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ISSN 0303-6979
Gomez SM, Danser MM, Sipos PM, Rowshani B, Van der Velden U, Van der
Weijden GA: Tongue coating and salivary bacterial counts in healthy/gingivitis subjects and periodontitis patients. J Clin Periodontol 2001; 28: 970978. C Munksgaard, 2001.
Abstract
Background: The papillary structure of the dorsum of the tongue forms a unique
ecological site that provides a large surface area favoring the accumulation of oral
debris and microorganisms. These micro-organisms of the tongue may be of influence on the flora of the entire oral cavity. The normal appearance of the
dorsum of the tongue is either pinkish or has a thin white coating. For the present
study a scoring method was developed to describe the appearance of the dorsum
of the tongue in relation to the extent of color and thickness of tongue coating.
Aim: The purpose of this study was to investigate the discoloration and coating
of the tongue in healthy/gingivitis subjects and periodontitis patients. Furthermore,
to determine the relationship between the appearance of the tongue and the bacterial load in salivary samples.
Material and Methods: 2 groups of patients were studied, 70 healthy/gingivitis
subjects and 56 periodontitis patients. After scoring of the tongue a salivary sample
of each patient was taken and analyzed using a phase-contrast microscope.
Results: This investigation showed that most discoloration was found on the distal part of the tongue. The mean number of bacteria per ml sample in relation to
a pink, white and yellow appearance of the tongue was 948, 855 and 900 (106)
respectively. The mean number of bacteria per ml sample in relation to no, thin
and thick coating was 948, 863, and 895 (106), respectively. Analysis did not
reveal a relationship between discoloration, coating thickness and total bacterial
load. The mean number of bacteria per ml in healthy/gingivitis subjects was 860
and in periodontitis patients 918 (106).
Conclusion: No relationship between the appearance of the tongue and salivary
bacterial load could be detected. There was no difference in bacterial load between the healthy/gingivitis and the periodontitis group within the present study
population.
The study population consisted of 2 distinct patient groups. One group consisted of 70 participants who were
healthy/gingivitis patients attending
their biannual check-up at the policlinic
of ACTA (Academic Centre for Dentistry Amsterdam). The inclusion criteria for this group were as follows:
1. DPSI score 0, 1, 2 or 3 (Dutch
Periodontal Screening Index, a
modification of the CPITN index;
see Table 1/ Anonymous 1999, Van
Rossum & Zeegers 1999).
2. Age 18 years.
3. No full dentures.
The 2nd group consisted of 56 patients referred to the Department of
Periodontology at ACTA for periodontal treatment. For these periodontitis patients the inclusion criteria
were:
1. DPSI score 3 or 4 (see Table 1/
Anonymous 1999, Van Rossum &
Zeegers 1999).
2. Age 18 years.
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Questionnaire
Characteristics
1
2
3
3
4
The mouth is divided into 6 sextants. The highest score per sextant is given. There must be
at least two teeth in each sextant, if there is only one tooth, it will be counted in the adjacent
sextant.
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Gomez et al.
using slides and the clinical assessment,
the slides were projected on a screen
and the examiner (SMG) scored the
slides using the same method and criteria as used during the clinical assessment. In order to avoid the recall bias
of the examiner the slides were shown
in a random order.
To assess the agreement within and
between examiners, two examiners
(PMS and BR) participated in a training
and calibration exercise by the first
examiner (SMG). Subsequently, they
scored all clinical slides, using the same
method and criteria as used during the
clinical assessment, and scored them a
2nd time, 1 week later. In this 2nd session, the slides were projected in another
random order to avoid examiner recall
bias.
Fig. 1. Discoloration of the tongue: score 0: pink; score 1: white; score 2: yellow/light brown;
score 3: brown; score 4: black.
Fig. 2. Thickness of coating: score 0: no coating; score 1: thin coating; score 2: thick coating.
Examples are given for white and yellow discoloration.
Microbiology
70
40 (11)
1970
37 (53%)
18 (26%)
Periodontitis
56
43 (9)
2571
28 (50%)
30 (53%)
Total
126
41 (10)
1971
65 (51%)
48 (38%)
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Fig. 3 shows the geographical distribution of the prevalence of discoloration on the dorsum of the tongue. Most
discoloration is found on the distal 2/
3 where the mid distal part shows the
highest prevalence of a yellow coating
(46%). Statistical analysis of the questionnaire in relation to discoloration
showed that the number of cups of coffee was highly correlated to this yellow
discoloration (OR1.20, p0.05).
The tongue coating scores in relation
to the geographical prevalence on the
tongue surface is illustrated in Fig. 4.
As is clear from this figure and in line
with discoloration most coating was
found in the mid-distal part of the dorsum of the tongue.
The study population was further divided into a normal tongue appear-
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Gomez et al.
