ORIGINAL RESEARCH

Effectiveness of Various Tongue Cleaning Aids in the Reduction of

Tongue Coating and Bacterial Load: A Comparative Clinical Study
Vartul Dwivedi1, Nilesh A Torwane2, Sanjeev Tyagi3, Satish Maran4

A b s t r ac t
Aim: To remove tongue biofilm and improve breath odor, specific instruments (tongue scrapers) or toothbrushes are used.
Materials and methods: This study compared the effectiveness of a manual toothbrush that has a tongue scraper on the back of its head and
two commercially available tongue scrapers in reducing the tongue coating and aerobic and anaerobic microbiota of the tongue dorsum. A
randomized, negative controlled, double-blind, parallel design study for three different treatment interventions was conducted.
Results: All tongue cleaners showed a significant reduction in Winkle’s tongue coating scores with significant values of reduction (p <0.001) of
the anaerobic bacterial count with plastic and metal tongue scraper when compared to brush scrapper.
Conclusion: There was an effective reduction of bacterial load on tongue dorsum with the use of tongue cleaners, with maximum load reduction
by using plastic tongue cleaners.
Clinical significance: The results of the present study may be helpful for the dentists while prescribing tongue cleaners to their patients in
their clinical practice.
Keywords: Biofilm, Brush scraper, Micro bacteria, Tongue, Tongue scraper
The Journal of Contemporary Dental Practice (2019): 10.5005/jp-journals-10024-2536

Introduction 1,3
Department of Conservative Dentistry and Endodontics, People’s

I t is estimated that approximately 85% of all halitosis cases have

their origin in the mouth; of these, 50% are caused by tongue
residue. The tongue which is also considered as a gateway to all
Dental Academy, Bhopal, Madhya Pradesh, India
2
Department of Public Health Dentistry, College of Dental Sciences,
Bhavnagar, Gujarat, India
important digestive systems is a home of a number of bacteria that 4
Department of Pediatric and Preventive Dentistry, People’s Dental
cause several health hazards. Human oral cavity has been identified Academy, Bhopal, Madhya Pradesh, India
with more than 700 species of bacteria. Whereas an average Corresponding Author: Nilesh A Torwane, Department of Public
individual may carry 100–200 species of bacteria; this shows vast Health Dentistry, College of Dental Sciences, Bhavnagar, Gujrat,
heterogeneity between the individuals.1 The dorsum of the tongue India, e-mail: nealdip@gmail.com
carries a distinctive ecological niche by providing a large surface How to cite his article: Dwivedi V, Torwane NA, Tyagi S, Maran S.
area which helps to promote the acquisition of microorganisms Effectiveness of Various Tongue Cleaning Aids in the reduction of
along with food debris, saliva, and degenerated epithelial cells Tongue Coating and Bacterial Load: A Comparative Clinical Study. J
which can be responsible for metabolism and growth of these Contemp Dent Pract 2019;20(4):444-448.
entities. Further, the bacterial metabolism may break into the Source of support: Nil
production of volatile molecules such as short-chain organic acids, Conflict of interest: None
volatile sulfur, diamine and phenyl derivatives. A tongue cleaner
(also called a tongue scraper or tongue brush) is an oral hygiene the other way, there is urgency for dental professionals to update
device designed to clean the bacterial build-up, food debris, fungi, and consolidate the recent knowledge in this field. This will provide
and dead cells from the surface of the tongue. equitable scientific information to patients and will enhance the
According to Tonzetich, 2 bad breath is prevalent (at least education of dental professionals in this area.
occasionally) in more than 50% adults. According to some investigators; Therefore, the present comparative clinical study was
the majority of the adult populations have experienced a bad breath conducted to evaluate the mechanical effectiveness of three tongue
at least once in a while, especially after waking or after eating a specific cleaning aids in reducing the extent of tongue coating and bacterial
type of food. Some of the researchers in their study have also found that load of the tongue.
at least 50% of their sampled population was suffering from lasting bad
breath and that for nearly half of the population had a severe chronic
problem of bad breath. Also, it has been found that the prevalence
M at e r ia l s and methods
of oral malador in the USA is very much high and the problem is only Study Setting
lagging behind dental caries and periodontal diseases.3 The present study was conducted in the Department of Public
Boever and Loesche4 indicated that the proteolytic, anaerobic Health Dentistry of a dental institute.
flora residing on the tongue plays an essential role in the
development of halitosis. Study Duration
Oral malodor is an identifiable condition which needs professional The present study was conducted for a period of 15 days.
attention. Apprehensions have been raised against commercial Ethical clearance and informed consent: Present randomized,
“breath clinics” and substances that deficit scientific credentials.5 On double-blind, parallel designed study was conducted after approval

