice of retainer: the severity and type of malocclusion, duration of treatment and retention protocols and guidelines provided by specialist orthodontist were decisive. It was common for GDPs from both groups to prescribe fixed retainers for the most severe cases of malocclusion, more complex and longer duration of treatment and to those with a high likelihood of relapse. “ Essix retainers, for the simple. Fixed ones are better for rotations because the teeth tend to creep back a little bit... If I’ve done a complex case, it’s been quite a long journey, I’d prefer to use a lab made fixed retainer... an easier case, I’d use a gold chain” (GDP M3,>10 years since qualification ) GDPs in most instances preferred the use of laboratory-made bonded retainers to ensure good adaptation to the tooth surface, better stability and minimise on clinical time. “... because I don't know enough about what type of wire to use, and what level to attach the wire on. So, for me it's less headache if I attach it straight with the jig” (GDP M16, <10 years since qualification ) Discussion This study adopted a unique research design to comprehensively assess the training and working experiences of GDPs in England providing CAT to adult patients and thereby address a gap in the literature for this significant dental workforce.. Rather importantly, in terms of their training, the majority of GDPs reported that despite having completed aligner certification, they feltthe benefits were limited to theoretical background. with few reporting practical hands-on training, 16 on placing auxiliaries and performing IPR on models. There was a strongly expressed preference for practical training to improve their CAT skills and confidence. Moreover, GDPs highly preferred training courses that covered case assessment, planning, guidance on treatment mechanics, troubleshooting management, and treatment of more severe malocclusions. Similarly, previous research recommended emphasis on training less experienced dental practitioners, with attention to CAT mechanics, extraction treatments, as well as troubleshooting governance, which may explain the above. 6 In regards to their CAT experiences, the majority ofGDPs had completed a larger number of cases in the past year, with GDPs mainly treating mild to moderate malocclusion traits but feeling less comfortable in treating more complicated cases, in line with previous reports. 17 In contrast, d'Apuzzo et al. (2019) concluded that 40% of GDPs do not provide CAT in their practices due to a lack of experience in CAT provision. 3 Interestingly, the assessment of GDPs’ confidence in treating seven different malocclusion traits with CAT before and after a 4-week webinar course, in the present study revealed that they changed their rating of the malocclusion trait complexity from moderate to severe. This finding suggests that there was a change in their GDPs’ views on case suitability over time; along with an observed increase in their confidence. Indeed, some GDPs who were less than 10 years qualified, subsequently expressed their preference to treat milder relapse cases, requiring anterior tooth alignment only to facilitate restorative treatments in this study. Similar findings were identified in previous research. 4 , 5 In the present study, the change of views may be attributable to the gained self-awareness of GDPs skills and limitations and their now clearer understanding of tooth movement predictability with CAT. Moreover, this may also reflect the fact that GDPs felt their case complexity was now being assessed and the case treatment planned by a specialist orthodontist treatment for suitability. These findings show that having the orthodontic specialist support backup, such as made available with 32Co, had encouraged GDPs to consider submitting cases of greater complexity for consideration. Therefore, this support system was perceived as crucial for better patient-centered care and treatment outcomes. With regards to the use of digital scanning technology, the current study highlighted that GDPs, qualified for less than 10 years, more readily incorporated this into their practice, reporting numerous advantages, from the ease of use, efficiency in communication with the laboratory and patient through visualization of the treatment plan. Despite the role of digital scanning in the efficiency of treatment planning and delivery of care in CAT, 18 , 19 a few of the GDPs in this study reported not to have used digital scans for CAT previously. The high cost of digital scanners as reported by a few working in small and rural areas in this study, or the lack of accuracy in some more affordable, 19 may be a barrier to their use amongst the GDPs in this study and in particular those qualified more than 10 years. In terms of the clear aligner provider, the current study suggested that Invisalign (Align Technology®) was commonly selected by GDPs as their CAT provider, with similar findings identified somewhere else. 21 GDPs provided a wide range of reasons for their choice, ranging from the ease of use of the software planning tool, marketing of the brand, quality of the aligners. In contrast, newer emerging companies were recognised for their ability to access a specialist orthodontist to assess case complexity, suitability for CAT and provision of a treatment protocol, and ongoing customer support. As such, a trend was reported with participants moving away from the more popular but expensive aligner providers towards the latter. The present study found that GDPs qualified for more than 10 years used a variety of complex CAT mechanics. 22 Furthermore, 98 per cent of GDPs had used IPR in relation to CAT, 23 – 26 and showed a greater understanding of the reasons for using IPR and the need for staging when 0.3-0.5mm was indicated. The greater GDPs confidence in performing IPR in the present study could be related to the perceived usefulness of the training courses in CAT and the number of cases they treated with CAT. Indeed, GDPs qualified for more than 10 years, agreed that ‘performing IPR’ was a beneficial aspect of the training courses and performed greater than 50 cases compared to those GDPs who were less than 10 years qualified. Moreover, GDPs in the present study had a stronger inclination towards alternative approaches for creating space within the dental arch, such as extractions. GDPs who were more than 10 years qualified expressed similar preferences in deciding a lower incisor extraction or premolar extraction in malocclusions necessitating creating space by means of extractions in CAT. In contrast, previous research showed that both specialist orthodontists and GDPs were confident in performing IPR equally, however, discrepancies were noted in the application of all other auxiliaries, with GDPs showing less confidence in using elastics and prescribing extractions. 4 , 5 Meade and Weir (2024) revealed that nearly one-fifth of GDPs preferred a lower incisor extraction pattern, while only 6% were comfortable with prescribing a premolar extraction in CAT. 17 These findings may be attributed to the support acquired from specialist orthodontists, who encouraged GDPs in this study to use a variety of auxiliaries including elastics and buttons, bite ramps and prescribe extractions. In addition, working with specific protocols and tools, and following provider instructions helped increase GDPs’ confidence levels and build a strong trust relationship with the CAT providers. The present study showed that GDPs used more than one type of orthodontic retainer following CAT provision. GDPs, greater than 10 years qualified, commonly used laboratory fabricated fixed retainers in both arches. GDPs, irrespective of their number of years qualified, often recommended removable VFRs either on their own or in combination with fixed retainers. Similar findings were reported by Meade and Weir (2024) in which GDPs commonly chose to prescribe clear vacuum-formed retainers for the upper arch, while the most frequently preferred option for the lower arch was a combination of a fixed retainer and a vacuum-formed retainer. 