Combining evidence-based healthcare with environmental sustainability: using the toothbrush as a model

Abstract

Introduction Healthcare professionals should consider environmental sustainability when recommending medical devices to patients, although there is currently little quantitative data available. The toothbrush is a widely recommended healthcare device worldwide. The aim of this study was to compare the sustainability of different types of toothbrush.
Materials and methods Four types of toothbrush were studied: a traditional plastic and electric toothbrush, as well as a plastic manual toothbrush with replaceable heads and a bamboo manual toothbrush. Life cycle assessment (LCA) methodology was applied to quantify the environmental impact of these toothbrushes over five years.
Results The electric toothbrush performed consistently poorly compared to the three manual toothbrush types and had the greatest impact in 15 out of 16 environmental categories. The bamboo and replaceable-head plastic toothbrushes had the lowest impact in all categories. The climate change potential of the electric toothbrush was 11 times greater than the bamboo toothbrush.
Discussion Switching toothbrushes from the traditional toothbrushes to bamboo or replaceable-head plastic is more environmentally sustainable. These results could be used to inform individual consumer choice, oral health recommendations, procurement of toothbrushes for public health programmes and toothbrush manufacturers. LCA methodology can be used to make healthcare more sustainable.

Full text

Combining evidence-based healthcare with
environmental sustainability: using the toothbrush
as a model
Alexandra Lyne,*1 Paul Ashley,2 Sophie Saget,3 Marcela Porto Costa,4 Benjamin Underwood5 and Brett Duane6
Introduction
Environmental sustainability is a worldwide
public healthissue.1 e planet and its global
population face a range of challenges, including
climate change, reduction in biodiversity, air
and water pollution, and ozone depletion.
Global healthcare is a signicant contributor
to national carbon dioxide emissions - and is,
on average, responsible for 5% of emissions.2 In
England, the National Health Service (NHS) is
responsible for 25% of England’s public sector
carbon footprint.3 Established to improve
population health, healthcare systems are
harming the planet.
As an ‘anchor organisation’ in the UK, the
NHS aims to be a sustainable healthcaresystem.4
e NHS Long Term Plan commits to three
environmental aims: to reduce air pollution,
waste and greenhouse gas emissions.5 In
England, this is driven by the Sustainable
Development Unit (SDU), which was
established to embed sustainable development
at all levels of healthcare.6 One measure of
success is that ‘professionals are encouraged to
consider sustainability principles when deciding
what is right for patients and clients’. For NHS
professionals to understand the environmental
impact of a product or service, dierent methods
can be used. ese range from carbon footprint
analysis to more detailed methods which look
at wider environmental impacts.
Life cycle assessment (LCA) is used to
measure the environmental impact of dierent
services or products.7,8 Also referred to as a
cradle-to-grave analysis, LCA considers all
aspects of a product along its life cycle, including
raw materials, manufacture, use, transport and
disposal. e NHS, along with other healthcare
companies, established the Coalition for
Sustainable Pharmaceuticals and Medical
Devices (CSPM), which recommends LCA
to compare services and enable policymakers
to make informed recommendations.9 More
recently, the European Union adopted the
Product Environment Footprint (PEF) to
provide a consistent, standardised, comparable
approach to undertakingLCA.10
There is currently little evidence or
guidance regarding the sustainability of
specic healthcare interventions, services or
devices. is includes both evidence-based
interventions within a healthcare setting (such
as a hospital or dental practice) and those
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 
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 
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Key points
Abstract
Introduction
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Materials and methods


Results


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Discussion



1Department of Paediatric Dentistry, Eastman Dental
Hospit al, 47–49 Huntley St reet, London, WC1E 6DG , UK;
2Paediatr ic Dentistr y, UCL, 256 Gr ay’s Inn Road, Londo n,
WC1 X8LD, UK; 3B otany, Trinity Colle ge Dublin, Colleg e
Green, Du blin, Ireland; 4Bang or University, Ba ngor, LL57
2DG, UK; 5Ec kington Denta l Care, 2 High Street , Eckington,
S21 4DN; 6Trinit y College Dublin, D epartment of Ch ild and
Public Den tal Health, Dubl in, Ireland.
*Corresp ondence to: Alexan dra Lyne
Email address: alexandra.lyne@nhs.net
Refereed Paper.
Accepted 6 A pril 2020
https://doi.org/10.1038/s41415-020-1981-0
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

