JADA Continuing Education
Effectiveness of mechanical tongue cleaning on oral levels of volatile sulfur compounds
RAINER SEEMANN, D.M.D., Ph.D.,
ANDI KISON,
MOZHGAN BIZHANG, D.M.D., Ph.D. and
STEFAN ZIMMER, D.M.D., Ph.D.
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ABSTRACT
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Background. Mechanical tongue cleaning may be an effective method for decreasing oral levels of volatile sulfur compounds, or VSC, and oral malodor. The authors conducted a study to compare the effectiveness of a specially designed tongue cleaner (One Drop Only Tongue Cleaner, One Drop Only, Berlin), a tongue scraper and a toothbrush in reducing oral VSC levels.
Methods. In this balanced, crossover study, 30 subjects had four morning appointments each with a waiting period of one week between appointments. At each appointment, a dental professional performed a single standardized tongue cleaning procedure using one of the cleaning tools. The authors monitored the subjects’ oral VSC values using a portable sulfide monitor until their baseline VSC values were reached.
Results. The baseline values showed no significant difference between the three groups. The tongue cleaner and the tongue scraper (42 percent and 40 percent, respectively) reduced oral VSC levels more than the toothbrush (33 percent) did. Reduced VSC values could be detected significantly longer after using the tongue cleaner than after using the tongue scraper or the toothbrush. The authors, however, could not detect a significant VSC reduction for more than 30 minutes in any of the subjects.
Conclusions and Clinical Implications. The tongue cleaner, a combination brush and scraper, was slightly more effective in reducing oral VSC levels than were the tongue scraper and a regular toothbrush. Because of the limited duration of the effect, however, the clinical efficacy on the reduction of oral malodor remains questionable.
Volatile sulfur compounds, or VSC, are important components of oral malodor.1,2 They are produced mainly at the dorsum of the tongue and are the result of bacterial putrecleaning the tongue is suggested as an effective method for decreasing VSC and oral malodor, but it is supported by only limited scientific evidence.6,7 A variety of tongue cleaners with different designs are available and are said to be more effective than a regular toothbrush.6 According to Bosy and colleagues,8 VSC levels registered by a portable sulfide monitor correlate with organoleptic ratings—those involving use of the sense organs—of oral malodor.
Mechanically cleaning the tongue is suggested as an effective method for decreasing volatile sulfur compounds and oral malodor.
We conducted this study to compare the effectiveness of a specially designed tongue cleaner, a tongue scraper and a regular toothbrush in reducing oral VSC levels.
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MATERIALS AND METHODS
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Thirty volunteer subjects (15 male subjects and 15 female subjects) participated in the study. We recruited them from a special bad breath consultation hour at the dental school at Humboldt-University in Berlin. We organoleptically determined these subjects’ oral malodor and measured their oral VSC levels using a portable sulfide monitor (Halimeter, Interscan).
Study inclusion criteria included subjects’ having morning VSC values higher than 130 parts per billion and having oral malodor that was detectable by organoleptical measurement performed by a dental professional (A.K.) 15 centimeters from the subject’s mouth. We excluded patients who had systemic diseases, removable dentures, dental caries, active periodontitis or mucosal lesions, as well as those who took medication on a regular basis during or within three months of the study or who were active smokers. We also excluded patients who had had their teeth professionally cleaned within the two months before the start of the study and those who used a mouthwash regularly.
We asked the subjects to keep all of their oral hygiene procedures such as flossing and toothbrushing constant during the study period, though if they usually cleaned their tongues, we asked them to not do so at least 24 hours before the appointment. We also instructed them to not consume onion, garlic or alcohol for at least 48 hours before their appointments.
We tested the effectiveness of three tongue cleaning devices: the One Drop Only Tongue Cleaner (One Drop Only GmbH, Berlin) that both brushes and scrapes, the Tongue-Putzer tongue scraper (Safident, Gland, Switzerland) and a regular toothbrush (Elmex-super 39, GABA, Münchenstein, Switzerland) (Figure 1
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Figure 1. The One Drop Only Tongue Cleaner (One Drop Only GmbH, Berlin) is a combination brush and scraper. Image of the One Drop Only Tongue Cleaner is reproduced with permission of One Drop Only GmbH.
