___.In an attempt to answer a major problem which may haunt future generations, the International Association of Orthodontists (IAO), has invited us to share our views at their 1999 Annual Meeting (Walt Disney's World Contemporary Resort, April 14). In response, we presented a slide show having the above title. Noting the interest that this has stirred, we thought that we should share some of the slides presented (less than a third of the total) to our readers.
Recycling today
___.There is hardly a place in the U.S. where the signs encouraging recycling are missing. With reference to used cans and paper, everything goes smooth: the instant someone attempts to reuse items which can compete with products currently on the market, things change. The explanation is obvious: money.Companies like Ormco boast their use of recycled paper for advertising purposes, while fighting the reuse of what they sell. It became necessary, however, to demonstrate that the reuse of a product is unacceptable. This was contrary to the evidence and has become dangerous: it may demonstrate that the product in question could have been, to start with, unacceptable even for its first use.
And, as time elapses, more and more voices are advocating the reuse of even the most sophisticated and intrusive medical devices, against the manufacturer's protests. ___.The simple addition of a caveat such as "for single use only" is not enough, as more and more voices protest against this claim if not properly documented. In what follows, we will provide some of the most recent related literature, mainly taken from Medline.
News concerning the reuse of orthodontic devices
___.–Recycled ceramic brackets have been found to provide shear bond strengths adequate for clinical use. Moreover, they exhibit bond failures mostly at the bracket/adhesive interface, without causing enamel damage [A. Martina, A. Laino, V. Cacciafesta, P. Cantiello, "Recycling effects on ceramic brackets: a dimensional, weight and shear bond strength analysis", European J. Orthod. 1997; 19(6): 629-36].
___.–With wires, no statistically significant differences were found between the groups or against an untreated control. [O.P. Crotty, E.H.Davies, S.P. Jones, "The effect of cross-infection control procedures on the tensile and flexural properties of super-elastic nickel titanium wires", Brit. J. Orthod. 1996; 23(1); 37-41].
___.–"Recycled brackets are not statistically different from the new ones. In NBC’s broadcast of March 9, 1998, some of the information was watered down, omitted, in some cases misrepresented" [T.A. Fisher, e-mail to Ortho-Cycle regarding NBC-TV Dateline of February 1998 presentation of his thesis “An in vitro comparative study of new and recycled orthodontic brackets”, thesis at the U. of Iowa.]
Note: As in our case, the quality of the pacemakers selected for reuse was found to exceed that of the new ones due to a better inspection and lack of component failure [Canadian Hospital Assoc., Internet www.hrt.org/carecharim.html]. (See our past articles about some brand new brackets, real "lemons"...)
Environment protection
___.–Small amount? The dental profession contributes approximately with 14% to the discharge of mercury. ___.Governmental strategies include an outright ban, the establishment of discharge standards, and educational efforts [Editorial, J. Michigan Dental Assoc. 1996; 78(2): 32-6].
___.–Protests against medical waste polluting the environment: [Z.G. Turi, "Reuse of disposables: let’s not embrace waste" [Catheterization & Cardiovascular Diagnosis 1996; 38(2): 133-4; L.M. Bruning, "Disposables vs. reusables in OR practice, Part II. Weighing costs, risks and wastes". Nurs. Management 1992; 23: 721].
Note: In the absence of oxygen, stainless steel ceases to be passive and becomes corrosion susceptible. The ions released in subterranean waters are Cr⁺⁺⁺, Ni⁺⁺, Mo⁺⁺, V⁺⁺.
