J Appl Oral Sci.

2008;16(4):271-4
www.fob.usp.br/jaos or www.scielo.br/jaos

EFFECTIVENESS OF A NEW TOOTHBRUSH DESIGN

VERSUS A CONVENTIONAL TONGUE SCRAPER IN
IMPROVING BREATH ODOR AND REDUCING TONGUE
MICROBIOTA

Luciana Assirati CASEMIRO1, Carlos Henrique Gomes MARTINS2, Tatiane Cruz de CARVALHO3, Heitor PANZERI4,
Marco Aurélio Sichirolli LAVRADOR5, Fernanda de Carvalho Panzeri PIRES-DE-SOUZA6

1- DDs, MsC, PhD, Professor, Dental School, University of Franca, Franca, SP, Brazil.
2- DDs, MsC, PhD, Professor, Laboratory of Applied Microbiology, University of Franca, Franca, SP, Brazil.
3- DDs, Laboratory of Applied Microbiology, University of Franca, Franca, SP, Brazil.
4- DDs, MsC, PhD, Full Professor, Dental School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.
5- DDs, MsC, PhD, Associate Professor, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP,
Brazil.
6- DDs, MsC, PhD, Associate Professor, Dental School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.

Corresponding address: Profa. Dra. Luciana Assirati Casemiro, Avenida Caramuru, 2100 ap.901, Ribeirão Preto - SP - 14030-000 - Phone:
+55-16-3620-6716. Fax: +55-16-3620-6716 - e-mail: [email protected]

Received: April 13, 2007 - Modification: September 03, 2007 - Accepted: April 14, 2008

ABSTRACT
F or centuries, specific instruments or regular toothbrushes have routinely been used to remove tongue biofilm and improve
breath odor. Toothbrushes with a tongue scraper on the back of their head have recently been introduced to the market. The
present study compared the effectiveness of a manual toothbrush with this new design, i.e., possessing a tongue scraper, and
a commercial tongue scraper in improving breath odor and reducing the aerobic and anaerobic microbiota of tongue surface.
The evaluations occurred at 4 moments, when the participants (n=30) had their halitosis quantified with a halimeter and scored
according to a 4-point scoring system corresponding to different levels of intensity. Saliva was collected for counts of aerobic
and anaerobic microorganisms. Data were analyzed statistically by Friedman’s test (p<0.05). When differences were detected,
the Wilcoxon test adjusted for Bonferroni correction was used for multiple comparisons (group to group). The results confirmed
the importance of mechanical cleaning of the tongue, since this procedure provided an improvement in halitosis and reduction
of aerobe and anaerobe counts. Regarding the evaluated methods, the toothbrush’s tongue scraper and conventional tongue
scraper had a similar performance in terms of breath improvement and reduction of tongue microbiota, and may be indicated as
effective methods for tongue cleaning.

Key Words: Tongue biofilm. Tongue scraper. Toothbrush. Salivary bacterial count. Halimeter.

INTRODUCTION include Porphyromonas gingivalis 14, Aggregatibacter

actinomycetemcomitans1,21, Spirochaetes 14, Prevotella
The dorsum of the tongue is a large surface for oral intermedia4,5 and Capnocytophaga.12
accumulation of microorganisms and debris2,9,17. Biofilm is Depending on the bacterial strain, the production of
formed on tongue surface, being a dynamic structure volatile sulfur compounds2,6,25, such as methyl mercaptan,
composed by bacteria, epithelial cells scaled from oral hydrogen sulfide and dimethyl sulfide10,11,22,23, is associated
mucosa, leukocytes from periodontal pockets, blood with the tongue biofilm. These compounds are carried by
metabolites and different nutrients3,7,26. exhaled air, contributing for the occurrence of halitosis6.
The existence of an association between tongue The etiology of halitosis (from latin: halitus, that means
microorganisms and those present in saliva has been exhaled air; and osis, that means pathological alteration) is
reported13,15. The anaerobic microbiota of the tongue biofilm varied. However, in 85% of the cases, periodontal pockets
is one of the main responsible for the release of sulfur are the main responsible for this condition8. Some clinical
compounds, which are directly involved in the occurrence conditions, such as fissured tongue, periodontal illness24,
of halitosis. The microbial species isolated from the tongue gastric reflux, prolonged fast and predominantly liquid or

