ADA interview with Dr Nour Tarraf

Dr Nour Tarraf

You already know a little about Dr Tarraf, below is the transcript of a recent interview he had in 2015 with the Australian Dental Association, which highlights his attitude towards orthodontics, his family life and the way it has changed his practice for the benefit of his patients.

What first led you to dentistry?

I come from a medical family with both my parents and a grandparent being professors in different fields of medicine. I was very lucky to have had a very good dentist from childhood and I really liked going there and I loved how his work was so hands-on. Since I loved working with my hands building miniature models, dentistry seemed to tick all the boxes – it was medical and it was very hands-on with a significant element of art and craftsmanship.

What has excited you the most about recent developments in Orthodontics?

Almost 15 years ago, around the same time that you completed your Bachelor of Dentistry degree with Honours at Cairo University (followed by an Orthodontic residency and a Masters degree in Orthodontics with Honours at the University of Sydney in 2008) Time magazine in the US got it horribly wrong when they nominated Orthodontics as one of 10 careers that would disappear in the “new millennium”. What has excited you the most about recent developments in Orthodontics?

Wow, were do I start. Orthodontics is probably one the most exciting fields to be involved in at the moment. New technology has transformed the way we practice in many ways. Starting with diagnosis we can now use three dimensional models combined with facial scans and CBCTs to provide a true three dimensional model of our patients
and this is something orthodontists have dreamed about for over a 100 years. This has improved our ability to diagnose the source of the malocclusion, especially in complex cases.

Furthermore we can now use these virtual models in treatment planning software to project different treatment options and test them before starting treatment. This has allowed us, with a great deal of con dence, to show patients different outcomes based on different plans but it has also improved our ability to communicate with our restorative and surgical colleagues to ensure well-coordinated interdisciplinary care. Gone are the days of posting plaster models and praying that they arrive to your colleagues in one piece. It does not stop there, CAD/CAM technology has transformed appliance manufacturing and as a result we can now
design and manufacture customised orthodontic appliances such as Invisalign, Incognito and suresmile based on our desired outcomes.
This has not only reduced treatment times but also improved the quality and precision of our achievable results.

What Time Magazine didn’t realise is that the above-mentioned are still only tools that can help but do not replace Orthodontists. We need not forget that at the end of the day every patient and every malocclusion is unique and good Orthodontics is about the correct diagnosis which then leads into a treatment plan that is used to formulate a biomechanical plan to achieve it.

All the technology in the world will not rectify the wrong diagnosis nor make an unrealistic treatment plan work. So we still have to drive this technology, but it certainly makes the driving so much more enjoyable for everyone involved.

If one’s only tool is a hammer, everything begins to look like a nail.

Your presentation topic for the 36th Australian Dental Congress is focused on Temporary Anchorage Devices (TADs). In their book, Orthodontics: Current Principles and Techniques, authors L. Graber. R. Vanarsdall and C. Vig (Elsevier Health Sciences,
2011) suggest that the availability of major noncompliance treatments such as TADs brings to mind the old expression, “If one’s only tool is a hammer, everything begins to look like a nail.” That is, this idea of a ‘best option’ treatment may have negatively affected the decision-making process in Orthodontics by eliminating other viable options that would normally be considered for compliant patients. Is that a fair assessment to make in your opinion?

Like with any new technology the pendulum can swing to both extremes before it finally settles.
I have used TADs since 2004 and I believe that initially we were out to see the boundaries of the new technology and what it can offer.
Currently, if you look at a more recent survey performed by the Journal of Clinical Orthodontics, 75% of orthodontists said that they used TADs routinely in their practice but ultimately it was used for less than 10% of the cases. Also, keep in mind, TADs are not merely an option to offer non- compliance treatment options. The introduction of TADs has offered us the ability to do things normally considered impossible with conventional orthodontics. Things like molars intrusion to correct skeletal open bite, retraction of entire arches and the closure of very large spaces without side effects. This has made it possible for us to expand the envelope of what orthodontics can do alone and in many cases has offered a very viable alternative to orthognathic surgery. It also has opened up options for adult patients and those with many missing teeth to have space closured with their own natural teeth and less need for prosthesis.
In addition to that, TADs have also offered a very viable way to apply conventional treatment with minimal patient compliance. Nowadays, who really wants to wear headgear? Kids in Australia are very active and it just so happens that after school they are not sitting at home wearing headgear, they are outside doing sport, music and dance. They don’t have time to wear headgear 12-16 hours a day. We must adapt our treatment modalities to deliver what our patients need.

Patient compliance and results with Invisalign?

You also have a distinct interest in Invisalign which, of course, requires a high degree of compliance. Can you share if you have ever found the requirement for patient compliance an obstacle to effective treatment and overall patient satisfaction with the result?

I should probably correct the statement in the question first. I have a distinct interest in invisible orthodontics and invisible orthodontic techniques with 50% of my patients using some form of invisible treatment. Invisalign is but one option in that toolbox. I have a great passion for lingual orthodontic appliances as well and use a variety of customised lingual appliances in my practice. Today’s lingual appliances such as Incognito and suresmile have evolved to be comfortable and predictable, pretty much on par with conventional labial fixed appliances. I strongly believe that with today’s appliance technology we can offer invisible orthodontic treatment for any patient no matter how complex the malocclusion or how compliant they are without necessarily compromising the quality of the outcomes. It is a matter of selecting the correct appliance that will be most efficient in correcting the malocclusion and also one that ts within that particular patient’s lifestyle requirements. In many cases I combine Invisalign with lingual appliances to tailor the solution to stay invisible and to deliver a high quality result without compromise.