Economy vs. safety (medical devices)
___.-"Reuse leads to substantial savings, which possibly could make advanced pacemaker treatment available to all eligible patients irrespective of age" [R.P. Solomon, "ECRI expert reviews reuse of 'single-use' medical devices", J. Clin. Monitoring and Computing, 1998; 14(3) 203-5].
___.–"Management care has brought about changes in the way surgical departments function. The reuse of reusable or resposable instruments can help keep costs down" [ P. Abbott, "The best of both worlds -”resposables”. Today’s Surgical Nurse 1997; 19(2): 35-8].
___.–"Procedural costs routinely exceed reimbursement. Environmental concerns are pressuring hospitals to reduce waste. Standards and protocols have changed, removing the barriers to reuse. Reuse of disposables has become a viable option". [N. English,"Reprocessing disposable: one strategy to balance cost reduction and quality". Today’s Surgical Nurse, 1996; 18(4): 23-6].
___.–"Catheter reuse is not associated with an increased rate of in-hospital complications". [Editorial, "Absence of increased in-hospital complications with reused balloon catheters", Am. J. Cardiology 1996; 78(60: 717-9].
–A study comparing two cardiology centers, one reusing and the other using only new catheters, has led to similar rates of in-hospital events [M.G. Bourassa, "The reuse of single-use balloon angioplasty catheters: is it now legitimate?" Am. J. Cardiology 1996; 78(60: 673-4].
___.–"There is no evidence that any patient has been injured as a result of wearing recycled brackets. The recycling process to which brackets are subjected involves a combination of intense cleaning and heating which effectively decontaminates and sterilizes brackets" [Alberta Dental Assoc., Updaters, February 1997, "Recycled orthodontic brackets"]
Titles of articles disputing the “single use only” claim in medicine
___.I. Stewart, “Single use only” labeling of medical devices: always essential, or sometimes spurious? Medical J. of Australia, 1997; 167(10): 538-9;
___.M. Parsons, The dilemma over the reuse of “single use” medical device. A risk manager’s perspective. Today’s Surgical Nurse, 1997;19(3): 17-21;
___.C.K. Ball, E.M. Schafer, D. Thorne, "Reusing disposables”; the same old story -more characters added", Insight 1996; 21(3): 77-84;
___.M. Fallani, M. Milandry, "Reuse of disposable equipment. Medicolegal viewpoint.". Minerva ___.Cardio-angiologica, 1996; 44(5): 263-73;
___.K. Woolard, Reuse of single-use medical devices: who makes the decision? Medical J. of Australia 1996; 164(9): 538;
___.P. J. Collignon, E.Graham, D.E. Dreimanis, "Reuse in sterile site of single-use medical devices: how common is this in Australia", Med. J. of Australia 1996; 164(9); 533-6.
Are brackets recycled, refurbished, or just... cleaned ?
___.“…Commercial processes employ either heat (about 450ºC) to burn off the resin, followed by electro-polishing to remove the oxide buildup (e.g. Esmadent), or solvent stripping combined with high frequency vibrations and only flash electro-polishing (e.g. Ortho-Cycle)”. [B. U. Zachrisson, “Bonding in Orthodontics” in Orthodontics, Current Principles and Techniques, T. M. Graber and B. F. Swain, editors, C. W. Mosby, St. Louis, Toronto, Princeton, 1985].
Note: a. A third process has not been mentioned: adhesive abrasion. b. Solvent stripping or dissolution amounts practically to bracket cleaning. Ortho-Cycle Co. has practically phased out electro-polishing.