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EFFECTIVENESS OF A NEW TOOTHBRUSH DESIGN VERSUS A CONVENTIONAL TONGUE SCRAPER IN IMPROVING BREATH ODOR AND REDUCING
TONGUE MICROBIOTA

semi-solid diet, affect the rate of tongue biofilm formation Thereafter, two milliliter of non-stimulated saliva of each
and predispose the individual to halitosis16. Psychological participant were collected and stored in sterile bottles with
factors also contribute to aggravate this scenario since glass pearls. The maximum time elapsed between collection
salivary flow is reduced in this condition20. and laboratorial processing of the saliva samples was 10
In order to remove tongue biofilm and improve breath min. The bottles with saliva were agitated in an automatic
odor, specific instruments (tongue scrapers) or toothbrushes tubes agitator (Phoenix, São Paulo, SP Brazil) for 1 min and
are used. New chemical and mechanical methods have also placed in an anaerobic chamber (MiniMac, Don Whitley
gained popularity for control of dental and tongue biofilm19. Scientific, Bradford, UK). After, serial dilutions of 10-1 to 10-
4
New toothbrush designs have also been developed with in pre-reduced Schaedler broth (BBL, Nevada, CA, USA)
this purpose. This study compared the effectiveness of a were performed. For anaerobes, 50 mL of each dilution were
new manual toothbrush that has a tongue scraper on the seeded on the surface of Schaedler agar (BBL) supplemented
back of its head and a commercial tongue scraper in with 5% of defibrinated sheep blood, 1 mL/L of hemine
improving breath odor and reducing the aerobic and (Sigma-Aldrich Corp., St. Louis, MO, USA) and 1 mL/L of
anaerobic microbiota of tongue surface. menadione (Sigma-Aldrich Corp.). For facultative aerobes,
the same amounts of the dilutions were seeded on the
surface of Schaedler agar (BBL) supplemented with 5% of
MATERIAL AND METHODS defibrinated sheep blood. For the growth of anaerobes, the
plates were incubated in atmosphere of 10% H2, 10% CO2
Thirty individuals (15 male and 15 female) aged 18 to 50 and 80% N2 (36°C, 3 days) and for the growth of facultative
years with no evident pathological processes were enrolled and aerobic microorganisms, in aerobic atmosphere (36°C, 2
in this crossover study. Eligible subjects could not have days). After incubation, each plate was examined in a
worn dentures or used medicines that cause xerostomy, stereoscopic microscope (Nikon, Tokyo Japan) and the total
mouthwashes or systemic antimicrobials for at least 1 month number of colony forming units per milliliter of saliva (cfu/
prior the study. Patients with conditions that cause breath mL) was counted.
alterations, such as diabetes mellitus, chronic renal illness, In both assays (quantification of halitosis and
gastrointestinal disorders, cirrhosis, respiratory microbiological analysis), Friedman’s test was used to
dysfunction, carcinomas and smoking, were excluded from determine the differences between the measures supplied
the study7,16,18,23,24. All participants signed an informed by the halimeter and the bacterial counts of the groups.
consent form approved by the Research Ethics Committee When statistically significant differences were detected
of the University of Franca, Brazil (Protocol #211/05). among the groups, Wilcoxon’s test adjusted with Bonferroni
Chemical and mechanical oral hygiene methods were correction was used for multiple comparisons (group to
prohibited 24 h before each evaluation session. Ingestion group). Significance level was set at 5%.
of alcoholic beverages or flavored foods was suspended.
Approximately 1h30min before the examination, the
participants ate a light meal offered by the researchers. The RESULTS
volunteers were assigned to four groups, as follows: Group
1: The teeth and tongue were not cleaned; Group 2: The Comparing the values recorded with the halimeter, Group
volunteers brushed their teeth with a toothbrush that has a 1 (no toothbrushing or tongue cleaning) and Group 2
tongue scraper on the back of its head (Condor Evolution, (toothbrushing alone) differed significantly from each other
Condor, São Bento do Sul, SC, Brazil), but no tongue scraping (p<0.05). These groups were also significantly different from
was performed; Group 3: Toothbrushing was done (Condor Groups 3 (toothbrush with a tongue scraper on the back of
Evolution) and the toothbrush’s tongue scraper was used the head) and 4 (conventional tongue scraper) (p<0.05). The
for 15 s on the dorsum of the tongue; Group 4: adoption of tongue cleaning methods was associated with
Toothbrushing was performed (Condor Evolution) and a a decrease in the scores of halitosis recorded with the
commercial tongue scraper (Kolbe, Salvador, BA, Brazil) was halimeter in a similar manner, as no statistically significant
used for 15 s on the dorsum of the tongue. The evaluations differences (p>0.05) were observed between Groups 3 and 4
were performed at 1-week intervals. Toothbrushing was (Table 1). There were no differences (p>0.05) between men
performed as usual. No flossing was performed. and women regarding halitosis.
Using a halimeter (BreathAlert, Tanita Corporation of The results of this study indicate that toothbrushing
America, Arlington Heights, IL, USA), halitosis was per se did not alter significantly the breath odor. No
quantified according to a 4-point scoring system (1 - no statistically significant differences (p>0.05) were found
halitosis, 2 - mild halitosis, 3 - moderate halitosis and 4 - between the toothbrush’s tongue scraper and the commercial
strong halitosis). After calibration following the tongue scraper, regarding their effectiveness in improving
manufacturer’s instructions, the halimeter was given to the breath odor.
volunteer, who secured the device in the front of the mouth Regarding bacterial counts, Group 1 was statistically
at a 1.0-cm distance and exhaled air until the intensity level different from Group 2 (p<0.05), indicating that
was recorded. This procedure was repeated three times for toothbrushing promoted a significant decrease in the number
each participant. of microorganisms. Both groups differed significantly from