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
 Effectiveness of Various Tongue Cleaning Aids

by the ethical committee of a dental institute. Also, before the Following the intervention and sample taking, there was
commencement of study; complete study protocol was explained a period of washout for 48 hours in which the subjects were
and informed consent was obtained from each study participant. asked only to brush their teeth normally twice daily and visit the
Department of Public Health again for recording baseline and
Sample Size post-intervention with the new tongue cleaning aid. Similarly after
A total of 20 healthy adult male and female dental assistants of a every 48 hours samples and index was recorded for baseline and
dental college were enrolled in the study. post-intervention. This cycle continued till about two weeks until
• Selection criteria: The eligibility criteria for the willing participants all pre and post-intervention scores and samples were recorded for
were decided before the study. The eligibility criteria included that all subjects with all three tongue cleaning aids (Fig. 2).
all subjects must have at least 20 natural teeth and no gagging
reflex. Subjects with severe abnormal tongue defects like fissured Winkle Tongue Coating Index7
and geographic tongue, subjects having pierced tongue or To record the tongue coating, the dorsal surface of the tongue was
with any other abnormality which might interfere with tongue further divided into six regions (3 anterior and 3 posterior) anterior
sampling procedures were excluded from the study. Subjects to sulcus terminalis.
are instructed to avoid the use of antimicrobial mouthwashes, Tongue coating was assessed in each sextant as:
peroxide tooth bleaching products, or any systemic antibiotics • 0 = No coating,
during the study period. Also, the subjects were asked to avoid • 1 = Light coating,
elective dentistry and prophylaxis during the trial and not to use • 2 = Severe coating.
any non-study oral care products for the duration of the study. The WTCI was obtained by addition of all 6 scores, range 0–12.
• Study procedure and intervention: The present study was • 0–4 = Mild coating
investigated by a single examiner. Initially, all the study • 4.1–8 = Moderate coating
participants carried out unsupervised acclimatization period • 8.1–12 = Severe coating
wherein they set aside their normal oral hygiene routine and
were asked to brush for two minutes twice daily with a manual Microbiological Tests
soft toothbrush and paste provided by the examiner. Subjects To record the bacterial load baseline and post-intervention
were instructed to abstain from tongue cleaning for the entire microbiological samples were collected from the tongue dorsum
acclimatization period. To avoid confounder’s bias, subjects were anterior to sulcus terminalis. The microbial samples from the
cautioned to abstained from the use of oral hygiene product and dorsum of the tongue were obtained by wiping a sterile cotton
to carry out any personal habit (i.e. eating, drinking, performing swab. The cotton swabs were transferred and stored in screw-
oral hygiene, smoking, drinking alcohol or using breath mints, capped vials, containing 3 mL RTF. The collected swabs were then
lozenges, or chewing gum) after 10:00 pm prior to the evening taken to the microbiological lab for further analysis. For all the
preceding their baseline visit. samples; dilutions 10 -1–10 -5 were plated by means of a spiral platter
Before the onset of the study the examiner was calibrated onto non-selective blood agar plates. After 24 hours of aerobic
and kappa value was calculated for the recording of the index and and 48 hours of anaerobic culturing at 37°C in the incubator, then
professional training from a microbiologist was obtained in order to all the aerobic and anaerobic colony forming units (CFU/mL) were
take cultural swabs of the subjects. On the 7th day, Winkles tongue counted for the pre-intervention and post-intervention samples.
coating index (WTCI) and culture swab samples were collected for
all the subjects selected for the study. After the collection of the Questionnaire
samples the subjects were demonstrated the proper way of tongue A close-ended questionnaire was framed in order to do the
cleaning with the aid provided to them on that particular day, and subjective analysis of each aid (Fig. 2). Each time the subjects used
then the subjects were asked to clean their teeth and tongue with a particular tongue cleaning aid they were instructed to provide
the intervention aid provided by the examiner (Fig. 1). Following the their response to a questionnaire pertaining to any possible side-
tongue cleaning procedure the post-intervention records of Winkles effects or discomfort of the cleaning aids. At the end of the study;
Tongue Coating Index and culture swabs of the tongue dorsum were the subjects were also asked to record their experience related to
recorded.6 usage of a tongue cleaner.