Table 4. Bacterial load in samples taken from saliva in relation to periodontal health status
Healthy/gingivitis
Coating
Age group (years)
1929
3039
4049
5059
6071
14
10
6
5
0
45
47
33
40
40
41
43
61
55
60
(n22)
(n30)
(n49)
(n20)
(n5)
Periodontitis
Total
886
797
73
11
4.8
(169)
(142)
(45)
(23)
(9)
90
8
1
0.5
(6)
(4)
(2)
(1)
88
10
1
0.9
(6)
(4)
(3)
(1)
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Periodontitis
Total
56
126
n
70
% subjects with tongue discoloration*
0no discoloration
6%
1white discoloration
40% [2.9]
2yellow discoloration
54% [4.1]
11%
37% [4.9]
52% [3.7]
8%
39% [3.7]
53% [3.9]
11%
32% [3.4]
57% [3.3]
8%
40% [3.4]
52% [2.9]
50%
(n63)
50%
(n63)
Discoloration
examiner 1
examiner 2
assessment 1
assessment 2
mean
Coating
*One or more of the 9 sections showing this aspect as highest score for the total tongue
surface.
[ ] Mean number of sections of the tongue (out of 9) with this score in the study population.
examiner 1
examiner 2
assessment 1
assessment 2
mean
Withinexaminer
Betweenexaminer
62%
76%
69%
56%
43%
50%
withinexaminer
between
examiner
63%
77%
70%
64%
51%
58%
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Gomez et al.
Discussion
In spite of the fact that the tongue occupies one third of the oral cavity it
seems to be unnoticed. In the last decades the tongue has been neglected because of the need to concentrate on the
protection and treatment of the hard
dental tissues and their supporting
structures (Ralph 1988).
A thin layer of a whitish coating is
considered as a normal appearance of
the tongue (Chen 1987). This type of
coating is made up of a mixture of
cornified branches, epithelial debris, saliva, bacteria, food particles as well as
exudate white cells. Cytologic examination of normal tongue coating rarely
shows leukocytes, suggesting nonexistence of visible inflamation on the
tongue. The pH in the oral cavity environment with a pink or whitish coating
is within the neutral scope. The pH of the
oral cavity with other appearance of
tongue has been found to be acid or alkaline (Chen & Hu 1986). Several
methods have been used to assess the
presence of tongue coating. Yaegaki &
Sanada (1992b), describe a method to
measure the tongue coating where the
coating was carefully removed with a
tongue scraper and the wet weight was
estimated. Gross et al. (1975) used an
index (0 to 3, i.e., no coating to severe
coating), however neither a clinical description, nor photographs were given to
visualize such an index. Bosy et al.
(1994) estimated the amount of coating
on the tongue dorsal surface by visual
examination as heavy, medium, light, or
none. Miyazaki et al. (1995), assessed the
tongue coating status according to the
distribution area as follows: score 0:
Resume
Recouvrement de la langue et comptages bacteriens salivaires chez les patients sains, avec
gingivite et parodontite
Origine: La structure papillaire du dos de la
langue forme un site ecologique unique qui
comporte une large surface favorisant laccumulation de debris buccaux et de micro-organismes. Ces derniers peuvent avoir une influence sur la flore de lensemble de la cavite
buccale. Lapparence normale du dos de la
langue est rosee ou posse`de un tre`s fin recouvrement blanc. Une methode dechellonnage
a ete developpee afin de decrire lapparence
du dos de la langue en relation avec lampleur de la couleur et lepaisseur du recouvrement de la langue.
But: Le but de cette etude a ete detudier la
decoloration et le recouvrement de la langue
chez des sujets sains/avec gingivite et parodontite. De plus la relation entre lapparence
de la langue et la charge bacterienne dans les
echantillons salivaires a ete determinee.
Materiaux et methodes: 2 groupes de patients
ont ete etudies, 70 sujets sains ou avec gingivite et 56 patients avec parodontite. Apre`s
avoir evalue la langue, un echantillon salivaire de chaque patient a ete preleve et analyse
en utilisant un microscope a` contraste de
phase.
Resultats: Les resultats ont montre que la
plupart de la decoloration etait trouvee dans
la partie distale de la langue. Le nombre
moyen de bacteries par ml dechantillon en
relation avec la couleur rose, blanche ou jaune etait respectivement de 948, 855 et 900
(106). Le nombre moyen de bacteries par
ml dechantillon en relation avec un recouvrement inexistant, fin ou epais etait respectivement de 948, 863 et 895 (106). Lanalyse
na pas mis en evidence une relation entre la
decoloration, lepaisseur de recouvrement et
la charge bacterienne totale. Le nombre
moyen de bacteries par ml chez des sujets
sains/gingivite etait de 860 et chez les patients
avec parodontite de 918 (106).
977
Conclusion: Aucune relation entre lapparence de la langue et la charge bacterienne salivaire na donc pu etre detectee. Il ny avait
aucune difference dans la charge bacterienne
entre le groupe sain/gingivite et le groupe parodontite dans la population etudiee.
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Address:
Fridus Van der Weijden
Department of Periodontology
Academic Centre for Dentistry Amsterdam,
ACTA
Louwesweg 1
1066 EA Amsterdam
The Netherlands
Fax: 31205188512
e-mail: ga.vd.weijden/acta.nl