17 In addition, both groups of GDPs ( 10 years qualified) preferred to prescribe fixed lingual retainers for the more complex malocclusions with high risk of relapse. Limited clinicians' skills in placing a chairside fixed retainer were a decisive factor for providing laboratory-made fixed retainers. The mixed-methods research applied in the current study identified the limited understanding and diverse practices of GDPs in CAT provision. This highlights the need to further train GDPs on suitability for CAT and their role in treatment provision. Thus, appropriate training in various aspects of clear aligner treatment, particularly case selection criteria, need for dental extractions and a variety of treatment mechanics would be relevant to enhance confidence in CAT provision and more importantly treatment outcomes amongst GDPs. 27 Strengths and limitations The current study contributes to the literature through exploring the views of GDPs practising orthodontics with CAT; however, there are limitations which need to be considered. Firstly, responses were restricted to GDPs who had been registered for the 32Co training course in CAT and working in England. Nevertheless, the wide range of locations where GDPs were trained and worked limits this impact. Moreover, in line with the current studies inclusion criteria and objectives, and in an attempt to overcome the limitations of other studies, the present study did not want to recruit GDPs who had either no interest or experience in CAT. Thus, the included GDPs, were from across England and had all gained both training in various forms and experience, with a range of CAT providers, making the findings more real-world and arguably generalisable. Furthermore, the findings of this study provide baseline data on the training and experiences of GDPs providing CAT, to which comparison can be made by other researchers. Considering that the online questionnaire used in the survey was self-administered, certain views of GDPs may be lost or misunderstood. To minimise this limitation, a mixed-methods research approach was adopted. Adding a qualitative research method to explore in detail and understand the reasons behind their responses. The findings from the two stages of the research do provide similar perspectives and the combination of approaches provides triangulation; ensuring the validity and robustness of the findings and their interpretation in the present study. 28 Conclusion The present study provides important insights into the GDPs’ training and working experiences in CAT provision for adult patients. Significant shortcomings were identified in theirtraining courses,despite having gained certification.. GDPs showed greater confidence in treating a range of malocclusion traits with CAT, with ongoing support from specialist orthodontists. The use of digital scanning for CAT treatment planning was less common amongst GDPs qualified greater than 10 yearsA variety of retainer types was selected by GDPs following CAT provision to adult patients. Declarations Conflicts of interest AJ acts as a clinical lead for 32Co, in providing mentorship and educational resources. FCS and GB declare that they have no conflict of interest. RM is employed by 32Co and leads the Educational resources. Author contributions statement Acknowledgments We would like to thank all the general dental practitioners who volunteered their time and participated in this study. References Johal A, Bondemark L. Clear aligner orthodontic treatment: Angle Society of Europe consensus viewpoint. Journal of Orthodontics. 2021;48(3):300–4. Hansen V, Liu SS, Schrader SM, Dean JA, Stewart KT. Personality traits as a potential predictor of willingness to undergo various orthodontic treatments. The Angle Orthodontist. 2013;83(5):899–905. d’Apuzzo F, Perillo L, Carrico CK, Castroflorio T, Grassia V, Lindauer SJ, Shroff B. Clear aligner treatment: different perspectives between orthodontists and general dentists. Progress in Orthodontics. 2019;20:1–9. Vicéns J, Russo A. Comparative use of invisalign® by orthodontists and general practitioners. Angle Orthodontist. 2010;80(3):425–34. 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Factors affecting willingness to pay for NHS-based orthodontic treatment. British Dental Journal. 2022 Jan 28:1–6. Park JJ, Duong ML, Thayer JJ, Park JH. Clear aligner treatment education in dental schools in the United States and Canada. Journal of Clinical Orthodontics. 2021;55(11):684. Meade MJ, Weir T. A Cross-Sectional Survey of the Use of Clear Aligners by General Dentists in Australia. Clinical and Experimental Dental Research. 2024;10(4):e919. Sehrawat S, Kumar A, Grover S, Dogra N, Nindra J, Rathee S, Dahiya M, Kumar A. Study of 3D scanning technologies and scanners in orthodontics. Materials Today: Proceedings. 2022;56:186 – 93. Carvalho PE, Ortega AD, Maeda FA, da Silva LH, Carvalho VG, Torres FC. Digital scanning in modern orthodontics. Current Oral Health Reports. 2019;6:269–76. Meade MJ, Weir T. A survey of orthodontic clear aligner practices among orthodontists. American Journal of Orthodontics and Dentofacial Orthopedics. 2022;162(6):e302-11. Almotairy N. Public perception of Invisalign® clear aligner treatment: a cross-sectional survey-based study. APOS Trends Orthod. 2023;13(1):38–45. Gao Y, Sun X, Yan X, Tang Z, Lai W, Long H. Orthodontic Practitioners’ knowledge and education demand on Clear Aligner Therapy. International Dental Journal. 2023;74(1):81–7. Donovan J, Millett DT, Harding M. Interproximal reduction in orthodontics: Reported practices and perceptions of orthodontists in the Republic of Ireland. Journal of the Irish Dental Association. 2024 Jul 5. Sheridan JJ. The readers' corner. On what percentage of your patients do you perform enamel reproximation?. Journal of clinical orthodontics: JCO. 2006;40(3):155–7. Srivastava SC, Verma V, Panda S, Anita G. Current status of interproximal enamel reduction in orthodontic treatment. Pakistan Oral & Dental Journal. 2012;32(2). Barcoma E, Shroff B, Best AM, Shoff MC, Lindauer SJ. Interproximal reduction of teeth: differences in perspective between orthodontists and dentists. The Angle Orthodontist. 2015;85(5):820–5. Jauhar P, Mossey PA, Popat H, Seehra J, Fleming PS. A survey of undergraduate orthodontic teaching and factors affecting pursuit of postgraduate training. British dental journal. 2016;221(8):487–92. Creswell JW, Clark VL. Designing and conducting mixed methods research. Sage publications; 2017 Aug 31. Additional Declarations There is no duality of interest Supplementary Files Figure1.docx Supplementary Figure 1. Illustrates intra-oral photographs of 7 different occlusal traits (1a-g). Tables.docx Tables 1-9 Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: revise 21 Oct, 2025 Review # 2 received at journal 10 Oct, 2025 Review # 1 received at journal 30 Sep, 2025 Reviewer # 2 agreed at journal 19 Sep, 2025 Reviewer # 1 agreed at journal 11 Sep, 2025 Reviewers invited by journal 09 Sep, 2025 Editor assigned by journal 08 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 01 Sep, 2025 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. 