Statistical Analysis
Statistical analysis was carried out using SPSS 14.0 software. The
mean results were calculated for each aid and then compared within

Ql: Have you experienced any reduction in the level of bad breath
after using the tongue cleaner?
a. Yes b. No
Q2: Have you experienced any improvement in taste after using
the tongue cleaner?
a. Yes b. No
Q3: Have you experienced any gagging reflex while using the
tongue cleaner?
a. Yes b. No
Q4: How was your experience about usage of a tongue cleaner?
a. Comfortable b. Uncomfortable
Fig. 1: Tongue cleaning aids used Fig. 2: Questionnaire used in the study

The Journal of Contemporary Dental Practice, Volume 20 Issue 4 (April 2019) 445
 Effectiveness of Various Tongue Cleaning Aids

(baseline and post intervention) and between the three different was compared between the three intervention products used in
aids using the student t-test. p <0.05 was considered statistically the study, a highly significant value was obtained when the mean
significant. reduction of bacterial count of brush scrapper was compared to
plastic scrapper. Mean reduction of bacterial load with plastic
scrapper in comparison to the others showed significant reduction
R e s u lts (Tables 5 and 5A).
The results of the study reported no dropouts with the mean age After each intervention the subjects were assessed on the usage
for the male and the female participants as 24.18 + 3.38 years and and effects of the products provided to the subjects, according to
23.44 + 3.97 years respectively (Table 1). All three cleaning aids which 80% of the study subjects experienced reduction in halitosis
reported a highly significant scores of reduction although with brush and plastic tongue scrapper compared to metal tongue
maximum mean reduction of tongue coating was obtained with scrapper. About 50% of the subjects reported change in taste
the plastic tongue scrapper, i.e., mean reduction 2.80 (Table 2). alteration after usage of plastic tongue scrapper. More than three
The mean values of pre and post-intervention scores of the fourth of the subjects using plastic tongue scrapper reported
aerobic bacterial count was compared for the three different increased gagging reflex and discomfort level. Overall, in terms
tongue cleaning aids used, all aid showed a significant reduction. of preference, it was observed that brush scrapper was highly
Although the mean reduction scores was highly significant preferred by the study subjects compared to plastic and metal
(p <0.001) amongst those who cleaned their tongue with the plastic tongue scraper as it greatly reduced halitosis level with minimum
tongue scraper (Table 3). On comparing the mean value of pre, post- discomfort (Table 6).
intervention and reduction scores of the anaerobic bacterial count The data of this study indicates that tooth brushing alone
only plastic and metal tongue scraper showed significant values of does not improve significantly the breath odor of the participants.
reduction (p <0.001) whereas, the mean reduction scores obtained Tongue cleaning notably is required in order to minimize the
by the brush scrapper were not found to be significant (Table 4). level of tongue coating and bacterial load. Although the patient’s
The mean reduction of aerobic and anaerobic bacterial count when compliance with plastic tongue cleaner was not very high but
Table 1: Age and gender wise distribution of study subjects
maximum reduction of bacterial load was seen in association to it.

