At this point, we have no Ogold standardO by which we can measure the effectiveness of any tongue-cleaner or tongue-deplaquing approach.
Trisha E. O`Hehir, RDH, BS
Based on newspaper articles and the number of tongue-scrapers on the market today, tongue-cleaning currently is a hot topic. I have seen well over a dozen brands of tongue-cleaners - and I`m still counting! That includes both the manual and power scrapers.
Tongue-cleaning is not new, but it has assumed a new place of importance for both patients and clinicians. This new importance is due almost entirely to the general public`s concern over bad breath. Unfortunately, scientific research is lacking in this area, both in what influences coating of the tongue and how best to remove it.
Historical evidence exists for tongue-cleaning in ancient civilizations, as well as the past few centuries. In my dental hygiene education, tongue-cleaning was suggested as part of toothbrushing, but not really stressed. It is the ignored area of oral hygiene.
For years, I`ve had a simple, metal tongue-scraper with no markings on it whatsoever. I can`t remember how long I`ve had it or where I got it, but it does work well for the anterior half of the tongue. Reaching the very back of the tongue is a trick, whatever you use. Some scrapers look like miniature rakes or razors without the blades. Others look like simple, flexible metal or plastic strips that can be bent to form a U-shaped scraper. I prefer a soft, thin, washcloth, wrapped around the finger, for effective, non-traumatic deplaquing of the tongue. This soft fabric seems to remove more of the coating than the scrapers.
That is my personal opinion, with no scientific evidence to back it up, so I suggest you try the various tongue-cleaners yourself and see which ones you find effective and easy to use. Clinical Research Associates has tested several and found six to be favorably rated by its clinicians (CRA Newsletter, May 1998). Besides the commercial products available, a plastic or metal teaspoon also works well.
At this point, we have no "gold standard" by which we can measure the effectiveness of any tongue-cleaner or tongue-deplaquing approach. Effective plaque removal from tooth surfaces can be determined with disclosing solution or by feeling with the tongue. Not so on the tongue itself. We have no way of knowing when the bacteria are removed completely from the tongue. We also don`t know if complete bacteria removal from the tongue is essential. Sellers of tongue-cleaners simply say, "gently scrape the tongue several times to remove the plaque." For some people, scraping never seems to completely remove the coating. They could scrape all day and still find material on the scraper each time. The architecture of the tongue`s surface provides well-protected areas for bacteria and debris to accumulate. Until we have an accepted "gold standard" for tongue-cleaning, we have no way to measure the effectiveness of any of the tongue-cleaners on the market today.
Coating of the tongue has not been well-documented. Over the years, I`ve searched for information on the subject, asked lots of experts, but found very little scientific information. It provides an interesting gap in our scientific literature, since it is postulated that bacterial accumulations on the tongue - particularly the dorsum of the tongue - contribute in some way to both caries and periodontal disease. The tongue certainly does provide a rather large area for bacteria to accumulate undisturbed.
If you look at enough tongues, it is apparent that tongue-coating is not the same for all people. It varies from young to old, from smokers to nonsmokers, and from early morning to after eating. It is influenced by the foods we eat, the medications we take, tobacco products used, and probably by our own individual metabolism. Without a base of scientific literature, your guess is as good as mine about how this coating forms and what helps or hinders its accumulation.
As part of primary prevention, tongue-deplaquing is a perfect area for dental hygienists to research. We need to know what causes tongue-coating, what contributes to accumulation, how best to control it on a daily basis, and how to deplaque a tongue that has years of undisturbed accumulation.
Information gathered by clinicians can encourage researchers to scientifically test various theories and approaches to care. What we find effective in clinical practice then should be validated by randomized, clinical trials. As with many other clinical approaches, it will start first in clinical practice and then find its way to the research laboratories.
We have two aspects of tongue-deplaquing to consider. First, daily tongue-cleaning by patients at home. With the documented link to bad breath, this should be easy to get people to do, especially with easy-to-use, effective tongue-cleaners.
The second is professional tongue-deplaquing. Breath clinics have been opened specifically for this purpose. Dr. Jon Richter of the Richter Center in Philadelphia uses a modified Prophy Jet® with spray deflector. Instead of sodium bicarbonate, chlorine dioxide is used to professionally deplaque the tongues of people seeking treatment for bad breath.
From the dental hygienist`s point of view, a very practical approach was introduced at the 1998 ADA meeting in San Francisco by Kristy Menage Bernie, RDH, BS, and Director of Educational Designs. Ms. Bernie presented a table clinic on professional tongue-deplaquing as part of routine, dental-hygiene visits. Her premise was well-founded. If we spend time and expertise professionally removing plaque and calculus from supragingival and subgingival areas around the teeth, why do we send patients home with a tongue full of bacteria? Good point! Deplaquing the tongue as part of a dental hygiene appointment certainly makes sense. Why didn`t we think of it sooner? If we teach toothbrushing and then give the patient the brush to take home and use, why not do the same thing with tongue-cleaning? Give patients their own tongue-cleaners after showing them how to use it effectively.
Should we be doing more? We don`t just brush our patients` teeth; we professionally "clean" them. Shouldn`t we also professionally "clean" their tongues? The question is, how do we do it?
Many repeated scrapings with the selected tongue-cleaner may be needed to completely remove the bacteria and coating on the tongue. With some serrated tongue-cleaners, that can lead to a very sore, even abraded and bleeding tongue. A soft fabric may be the answer, but if you`ve tried cotton gauze, you will spend more time picking pieces of thread off the tongue (how much depends on the brand)! The terrycloth, single-finger swabs for babies (Tenders® by Practicon Dental) may be useful for this task. This looks like an opportunity for a brand, new mechanical approach. Which company do you think will be the first to market the professional tongue-deplaquer?
Chlorhexidine swabbed on the dorsum of the tongue may not taste too good, but the substantivity may be a helpful adjunct in effectively deplaquing the tongue. Other chemicals may prove just as effective without the side effects.
Which form is better: liquid to swab, gel to coat, or spray to reach the very back of the tongue? Put on your research cap and see what works best for you. Let me know what you discover.
Professional tongue-deplaquing is a whole new area for hygienists. I suggest following Kristy Menage Bernie`s advice: make tongue-deplaquing part of each dental-hygiene appointment. Our experience, plus our imagination, should lead to some exciting new approaches to this task.
Trisha E. O`Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics. The Web site for Perio Reports is www.perioreports.com. Her e-mail address is [email protected].