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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-7509774","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":512692410,"identity":"861f6c9a-7dbe-4c8b-94d3-e2d4e0ed83bf","order_by":0,"name":"Ama Johal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYLACCYYDDHzsDUBWAZjPTJwWNp4DQJYBsVoYQFokEojUwt/A/oDBouKOPJvk462beQwY5PkbeIwN8LrpAFCZxJlnhm3SaWW3gWzDGQd4jBPwO4mHgUGy7TBjm3SOGUgL4wYGHuMD+HTIHwA6DKjFvk3yDFiLPUEtBgeAXgZqSWyT4AFrSQRpwesww8M8BgckzhxObuNJK7s5x0AiecZhtmK83pc73v7wsUTFYdt+9sPbbrypsLHtb2/eLIFPCygODkNVgMyWIC4iGT8gtIyCUTAKRsEowAQARJdAbHNSQ9UAAAAASUVORK5CYII=","orcid":"","institution":"Queen Mary University London","correspondingAuthor":true,"prefix":"","firstName":"Ama","middleName":"","lastName":"Johal","suffix":""},{"id":512692411,"identity":"5aff70e3-4819-4acc-8ed5-ae9d0eae3511","order_by":1,"name":"Ghofran Ghofran Badabaan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ghofran","middleName":"Ghofran","lastName":"Badabaan","suffix":""},{"id":512692412,"identity":"b6060d9d-04dd-4ff8-bf93-1415ee616557","order_by":2,"name":"Ryan McMeekin","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ryan","middleName":"","lastName":"McMeekin","suffix":""},{"id":512692413,"identity":"e7655941-b119-405b-a599-89b9d0b70ae7","order_by":3,"name":"Fiorella Colonio-Salazar","email":"","orcid":"","institution":"QMUL","correspondingAuthor":false,"prefix":"","firstName":"Fiorella","middleName":"","lastName":"Colonio-Salazar","suffix":""}],"badges":[],"createdAt":"2025-09-01 15:06:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7509774/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7509774/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91565951,"identity":"0748a1f9-bac7-4a5b-9d24-d2db89f12525","added_by":"auto","created_at":"2025-09-17 19:33:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":418659,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7509774/v1/27233326-ab64-42b0-af21-01f3b68b9b5f.pdf"},{"id":91565120,"identity":"49842a82-e8d9-4b69-ad07-0dd570e5d0ce","added_by":"auto","created_at":"2025-09-17 19:17:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":5007937,"visible":true,"origin":"","legend":"Supplementary Figure 1. Illustrates intra-oral photographs of 7 different occlusal traits (1a-g).","description":"","filename":"Figure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7509774/v1/c3bec6967f9f88a95373bd7c.docx"},{"id":91564455,"identity":"ec8790bc-b060-4cb7-9d6c-c90b6efc9d49","added_by":"auto","created_at":"2025-09-17 19:09:39","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":80047,"visible":true,"origin":"","legend":"Tables 1-9","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7509774/v1/02bddbd40d0e2fed77959d4f.docx"}],"financialInterests":"There is no duality of interest","formattedTitle":"The provision of clear aligner treatment by general dental practitioners in England: a mixed-methods study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe increased demand for adult orthodontic treatment has seen an exponential rise in the use of more aesthetic appliance choices, amongst which there has been a corresponding increase in the popularity of clear aligner treatment (CAT).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The reported advantages of CAT include: better aesthetics; their removable nature; and range of tooth movements permissible.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In contrast, they require optimal wear adherence; removal for eating and notable limitations with challenging malocclusions.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCAT treatment has been portrayed to general dental practitioners (GDPs) as being relatively straightforward to undertake, with an unprecedented increase in their provision. \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, GDPs often graduate with limited training in orthodontic diagnosis and mechanotherapy and often acquire a variable level of training and experience in CAT.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Two surveys compared levels of experience between orthodontists and general dentists.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e They found that orthodontists received more CAT training and were treating more cases than dentists, with the latter group expressing a lack of confidence after their initial certification course.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Interestingly, GDPs expressed greater confidence in treating more severe complexities of malocclusion with CAT.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Apart from performing interproximal enamel reduction (IPR), significant differences were observed in the use of all other auxiliaries, with GDPs less likely to use elastics and extractions.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e More recently, d'Apuzzo \u003cem\u003eet al.\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e highlighted GDP's lack of experience, as their reasoning for not undertaking CAT. A recent study reported that orthodontic tooth movement predictability via CAT was frequently overestimated by GDPs; thus, provision of future training for enhanced CAT efficacy with attention to CAT mechanics, cases requiring extractions, and troubleshooting governance has been emphasised.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eGiven the lack of evidence into the level of training and experience of GDPs providing CAT to adult patients, adopting a prospective mixed-methods approach would be invaluable to gaining a deeper and much need understanding, given their growing popularity of this treatment. The aim of the present mixed-methods research study was to explore the training and working experiences of GDPs, who were both less and more than 10 years qualified, and working in a private dental setting in England, in providing CAT for adult patients.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study adopted a sequential explanatory mixed-methods design.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The training and working experiences of GDPs in providing CAT to adult patients were explored quantitatively and qualitatively; firstly, by means of a questionnaire survey and secondly, one-to-one semi-structured interviews. Ethical approval was granted by the Research Ethics Committee, Queen Mary University London, UK (QMERC23.032) and all participants provided written informed consent.\u003c/p\u003e\u003cp\u003eQuantitative research study\u003c/p\u003e\u003cp\u003eA cross-sectional quantitative study including a self-developed online survey questionnaire administered to a convenient sample of 100 GDPs, of all genders from across England, working in a private practice setting and providing CAT to adult patients. The GDPs undergoing formal orthodontic training or those with no previous experience of CAT for adults were excluded from this study. The GDPs were selected from those registering to undertake further free online training webinars in CAT and treatment planning support and mentorship from Specialist Orthodontists, through an independent organization called 32Co (London, UK). They are a registered private UK company that provide free registration and educational webinars, offering a range of commercially available clear aligner materials to GDPs. The 32Co organisation arranged access to the database (register list) of GDPs, who were recruited by the research team (AJ, RM and GB). Self-completion of the online survey questionnaire implied consent.\u003c/p\u003e\u003cp\u003eThe survey questionnaire was developed by the research team (AJ, GB, FCS) and administered online using HubSpot (Cambridge, MA, USA), with the assistance of 32Co. The survey was meticulously revised and refined by an experienced professional in the field (AJ), in addition to referring to similar surveys published in previous studies,\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e to optimise the formulated survey questions. It was piloted and any necessary modifications undertaken prior to adoption. The survey questionnaire included two parts: The first part explored the level of training gained and experiences of GDPs in providing CAT to adult patients; their use and understanding of the treatment mechanics in CAT; their choice of CAT provider and use of retention following CAT (see supplementary Table\u0026nbsp;1). The second part assessed seven different malocclusions, in respect of their suitability for treatment with CAT. The cases were presented in the form of a series of intraoral photographs (frontal view, right buccal view, left buccal view, maxillary occlusal view, and mandibular occlusal view; see supplementary Fig.\u0026nbsp;1). Email reminders were sent to potential participants to complete the online surveys following Dillman's \u003cem\u003eet al.\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e approach.\u003c/p\u003e\u003cp\u003eThe data were coded and computerised using MS Excel. Random checks were carried out for typological errors during data entry. All statistical tests were executed using Statistical Package for the Social Sciences (SPSS), version 24 (IBM\u0026reg; SPSS\u0026reg; Statistics, 2016). Descriptive statistical analysis was performed.