Succesful advertising and self diagnosis

Successful advertising campaigns are known to influence public awareness and opinion such as the
wider community interest shown for Invisalign. Does the community awareness factor make it difficult to convince a self-diagnosing patient who is very keen on having a particular treatment that another form of treatment may be more effective?

In my opinion Invisalign has done Orthodontics a massive favour with direct marketing to the public. It has made many adults realise that, ‘hey, it’s never too late’ and you are never too old to have Orthodontic treatment. Many more adults have walked into an Orthodontic office on the back of an Invisalign commercial, which is great for us. According to the JCO survey, 24% of orthodontic patients are now adults as opposed to 10-15% 15 years ago. I believe this is thanks to Invisalign. It is also important to mention that the company did not only put its dollars behind marketing but also invested an enormous amount into research and development of their appliance. It has evolved into a predictable and very viable treatment option and is continuously evolving into a better appliance every year.
However, it is still up to the professional to explain to the patient what the appliance can and cannot do but more importantly,
to be aware of the limitations of their own ability to use the appliance. Keep in mind that in some cases there may be other invisible solutions that may be more efficient or more effective. Unfortunately the quote you had referred to earlier, “If one’s only tool is a hammer, everything begins to look like a nail” rings true here. Many people have used the appliance in cases where other alternatives would have delivered a better result or have used the appliance beyond their own ability. This has resulted in the appliance developing the reputation that ‘it is not as good as braces’, which I believe is incorrect. If the only invisible tool you have is Invisalign, every adult case is an Invisalign case … then you run into problems. In many cases patients ask for Invisalign because they want invisible treatment and think it’s the only way to do it. So offering a viable invisible alternative such as lingual orthodontics or combining Invisalign with a fixed appliance element can ensure a great outcome that is still going to fit the patient’s lifestyle needs.

How research has benefited your day-to-day work?

You are currently working towards a PhD on the application of skeletal anchorage in growth modification for children on top of your usual work as a practicing orthodontist.
Can you tell us how your research has benefited your day-to-day work?

The reason for research was to find a way to treat the complex problem of Class III malocclusion with a less obtrusive and more effective appliance than the facemask. For years we
only had the protraction facemask as the gold standard for Class III growth modification treatment. This, though, proved to have many limitations. Firstly, it is an extra-oral appliance that requires 12-16 hours of wear every day/night for a period of 10- 12 months to deliver the results. This makes it cumbersome but is also very difficult for children to comply with. It is especially difficult in Australia with our kids being so active and spending so much time outdoor in sports and other extracurricular activities. Secondly, the window of opportunity for correction is quite small with the appliance being most effective before the age of 10 years so older kids do not tend to get good outcomes. The use of skeletal anchorage (TADs) in growth modi cation is making it possible to provide a very effective intra-oral means
to correct this malocclusion and also provide great results for children normally considered too old for skeletal Class III correction.
Being actively involved in research has also always made me on the lookout for new evidence and new developments in the profession thus ensuring that I keep my services at the practice at the cutting edge of new technology.
I strongly believe in timely treatment when it comes to growth modification and with TADs we have a greater ability to apply our forces directly to the jaw bones thus reducing undesirable tooth movement and maximizing skeletal growth modification.

Work/Life balance

Maintaining a work/life balance is a challenge for most of us but in your case, your family’s plight was made public on the front page of The Sunday Telegraph in October last year. Can you talk a little bit about it?
2014 was a very dif cult year for us. [Our daughter] Hana’s diagnosis showing she had a massive brain tumour and the subsequent fall-out from her surgery has turned our life upside down. It has certainly made us re-evaluate our priorities and it continues to be a battle on a day-to-day basis. Fortunately my wife Naomi is not only supermum but also a superwoman. She has managed to be both a fulltime caretaker for Hana, a mother of two, a wife and a full time researcher into Hana’s condition. With her nursing background she has researched into different ways to improve Hana’s quality of life as well as help inform and educate other parents in similar situations about how to deal with it. You can read more about her from her blog []. I am also very lucky that Hana is such a brave girl and her bravery has been inspirational.
For a work/life balance it is now paramount for me to have efficient systems at work to ensure that I never end up working late. I also make sure I leave work at the office. I have invested heavily in upgrading the technology at the practice so that there is minimal time wasted. In order to maintain my fitness without affecting family time, I now cycle or run to work and swim in my lunch break and that way when I get home, it’s family time.As a health professional, being at the receiving end of healthcare for 14 months now and having experienced many of its shortcomings, I have developed a very different understanding and perspective of what it is like to be the parent of a child that needs a high level of care. I have changed a lot in the way I run my practice. From making sure we always run on time to making sure we provide our patients with enough time and information about the treatment they will undergo as well as being more prepared to communicate with patients via email to answer questions.

How do you like to spend your time away from work?

How do you like to spend your time away from work?
I love sports and the outdoors in general. I used to play Golf off a handicap 5 in years gone by. Now time is precious and free time is mainly focused around maximizing fitness and family time. My wife and I are both keen triathletes. We have both been to the amateur age group world championships in 2012 where she represented Australia and I represented Egypt. This year I have qualified to represent Australia as an amateur in the Duathlon World championships, which will be in Adelaide at the end of October 2015. It’s of particular signicance for us because the week of the race will be exactly 10 years since we came to Australia and what a way to celebrate the ten year anniversary than the honour of wearing the green and gold!

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