Tongue hygiene: Are you missing this critical third step?

How would you feel if your carpet was not vacuumed in a week? The 200,000 bacteria per square inch of your carpet is 4,000 times dirtier than a toilet seat, because the bacteria are harbored in the fibers. Now, think about your tongue: 20 billion bacteria reside in similar fibers, or papilla, on the dorsal surface. As dental hygienists, it seems commonplace to discuss tongue hygiene with our patients because everyone has this coating at one time or another every day.

Dental hygienists radically influenced the oral hygiene habits of the masses during the 1970s when they motivated patients to go from brushing … to brushing and flossing. Now that same phenomena is happening with a “brush, floss, brush your tongue” oral hygiene routine.

We know that harmful anaerobic bacteria originating in the mouth produce volatile sulfur compounds and are responsible for up to 90% of halitosis, or oral malodor. These same bacteria harboring on the tongue serve as a precursor to periodontal disease, which we know can have serious health implications.¹ If we are keenly aware of this information, then we must ask ourselves as dental professionals, why is tongue hygiene—and more specifically, tongue brushing—not part of every patient’s oral hygiene routine?

In the largest survey of its kind, a worldwide consumer study of oral health and dental care across 15 countries was conducted in 2021. Trends in oral health care, oral hygiene routines, and attitudes and beliefs toward the value of adequate oral hygiene were all evaluated. When asked what individuals do to keep their mouth healthy and their breath fresh, 54% of respondents from the US and 39% of respondents overall identified the importance of tongue brushing.²

A toothbrush is not a tongue brush

When looking at products for tongue hygiene, let’s consider what is being done to the dorsal surface of the tongue. Toothbrushes are narrow, with long, soft bristles intended for biofilm removal on enamel surfaces and along the gingival margin. On the other hand, properly designed tongue brushes are wide with short bristles. Their intent is to penetrate hidden and hard-to-reach areas of the tongue where bacteria are located, while minimizing the gag reflex. The tongue has many deep, rough crevices that harbor harmful bacteria, all of which a tongue brush is responsible for removing; a traditional toothbrush cannot remove all the bacteria from the tongue. Research shows that mechanical removal of these bacteria is the only effective way to solve this condition.³ As the names suggest, each product should be used for its own designated purpose and to avoid cross-contamination. Toothbrushes used on the tongue will spread bacteria into the gums.

This is not new information, yet there are still numerous dental professionals and patients who seem to be skipping this critical step of tongue brushing, which takes less than one minute to complete. Despite the widespread evidence that points to 90% of halitosis being attributed to tongue biofilms and the associated bacteria being linked to periodontal disease, many oral health-care professionals are missing this critical element in a patient’s oral hygiene routine.

Educating patients with the right tools

Is the reason the tongue is neglected due to the lack of comfortable and effective tools available to patients? If so, how can we serve as better stewards around tongue brushing? Dental professionals need to recognize that there are new advancements in tongue cleaning medicaments that will not only encourage use and increase compliance but also inspire professionals to tackle this topic more often.

Can we take the tongue challenge and make a commitment to ourselves and our patients’ oral health by taking only two minutes to provide tongue hygiene instruction to every patient in our chair? Shouldn’t we be more intentional with the products we hand out to our patients to increase compliance? Regardless, patients face barriers with tongue brushing that often keep them from performing the task, including gag reflexes, scrapers that are uncomfortable to use, and toothbrushes that ineffectively remove tongue biofilms, all of which lead to low compliance. We as professionals need to seriously consider the vital role tongue cleaning plays in complete, daily oral care and reprogram our patient care protocol to include the three critical steps in a patient’s daily oral care regimen: toothbrushing, interdental cleaning, and tongue brushing. We can now coin this routine as brush, floss, brush … your tongue! 

Editor's note: This article appeared in the August/September 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Van der Sleen MI, Slot DE, Van Trijffel E, Winkel EG, Van der Weijden GA. Effectiveness of mechanical tongue cleaning on breath odour and tongue coating: a systematic review. Int J Dent Hyg. 2010;8(4):258-268. doi:10.1111/j.1601-5037.2010.00479.x
2. Holland C. Global healthy thinking report. Sunstar. 2021. https://www.sunstar.com/assets/sunstar-global-healthy-thinking-report-2021-oral-health-report.pdf
3. Kuo YW, Yen M, Fetzer S, Lee JD. Toothbrushing versus toothbrushing plus tongue cleaning in reducing halitosis and tongue coating: a systematic review and meta-analysis. Nurs Res. 2013;62(6):422-429. doi:10.1097/NNR.0b013e3182a53b3a