\u003c/p\u003e\u003cp\u003eQualitative research study\u003c/p\u003e\u003cp\u003eA qualitative research study was undertaken with a sub-sample of GDPs who had completed the quantitative study. This consisted of semi-structured interviews to explore issues arising from the survey questionnaire in more depth. The study design was reported in line with the consolidated criteria for reporting qualitative research.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe sample was purposively selected to include GDPs of both gender and years since qualification (1\u0026ndash;10 years \u0026amp; \u0026gt;10 tears qualified). This provided an opportunity to gain a greater insight in their views on their training and working experiences in CAT provision to adult patients. The sample size was based on \u0026lsquo;data saturation\u0026rsquo;, which was achieved when no new themes were elicited from the last 2 interviews.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e GDPs were provided with an information and informed written consent obtained prior to the start of the interviews for those choosing to participate.\u003c/p\u003e\u003cp\u003eA topic guide was developed by the research team (AJ, FCS and GB) and used to standardise data collection. The guide was created in line with previous research, prior professional experience, the research objectives, and following initial analysis of the survey questionnaire responses. The guide was piloted to assess its scope and clarity,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e enabling further revisions and refinements. The findings from this pilot exercise were excluded from the data analysis. The CAT training and experience; digital scanning; used mechanics; choice of CAT provider and retention planning were explored in turn.\u003c/p\u003e\u003cp\u003eOne-to-one semi-structured interviews were carried out by a single researcher (GB), after being formally trained and observed by an experienced qualitative researcher (FCS). Interviews were undertaken online, using the Microsoft Teams (Redmond, USA) platform, in a quiet private space and at mutually convenient times within agreed office hours. Data were audio-recorded using a digital audiotape (WS-831, Olympus Corporation) and fieldnotes. The 50\u0026ndash;70-minute interviews were transcribed verbatim by a confidential service (Essential Secretary Ltd, Farnborough, UK) without the inclusion of any personally identifiable data.\u003c/p\u003e\u003cp\u003eMicrosoft Excel was used to organise the qualitative data, facilitating analysis. A matrix-based approach, Framework methodology, was used to analyse the qualitative data.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e This approach enables data analysis in a structured way around the key questions in the topic guide and comparison within and across participant groups. Specifically, data are transcribed, read, and reread by the research team, with subsequent coding of the data to permit development of major themes.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e An analytic framework is then developed and tested. The research team (FCS, GB and AJ) regularly met during data collection and analysis to discuss and agree on the emerging themes, and any disagreement was discussed and resolved jointly.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant characteristics\u003c/p\u003e\u003cp\u003eOne hundred completed surveys were available for analysis. Just over half of the total respondents were male (n\u0026thinsp;=\u0026thinsp;55) and were greater than 10 years qualified (n\u0026thinsp;=\u0026thinsp;55).\u003c/p\u003e\u003cp\u003eSixteen participants were purposively sampled and completed the semi-structured interviews. Nine GDPs were male, all working in private practice in England.\u003c/p\u003e\u003cp\u003eGDPs\u0026rsquo; learning experience of CAT training courses\u003c/p\u003e\u003cp\u003eOverall, 86 GDPs had attained certification, with the majority (n\u0026thinsp;=\u0026thinsp;77) attending 1\u0026ndash;4 days of training in total. Only 31 GDPs felt the course met their needs in terms of theoretical understanding. Similar distributions were observed in terms of performing IPR, case selection, trouble shooting, patient monitoring and pricing. Only GDPs who were more than 10 years qualified reported a high degree of satisfaction with use of auxiliaries, though only a few (n\u0026thinsp;=\u0026thinsp;14) reported they felt were adequately trained. The majority (n\u0026thinsp;=\u0026thinsp;71) of GDPs reported feeling a need for further training in all aspects of CAT provision (see supplementary Table\u0026nbsp;1). When exploring further through semi-structured interviews, the perceived usefulness of webinar series based CAT training courses, with specialist orthodontists,, the GDPs reported gaining a better understanding of the theoretical background of CAT, ranging from the biology of tooth movement, functionality of CAT in correcting malocclusion, diverse clinical techniques, through the benefits and limitations of the treatment, and to how to undertake clinical assessment. Some went further and reported that the acquired knowledge enhanced their diagnostic skills, ability to select clinical cases and confidence in providing CAT.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...They [training facilitators at 32Co] discuss modifying molar relationships. I felt like that really gave me a lot more confidence in diagnosing patients\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF5,\u0026lt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMoreover, GDPs, irrespective of the number of years since qualification, highlighted some key \u0026ldquo;features of the training courses\u0026rdquo; that were of clear benefit to their understanding and confidence in providing CAT, such as learning mode, training duration, content, training facilitators, cost and access to appropriate learner-support elements (see supplementary Table\u0026nbsp;2).\u003c/p\u003e\u003cp\u003eGDPs\u0026rsquo; working experience in providing CAT\u003c/p\u003e\u003cp\u003eReasons for selecting CAT provision\u003c/p\u003e\u003cp\u003eThe variety of reasons influencing GDPs decision to provide CAT is presented in supplementary Table\u0026nbsp;3, ranging from patients\u0026rsquo; preferences, compliance and expectations, through case complexity to cost. A similar theme \u0026ldquo;patient-related factors\u0026rdquo; also arose from the interviews; GDPs perceived high demand for CAT related to patients\u0026rsquo; preferences for a cosmetic and comfortable solution. Furthermore, GDPs echoed the importance of CAT in the success of other dental treatment outcomes and/or retreatment, motivating them to perform this treatment in their practices.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I just wanted to improve the outcome of restorative cases, and orthodontics was one of the ways to do that. Basically, if you need to do veneers, or if you want to treat wear cases, many times those teeth are in the wrong place, that's why they are worn away. Many patients also have had orthodontics before and it's relapsed, and orthodontics can sometimes be one of the first steps in enabling them to have a better form function and anatomy and the shape of the teeth\u0026hellip;\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM11, \u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrom the interviews, it was also found that \u0026ldquo;clinician-related factors\u0026rdquo; influenced decision. GDPs with less than 10 years qualified, expressed motivation to perform CAT for continuing developing professionally and broadening their scope of practice. For others, delivering CAT to their patients results in job satisfaction:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...Actually, you get a good degree of satisfaction from doing it. Because you\u0026rsquo;ve transformed that patient into what they wanted...