Literature comments regarding recycling processes
___.Adhesive burn-off. “It is well known that austenitic steels are metallurgically unstable when heated in the temperature range of 350-800ºC (650-1500ºF). After heating in this temperature range, they become subject to severe attack at the grain boundaries by even mild corrosive media. This attack is referred to as intergranular corrosion, and is so severe that steel literally disintegrates into separate grains, losing substantially all its properties”… [ R. Franks, in “Corrosion Handbook”, p.161, H. H. Uhlig editor, J. Wiley & Sons, N.Y. 1948].
___.“If this steel is heated between 400o and 900o C, a chromium carbide precipitate is formed, and as a result, a partial disintegration of the alloy occurs, leading to general weakening” [ D.J.L. Buchman, A.J.O -D.O. 1980;77: 656].
___."With Esmadent 'Big Jane', the slot increased in size in a linear response to the increasing number of recycles... total weight loss was also directly proportional to the number of times recycled. Thus, the electro-polishing step, with its removal of not only tarnish and surface oxidation but also metal, may be an important variable affecting bracket tolerance" [M.E. Hixon, W.A.Brantley, J.J. Pincsak, J.P. Conover, A.J.O.-D.O. 1982; 81: 447].
___."It is possible to recycle direct bonding brackets by a single resin charring procedure, followed by a single electro-polishing procedure, without compromising retention [J.J. Wheeler, R.J. Ackerman, A.J.-D.O. 1986; 83: 181]. Note: the highlighting showing the limitation is ours.
___."Heat exposure produces: change in the steel structure (separation of chromium carbide) and loss of stainless characteristics (passivation). Consequence: metal softening, reduced surface hardness, loss of spring resiliency (with impossibility of applying torque with rectangular arch wires" (F.V. Tenti, Atlas of Orthodontic Appliances, Caravel, Genova)
___.Adhesive abrasion. Of the ones checked, "one process was particularly unsatisfactory in this regard, facilitating corrosion of even 316L brackets.”(Our note: adhesive abrasion) [R. Maijer, D.C. Smith, A.J.O. 1986; 90: 198].
___.“We have attempted to process with our vibratory tumbling equipment orthodontic parts submitted by your firm. The fine mesh which is on these parts does not warrant or subject itself to this type of process, the problem being that the burn stains on the parts are very difficult to remove and hence the media also severely wears on the mesh." [P. Erdo, "Graves Co., Precision Lapidary equipment Since 1946”, Pompano Beach, FL, in a letter to Ortho-Cycle Co. regarding the used direct bonding brackets sent to be cleaned for research purposes].
___.Adhesive dissolution. “The Ortho-Cycle method did not alter the mechanical properties of the bracket... Hardness, theoretical tensile strength and microstructure were similar to those of the control... Company Esmadent‘s process falls in the range of carbide precipitation leading to a decrease in corrosion resistance” [D. J. L. Buchman, A.J.O.-D.O. 1980; 77: 656].
___." A real-life test... was extended for three reuse cycles involving 100 cases of GAC brackets. All the reconditioning has been performed by Ortho-Cycle Co... Each cycle has lasted 1^1/2 years and the characteristics of each series of brackets were investigated and compared... The reuse of ''dissolution' reprocessed appliances becomes an effective way by which the clinician can keep overhead costs lower, while the cost of new appliances are steadily climbing... For the average clinician, the repeated use of delicate appliances demonstrates that with proper reconditioning, it is possible not only to save, but also to achieve a performance similar to that of the new ones" [A. Buchwald, A.J.O. 1989; 95: 352].
___."The only safe way for bracket reconditioning is to remove the adhesive chemically (Ortho-Cycle system)". [F.V. Tenti, Atlas of Orthodontic Appliances, Fixed and Removable, Caravel, Genova 1986: 305].
Recycling should mean thorough research...
