Tongue cleaners: Are they truly beneficial?

The importance of tongue cleaning is in the spotlight as studies that link good oral hygiene to the prevention of COVID-19 transmission emerge. With this, dental professionals are giving renewed attention to the importance of tongue cleaning, which remains one of the most neglected oral care steps in the US.

Since patient education is among the responsibilities of dental hygienists, they are the first authorities who should shed light on topics like this. To help you educate patients in achieving optimum oral health, I will review the importance of keeping the tongue clean. I will also discuss a step-by-step guide for using a tongue cleaner that you can share with your patients. But first, I’ll touch briefly on the questions regarding the link between oral hygiene and COVID-19.

Tongue cleaners and COVID-19: Why the sudden link?

Among the many questions circulating online is whether people should change toothbrushes and tongue cleaners after recovering from COVID-19. While it’s hard to trace what brought about such questions, one thing is apparent—the spread of COVID-19, which is transmitted mainly through direct or indirect contact with the eyes, nose, or mouth, prompted some researchers to explore possible links between oral hygiene and disease transmission.

One study published in October 2020 looked at how the misuse of dental hygiene could facilitate the transmission of COVID-19 among infected people and the individuals living with them. The study found that SARS-CoV-2, the virus that causes COVID-19, can be present on the tongue.¹ The study states, “They [the virus] can also be in the mouth, mainly on the tongue, which is a great reservoir of viral germs. Therefore, tooth brushing, interproximal hygiene, and tongue cleaning are essential to reduce the viral load in the oral area.”

Another published research mentioned a “COVID-19 tongue,” described as a bumpy, inflamed, and/or swollen tongue observed on a significant number of COVID-19 patients.² The research clarified that this description is also accurate with patients infected with other types of viruses and not isolated among COVID-19 patients.

It is important to note that these findings are not official. Although the loss of taste is on the list of COVID-19 symptoms compiled by the Centers for Disease Control and Prevention,³ there is no official evidence that tongue cleaning will minimize COVID-19 transmission.

While the link between tongue cleaning and COVID-19 remains unproven, this should not be a reason to overlook the tongue during oral care. With or without the pandemic, tongue cleaning is crucial in maintaining overall oral health. Sadly, in general, even dental professionals don’t place much emphasis on tongue cleaning. The practice is not as widely discussed during patient appointments as brushing, flossing, and using a mouthwash.

Why should you clean your tongue (and advise your patients to)?

The mouth is home to more than six million bacteria of 700 different types.⁴ In fact, of all the body parts, the mouth has the most bacteria. The environment of the mouth—its moisture, pH level, and temperature—is ideal for unicellular microorganisms.⁴ Most of the bacteria in the mouth are found on the tongue.⁵

The structure and texture of the tongue are the reasons why bacteria quickly accumulate on it. Two-thirds of the tongue’s front surface is covered with papillae, which gives the tongue its rough, carpetlike appearance. Additionally, the tongue has many crevices, nooks, and crannies that make perfect hiding spots for bacteria.⁶

Bacteria, food particles, and dead cells that lodge between the papillae form a white coating when the tongue is neglected. This condition is called white tongue.⁷ While white tongue is often not a symptom of a severe health condition, it impacts a person’s oral and overall health.

How to get rid of white tongue

In most cases, white tongue is easy to resolve as the condition is usually related to oral hygiene and lifestyle. Here are some ways to treat and prevent white tongue.

• Practice regular and proper brushing and flossing.
• Avoid excessive alcohol use.
• Drink plenty of water to avoid dry mouth.
• Stop smoking or chewing tobacco.
• Scrape off the white coating with a tongue cleaner.

Note that although white tongue is often harmless, it can also be a symptom of other severe conditions.⁸ If a patient has been experiencing white tongue persistently despite practicing proper oral hygiene, the best advice is to consult a doctor.

What are the benefits of cleaning the tongue?

