Expand podcast. Aligners: is the planet smiling?

This transcript has been reviewed by AI and may contain inaccuracies.

Dr. Daniel Ramos: For today's episode, I am bringing a very important topic, aligners. Is the planet smiling? And in my opinion, there’s no one better to discuss this with me than my colleague and friend, Dr. Lotte Meereboer. This is the part where you need to help me later, okay, Lotte? This is difficult for me coming from Brazil, but she is a very experienced dentist, treating patients with aligners from the Netherlands. She owns a clinic and she’s done more than 4,000 cases, right, Lotte? She is also the founder of the Dutch Aligner Society. We meet very often at congresses, and this topic, we’ve discussed it already, and today I think it’s a great moment for us to bring it back. Welcome, Lotte, thank you.

Dr. Lotte Meereboer: So honored to be here with you.

Dr. Daniel Ramos: My pleasure. I remember meeting you at a congress in Apeldoorn, right? And you were the first doctor who opened my mind to some topics that I need to confess, I wasn’t thinking about before. About the impact that all these technologies are causing. The first thing to mention, because I don’t want to transmit the wrong message—we both love aligners, right? And we both love technology and we use it to provide the best care for our patients. But what is the cost for the planet? What’s your opinion about what this technology—the downside of the technology—that we might not be noticing, or we need to start thinking about?

Dr. Daniel Ramos: Okay, perfect. Well, I mentioned that we both love aligners, but what is the cost of this technology? Specifically, aligners and all the technologies that are associated with aligners, to our planet, to nature, to the forests, to the oceans?

Dr. Lotte Meereboer: Yeah, so I’ve been doing these treatments for about 15-16 years now. And of course, I’ve seen enormous growth in the demand for orthodontic treatments in general, and especially aligners. It was already a few years after I started that I began to think, "Wow, how can this huge package enter my clinic with aligners from UPS, of course, always?" And it’s a huge package, individually packed, and then another bag, another box with more plastic. And then finally, those aligners, in huge amounts. I thought, "Wow, this is totally different from what I have in my hand compared to a handful of brackets." And I was already questioning the volume and the material, where does it come from? And it has to fly from other countries, other continents to be transported. So, I had questions very early on about this.

Dr. Daniel Ramos: It’s a huge difference in terms of type of material, right? And quantity, and plastic. We know it’s very challenging in terms of recycling, in terms of not just how it’s getting to our clinics, but what we are going to do with all this material after, right? I don’t know about in the Netherlands, but in Brazil, when I was practicing there, we used to have a whole program for recycling. How is this process for you, Lotte?

Dr. Lotte Meereboer: Yeah, like ten years ago, we already had in the Netherlands questions about plastic bottles, bisphenates, or BPA in plastics, hormone-disrupting substitutes. So, the whole plastic question was already going on from around 2010-2011, and we needed to recycle more. Today, we have huge plastic containers where all the households need to bring their waste. So, this is apart from my job, my clinic, but it’s going on all around me, all the other companies around me, like lawyers, anybody around me is doing something with recycling—except for us. That was strange in my eyes.

Dr. Daniel Ramos: Yeah, I agree that we need to be an important player in this game, right? I can see an example completely outside our business. I am a huge fan of music and I like to collect vinyl records. And recently, I received one from a good friend on my birthday from Coldplay and I really love them. And I was reading, and the material that was used to manufacture the vinyl is from recycled plastic, and all the papers were recycled. This is something that uses much less plastic than a package of aligners, and I’m going to use it a lot of times, multiple times in my life, and it’s going to be there with me for my whole life and maybe I’ll leave it for my kids. So, we are talking here about a lot of plastic that we are using once for a patient, maybe one week, five days, ten days, fourteen depending on your protocol, right? And this is something we need to actually start making pressure about or discussing with the companies because in the end, everyone should do their part, right? But the biggest responsibility, I believe, is also with the companies. I don’t know your opinion on that.

Dr. Lotte Meereboer: But it’s not only the aligner itself, it’s also all these models that are printed and all this liquid material for the resin.

Dr. Daniel Ramos: Great point.

Dr. Lotte Meereboer: And the waste around the manufacturing, it’s insane.