carried out within the home setting. In this
paper, we have selected a commonly prescribed
intervention (the toothbrush) to explore the
impact of this preventative device on the
environment. Its ecacy as an intervention
to prevent oral disease is well established.11
ere are several dierent types of toothbrush
available in the UK, with dierent sustainability
‘credentials’. Although there is evidence that
electric toothbrushes are associated with a
greater level of plaque and gingivitis reduction
compared to manual toothbrushes, there is no
evidence that any type of toothbrush is more
clinically eective for the prevention of dental
caries and periodontal disease.12 erefore,
potentially, the environmental impact
could be the prime consideration for NHS
providers when selecting or recommending
a product. e national Scottish oral health
programme, Childsmile, has pledged to
include sustainability as part of the product
specication when procuring toothbrushes.13
This paper uses LCA methodology to
quantify the environmental impact of
perhaps the most used healthcare device
worldwide: the toothbrush. The aim was
to compare the sustainability of different
types of toothbrush and identify which
aspects of the life cycle have the greatest
environmentalimpact.
Materials and methods
A comparative LCA of four dierent types of
toothbrushes was undertaken at the Eastman
Dental Hospital, London, in partnership with
the Dublin Dental University Hospital (Trinity
College Dublin, Ireland).
e soware OpenLCA v1.8was used for
the LCA, alongside the reference database
Ecoinventv3.5. e LCA methodology was
applied in line with ISO standards and PEF
guidelines.8,9,10
e four types of toothbrush were:
1. Plastic manual: plastic handle with
xedhead
2. Bamboo manual: bamboo handle with
xedhead
3. Plastic manual with replaceable head:
reusable plastic handle (made from a
bioplastic) with replaceableheads
4. Electric: handle and charging unit, with
replaceableheads.
Four individual products, available in
the UK, were selected to represent each
type of toothbrush. e specic brands and
manufacturers have been anonymised.
An attributional LCA was conducted from
cradle to grave, using physical allocation
by mass. e functional unit was dened as
individual toothbrush use over ve years. e
time period of ve years was chosen as this is
the average life span of the battery in an electric
toothbrush.14
e system boundaries are shown in Figure
1. The entire product system, including
geographical location, was compared, as only
the bamboo toothbrush was manufactured
outside of Europe (bamboo was cultivated and
manufactured in China).
Environmental data for raw bamboo, used
to form the handle of the bamboo manual
toothbrush, was not available. Therefore,
inputs from cultivation of raw bamboo in
China were estimated by the consultancy rm
GreenDelta (GmbH, 2019) and authors (SS
and MC). All assumptions made in this study
are listed in Table 1.
A life cycle inventory was created for each type
of toothbrush. A sample of each product was
dismantled to identify and weigh the component
materials. Manufacturers were contacted
to clarify any materials, manufacturing and
packaging process, plus the transport route.
e number of products needed over ve years
was calculated. For machinery not available in
the database, the energy consumption (kWh) of
the machine wasused.
Data from the life cycle inventory was
modelled in OpenLCA v1.8for the life cycle
Fig. 1 LCA boundaries
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