\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM3 \u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;Oral health care service-related factors\u0026rdquo; were discussed broadly by GDPs, who qualified more than 10 years. They felt motivated to provide CAT due to the high perceived demand for CAT and the lack of specialist practices in their local area. Another reason was the effect of competition and how this interacts with patients as consumers, as well as the remuneration opportunity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Any specialist practices are at least half an hour, or more away, and people aren\u0026rsquo;t always that willing to travel. It's more inconvenient for them... So expand the services that we were offering at the practice...\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM1, \u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGDPs\u0026rsquo; experience and confidence in CAT provision\u003c/p\u003e\u003cp\u003eWhilst GDPs who were more than 10 years of qualified, had undertaken more CAT cases, similar numbers of cases (1\u0026ndash;10 cases) had been undertaken in the past year in both groups of GDPs. All GDPs had provided CAT to adults, with only a third (n\u0026thinsp;=\u0026thinsp;33) being confident in treating teenagers (see supplementary Table\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eMost GDPs reported treating more \u0026ldquo;mild\u0026rdquo; or \u0026ldquo;moderate\u0026rdquo; malocclusion traits, including crowding, simple tipping movements, mild class II and III posterior corrections, and rotational corrections. GDPs across both groups revealed less confidence in treating more severe complexities of malocclusion involving severe crowding, class II and III corrections, deep overbites and open bites, and bilateral posterior crossbites. Most GDPs (58%) felt more confident in prescribing extractions with their preference for a premolar extraction (see supplementary Table\u0026nbsp;4).\u003c/p\u003e\u003cp\u003eSupplementary Fig.\u0026nbsp;1 illustrates the findings of the GDPs\u0026rsquo; evaluation of treatment complexity and confidence with CAT for seven different malocclusion traits, before and after further training. Overall, the following trends were observed: the assessment of case complexity changed in similar degrees for both groups; a greater reported confidence in treating the following occlusal traits: overbite; crossbite; crowding correction; anterior open bite correction; overjet reduction and median diastema closure.\u003c/p\u003e\u003cp\u003eSimilar responses around working experiences in CAT provision were reported in the semi-structured interviews. The varied experience and opportunities that GDPs had in CAT provision alongside the ongoing development of \u0026ldquo;self-awareness\u0026rdquo; notably influenced their confidence in selecting cases and patients and managing varying malocclusion traits. Having recently completed a 4-week webinar training course with specialist orthodontists, GDPs felt they better recognised their abilities and limitations. As such, they were able to make decisions on patient care ethically and to learn about one\u0026rsquo;s responsibilities to prevent patient harm and practice dentistry safely.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, to keep myself like clinically safe and then not over promise and not be able to deliver things to patients.\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF9,\u0026lt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFurthermore, as part of the training course and regardless of the level of confidence, their \u0026ldquo;access to ongoing specialist support\u0026rdquo; using different channels (e.g. a dedicated online platform; web portal; email correspondence), particularly in case selection, treatment planning and advice received from specialist orthodontists enabled GDPs to deliver CAT with further confidence and achieve a successful treatment outcome.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there's only one reason behind why I feel confident now to treat it (malocclusion)...because I've got a specialist orthodontist at 32Co helping me with the treatment planning...\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF14,\u0026lt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDigital scanning in CAT provision\u003c/p\u003e\u003cp\u003eMost GDPs (n\u0026thinsp;=\u0026thinsp;73) reported having used a digital scanner for treatment planning for CAT. However, over a quarter of GDPs (n\u0026thinsp;=\u0026thinsp;27) remained impression-based, with those GDPs who were more than 10 years qualified, expressing less confidence with digital scanning or planning software (see supplementary Table\u0026nbsp;5). From the semi-structured interviews, it emerged that confidence in using digital scanning was related to the familiarity with digital scanners and support from providers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think confidence comes with practice, so, that\u0026rsquo;s what you need to do, is just practice with it really and the more you practice, that\u0026rsquo;s how the confidence comes\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF4,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eExploring the influential factors for digital scanner adoption through interviews, some \u0026ldquo;enablers\u0026rdquo; and \u0026ldquo;barriers\u0026rdquo; emerged from the data analysis. Regarding the \u003cem\u003eenablers\u003c/em\u003e, the manufacturers\u0026rsquo; reputation and ongoing support were highly valued by GDPs due to the perceived high-quality service provided and the opportunity to access further training and access to advice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I wanted something that was going to have good backup, good support... I wanted it to be a kind of well recognized brand and company. I'm the practice owner as well... also, do provide good training\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM1,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDigital scanner features were also key in decision-making. Some found that their chosen digital scanners offered greater accuracy, avoided repeat remakes and undesirable gag reflexes, as well as eliminating the risk of postal damage with conventional impressions. Others valued the perceived clinical efficiency in reduced chairside time. Moreover, the ease of use, quick turnaround of scans, ease of communication with the laboratory and patient and no space consumption with digital storage were also highly valued.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It's easier to communicate, digitally, with someone, specialist or a laboratory, because then they can look at the scan in 3D and they can give better advice. Obviously, it doesn't consume any space in the clinic, so that's amazing\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM11,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWhat I really like is the high definition, the quality of the animation and the picture. Because this is my selling point! Then I meet my patients face to face, we discuss all the details of the treatment, clear view where the attachments are placed, where the IPR [interproximal enamel reduction] will be done, how much IPR. So, patient knows all the details of the treatment.\u0026hellip;\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM8,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;Barriers\u0026rdquo; to scanner adoption were discussed by GDPs, with those qualified more than 10 years, identifying their high cost as a primary deterrent, along with unrealistic plans being proposed:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIt\u0026rsquo;s mainly financial, because they\u0026rsquo;re super expensive, and we\u0026rsquo;re a small clinic, we have two chairs in the surgery. I mean definitely we wouldn\u0026rsquo;t have money to get one of those high end or whatever scanners!