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We designed the study as a three-way crossover trial (Figure 2). We randomly assigned subjects to three groups—A, B and C—each of which comprised 10 subjects. Each subject was seen on four mornings, and there was a one-week period between appointments. At each of the first three appointments, one of the test products was used. Each group’s treatment was started with a different device. The fourth appointment served as a control; no treatment was performed.
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Figure 2. In this crossover study, the subjects were divided into three groups: A, B and C. In each of the groups, the products (TC: tongue cleaner, TS: tongue scraper, T: toothbrush) were tested in a different sequence to avoid bias toward any one of the products. Each subject served as his or her own control.
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At the first three appointments, one dental professional (A.K.) performed treatment in a standardized manner (10 strokes from the back to the tip of the tongue with the toothbrush, 10 strokes from the back to the tip of the tongue with the tongue scraper, and five strokes brushing and five strokes scraping from the back to the tip of the tongue with the tongue cleaner) in the morning approximately two hours after the subject’s last meal and the last oral hygiene procedure. After the cleaning procedure was completed, the subjects rinsed with 50 milliliters of tap water.
All VSC measurements were taken operator-blind using a portable sulfide monitor, as described in detail elsewhere.9 The operator took readings before tongue cleaning, immediately after tongue cleaning and then every five minutes for a period of at least 35 minutes or until the baseline VSC reading was reached within a range of ± 5 percent. We registered peak values as parts-per-billion sulfide equivalents, and they were expressed as the mean value of two repeated measurements.
We used the Friedman test and the Wilcoxon signed rank test to analyze the data, and we set the level of significance at P < .05.
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RESULTS
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We excluded two of the study’s subjects from our analysis, because they had baseline VSC values lower than 130 ppb during the study period. Thus, 28 subjects (14 male subjects and 14 female subjects) finished the study. The results of the study are summarized in the table, which shows the mean values of oral VSC in ppb and percentage. Between the baseline values and the control measures on the fourth visit, we detected no statistically significant differences.
The tongue cleaner showed statistically significantly lower VSC values and a higher percentage of VSC reduction than did the toothbrush up to 25 minutes after tongue cleaning. After 15 minutes, the tongue cleaner showed a tendency (P = .06) for a higher reduction of VSC than the tongue scraper. This difference was statistically significant at 20 minutes and 25 minutes after tongue cleaning.
The tongue scraper showed statistically significantly lower VSC values than did the toothbrush immediately, at five minutes and at 20 minutes after tongue cleaning. We could detect a higher percentage of VSC reduction up to 20 minutes after tongue scraper use compared with toothbrush use.
We could not detect VSC reduction for longer than 30 minutes after cleaning in any of the subjects (Figure 3).
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Figure 3. Number of subjects reaching their baseline volatile sulfur compound values (± 5 percent from the baseline value) after tongue cleaning, by product.
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DISCUSSION
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The importance of mechanical tongue cleaning as an oral hygiene procedure has gained new interest because it has been shown that bacterial tongue coating is an important source for VSC, which are major components in oral malodor.6 In addition, a 1999 study has shown that VSC also play a pathological role in the development of periodontitis and gingivitis.10 With these considerations in mind, we find it astonishing that only limited scientific data are available on the reduction of oral levels of VSC by mechanical means. It has been stated that using a regular toothbrush for tongue cleaning is inferior for removing debris and organisms from the tongue6 compared with using a scraping débridement tool. And it is desirable to use a product that provides maximum effect with a minimum number of movements on the tongue, thus reducing the gagging reflex. Considering this last fact, we chose a cleaning procedure that used 10 strokes on the tongue for each product; it was performed by one operator (A.K.) to avoid the influence of bias toward one of the products. Our study results showed that two specially designed tongue cleaners produced a statistically significantly higher reduction of VSC levels than did a regular toothbrush after a single use in a standardized manner.
The lower efficiency of the toothbrush in our study might be explained by the fact that the width of the toothbrush was slightly smaller than the width of the tongue cleaner and tongue scraper, or the toothbrush simply might be less effective in removing loosened debris from the tongue. This latter assumption is supported by the fact that scraping is a very important action in removing debris from the tongue; brushing also may be important as a precleaning procedure that loosens debris in deeper areas of the tongue. Therefore, a combination of brushing five times and scraping five times with a tongue cleaner may be slightly more effective than performing either procedure 10 times.