Age group Gender Discussion

(in years) Male Female Total The papillary structure of the dorsum of the tongue forms a
<23 6 (30.00) 7 (35.00) 13 (65.00) distinctive ecological niche that provides an adequate surface
>23 5 (25.00) 2 (10.00) 7 (35.00) area favouring the acquisition of microorganisms and food
debris. Tongue microorganisms may contribute to dental plaque
Total 11 (55.00) 9 (45.00) 20 (100.00) formation. The present study showed highly significant reduction
Mean age Mean age in aerobic and anaerobic bacterial load by all three aids except
(Male) (Female) for the anaerobic bacterial load seen with brush tongue scrapper.
24.18 + 3.38 23.44 + 3.97 When in-between comparison was done for the three aids, highly

Table 2: Differences in mean WTCI score among tongue cleaning aids

Mean + Sd
Aids Pre Post Mean + SD p value Significance
WTCI-I (brush) 5.55 + 2.73 1.85 + 2.68 3.70 + 2.68 < .001 S
WTCI-II 5.57 + 2.67 2.90 + 1.73 2.80 + 2.29 < .001 HS
(plastic scrapper)
WTCI-III (metal 6.35 + 1.95 3.35 + 1.96 3.00 + 1.55 < .001 S
scrapper)
Table 3: Differences in mean aerobic bacterial count among tongue cleaning aids
Mean + SD
Aids Pre Post Mean + SD p value Significance
Brush scrapper 448000 + 420697.83 133750 + 64398.66 314250.00 + 424815.47 <0.05 S
Plastic scrapper 2460000 + 682798.12 263500 + 262417.10 2196500 + 1711748 <0.001 HS
Metal scrapper 3140000 + 404550.43 266000 + 255331.20 2874000 + 1400526.33 <0.001 HS

Table 4: Differences in mean anaerobic bacterial count among tongue cleaning aids
Mean + Sd Mean + SD
AIDS Pre Post p value Significance
Brush scrapper 2525000 + 1417198.78 2475000 + 1260506 50000 + 1633248 >0.05 NS
Plastic scrapper 2205000 + 1016752.53 294000 + 227319.16 1911000 + 1036576 <0.001 HS
Metal scrapper 2155000 + 1016284.08 260500 + 229553.40 1894500 + 1017509 <0.001 HS

446 The Journal of Contemporary Dental Practice, Volume 20 Issue 4 (April 2019)
 Effectiveness of Various Tongue Cleaning Aids

Table 5: Differences in mean value of bacterial load among tongue cleaning aids
Mean ± standard deviation Mean ± standard
Pre Post deviation p value Significant
Brush scrapper Anaerobic 252500 ± 1417198.78 2475000 ± 1260506 50000 ±1633248 >.05 NS
Aerobic 448000 ± 420697.83 133750.00 ± 64398.66 314250.00 ± 24815.50 <0.001 HS
Plastic scrapper Anaerobic 2205000.00 ± 1016752.53 29400 ± 227319.16 19110000 ±1036576 <0.001 HS
Aerobic 2460000 ± 1682798.12 263500 ± 262417.10 2196500 ± 1711748 <0.001 HS
Metal scapper Anaerobic 2155000 ± 1016284.08 260500 ± 2293553.40 1894500 ± 1017509 <0.001 HS
Aerobic 3140000 ± 1404550.43 2660000 ± 255331.20 2874000 ±14000526.33 <0.001 HS

Table 5(A): Comparison of mean values of bacterial load reduction among tongue cleaning aids
Mean ± standard deviation p value Significant
Brush scrapper Plastic scrapper
Anaerobic 50000 ± 1633248 19110000 ± 1036576 <0.001 HS
Aerobic 314250.00 ± 24815.50 2196500 ± 1711748 <0.001 HS
Brush scrapper Metal scrapper
Anaerobic 50000 ±1633248 1894500 ± 1017509 <0.001 HS
Aerobic 314250.00 ± 24815.50 2874000 ± 14000526.33 >.0.05 NS
Plastic scrapper Metal scrapper
Anaerobic 19110000 ± 1036576 1894500 ± 1017509 >.0.05 NS
Aerobic 2196500 ± 1711748 2874000 ± 14000526.33 >.0.05 NS