\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF7, \u0026gt;10 years since qualification provision\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like Invisalign are sometimes a little ambitious. I'm wary of the amount of expansion and the amount of intrusion and extrusion that's planned. Clinicians need to understand the limits of that and sometimes what is planned is going to be very difficult to achieve clinically\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM1,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSelecting the CAT provider\u003c/p\u003e\u003cp\u003eFrom the survey questionnaire, it was found that Invisalign (Align Technology\u0026reg;) was the commonest reported CAT provider amongst both GDP groups. Several reasons were reported including: the ease of use of the software planning tool; technical support; marketing; quality of the aligners and reported patient satisfaction and ongoing clinical training and educational resources (see supplementary Table\u0026nbsp;6).\u003c/p\u003e\u003cp\u003eWhen exploring further the reasons for selecting a clear aligner provider through interviews, GDPs highlighted services provided after purchase, such as access to specialist orthodontist support including technicians and the quality of specialists\u0026rsquo; response to GDPs concerns were valued by both groups for helping guide the management of their patients\u0026rsquo; care. Some however acknowledged frustration with certain providers due to the lack of a specialist\u0026rsquo;s support and the depth of the answer that was provided.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eThe specialist support with 32Co is brilliant, it's like there's an instant messaging service built into the website. They get back within like a couple of hours! With others, I think the biggest thing was lack of support. It took a lot of time to get a response\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF16,\u0026lt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther examples included access to further training free of charge:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...and free training\u0026hellip; there\u0026rsquo;s a whole amazing customer service behind it...\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF7,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eConfidence in using the treatment mechanics in CAT\u003c/p\u003e\u003cp\u003eAs part of the planned CAT, a higher proportion of GDPs who were more than 10 years qualified, felt more comfortable with placing attachment; performing IPR; and using elastics and bite blocks. There also appeared to be a greater understanding of the reasons for performing IPR; the greater need for staging when 0.3-0.5mm was indicated and awareness of undertaking this in the presence of rotations. These longer qualified dentists also reported greater preference for alternative methods of space creation in the dental arch (see supplementary Tables\u0026nbsp;7 \u0026amp; 8).\u003c/p\u003e\u003cp\u003eGPDs were asked in the interviews about factors that influenced their choice of treatment mechanics in CAT. Access to specialist support was commonly reported by GDPs. By engaging in iterative conversations with specialists for example at 32Co, GDPs felt they gained valuable knowledge in a wider variety of treatment mechanics they were previously unfamiliar with and refreshed their knowledge of areas they had not worked in previously. GDPs felt that this knowledge and support meant they could now manage their patients\u0026rsquo; care in a more confident and informed manner.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Duo cases at 32Co, you get more support from an orthodontist, who's already familiar with the case and they'll give you some advice if things are going wrong. Or, if something is worrying you, you can just message them online\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eF6,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs a result of the professional relationship with the specialists and technicians most felt confident and followed the providers\u0026rsquo; prescription for treatment mechanics created by the specialists and technicians without the need to challenge the decisions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m quite confident in doing IPR, I would only do it to a prescription that\u0026rsquo;s been provided by the lab tech, or by a specialist orthodontist at 32Co\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM3,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSelecting retainers following CAT\u003c/p\u003e\u003cp\u003eWhilst both groups of GDPs used laboratory fabricated fixed retainers, those who were more than 10 years qualified, reported a higher use.. Both groups of GDPs frequently prescribed removable retainers in isolation and in smaller numbers in combination with fixed retainers (see supplementary Table\u0026nbsp;9).\u003c/p\u003e\u003cp\u003e In the interviews, GDPs reported the following factors influenced their choice of retainer: the severity and type of malocclusion, duration of treatment and retention protocols and guidelines provided by specialist orthodontist were decisive. It was common for GDPs from both groups to prescribe fixed retainers for the most severe cases of malocclusion, more complex and longer duration of treatment and to those with a high likelihood of relapse.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eEssix retainers, for the simple. Fixed ones are better for rotations because the teeth tend to creep back a little bit... If I\u0026rsquo;ve done a complex case, it\u0026rsquo;s been quite a long journey, I\u0026rsquo;d prefer to use a lab made fixed retainer... an easier case, I\u0026rsquo;d use a gold chain\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM3,\u0026gt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGDPs in most instances preferred the use of laboratory-made bonded retainers to ensure good adaptation to the tooth surface, better stability and minimise on clinical time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;...\u003cem\u003ebecause I don't know enough about what type of wire to use, and what level to attach the wire on. So, for me it's less headache if I attach it straight with the jig\u0026rdquo; (GDP\u003c/em\u003e\u003csup\u003e\u003cem\u003eM16, \u0026lt;10 years since qualification\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study adopted a unique research design to comprehensively assess the training and working experiences of GDPs in England providing CAT to adult patients and thereby address a gap in the literature for this significant dental workforce..\u003c/p\u003e\u003cp\u003eRather importantly, in terms of their training, the majority of GDPs reported that despite having completed aligner certification, they feltthe benefits were limited to theoretical background. with few reporting practical hands-on training,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e on placing auxiliaries and performing IPR on models. There was a strongly expressed preference for practical training to improve their CAT skills and confidence. Moreover, GDPs highly preferred training courses that covered case assessment, planning, guidance on treatment mechanics, troubleshooting management, and treatment of more severe malocclusions. Similarly, previous research recommended emphasis on training less experienced dental practitioners, with attention to CAT mechanics, extraction treatments, as well as troubleshooting governance, which may explain the above.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn regards to their CAT experiences, the majority ofGDPs had completed a larger number of cases in the past year, with GDPs mainly treating mild to moderate malocclusion traits but feeling less comfortable in treating more complicated cases, in line with previous reports.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e In contrast, d'Apuzzo et al. (2019) concluded that 40% of GDPs do not provide CAT in their practices due to a lack of experience in CAT provision.