Brushing the tongue has proven to be effective in reducing the number of bacteria in the mouth.⁵ Cleaning the tongue will help minimize the possible presence of bacteria that causes oral health issues. Here are some of the benefits of tongue cleaning that you can share with your patients.

Makes breath fresher: The most common effect of white tongue is bad breath or halitosis. It is estimated that 80 million Americans suffer from chronic bad breath, and between 35% and 45% of the global population have experienced bad breath at some point in their lives.⁹ Although bad breath is not contagious, it can profoundly affect one’s self-esteem, relationships, and quality of life. Bad breath can even put careers on the line.

Bad breath usually starts in the mouth as a result of poor oral hygiene. When bacteria harbor on the rough surfaces and crevices of the tongue, they feed on the proteins and other organic substrates in the mouth. The metabolism process triggers the release of volatile sulfur compounds responsible for producing a foul mouth odor.¹⁰

Helps prevent oral yeast infection: While it has not been proven if the COVID-19 virus can harbor on the tongue, it has been proven that some types of fungi can.¹¹ Candida, the fungus that causes thrush or oral yeast infection, is among them. Candida is naturally present in different parts of the human body, such as the skin, throat, and mouth. It is usually not harmful as it is primarily present in small amounts and can be controlled by other microorganisms in the body. However, it can grow out of control due to a weakened immune system or a response to certain medications.¹¹ This can result in different health issues, such as oral thrush.

Indications of thrush include white, bumpy patches on the tongue and other parts of the mouth.¹² In most cases, it’s easy to treat. However, it’s always best to consult a medical professional for the appropriate treatment plan.

Helps prevent tooth decay: Cavities don’t always originate on the teeth. Even if a patient brushes and flosses religiously, he or she can still get dental caries if the tongue is overlooked during oral care. Bacteria left on the tongue can stick to and harden on tooth surfaces, resulting in calculus formation. When this occurs, it’s tough to remove the calculus without dental intervention. Calculus destroys the enamel and causes cavities.

Prevents gum diseases: Periodontal disease is another result of poor oral hygiene. Most gum disease happens in the same manner cavities form on the teeth. When plaque-causing bacteria remains on the tongue, it can be transferred to the gum line, causing gum infection and inflammation. Depending on the gravity of the case, most gum problems can be reversed through proper at-home oral hygiene. If it’s an extreme case, professional intervention by a periodontist should be sought immediately.

Improves the sense of taste: The tongue’s papillae are where most taste buds are located. The taste buds do more than just provide a pleasurable eating experience; they make a great hiding place for bacteria. When bacteria build up on the tongue, the white coating affects the taste buds’ sensitivity. In one published study, it was found that removing the coating on the tongue using a scraper for two weeks helped improve the taste sensation.¹³ To help your patients enjoy their meals more, tell them about the benefits of tongue cleaners.

Gives a fresh mouth feeling: Some patients complain they have bad taste in their mouth even after brushing. Harmful bacteria left in other parts of the mouth, such as the tongue, can contribute to that not-so-fresh sensation. Cleaning the tongue is a great way to make the mouth feel fresher.

What is the best way to clean the tongue?

Some people use their toothbrushes to clean the tongue. According to research, the best way is to use a tongue cleaner specially designed to eliminate the white coat formation on the tongue. Using a tongue cleaner is easy and should be pain free. Twice-a-day tongue cleaning is generally enough,¹⁴ but you can do it multiple times during the day before brushing.

What to look for when choosing a tongue cleaner

When choosing a tongue cleaner, look for one with the American Dental Association (ADA) seal of approval, such as the Pro-Sys tongue cleaner. This easy-to-use product is a plastic tongue scraper designed to easily remove the bacteria, food particles, and other elements that cause bad breath and other oral issues. Additionally, the product comes with a comfortable handle that quickly reaches the back of the tongue without causing a gag reflex. Regular use of this tongue cleaner and proper brushing and flossing will help promote optimal oral health.

A step-by-step guide to using a tongue cleaner

Share this guide with patients. Print it and post it in your clinic or distribute copies to patients.