Table 6: Percentage distribution of response regarding acceptability of each tongue cleaning aid
Response Brush tongue cleaner Plastic tongue cleaner Metal tongue cleaner
Difference in level of halitosis (%) 16 (80%) 16 (80%) 2 (10%)
Taste alteration (%) 2 (10.00) 2 (50.00) 9 (45.00)
Gagging reflex (%) 9 (45%) 13 (65%) 1 (5%)
Uncomfortable (%) 1 (5%) 12 (60%) 16 (80%)

significant reduction was observed with the plastic tongue crater with uplifted borders. These numerous depressions situated
scrapper. The results of the present study were similar to the on the tongue act as perfect niches for bacterial attachment and
studies conducted by Menon and Coykendall8 and Quirynen et growth and also provide shelter against various cleaning actions.
al.9,10 which also demonstrated a minor change in bacterial count The mean value of tongue coating obtained by WTCI showed a
after tongue cleaning. reduction with all three aids although highly significant reduction
The impact of surface roughness increased the bacterial count was seen with plastic tongue scraper. An approximately 55%
on the dorsum of the tongue. Luciana11 observed that there was a reduction of tongue coating was seen with plastic tongue scraper
reduction of the total number of colony forming units when tooth in the post-intervention results. The rough surface of the plastic
brushing and tongue cleaning were performed. Counting of salivary scraper helps to remove the tongue coating by penetrating
bacteria for evaluation of mechanical methods of tongue cleaning deep into the muscular folds of tongue. Arthur et al.14 concluded
has been justified since the removal of bacterial niches, as those additive effects of mechanical and chemical tongue cleaning aids
present on tongue surface, contributes to reduce the total number showed higher reduction as compared to the present study i.e. 74%
of bacteria of oral cavity. reduction was seen on tongue coating.
The surface characteristics of the dorsum of the tongue are Winkler et al.15 revealed that tongue brushing can increase
mainly responsible to cause difficulty in removing its bacterial load. the taste recognition in old age adults (especially those wearing
According to Collins and Dawes,12,13 the dorsal mucosa of the tongue a denture) by eliminating the thick bacterial coating present on
has an approximate area of 25 cm2 which possesses very irregular the tongue. The subjective evaluation of the instruments used
surface topography. The posterior surface exhibits a variety of slightly increases in taste recognition for all flavor whereas the chief
oval crypto lymphatic units which provides roughness to this area. complaint of the study subjects was related to gagging reflex. More
The anterior portion is more rough due to presence of numerous than three fourth of the subjects complained of gag reflex with the
number and variety of papillae. This comprised of fungiform plastic tongue cleaner, this might be a major cause of dissatisfaction
papillae with average length of 0.5–0.8 mm, filiform papillae with regarding tongue-cleaning aids. Rowley et al.16 and Christensen17
its 0.5 mm core, foliate papillae situated at the edge of the tongue, stated that most of the people use toothbrush to clean their tongue
vallate papille with 2–3 mm diameter and 1mm height and central because it does not require any additional tool. Although on contrary

The Journal of Contemporary Dental Practice, Volume 20 Issue 4 (April 2019) 447
 Effectiveness of Various Tongue Cleaning Aids

on the basis of the present study it is not the most effective way of 4. De Boever EH, Loesche WJ. Assessing the contribution of anaerobic
reducing tongue coating and bacterial load. The major drawback of microflora of the tongue to oral malodor. J Am Dent Assoc
the study was that sample size was small and the study design was 1995;126(10):1384-1393.
5. Hinode D, Fukui M, Yokoyama N, et al. Relationship between tongue
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with long duration and with higher sample size is advised. 2003;30(12):1017-23.
6. Loesche WJ, Kazor CE. Microbiology and treatment of halitosis.
C o n c lu s i o n Periodontol 2000 2002;28:256-279.
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Finally, the data obtained by the study indicate that the use of a mouthrinse containing chlorhexidine, cetylpyridinium chloride and
tongue cleaner plays an important role in controlling bacterial load zinc-lactate on oral halitosis. A dual-center, double-blind placebo
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10. Quirynen M, Zhao H, van Steenberghe D. Review of the treatment
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a new toothbrush design versus a conventional tongue scraper in
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