impact assessment (LCIA). The impact
categories and LCIA methods are shown in
Table 2.e LCIA method for each category
was selected based on the PEF Category Rules
Guidance.10
Results
The life cycle inventory for each product
is available in our online supplementary
information.
e results of the LCIA are shown in Figure
2. e electric toothbrush had the greatest
environmental impact in all categories, except
water scarcity. e plastic manual replaceable-
head and bamboo manual toothbrushes had
the lowest environment impact in 11and 5of
the impact categories, respectively.
Figure 3 demonstrates how each life cycle
stage contributed to the impact assessment.
For the bamboo manual toothbrush, the
biggest contributing factor was consumer use
(the tap water used during brushing). e
materials contributed the most in both the
manual plastic toothbrush and plastic manual
replaceable-head toothbrush. The material
polypropylene, used to make the plastic
handle, was the single biggest contributing
factor in both these toothbrushes (37% and
33%, respectively). e electric toothbrush was
Area Assumptions and exclusions
Materials
Any materials weighing <0.01 g were excluded
To create the dataset for bamboo, the following assumptions were made about
bamboo cultivation:
Bamboo shoots produced during cultivation but are not used in toothbrushes were
excluded
The carbon sequestration was excluded as bamboo is assumed to be recycled back
into the environment within 100 years
No pesticides were applied15
Nurser y phase and emissions from crop residues were not included
Fertilisers were applied once yearly. All fer tilisers were from synthetic sources.
Direct and indirect eld emissions from nitrogen fer tilisers, leaching potential and
emissions to water from phosphorus fertiliser were based on agricural guidelines16
The main agricultural values for yearly bamboo cultivation were taken from a report
by the International Network for bamboo and Rattan17
The agricultural machinery used diesel petrol
Bamboo was transpor ted via lorry directly to the manufac turer
Manufacture All waste was rec ycled back into the manufacturing process
Products were manufactured and packaged in one location
Transp or t
Products are transported directly from the factory location to the company UK
headquarters
Distances were determined using Google Maps
Consumer use
No toothbrush products were shared bet ween individuals
The toothbrush was used twice daily, every day for two minutes11
The toothbrush, or the replaceable head, was changed every three months18
The energy required to charge an electric toothbrush was 2.8 kW/year, as advised by
the manufacturer
For every episode of tooth brushing, 0.6 litres of tap water was used. This volume
was estimated by measuring the volume of water used by ten colleagues
The impact of toothpaste use was excluded
All tap water used during tooth brushing is washed down the mains drain
Disposal Every product was disposed of according to the manufacturer’s instructions
Table 1 Assumptions and exclusions
Impact category (abbreviation) LCIA method (units) Description
Acidication (A) ILCD 2011 Midpoint+ (Mol H+ eq) Acidication of soils and freshwater due to gas release
Climate change (CC) IPCC 2013 GWP 100a (kg CO2 eq) Potential for global warming from greenhouse gas emissions
Ecotoxicit y freshwater (ECF) ILCD 2011 Midpoint+ (CTUe) Harmful eects of toxic substances on freshwater organisms
Eutrophication freshwater (EUF) ILCD 2011 Midpoint+ (kg P eq) Changes in freshwater organisms and ecosystems caused by excess nutrients
Eutrophication marine (EUM) ILCD 2011 Midpoint+ (kg N eq) Changes in marine organisms and ecosystems caused by excess nutrients
Eutrophication terrestrial (EUT) ILCD 2011 Midpoint+ (mol N eq) Changes in land organisms from excess nutrients in soil and air
Human health: cancer eec ts (CE) ILCD 2011 Midpoint+ (CTUh) Harm to human health that causes or increases cancer risk
Human health: ionising radiation (IR) ILCD 2011 Midpoint+ (kBq U235 eq) Potential damage to human DNA from ionising radiation
Human health: non-cancer eec ts (NCE) ILCD 2011 Midpoint+ (CTUh) Harm to human health that is not related to cancer or ionising radiation
Human health: particulate matter
formation (PMF) PM method (disease incidence) Harm to human health caused by par ticulate matter emissions (respiratory
inorganics)
Human health: photochemical ozone
formation (POF) ILCD 2011 Midpoint+ (kg NMVOC eq) Harm to human health from gas emissions that contribute to smog in the lower
atmosphere
Land use (LU) Soil quality index based on LANCA (pt) Depletion of natural resources, change in soil quality and reduction in biodiversity
Ozone depletion (OD) ILCD 2011 Midpoint+ (kg CFC11 eq) Air emissions causing stratospheric ozone layer destruction
Resource use: energy carriers (REC) CML-IA baseline (MJ) Depletion of natural fossil fuels
Resource use: minerals and metals (RMM) CML-IA baseline (kg Sb eq) Depletion of natural non-fossil fuel resources
Water scarcit y (WS) AWARE (m3 deprivation) Potential for water deprivation to humans and ecosystems globally
Table 2 Impact categories and LCIA methods used in this study10
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