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eInterestingly, the assessment of GDPs\u0026rsquo; confidence in treating seven different malocclusion traits with CAT before and after a 4-week webinar course, in the present study revealed that they changed their rating of the malocclusion trait complexity from moderate to severe. This finding suggests that there was a change in their GDPs\u0026rsquo; views on case suitability over time; along with an observed increase in their confidence. Indeed, some GDPs who were less than 10 years qualified, subsequently expressed their preference to treat milder relapse cases, requiring anterior tooth alignment only to facilitate restorative treatments in this study. Similar findings were identified in previous research.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn the present study, the change of views may be attributable to the gained self-awareness of GDPs skills and limitations and their now clearer understanding of tooth movement predictability with CAT. Moreover, this may also reflect the fact that GDPs felt their case complexity was now being assessed and the case treatment planned by a specialist orthodontist treatment for suitability. These findings show that having the orthodontic specialist support backup, such as made available with 32Co, had encouraged GDPs to consider submitting cases of greater complexity for consideration. Therefore, this support system was perceived as crucial for better patient-centered care and treatment outcomes.\u003c/p\u003e\u003cp\u003eWith regards to the use of digital scanning technology, the current study highlighted that GDPs, qualified for less than 10 years, more readily incorporated this into their practice, reporting numerous advantages, from the ease of use, efficiency in communication with the laboratory and patient through visualization of the treatment plan. Despite the role of digital scanning in the efficiency of treatment planning and delivery of care in CAT,\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e a few of the GDPs in this study reported not to have used digital scans for CAT previously. The high cost of digital scanners as reported by a few working in small and rural areas in this study, or the lack of accuracy in some more affordable,\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e may be a barrier to their use amongst the GDPs in this study and in particular those qualified more than 10 years.\u003c/p\u003e\u003cp\u003eIn terms of the clear aligner provider, the current study suggested that Invisalign (Align Technology\u0026reg;) was commonly selected by GDPs as their CAT provider, with similar findings identified somewhere else.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e GDPs provided a wide range of reasons for their choice, ranging from the ease of use of the software planning tool, marketing of the brand, quality of the aligners. In contrast, newer emerging companies were recognised for their ability to access a specialist orthodontist to assess case complexity, suitability for CAT and provision of a treatment protocol, and ongoing customer support. As such, a trend was reported with participants moving away from the more popular but expensive aligner providers towards the latter.\u003c/p\u003e\u003cp\u003eThe present study found that GDPs qualified for more than 10 years used a variety of complex CAT mechanics.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Furthermore, 98 per cent of GDPs had used IPR in relation to CAT,\u003csup\u003e\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e and showed a greater understanding of the reasons for using IPR and the need for staging when 0.3-0.5mm was indicated. The greater GDPs confidence in performing IPR in the present study could be related to the perceived usefulness of the training courses in CAT and the number of cases they treated with CAT. Indeed, GDPs qualified for more than 10 years, agreed that \u0026lsquo;performing IPR\u0026rsquo; was a beneficial aspect of the training courses and performed greater than 50 cases compared to those GDPs who were less than 10 years qualified.\u003c/p\u003e\u003cp\u003eMoreover, GDPs in the present study had a stronger inclination towards alternative approaches for creating space within the dental arch, such as extractions. GDPs who were more than 10 years qualified expressed similar preferences in deciding a lower incisor extraction or premolar extraction in malocclusions necessitating creating space by means of extractions in CAT. In contrast, previous research showed that both specialist orthodontists and GDPs were confident in performing IPR equally, however, discrepancies were noted in the application of all other auxiliaries, with GDPs showing less confidence in using elastics and prescribing extractions.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Meade and Weir (2024) revealed that nearly one-fifth of GDPs preferred a lower incisor extraction pattern, while only 6% were comfortable with prescribing a premolar extraction in CAT.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e These findings may be attributed to the support acquired from specialist orthodontists, who encouraged GDPs in this study to use a variety of auxiliaries including elastics and buttons, bite ramps and prescribe extractions. In addition, working with specific protocols and tools, and following provider instructions helped increase GDPs\u0026rsquo; confidence levels and build a strong trust relationship with the CAT providers.\u003c/p\u003e\u003cp\u003eThe present study showed that GDPs used more than one type of orthodontic retainer following CAT provision. GDPs, greater than 10 years qualified, commonly used laboratory fabricated fixed retainers in both arches. GDPs, irrespective of their number of years qualified, often recommended removable VFRs either on their own or in combination with fixed retainers. Similar findings were reported by Meade and Weir (2024) in which GDPs commonly chose to prescribe clear vacuum-formed retainers for the upper arch, while the most frequently preferred option for the lower arch was a combination of a fixed retainer and a vacuum-formed retainer.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e In addition, both groups of GDPs (\u0026lt;\u0026thinsp;10 and \u0026gt;\u0026thinsp;10 years qualified) preferred to prescribe fixed lingual retainers for the more complex malocclusions with high risk of relapse. Limited clinicians' skills in placing a chairside fixed retainer were a decisive factor for providing laboratory-made fixed retainers.\u003c/p\u003e\u003cp\u003eThe mixed-methods research applied in the current study identified the limited understanding and diverse practices of GDPs in CAT provision. This highlights the need to further train GDPs on suitability for CAT and their role in treatment provision. Thus, appropriate training in various aspects of clear aligner treatment, particularly case selection criteria, need for dental extractions and a variety of treatment mechanics would be relevant to enhance confidence in CAT provision and more importantly treatment outcomes amongst GDPs.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eStrengths and limitations\u003c/p\u003e\u003cp\u003eThe current study contributes to the literature through exploring the views of GDPs practising orthodontics with CAT; however, there are limitations which need to be considered. Firstly, responses were restricted to GDPs who had been registered for the 32Co training course in CAT and working in England. Nevertheless, the wide range of locations where GDPs were trained and worked limits this impact. Moreover, in line with the current studies inclusion criteria and objectives, and in an attempt to overcome the limitations of other studies, the present study did not want to recruit GDPs who had either no interest or experience in CAT. Thus, the included GDPs, were from across England and had all gained both training in various forms and experience, with a range of CAT providers, making the findings more real-world and arguably generalisable. Furthermore, the findings of this study provide baseline data on the training and experiences of GDPs providing CAT, to which comparison can be made by other researchers.