Dr. Daniel Ramos: It’s not only having maybe the clear aligners, which are the most visible part, right? Because this is the end, the final step that gets to us, and they leave this responsibility with us and we need to find ways to better recycle. But you raise a very important topic here—to get to the point of having the aligners, there’s a lot of processes, right?

Dr. Lotte Meereboer: Yeah.

Dr. Daniel Ramos: And this is also a lot of materials.

Dr. Lotte Meereboer: Yeah, now it’s more open to us how to manufacture our own aligners or retainers. So, as dentists, orthodontists, combine our own printers now. So now we step into this technician lab work and find out, "Whoa, there’s much more going on there than we even thought of." But yeah, there are some people, some companies, developing new materials, even the plant-based plastic with a bit less toxicity maybe. But we have to get rid of our plastic demand in orthodontics.

Dr. Daniel Ramos: And in your opinion, Lotte, at this point, everyone who is listening understands that we are talking about how aligners can be, let’s say, greener, more compatible with nature. But how? Right? This is a good question because we know sometimes companies and businesses are more focused on numbers and they close their eyes to some parts of the process. But if we could create an ideal system—I know the ideal is maybe impossible—but a better system where you would start in the plastic, in the process, in the way we are printing or the number of stages, how do you think it could be good? This is something we can discuss here and create something together. But in your opinion, how would you start making aligners greener?

Dr. Lotte Meereboer: Yeah, I think the first question is, what do I want as a person or as a mother or father for my children? How do I want to leave this planet eventually? And is what I’m doing contributing to a better world? And the main question is this whole idea of perfect dentition, even something that I should worry about or my clients should worry about? Is it not more about going back to basics from, "Hey, why are we like this?" And, "What are we fighting for?" Is it for the perfect bite? Is it for occlusion? Is it for aesthetics? Or is it for actually staying healthy? Are there not other ways to stay healthy? Are there not other attacks from all around us that keep our children unhealthy and keep them having unhealthy habits that deform their jaws when they are already young? We should go back to basics, really, in the beginning. This is only a reaction, what we’re doing on unhealthy habits. I think eventually the air should be more clean, the water should be more clean, and without microplastics.

Dr. Daniel Ramos: Yeah, if I’m honest, we are talking here about... we started talking about plastic and aligners. This is a consequence of a lot of other things that we can do, maybe much simpler to do, and changing habits, right? And the way we are evolving as human beings, because of the food we are eating, the way we're processing it... Well, this topic is big, right?

Dr. Lotte Meereboer: Yeah.

Dr. Daniel Ramos: There are giants to discuss. I really like you bringing this up because as orthodontists and dentists, the sooner we can guide parents to prevent one patient that we can prevent early, it’s less plastic after all, right?

Dr. Lotte Meereboer: But if they come when they’re sick, to our clinic with a congested nose and no breathing, asthma and glasses on, and everything has gone wrong, no sports, then what am I doing? What am I fighting for? Who is attacking all these young children? From where is it coming? TV? Commercials from other food chains? What are we doing? Where are we spending our time and money?

Dr. Daniel Ramos: Yeah. So, as I’m understanding here, the first thing you do to make aligners greener is before getting to aligners, actually—it’s maybe better education, changing habits, and taking care of our children, right?

Dr. Lotte Meereboer: Yeah.

Dr. Daniel Ramos: I mean, in Holland, is something going on there to help society understand that this is an issue? This is like a pandemic that no one’s talking about, right?

Dr. Lotte Meereboer: In Holland, the last 20 years, we’ve spent four times more money on prevention, all from healthcare. But the health, the dental health of children, did not improve in 20 years. It actually got worse. So, there are so many children’s dentists around here, putting them under full anesthesia to pull out their decayed molars. It’s crazy. We’ve spent so much money on prevention, but actually, it was not working. So, there must be another way to deal with this.

Dr. Daniel Ramos: Yeah. And how about the plastic itself? Are you aware of any new technology that is creating a better plastic to manufacture aligners? Something that can be more easily recycled? Because the plastic we are using nowadays is a contaminated plastic after the treatment, and it’s very difficult to be accepted in a regular recycling company, right?