the heaviest product at 1.42 kg – the greatest
contributor to its overall environmental impact
was the transport (47%), followed closely by
the materials (46%). All other aspects of the
electric toothbrush had much less contribution
to its overall impact, including the consumer
energy use from charging the handle (0.69%)
and disposal (0.16%).
e disposal of the products had the smallest
contribution to the environmental impact for
all toothbrushes.
Discussion
This study found that both the bamboo
manual and plastic manual replaceable-
head toothbrushes performed consistently
better than the plastic manual and electric
toothbrushes, in all impact categories. e
sustainability of the electric toothbrush was
poor, having the greatest environmental
impact in all but one category (water scarcity).
The climate change impact of the electric
toothbrush was over 11 times greater than
the bamboo toothbrush. When considering
land use, and the consequential reduction in
biodiversity and habitat, the negative impact
of the electric toothbrush was over 36 times
that of the bamboo toothbrush.
ere is increasing public concern about
the use of plastics and this alone may be the
most important environmental consideration
for individual consumers.19,20 All products in
this study used plastic to make the toothbrush
bristles (nylon), and all except the bamboo
product also used plastic for the toothbrush
handles (polypropylene) and as part of the
packaging (polyethylene). The bamboo
toothbrush used just 11 g of plastic over the
ve years, the lowest of all products (97% less
plastic than the plastic manual toothbrush).
e polypropylene in the handle of both the
traditional plastic manual and the plastic
manual replaceable-head toothbrushes
had the greatest contribution to the overall
environmental impact. e replaceable heads
did use a bioplastic, with 30% of the polymer
derived from starch, but the effect of this
was unclear and our results suggest that the
lower weight of plastic, from only replacing
the head and not the handle, had a greater
impact. Further research to identify the ‘ideal’
sustainable toothbrush could investigate the
exact impact of switching polypropylene for
biopolymers. If the average life expectancy in
the UK is 80years, then an individual using
plastic manual toothbrushes over their lifetime
1.12E-01
4.00E-02
2.26E-02
5.66E-01
2.56E-01
4.22E-00
5.16E-00
4.79E-01
1.35E-01
4.54E-00
2.76E-00
1.39E-02
1.42E-03
1.99E-023
2.87E-04
3.056E-02
1.90E-02
5.59E-03
3.83E-03
8.54E-02
1.99E-01
5.44E-02
4.02E-02
9.47E-01
3.69E-07
2.34E-07
7.46E-08
1.27E-06
3.26E-01
1.13E-01
6.58E-02
3.21E-00
1.18E-06
1.16E-06
2.39E-07
4.15E-05
9.51E-07
2.58E-07
2.92E-07
4.21E-06
8.30E-02
1.60E-02
1.68E-02
2.65E-01
1.25E-02
2.24E-01
2.53E-01
8.14E-02
1.33E-06
1.82E-07
2.69E-07
9.09E-06
5.68E-02
4.70E-01
1.15E-02
7.01E-02
4.04E-05
1.49E-05
8.16E-06
6.50E-03
2.36E-01
1.18E-01
4.78E-00
2.13E-01
Acidification
(MOL H+ EQ)
Climate change
(KG CO2 EQ)
Ecotoxicity freshwater
(CTU E)
Eutrophication freshwater
(KG P EQ)
Eutrophication marine
(KG N EQ)
Eutrophication terrestrial
(MOL N EQ)
Human health:
cancer effects
(CTU H)
Human health:
ionising radiation
(K BQ U-235 EQ) g
Human health: non cancer effects
(CTUH)
Human health:
particulate matter formation
(DISEASE INC.)
Human health:
photochemical ozone formation
(KG NMVOC EQ)
Land use
(PT)
Ozone depletion
(KG CFCll EQ)
Resource use:
energy carriers
(MJ)
Resource use:
mineral and metals
(KG SB EQ)
Water scarcity
(M3 DEPRIV.)
Plastic manual toothbrush
Bamboo manual toothbrush
Plastic manual replaceable toothbrush
Electric toothbrush
Fig. 2 LCIA results
306 BRITISH DENTAL JOURNAL |  | 