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 CASEMIRO L A, MARTINS C H G, CARVALHO T C de, PANZERI H, LAVRADOR M A S, PIRES-DE-SOUZA F de C P

TABLE 1- Halitosis scores recorded in each group

Group 1 Group 2 Group 3 Group 4

Mean (standard deviation) 4.0 (0.00) 3.6 (0.49) 2.8 (0.40) 2.7 (0.59)
Median 4 4 3 3
Lowest value 4 3 2 2
Highest value 4 4 3 4

TABLE 2- Aerobic and anaerobic microbial counts (cfu/mL of saliva, log base 10)

Anaerobic microorganisms Aerobic microorganisms

Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4

Mean 8.10 7.84 7.58 7.24 7.96 7.78 7.34 7.20

(standard deviation) (0.53) (0.58) (0.92) (0.62) (0.46) (0.59) (0.91) (0.64)
Median 7.81 7.64 7.39 6.85 7.76 7.65 7.11 6.90
Lowest value 7.55 7.39 6.41 6.54 7.39 6.84 6.38 6.54
Highest value 9.59 9.72 9.76 8.67 8.83 9.65 9.55 8.63

Groups 3 and 4 (p<0.05), in which tongue cleaning methods halitosis7,16,18,23,24 were not included in this study and hence
were performed. However, Groups 3 and 4 presented the use of a device to remove tongue biofilm was proved
statistically similar results to each other, demonstrating that effective in improving breath odor.
both types of tongue scrapers had a similar performance in Regarding to bacterial counts, no significant differences
reducing the number of bacteria on tongue surface (Table (p>0.05) were found between groups 3 and 4. All other group
2). There were no differences (p>0.05) between men and pairs differed significantly from each other. These results
women regarding bacterial counts. demonstrate that both methods of tongue cleaning were
equally satisfactory for reduction of the total number of
microorganisms from tongue surface. It was also observed
DISCUSSION that there was a reduction of the total number of cfu when
toothbrushing and tongue cleaning were performed.
Several devices for daily tongue cleaning have been Counting of salivary bacteria for evaluation of mechanical
developed and used over time. Currently, it has been a trend methods of tongue cleaning is justified since the removal of
to develop toothbrushes that have not only bristles for bacterial niches, as those present on tongue surface,
dental cleaning, but also projections on the back of their contributes to reduce the total number of bacteria of oral
head that act as a tongue scraper. In the present study, a cavity7. Moreover, the incubation of the collected saliva in
toothbrush with this new design and a conventional tongue aerobiosis and anaerobiosis is justified because strict
scraper commercialized in Brazil were compared. The results anaerobic, aerobic and facultative aerobic bacteria present
showed that toothbrushing alone (Group 2) did not improve on the dorsum of the tongue are usually isolated in saliva13,15.
significantly the breath odor of the participants compared In the present study, data from both assays indicate that
to no tooth/tongue cleaning (Group 1), as demonstrated by tongue scraping is an essential procedure to reduce tongue
the high incidence of scores 4 in Group 2 (mean score = 3.6) microbiota and release of volatile sulfur compounds. Both
(Table 1). Therefore, tongue cleaning is important to improve devices (toothbrush’s tongue scraper and commercial
breath odor2,6,25 mainly considering that oral conditions are tongue scraper) were similarly effective. The results of each
determinant for halitosis in about 85% of the cases8. group may have been influenced by variations in biofilm
The tongue cleaning methods evaluate in the present formation rate, which is affected by factors, such as diet
study (toothbrush’s tongue scraper - Group 3 and (quality and amount) during the course of the study. Thus,
commercial tongue scraper - Group 4) had a similar effect on is not possible to assure that the amount and quality of
the participants’ halitosis (Table 1). These groups presented bacteria present on the dorsum of the tongue was the same
mean scores of 2.8 and 2.7, respectively. It is likely that due at all evaluation periods, which may be considered a
to the halimeter accuracy, the recorded scores were higher, limitation of this study. In spite of this, the results reinforce
not being <2 in any situation. In spite of these values, the importance of using mechanical methods for tongue
individuals with characteristics that contribute to increase cleaning. It was also demonstrated that the reduction of the

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EFFECTIVENESS OF A NEW TOOTHBRUSH DESIGN VERSUS A CONVENTIONAL TONGUE SCRAPER IN IMPROVING BREATH ODOR AND REDUCING
TONGUE MICROBIOTA

number of aerobes and anaerobes from tongue surface 12- Könönen E, Asikainen S, Alaluusua S, Könönen M, Summanen P,
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