Dr. Lotte Meereboer: Of course, we have the graphene material. At least they don’t make models. That’s a huge reduction.

Dr. Daniel Ramos: Printed aligners is an interesting concept, right?

Dr. Lotte Meereboer: Yeah, direct or the natural aligner from Switzerland, that’s plant-based. I’m not sure, because I know... yeah. But organic gum, like chewing gum, is not really organic either. You cannot just throw it in the bushes and it will disappear in a year. It also stays there 100 years. Seed chain is not from orthodontics, but the carbon chains are very strong. So, you cannot just make any plastic made from carbon—it’s not so easily degradable.

Dr. Daniel Ramos: Yeah, so, but there are some movements, right, from some companies looking, because maybe there is someone who is listening to us now. We are talking about aligners. Everyone knows what aligners are, but to have an aligner, the normal process is to print a model, right? And then to mold this aligner over this model. And this printed model is a lot more material that we need to get rid of, right? And this new technology that is coming, and I believe most companies, they are looking for it, and it’s good for all sides because it’s less cost, I believe in the end, less time, but to print directly the aligners. So, this is maybe one step in a good direction.

Dr. Lotte Meereboer: Again, we do have to do a lot of research about monomers in blood, in saliva. Now we’re giving all our patients night retainers made of the same plastic. Again, polyurethane mostly, but we have to double-check the blood levels of microplastics.

Dr. Daniel Ramos: And there is one paper that we were sharing in advance that I really like, and I like the title: Orthodontic Aligners Between Passion and Science. Because a lot of times we fall in love with a new technology and we start using it and it’s amazing, but sometimes we don’t stop to think about the impact and if it’s really good. And aligners, in my opinion, for me at least, it happened like this. I started using them and then I realized I couldn’t go back. But in terms of science, right, there are a lot of chemicals and a lot of components in the plastic, and these studies are showing that there is a risk, for example, with the friction, of releasing some micro particles of plastic. And we also have bisphenol A that we need to take care of. So, what do you know about it? You don’t need to provide me with any data. Of course, these articles later we can leave the link. But what is the science saying to us at this point?

Dr. Lotte Meereboer: Yeah, it does release some, but very little. And eventually, we inhale, we drink microplastics a lot. So, it’s not just from aligners; there’ll be a combination.

Dr. Daniel Ramos: Yeah, well, for me, when I was a kid, I remember that my mother used to apply mercurochrome when I got hurt, injured, and then some research mentioned that it’s not good. I also remember my father saying to me that eating a lot of eggs is not good for health, and now it’s good. So, of course, with time and with research, we learn more. But it’s important for people to know that right now we have a lack of studies, right? We need more studies to really understand what is going on with our body after we insert plastic in our mouth and leave it there. For how long? We want our patients to use it 22 hours per day, right? So...

Dr. Lotte Meereboer: For the nights, for the rest of their lives.

Dr. Daniel Ramos: Yeah. And the retainer. So, this is something that in the past, of course, we didn’t use, right? It never existed. And braces also, we used metallic braces, arch wires for a period of time, and then we removed them. But aligners and retainers, it’s pretty much for the whole life. Right. So, we know at this point, and please confirm or if you have any extra information, that it’s known that some particles of the plastic can be released. But the level that the studies are showing, probably we can—our gastric and digestive system can get rid of, right? Is there any data showing association, for example, with any disease, any increase in the rate? Or at this point, we don’t know much about it.

Dr. Lotte Meereboer: No, fortunately not. No, it’s because we have so many other contacts with plastics around us. You cannot, like with amalgam, you cannot really point out, "Well, I got sick because of this filling," or… No. It’s so hard to prove.

Dr. Daniel Ramos: Yeah, yeah. Well, every time as a dentist, we are sometimes placing new materials for the long term, right? And we used a lot of metal, so aligners are kind of new, right? Even though we used plastic with acrylic for patients for a while. But the plastic we’re using that needs to have these characteristics, right? To have some resiliency and also memory, so we can generate force to promote the movement. This is a kind of plastic that’s new and it is evolving very fast, right?