equates to 6.3 kg of plastic. A decrease in public
demand for plastic and electric toothbrushes
may in turn encourage manufacturers to use
LCA to improve the environmental impact
of their products and use more sustainable
materials and processes.
There are limitations to using LCA to
compare dierent healthcare products. ere
is a range of impact categories and allocation
methods that can be used, along with dierent
methods for the LCIA, and this can make
the results difficult to interpret. Although
guidance by the PEF aims to standardise the
methodology, it advises that the toxicity-
related results are interpreted with caution, as
the corresponding three LCIA methods are still
in development.10 However, in this analysis,
clear differences between the two manual
toothbrushes and the electric toothbrush
wereseen.
In this study, four individual toothbrush
products were selected to represent each
type of toothbrush; however, the market is
constantly changing. In particular, electric
toothbrushes have a wide variability in
design, and their features and composition
are being continually updated. In this study,
the simplest rechargeable electric toothbrush
from a market-leading brand was selected,
but is not necessarily representative of all
electric toothbrushes. Since this study was
commenced, new toothbrush materials have
come to market, including reusable handles
made from aluminium. As the market evolves
and manufacturers change their materials,
LCA should be repeated and recommendations
reviewed.
LCA is usually conducted ‘in-house’ by the
manufacturer, which was not the case in this
study. In order to correctly identify all the
correct product materials and processes, the
authors had to request the relevant data from
the manufacturers. Where it was not possible
to conrm an exact material or process, or
the manufacturer was unwilling to supply the
information, assumptions were made by the
authors based on industry knowledge. is
would have aected the accuracy of the LCA
inventory. Ideally, a sensitivity analysis of the
most impactful processes and materials would
have been carried out, in order to identify what
changes in the material and manufacturing
processes could be altered to improve the
environmental impact of the product.
However, this requires in-depth knowledge
and data disclosure, and the authors feel that
the responsibility to analyse this and make
changes accordingly lies with the product
manufacturer.
Including a bamboo product was
challenging, as there was no available data for
this raw material in the reference database.
Therefore, the background processes to
cultivate bamboo had to be separately
modelled by GreenDelta and authors (SS
and MC). Several assumptions and exclusions
(Table 1) had to be made in order to produce
the dataset, and the eect these assumptions
had on the results would require further
research and sensitivity analysis. However,
bamboo cultivation practices can vary
widely, altering the environmental impact
of using bamboo as a product material. For
example, fertilisers are used in less than
5% of industrial bamboo plantations as
the fallen bamboo leaves provide sucient
nutrients for newshoots.17 As a conservative
estimate, in this study, we assumed yearly
%
%
%
%
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
ACC ECF EUF EUM EUT CE IR NCE PMF POF LU DO REC RMM WS ACCECF EUFEUM EUTCEIRNCE PMFPOF LU DO RECRMM WS
ACC ECF EUF EUM EUT CE IR NCE PMF POF LU DO REC RMM WS ACCECF EUFEUM EUTCEIRNCE PMFPOF LU DO RECRMM WS
Disposal
Manufacture
Transport
Consumer use
Materials & parts
A. Plastic manual toothbrush B. Bamboo manual toothbrush
C. Plastic manual replaceable head toothbrush D. Electric toothbrush
Fig. 3 Contribution analysis for: a) Plastic manual toothbrush. b) Bamboo manual toothbrush. c) Plastic manual replaceable-head
toothbrush. d) Electric toothbrush
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