\u003c/p\u003e\u003cp\u003eConsidering that the online questionnaire used in the survey was self-administered, certain views of GDPs may be lost or misunderstood. To minimise this limitation, a mixed-methods research approach was adopted. Adding a qualitative research method to explore in detail and understand the reasons behind their responses. The findings from the two stages of the research do provide similar perspectives and the combination of approaches provides triangulation; ensuring the validity and robustness of the findings and their interpretation in the present study.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study provides important insights into the GDPs\u0026rsquo; training and working experiences in CAT provision for adult patients.\u003c/p\u003e\u003cp\u003eSignificant shortcomings were identified in theirtraining courses,despite having gained certification..\u003c/p\u003e\u003cp\u003eGDPs showed greater confidence in treating a range of malocclusion traits with CAT, with ongoing support from specialist orthodontists.\u003c/p\u003e\u003cp\u003eThe use of digital scanning for CAT treatment planning was less common amongst GDPs qualified greater than 10 yearsA variety of retainer types was selected by GDPs following CAT provision to adult patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflicts of interest\u003c/h2\u003e\u003cp\u003eAJ acts as a clinical lead for 32Co, in providing mentorship and educational resources. FCS and GB declare that they have no conflict of interest. RM is employed by 32Co and leads the Educational resources.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor contributions\u003c/h2\u003e\u003cp\u003estatement\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e\u003cp\u003eWe would like to thank all the general dental practitioners who volunteered their time and participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJohal A, Bondemark L. Clear aligner orthodontic treatment: Angle Society of Europe consensus viewpoint. Journal of Orthodontics. 2021;48(3):300\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHansen V, Liu SS, Schrader SM, Dean JA, Stewart KT. Personality traits as a potential predictor of willingness to undergo various orthodontic treatments. The Angle Orthodontist. 2013;83(5):899\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ed\u0026rsquo;Apuzzo F, Perillo L, Carrico CK, Castroflorio T, Grassia V, Lindauer SJ, Shroff B. Clear aligner treatment: different perspectives between orthodontists and general dentists. Progress in Orthodontics. 2019;20:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVic\u0026eacute;ns J, Russo A. Comparative use of invisalign\u0026reg; by orthodontists and general practitioners. Angle Orthodontist. 2010;80(3):425\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBest AD, Shroff B, Carrico CK, Lindauer SJ. Treatment management between orthodontists and general practitioners performing clear aligner therapy. The Angle Orthodontist. 2017;87(3):432\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGao Y, Sun X, Yan X, Tang Z, Lai W, Long H. 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American Journal of Orthodontics and Dentofacial Orthopedics. 2022;162(6):e302-11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlmotairy N. Public perception of Invisalign\u0026reg; clear aligner treatment: a cross-sectional survey-based study. APOS Trends Orthod. 2023;13(1):38\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGao Y, Sun X, Yan X, Tang Z, Lai W, Long H. Orthodontic Practitioners\u0026rsquo; knowledge and education demand on Clear Aligner Therapy. International Dental Journal. 2023;74(1):81\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonovan J, Millett DT, Harding M. Interproximal reduction in orthodontics: Reported practices and perceptions of orthodontists in the Republic of Ireland. Journal of the Irish Dental Association. 2024 Jul 5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSheridan JJ. The readers' corner. 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Designing and conducting mixed methods research. Sage publications; 2017 Aug 31.\u003c/span\u003e\u003c/li\u003e\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":"british-dental-journal","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bdj","sideBox":"Learn more about [British Dental Journal](http://www.nature.com/bdj/)","snPcode":"41415","submissionUrl":"https://mts-bdj.nature.com/cgi-bin/main.plex","title":"British Dental Journal","twitterHandle":"@the_bdj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7509774/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7509774/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eThis study explored the training and working experiences of general dental practitioners (GDPs) in England in providing clear aligner treatment (CAT) to adult patients.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e\u003cp\u003eA unique mixed methods approach was adopted, including an online questionnaire and one-to-one semi-structured interviews of GDPs across England providing CAT. Quantitative data were analysed descriptively using MS Excel and qualitative data using framework methodology.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOne-hundred completed surveys were received, and 16 interviews were conducted. Most GDPs reported having attained aligner certification (n\u0026thinsp;=\u0026thinsp;86) and nearly one-third (n\u0026thinsp;=\u0026thinsp;31) gained some theoretical knowledge of CAT but highlighted key shortcomings of the training courses, which need addressing. GDPs felt confident in treating mild or moderate malocclusion traits and expressed several reasons for choosing a specific CAT and digital scanner and provider. Those GDPs qualified more than 10 years could apply complex treatment mechanics. Laboratory-made fixed retainers were of higher preference following CAT, especially in complex malocclusions with high risk of relapse.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eGDPs\u0026rsquo; limited understanding and diverse practices in CAT provision, suggest the need for policy makers to review the undergraduate dental curriculum and for educators to ensure the inclusion of theoretical and practical aspects of CAT, together with the ongoing support of specialist in orthodontics.\u003c/p\u003e","manuscriptTitle":"The provision of clear aligner treatment by general dental practitioners in England: a mixed-methods study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-17 19:09:33","doi":"10.21203/rs.3.rs-7509774/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-10-21T11:06:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-10-10T19:59:16+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-09-30T19:48:58+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-09-19T22:34:16+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-09-11T04:31:10+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-09-09T18:40:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T13:03:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T13:03:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"British Dental Journal","date":"2025-09-01T15:04:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"british-dental-journal","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bdj","sideBox":"Learn more about [British Dental Journal](http://www.nature.com/bdj/)","snPcode":"41415","submissionUrl":"https://mts-bdj.nature.com/cgi-bin/main.plex","title":"British Dental Journal","twitterHandle":"@the_bdj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8cae0970-e033-4c36-89b6-72f4b1a97f84","owner":[],"postedDate":"September 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":54461781,"name":"Health sciences/Health care/Dentistry/Orthodontics"}],"tags":[],"updatedAt":"2026-01-12T09:25:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-17 19:09:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7509774","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7509774","identity":"rs-7509774","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}