Dr. Lotte Meereboer: Yeah. Because I request all the safety data sheets from all the companies that I work with, but most of them just keep their recipes as a secret. They just say "mixture, mixture, mixture" on the 30 pages. So, it’s just very hard. I mean, we know a bit more about breast implants by now. We don’t want to be the second department with plastic problems as the breast surgeons have.

Dr. Daniel Ramos: Actually, maybe this is a great point to raise because every company keeps this recipe, right, of their plastic as their secret sauce, like the Coca-Cola formula, and they are not sharing it. And maybe this is making it hard for someone without any bias to do a proper investigation, right? So, normally what we know comes from the companies, right? And they are doing their own research, but we don’t actually know because we don’t have all the information. I wouldn’t know how to interpret it, right? Because I don’t know anything about biochemistry and this matter. But for someone who is involved and wants to research, or if they’re inside a company, they won’t receive all the data they need to know, right? So, this is tricky and probably one of the factors causing this lack of information in terms of the plastic. Okay. For those who are listening, I don’t think we need to be worried about it, of course, but we are not saying that you should stop using aligners. I believe that’s not what you and I are saying, right? It’s a great technology that until now we have thousands of cases, right? You have more than 4,000. We have a lot of cases here, we have been treating with our treatment planning service. And from time to time, we can see some reaction, some allergy, right? And this is something that we have been using for more than 20 years, of course, it’s changing. But it’s important for us to investigate. And we are talking about our health now. Moving back a little bit to the planet, Lotte, besides the plastic, besides the production of these materials, what came together with aligners is the digital technology, right? Software, scanning, the cloud, energy, data that we need to save. Somewhere in the past, I remember in my clinic, we needed to have a big room just to store all the cast models, right? And now this is good because I don’t need to rent a big place, I can be in a smaller place. But I need to save this information somewhere. Do you think this is something that we need to be concerned about? Is this something that is somehow creating any harm to our planet? What do you think about it?

Dr. Lotte Meereboer: Yeah. In Holland, we have a huge number of data centers, big blocks, rising next to highways. So, somehow the big companies like Holland for being here, so they’re absorbing—you are using a lot of energy. All the windmills you’ll see are used for Google, Amazon in the Netherlands, a lot of subsidies go there. So, somehow we are a kind of green country. But it’s used for even more huge amounts of data. And it’s not only from our scanners, of course, it’s used for many, many, many other things, like videos, music, emailing. But an email is using as much as CO2 or energy as two paper letters eventually. So, I’m not sure if a paper letter is better for the environment than an email. You have to really take care of your inbox as well, to clean it up and throw away things. All this data should be erased on time and deleted. Also, scans, maybe of the patient.

Dr. Daniel Ramos: Because when we think fast and compare writing and using a sheet of paper and sending an email, the first thing that comes to mind is, "Okay, I’m saving a tree here by doing an email." But how the energy to make this wheel keep rolling about sending a lot of files to the cloud and saving… So, this is a tricky discussion, because it’s very hard to put the balance into understanding where is the best way to go. Because from one side, I don’t believe we can take this step back, right? I’m not defending that we shouldn’t use technology. I am in love with technology. I really like this topic. Again, if we don’t question, when we realize that something is actually causing some problem, sometimes it’s too late. And this is something not only for scanners and orthodontists and dentists. It’s a problem that everyone—we have a smartphone, everyone is connected, everyone is using data and files, and there is a lot of energy involved, right? And to create this energy, we need to understand if it’s something that is going to be viable for the planet.

Dr. Lotte Meereboer: And our children with straight teeth.

Dr. Daniel Ramos: Exactly. Well, yesterday I was talking about this topic with some friends, right? And they started saying that, "But it’s kind of too—it’s not too much to think that how this data is going to be worse… What’s the word I’m missing here?" Like, am I too paranoid, right, about this worry? I need to say that on some level, we need to be concerned about it. Of course, we need to at least investigate and try to find better ways. Because my next question to you is, as dentists, orthodontists, we are there with our business, we want to offer the best for our patients. Our patients are coming to us asking for these technologies. How can we solve this math? How can we solve this problem? I don’t believe we can do this just by ourselves. But what are the measures that you, as a dentist, are taking to try to make it better for the planet?