___.The parallel testing of both used and new orthodontic attachments has led us to a series of findings, part of which have been published in specialty journals. In what follows, we will present only those related to brackets:
___.Matasa CG; "Not all appliances are created equal"; A.J.O.-D.O. 1988; 94: 168-169; "Adhesion and its ten commandments", A.J.O.-D.O. 1989; 95: 355-356;"Pros and cons in the reuse of direct bonded appliances", A.J.O.-D.O. 1989; 96: 72-76; "Flaws in bracket manufacturing"; J. Clinical Orthod. 1990; 24(3): 149-152; "Fallas sistematicas en la fabricacion de los brackets de pegado directo", Ortodoncia, Buenos Aires, 1991; 56 (109): 5-10; "Defend yourself against faulty appliances. I. Faults due to poor manufacturing", J.Gen.Orthod. 1991;2(4): 5-9; "Defend yourself against faulty appliances. II. Alterations produced by wear, debonding and poor reconditioning"; J. Gen. Orthod. 1992; 3(2): 13-17; "Nicht Rostende Edelstahle und Direkt-bonding-brackets"; Inform. Orthodontie und Kieferorthopadie 1992; 24(2): 237-249; "Direct bonding metallic brackets: Where are they heading ?", A.J.O. 1992; 102: 552-560; "Nicht rostende Edelstahle und Direkt- Bonding Brackets. II Chemishes Verhalten"; Inform. Orthodontie und Kieferorthopadie, 1993; 25(2): 147-166; "Microbial attack of orthodontic adhesives"; A.J.O.-D.O. 1995; 108: 132-41; "Bracket angulation as a function of its length in the canine distal movement", A.J.O.-D.O. 1996; 110: 178-184; "La corrosion des crochets poses directement", Archives de l'Union Medicale Balkanique 1993; 30(5): 5-17;"La corrosion des verrous: un defi pour l'orthodontiste",Actualites Odonto-Stomatologiques, 1994;187:401-409; "Orthodontic attachment corrosion susceptibilities", J. Clin. Orthod. 1995; 29(1): 16-23; "Arco recto o arco mas recto",Revista Venezolana de Ortodoncia, 1994;11 (1&2):231-236; "Edgewise-Friktionsbracket-Ligatur-Drahtbogen I. Stand der Technik", Informationen aus Orthodontie und Kieferorthopadie 1995; 27 (4):523-534, 1995; "La friccion entre la bracket de arco de canto, la ligadura y el alambre. I. Estado de la question", Rev. Esp. Ortod. 1996:26;179-188; "Edgewise-Friktionsbracket-Ligatur-Drahtbogen II. Friktiontests fuer Jedermann"; Information. Orthodontie und Kieferorthopadie 1995;27(4):535-548, 1995; "La friccion entre la bracket de arco de canto, la ligadura y el alambre. II. Test de friccion para todos", Rev. Esp. Ortod.1996: 26; 189; "Materiales usados por ortodoncistas: Aceros", J. Orthopedics, Orthodontics and Pediatrics, 1996; 1: 27-38; 32; "Could dentistry give up nickel?" Traditions and Perspectives in the Romanian School of Metallurgy, Conference Proceedings,Oct.15-26,1996;136-7, "Politehnica" University, Bucharest; "Encaixe do Braquete examiado a traves do Microscopio de Forca Atomica (MFA)", Rev. Dental Press Ortod. Ortoped. Max 1997; 2: 60-75; "Impact resistance of ceramic brackets according to ophthalmic lenses standards", A.J.O.-D.O. 1999; 115; 158-65; "Metal strength of direct bonding brackets", A.J.O.-D.O. 1998; 113: 282-286; "Compositos en ortodoncia", J. Orthopedics, Orthodontics and Pediatrics 1997; 2(1): 21-31.
G. Guan, Y. Asai, C. G. Matasa, T. Hattori, S. Mitani; "Resistencia da colagem em relacao a interface esmalte-adhesivo", Rev. Dental Press Ortod. Ortoped. Max. 1997; 3: 93-99.
Who are the recyclers ?
___.Today there are many orthodontic recyclers, almost all of them being active in the countries where fixed orthodontics prevails. There could be many more companies that we do not know about. Some of these are at the very low end of the scale, while very few are more than head and shoulders above.While some have discontinued their activities (we marked them with an asterisk*), some are still in business. Ortho-Cycle Co. and Esmadent were the oldest in this business (1976).
U.S.A.
Brackets Laboratories, 5375 McGinnis Ferry Rd., Alpharetta,GA 30201*
Century 2001, 110 Tomahawk Dr., Indian Harbour Beach, FL 32937*
Esmadent, POBox 162, Highland Park, IL 60035
Frol Corp. POBox 2089, Grass Valley, CA 95945-2089
Lancer Orthodontics, 6050 Avenida Encinas, POBox 819, Carlsbad, CA 92008*
Ortho Bonding Co., 28-15 Fairlawn Ave., Fair Lawn, NJ 07410*
Ortho-Cycle Co., 2026 Scott St., Hollywood, FL 33020-2417
Orthodontic Recycling, POBox 29980 New Orleans, LA 70189-9980
Orthotronics Co., 29 N.Main St., Gloversville NY 12078-3093
Vector Dental Corporation, POBox 1413, Arcadia, CA 91077