We found that the VSC reduction resulting from use of each of the tested products was of limited duration. We could not detect a significant reduction 35 minutes after tongue cleaning in of the subjects. This finding is comparable with that of a study performed by Hoshi and van Steenberghe.11 Their study showed that no statistically significant VSC reduction from baseline could be found one hour after a single tongue cleaning procedure using a regular toothbrush. Both our findings and those of Hoshi and van Steenberghe suggest that a single mechanical cleaning of the tongue to reduce oral odor related to VSC is at least questionable. The combination of tongue brushing with the use of a dentifrice has resulted in a VSC reduction for at least one and one-half hours.12 A longer lasting effect also might occur after regular use of a tongue-cleaning procedure, since studies from the 1970s and 1980s have shown that tongue cleaning on a regular basis results in a reduction of cultivable flora from the tongue and in reduction in plaque forming on teeth.13,14 However, only limited data are available regarding this point.
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CONCLUSION
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We found that the tongue cleaner, which uses both brushing and scraping, was slightly more effective in reducing oral VSC levels than were the tongue scraper or regular toothbrush. Because of the limited duration of the VSC reduction, however, the clinical effect on the reduction of oral malodor remains questionable.
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Dr. Seemann is a senior manager, scientific relations, MEDLive GmbH, Berlin. He was an assistant professor, Department of Operative and Preventive Dentistry and Endodontics, Dental School, Charité, Humboldt-University, Berlin. Address reprint requests to Dr. Seemann at MEDLive GmbH, Fabeckstrasse 60-62, 14195 Berlin, Germany, e-mail, "seemann{at}medlive.de".
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Dr. Bizhang is an assistant professor, Department of Operative and Preventive Dentistry and Endodontics, Dental School, Charité, Humboldt-University, Berlin.
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Dr. Zimmer is an assistant professor, Department of Operative and Preventive Dentistry and Endodontics, Dental School, Charité, Humboldt-University, Berlin.
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REFERENCES
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- Tonzetich J. Direct gas chromatographic analysis of sulphur compounds in mouth air in man. Arch Oral Biol 1971;16:587–97.[Medline]
- Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of analysis. J Periodontol 1977;48:13–20.[Medline]
- McNamara TF, Alexander JF, Lee M. The role of microorganisms in the production of oral malodor. Oral Surg Oral Med Oral Pathol 1972;34:41–8.[Medline]
- Kleinberg I, Westbay G. Oral malodor. Crit Rev Oral Biol Med 1990;1:247–59.[Free Full Text]
- Yaegaki K, Sanada K. Biochemical and clinical factors influencing oral malodor in periodontal patients. J Periodontol 1992;63:783–9.[Medline]
- Christensen GJ. Why clean your tongue? JADA 1998;129:1605–7.
- Tonzetich J, Ng SK. Reduction of malodor by oral cleansing procedures. Oral Surg Oral Med Oral Pathol 1976;42:172–81.[Medline]
- Bosy A, Kulkarni GV, Rosenberg M, McCulloch CA. Relationship of oral malodor to periodontitis: evidence of independence in discrete subpopulations. J Periodontol 1994;65:37–46.[Medline]
- Rosenberg M, Septon I, Eli I, et al. Halitosis measurement by an industrial sulphide monitor. J Periodontol 1991;62:487–9.[Medline]
- Ratcliff PA, Johnson PW. The relationship between oral malodor, gingivitis, and periodontitis: a review. J Periodontol 1999;70:485–9.[Medline]
- Hoshi K, van Steenberghe D. The effect of tongue brushing or toothpaste application on oral malodour reduction. In: van Steenberghe D, Rosenberg M. Bad breath: A multidisciplinary approach. Leuven, Belgium: Leuven University Press; 1996:255–64.
- Tonzetich J. Oral malodour: an indicator of health status and oral cleanliness. Int Dent J 1978;28:309–19.[Medline]
- Vasilakis GJ, Preis CO, Glaz J, Bissada NF. Effects of daily mechanical tongue cleaning of the rat on dental plaque and tongue mucosa. Clin Prev Dent 1981;3:7–10.
- Jacobson SE, Crawford JJ, McFall WR Jr. Oral physiotherapy of the tongue and palate: relationship to plaque control. JADA 1973;87:134–9.
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ABSTRACT
MATERIALS AND METHODS