Dr. Lotte Meereboer: Make it more visible for the clients? I think patients should be aware of what they’re ordering here, what they’re doing. In Holland, we have a term that’s called "vliegschaamte," which means you feel ashamed that you take a plane. If you do three holidays a year, you feel really bad. So, one holiday is okay, but yeah. So, even for flying, people feel bad about themselves, or burning wood in your home because the gas bill was high. If you’re burning wood, you feel ashamed because burning wood is very environmentally unfriendly, eventually. But people don’t care about their health, or going to the hospital, GP, or dentist. They put themselves above that. They don’t feel bad about demanding straight, beautiful teeth. And they feel they have a right to that. But is that really a human right? Question yourself, what you’re doing, how you’re balancing, and maybe do something to compensate. We try to plant trees, buy another company for every brace we plant a tree. But yeah, I want to stay away from greenwashing, too.

Dr. Daniel Ramos: So, yeah, I won’t be able to repeat the term in Dutch. But as I understood, it’s like being self-conscious about the problem.

Dr. Lotte Meereboer: Yeah.

Dr. Daniel Ramos: And trying to do our part to compensate whatever and whenever we can, right?

Dr. Lotte Meereboer: That will mean a lot of less consumption.

Dr. Daniel Ramos: And maybe one day, if everyone, including the companies, is doing—having the same self-consciousness about it and trying to compensate the energy we are using more here with avoiding some waste there, right? I feel this is the way. Okay, another comment I received recently from a friend is that, "Okay, us humans, we are like a virus today, to the planet." And somehow, this is true, because we are not here creating all these amazing inventions to benefit the planet, but for our own benefit, right? And most of the time, until you figure out we are creating harm. And as soon as we detect this—and this is why it’s important—and now this is my opinion regarding how dentists can help—is for us to be self-conscious and also to ask the questions, right? And to ask the companies, "Why are you doing this?" "Why are you not implementing this new plastic that you don’t need to print models?" Right? And even sometimes changing from one system to another system, if it is the same quality, if it’s the same efficiency, but this one is better for the planet, I feel that we should at least inform the patient to have the patient also participate in this process, right? Well, it’s a team sport, right? It’s not something that one person can do alone. But I really believe... I don’t know if you like this concept too, but I really believe in the power of a good example, right? If you see someone doing something nice, the tendency is for you to see and, "Oh, that’s great. I should do this," right? The same way the bad example can contaminate, right? But look, in the World Cup, the Japanese cleaning out their seats, right? Unfortunately, this is not something I’m seeing everywhere else. But it’s a good example that hopefully one day everyone is going to do this, at least for my sons. "Look, this is what you should do, right? It’s not your house, but you need to take care." And I really admire Dutch people the few times I’ve been in your country because you really incorporate this self-consciousness... What is the term again in Dutch you mentioned?

Dr. Lotte Meereboer: Well, we say "vliegschaamte" further than consciousness. It’s really feeling ashamed by doing un-environmentally friendly things.

Dr. Daniel Ramos: Yeah, but we should all have some of this.

Dr. Lotte Meereboer: Stay critical and ask things around you, and ask your suppliers, "Where does it come from?"

Dr. Daniel Ramos: Yeah, well, considering that aligners are here to stay, and I can see myself, I believe you also, using this kind of technology for a while, how do you feel that we can be like this, self-conscious about not only compensating but now talking about our job? How can we create good strategies, right? If we invest time in the planning, if we invest time learning, going after the information to do a better planning, we can probably reduce the number of aligners for these patients. It’s our commitment also to make things right, it’s our basics, right? It’s what patients are expecting. And this is something that is going the same road, the same path as doing good to the planet—to avoid wasting, right? So, in that sense, I know you are very engaged with congresses and you are part of the Dutch Aligner Society, as all the professors, speakers. The society has a great part in it, right?

Dr. Lotte Meereboer: Yes, definitely.