1. Open your mouth wide and stick out your tongue. It helps to stand in front of a mirror when cleaning your tongue because you can see the inside of your mouth better.
2. Put the tongue cleaner in your mouth as far back as you can. Do this carefully. Some people gag when using a tongue cleaner. If this happens to you, adjust the pressure and position the tongue cleaner accordingly.
3. Gently scrape your tongue starting from the back to the front to eliminate white coat formation and debris. Do this multiple times at different angles until you have covered the entire dorsal surface of your tongue.
4. Spit out excess saliva or rinse your mouth with water to eliminate the remaining white coating and food particles.
5. Rinse the tongue scraper with warm water or wipe it off with a clean cloth to remove the debris.
6. Repeat the process many times until you feel that your tongue is clean. In most cases, twice is enough.
7. Once done, wash the tongue cleaner with warm water and soap before storing it.
8. Store the tongue cleaner in a clean and dry place. Keep it at least six feet away from the toilet to prevent bacterial growth. 

Editor's note: This article appeared in the January print edition of RDH magazine.

References 

1. González-Olmo MJ, Delgado-Ramos B, Ruiz-Guillén A, et al. Oral hygiene habits and possible transmission of COVID-19 among cohabitants. BMC Oral Health. October 19, 2020. Accessed May 20, 2021. https://bmcoralhealth.biomedcentral.com/articles/10.1186/s12903-020-01274-5
2. Miller C. What is COVID tongue, and is it a sign you've been infected with the virus? Health.com. January 27,2021. Accessed May 20, 2021. https://www.health.com/condition/infectious-diseases/coronavirus/covid-tongue-swollen
3. Symptoms of COVID-19. Centers for Disease Control and Prevention. Updated February 22, 2021. Accessed May 21, 2021. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
4. Booth S. How to stop bad bacteria in your mouth from migrating to your brain. Healthline.com. May 5, 2019. Accessed May 17, 2021. https://www.healthline.com/health-news/bacteria-in-your-mouth-can-find-its-way-to-your-brain
5. Mantilla MM, Gomez S, Van der Weijden GA. Tongue coating and tongue brushing: a literature review. Wiley. May 8, 2003. Accessed May 19, 2021. https://onlinelibrary.wiley.com/doi/pdf/10.1034/j.1601-5037.2003.00034.x
6. Oral tissues: Oral issues: Tongue. Accessed May 19, 2021. https://www.histology.leeds.ac.uk/oral/tongue.php
7. Johnson J. What causes a white tongue? Medical news today. Accessed May 17, 2021. January 15, 2020. https://www.medicalnewstoday.com/articles/319814
8. Watson S. What causes a white tongue and how to treat it. Healthline. Accessed May 21, 2021. March 29, 2019. https://www.healthline.com/health/dental-and-oral-health/white-tongue#causes
9. Binnie B. Bad breath statistics. National Denturist. Spring 2017. Accessed May 19, 2021. http://nationaldenturist.com/NDA_magazine/National_Denturist_Magazine_Spring_2017.pdf
10. Uğur Aylıkcı B, Çolak H. Halitosis: From diagnosis to management. US National Library of Medicine National Institutes of Health. January-June 2013. Accessed May 19, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3633265/
11. Candida infections of the mouth, throat, and esophagus. Centers for Disease Control and Prevention. Accessed May 21, 2021. https://www.cdc.gov/fungal/diseases/candidiasis/thrush
12. Thrush. Cleveland Clinic. Accessed May 21, 2021. https://my.clevelandclinic.org/health/diseases/10956-thrush
13. Quirynen M, Avontroodt P, Soers C. Impact of tongue cleansers on microbial load and taste. J Clin Periodontol. 2004;31(7)506-510. doi:10.1111/j.0303- 6979.2004.00507.x. Accessed May 21, 2021.
14. Silver N. What’s the most effective way to clean your tongue? Healthline. May 10, 2019. Accessed May 21, 2021. https://www.healthline.com/health/how-to-clean-your-tongue#tongue-scraper