fertiliser application. Ideally, a robust
dataset produced with the specic bamboo
plantation used by the manufacturer would
have been created, but this was beyond the
scope of this study. Bamboo cultivation is
currently assumed to be carbon-neutral, as
bamboo ecosystems are carbon sinks, but an
increasing demand for this material may, in
future, lead to modications in the bamboo
ecosystem and bamboo cultivation could even
become a carbon source.21 It was conrmed
that no glue is used in the manufacture of
the bamboo toothbrush (the handle is made
from shaping raw bamboo and heat treating
the surface to sterilise), as concerns have been
raised regarding the melamine resins used in
the production of bamboo products, such as
reusable cups.22
Some of the assumptions made about
consumer use and disposal are likely to be
unrealistic. Individual use of a toothbrush
was based on clinical recommendations11,18
and informed the number of products needed
in ve years, as well as the waste water used
during tooth brushing. There is no data
available on public compliance with these oral
health recommendations, although studies
of health recommendations, such as physical
activity, suggest that public compliance is
moderate atbest.23 For the electric toothbrush,
it was assumed that the handle is only used
by one individual and was disposed of aer
five years.14 However, families may share
one electric toothbrush handle, and may
upgrade the handle and charging unit more
often or less often than every five years.
ere is currently no data available about the
sharing habits of electric toothbrush users.
is LCA further assumed that individuals
would dispose of their products according to
manufacturers’ recommendations – for the
bamboo toothbrush, this includes removing
the bristles and metal staples from the bamboo
handle. is was undertaken by one of the
authors (AL) as part of the product inventory
– as it took almost 30 minutes to remove all
the bristles and metal staples using tweezers, it
was considered that this is unrealistic to expect
from consumers. However, the authors felt that
using the manufacturers’ recommendations
was reasonable, given that the disposal
processes in the LCIA had little contribution
to the overall impact for all the toothbrushes in
this study. However, a sensitivity analysis using
dierent disposal scenarios, including bamboo
ending up in the ocean, could aect the results
and is a topic for further research.
Furthermore, some toothbrush
manufacturers have started oering recycling
schemes for their products, which could
reduce the impact of their materials. However,
at the time of this study, the products in this
trial were not oering a recycling scheme and
the exact procedure used in any recycling
scheme should be specically analysed by the
individual manufacturer, in order to ensure
that the impact created from the transport
and recycling processes doesn’t outweigh the
benets of reusing the materials.
Other oral health cleaning aids, such as
interdental brushes and oss, will also have an
environmental impact and would be subject to
a separate life cycle analysis, given their dierent
recommendations and disposal. Research
into this is already underway at the authors’
institutions (UCL and Trinity College Dublin).
The NHS should recommend healthcare
devices that are clinically effective, cost-
effective and environmentally sustainable.
ere is currently no evidence that using an
electric toothbrush reduces incidence of dental
caries or periodontal disease, even if it is better
for reducing plaquelevels.12 For this reason,
there is currently no evidence that individuals
switching to the more sustainable manual
toothbrushes from this study will develop more
dental disease, which could in turn increase the
environmental impact of providing dental care.
However, should new evidence emerge, the
clinical benet of one type of toothbrush should
be considered together with sustainability and
cost. Electric toothbrushes are more expensive,
and less environmentally sustainable, than
manual toothbrushes. This should be a
strong consideration when recommending
toothbrushes to the public. Similar principles
should apply to toothbrushes procured by the
NHS for public oral health programmes, and
based on this study, either bamboo toothbrushes
or replaceable-head manual toothbrushes
should be considered over traditional plastic
and electric toothbrushes. Admittedly, the
cost of bamboo and replaceable-head manual
toothbrushes, which are usually greater
than simple plastic manual toothbrushes,
may present a barrier to their widespread
use by consumers and by public oral health
improvement programmes.
Conclusion
This simple comparative LCA has shown
that a plastic manual replaceable-head
toothbrush and bamboo manual toothbrush
perform better than traditional plastic
manual and electric toothbrushes in every
environmental impact outcome measure used
in this study. ese results could be used to
inform individual consumer choice, oral
health recommendations, procurement of
toothbrushes for public health programmes
and toothbrush manufacturers. Using
LCA to inform healthcare policies and
recommendations will help move the
NHS towards a more environmentally
sustainablesystem.
Conict of interest
is study was funded by the Eastman Dental
Institute (University College London). e authors
declare no conict of interest.
Acknowledgements
e authors would like to thank the manufacturers
of the toothbrush products who helped clarify the
processes and product materials.
Author contributions
AL collected the data and draed the paper; PA
co-initiated the collaborative project, monitored data
collection and revised the dra paper; SS and MC
rened the bamboo cultivation dataset, monitored
data analysis and revised the paper; BU revised
the paper; BD co-initiated the collaborative project,
carried out all data analysis and revised the paper.
All authors give their nal approval and agree to be
accountable for all aspects of thework.
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