Dr. Daniel Ramos: Using…

Dr. Lotte Meereboer: Yeah, this morning a new client asked me, "Hey, but how many refinements do you order here?" Because I read things online that it can be down to six, seven, eight extra sets of aligners. I’ve been doing this many years, I try to avoid maybe one time, and if it’s really bad, I order a second time and a new set. And we hardly throw away aligners. I work on my setup, so…

Dr. Daniel Ramos: Yeah, exactly. That’s a good example of how you as an orthodontist or dentist can reduce the number of aligners that you use.

Dr. Lotte Meereboer: Good in what you do. This is what we need to be, right? It’s what a patient expects, and to do this, it takes time, right? We need to study, we need to go after the information, we need to get together at congresses to learn from each other. I can see in Brazil at least people, the dentists, they used to charge for orthodontic treatment per month. Sometimes if you finish fast, it’s not a good business. So, it’s not the norm. I’m not saying that everyone is doing this. A lot of times I was lecturing about accelerated orthodontics, biological modulation, to try to make things work faster, but I heard a lot of times, "But this is not good for my business because if I finish faster I’m going to earn less, so it’s good for me to keep going." Again, this is a very bad way to think because it’s bad for the patient, it’s bad for the planet because it’s more plastic, and it’s not a solid concept to keep in your clinic because at some point the patients will figure it out. So, good planning, in my opinion, is the most important part because this is where we’re going to save a lot of stages, a lot of plastics, a lot of data, and energy. If we can be predictable, if we can be assertive in terms of what we are planning there. And this is a great message to the patient also, right? "Let’s do it together. You need to collaborate, you need to use the aligners, I need to do good planning, and together we can finish our treatment faster." And also, we can do a lot of good for nature by avoiding unnecessary plastic.

Dr. Lotte Meereboer: Sure. And be aware and conscious about that. You’re part of an industry and also part of this planet.

Dr. Daniel Ramos: Yeah, for sure. We are all... there’s no other planet. So, we need to stick with it and we need to treat it better, right?

Dr. Lotte Meereboer: Our only planet.

Dr. Daniel Ramos: Yes. So, in the end, now as our final discussion, conclusion. Okay. We know that aligners are here to stay. We discussed some ways on how aligners can be greener in terms of reducing the number of stages. This is our job, making the plastic better is the company’s job. But we need to be putting some pressure to avoid unnecessary treatments, as you mentioned, and for patients to understand that there is a cost, right? Just because of aesthetics, just because of some shallow needs, is it really, really necessary? Right. As dentists, in the end, and here I leave it to you to summarize your opinion, the best way for us to do better for the patient as dentists, in my opinion, is to use this technology wisely and be the most efficient we can to use only what we need of it, right? And avoiding the excess. So, what do you think?

Dr. Lotte Meereboer: Totally agree with that. Yeah. Thank you.

Dr. Daniel Ramos: Oh, this is... I took it from you, from your work. So, we built this concept together today. So, I need to confess, when we started this episode, I thought we were going in one direction, talking about plastic, plastic, plastic, and preparing about bisphenol A. But I really like that we took a turn and we’re talking about much more accessible things that we as—not dentists now, but human beings—we can do, right? And I think everyone who is taking the time to listen to you and me today, the final message I would say is that we need to be aware, we need to be self-conscious, and we need to do our part as orthodontists to use this technology properly in the most efficient way. Okay, Lotte, thank you so much for your time. I know you are super busy being a mother, a dentist, a member and founder of the Dutch Aligner Society, with a lot of patients, changing clinics, and you saved some time to talk about this important topic today. I really appreciate it, as does everyone here and everyone who is listening. I leave it to you for a final message. It can be just a goodbye, whatever you want, and I really hope to see you soon.

Dr. Lotte Meereboer: Thank you so much. I was again super honored that you invited me for this podcast or this interview. And my final conclusion: be aware, and knowledge is everything, I would say.

Dr. Daniel Ramos: Yeah. Perfect. Okay, well, now we finish this beautiful topic—aligners, is the planet smiling? And I’m more optimistic than I was when we started because I can see some direction, Lotte. And well, thank you all for listening and hope to have you in the next episode with us. Bye bye.

Dr. Lotte Meereboer: You have a good day. Thank you so much.