BRAZIL
Ortho-Cycle Brazil, rua Candido Hartmann 920,8071
Curitiba, PR

FRANCE
Avantage Systeme, Chemin de Piecaud, 84360 Lauris
Euro-Cycle, 8, rue Jean Jaures, 06400 Cannes
Laboratoires Erdam, 24 rue des Vignettes, 78870 Thoiry
Laboratoire Roland, 19 Impasse Decaris, 78540 Vermouillet
Orthofirst Europe, Villa #3, 188 Corniche des Oliviers, 06000 Nice
Ortho-Sevice, POBox 47, 91371 Verieres le Buisson Cedex

DENMARK
Scanorto, Strandvejen 171, 2900 Hellerup

AUSTRIA
G. Planner GmbH, Florianergasse 41, 1080 Vienna

NETHERLANDS
Ortho-Cycle Benelux, Doelen 15, 1935 BN Egmond-Binnen
T.S.S.Recycling, Kael V. Laan 38, 5583 XH Aalst-Waalre

UNITED KINGDOM
Eurohelp Ltd.,13 Stratford Place, London
Hudson Ltd. 243 Crookesmoor Rd, Sheffield S6 3FQ
Orthonor, 9 Town Close Rd., Norwich NR2 2NB

GERMANY
Medikor, Meigener str. 82, 42651 Solingen 1
Orthonova, Kaiserstrasse 3, D-5300 Bonn 1

POLAND
Polorto, Ul. Dekabrystow 33, 42-200 Czestochowa

SPAIN
Vibvover, Apartado de Correos, 08950 Esplugues de Llobregat

ISRAEL
Medord, 11 Nevo St., Zur Igal 44962

Observation
___.As a result of bracket manufacturers' complaints, no recycling company has ever been more inspected and scrutinized by both federal and state agencies than Ortho-Cycle Co.
___.In addition, the company itself invited a crew from NBC-TV in the hope of an objective evaluation. After unlimited access and a full day of filming by a crew of six, only clips lasting a few seconds were broadcasted on March 9, 1998. The reaction of both the American Association of Orthodontists, and implicitly that of the public, is shown below.
Conclusion
___.Orthodontic attachments are highly valuable: if one counts the number of mini-brackets contained in an ounce and multiplies it by their price, the amount obtained exceeds the price of three ounces of gold bullion. At the IAO Convention mentioned earlier, "A"-Co.-Ormco's self-engaging TwinLockR metallic bracket was offered for over $10 each! While there is no wonder that manufacturers are aggressively fighting their recycling, it is strange to us that many clinicians carelessly discard excellent brackets: stainless steel attachments are perhaps the easiest to sterilize.
___.Fact: stainless steel items can remain stainless only as long as their protective layer of chromium oxide persists. In dumps, these are subjected to their worse enemy, chlorides from water. As no oxygen is available there to regenerate the oxide film, stainless steels dissolve, leaching toxic heavy metal ions in the subterranean waters which we all ultimately drink. Insignificant amount? Not so: the disposal of the mercury resulting from dental office is already subjected to government's control. It's up to you: cash on your used attachments, or contribute to the poisoning of our environment.
___.Irrespective of your decision, recycling will become sooner or later a matter of survival for our civilization!