Copyright C Munksgaard 2001

J Clin Periodontol 2001; 28: 970978

Printed in Denmark . All rights reserved

ISSN 0303-6979

Tongue coating and salivary

bacterial counts in
healthy/gingivitis subjects and
periodontitis patients

S. Mantilla Gomez1, M. M. Danser2,

P. M. Sipos2, B. Rowshani2,
U. van der Velden2 and
G. A. van der Weijden2
1

Netherlands Institute for the Health Sciences

(NIHES) Erasmus University Rotterdam,
The Netherlands; 2Department of
Periodontology, Academic Centre for
Dentistry Amsterdam, The Netherlands

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 papillary structure of the tongue

dorsum forms a unique ecological site
that provides a large surface area favoring the accumulation of oral debris and
microorganisms (Jacobson et al. 1973,
Bosy et al. 1994). These micro-organisms of the tongue may be of influence
on the flora of the entire oral cavity (Jacobson et al. 1973).

The results of a recent study showed

that conventional periodontal therapy
does result in a reduction of proportions
of periodontal bacteria in the periodontal pocket (Danser et al. 1994, 1995,
1996). However no simultaneous reduction was found in proportions of these
bacteria on the mucous membranes.
This raised the question whether

Key words: tongue coating; salivary bacterial

counts; periodontitis
Accepted for publication 11 October 2000

periodontal therapy should be limited to

the treatment of the periodontium, or
that the oral mucous membranes, such
as the tongue, should be involved in the
treatment as well (Danser 1996).
Several species have been recovered
in samples taken from the tongue e.g.
P. gingivalis (Lee et al. 1999), A. actinomycetemcomitans (Asikainen et al.

Tongue coating and salivary bacterial counts

1991, Timmerman et al. 1998), P. intermedia (Van Winkelhoff et al. 1986,
Danser et al. 1994, 1995, Timmerman
et al. 1998), Eikenella corrodens (Lee et
al. 1999), Capnocytophaga (Knnen et
al. 1991) and Spirochaetes (Lee et al.
1999). Van der Velden et al. (1986)
found that the presence of motile organisms and black pigmented Bacteroides on the mucosal surfaces of the
tongue and tonsils was correlated with
the presence of these micro-organisms
in the 23 day-old dental plaque. It was
concluded that, in particular, the mucosa of tongue and tonsils may harbor
periodontopathic microorganisms and
may possibly function as a nidus for
these bacteria. Several studies have indicated that there is a relationship between microorganisms present on the
tongue and those present in saliva
(Krasse 1954, Togelius et al. 1984, Lindquist et al. 1989). A recent study indicates that samples taken from saliva are
a good approach to detect microorganism such as P. gingivalis, P. intermedia and T. denticola in the oral cavity
(Umeda et al. 1998).
The normal appearance of the dorsum of the tongue is either pinkish or
has a thin white coating (Chen 1987).
This tongue coating comprises bacteria,
desquamated epithelial cells released
from the oral mucosa, leukocytes from
periodontal pockets, blood metabolites
and different nutrients (Quirynen et al.
1998, Yaegaki & Sanada 1992a, b). The
elderly are more likely to have a discolored coated tongue because of change
in diet, inability to cope with oral hygiene methods, decrease in salivary flow
(Ralph 1987, Massler 1980). Furthermore, there is an increase of filiform papillae with age (Chen & Hu 1986). The
periodontal status of the patient seems
to be a factor related to the thickness
of the tongue coating. Subjects with
periodontal disease are more likely to
have a thicker layer of coating compared to subjects with healthy periodontal tissues (Yaegaki & Sanada
1992a, b).
Review of the literature to date does
not provide a well described method to
assess the degree of tongue coating.
There is no defined index available although Miyazaki et al. (1995) have presented a method of scoring by dividing
the dorsum of the tongue into 3 sections and scoring the absence or presence of a tongue coating. However no
indication of thickness or discoloration
of coating was included in the assess-

ment. Therefore in the present study a

modification of this scoring method
(Miyazaki et al. 1995) was developed to
describe the appearance of the dorsum
of the tongue in relation to the extent of
color and thickness of tongue coating.
The objectives of the present study
were to investigate on the basis of the
newly developed index the prevalence of
the tongue coating in healthy/gingivitis
subjects and in periodontitis patients.
Furthermore to determine the relationship between tongue coating and bacterial load in salivary samples in these
two populations.
Materials and Methods
Subjects

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.

971

Questionnaire

The volunteers filled out a questionnaire with questions regarding their

age; diet habits (licorice consumption,
spices or other foods that could stain
their tongue); drinking habits (coffee,
tea and red wine); smoking habits
(number of cigarettes per day); oral hygiene habits, general health and awareness of halitosis.
Tongue discoloration and coating

For each patient the dorsum of the

tongue was scored for discoloration and
coating according to the method as described below. Next, 2 slides of the
tongues of all patients were taken, using
the same type of film and magnification. They showed the tip up to the
vallate papillae of the tongue.
Assessment of discoloration and coating

The procedure to assess coating was a

modification of the method as described by Miyazaki et al. (1995) and
suggested by Winkel (2000). The tongue
was divided in 9 parts. From the vallate
papillae to the tip i.e., back third,
middle third and front third (according
to Miyazaki et al. 1995). In addition
from the left to the right i.e., left third,
middle third and right third. For each
of the 9 sections discoloration and coating was visually assessed. The discoloration was scored on a scale from 0 to
4 (0pink, 1white, 2yellow/
lightbrown, 3brown and 4black)
(Fig. 1) and coating according to thickness on a scale from 0 to 2 (i.e., 0no
coating, 1light-thin coating and 2
heavy-thick coating) (Fig. 2). Light-thin

Table 1. DPSI (Dutch periodontal screening index) (Anonymous 1999)

Scores

Characteristics

no pockets deeper than 3 mm

no bleeding on probing
no calculus and/or overhanging restaurations
the same criteria as for score 0, but bleeding on probing
the same criteria as for score 1, but with calculus and/or overhanging restaurations
pockets from 45 mm
bleeding on probing
supra and subgingival calculus and/or overhanging restaurations
no recession
the same criteria as for score 3, but with recession
pockets deeper than 6 mm

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.

972

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.

coating was scored when the pink color

underneath was still visible through the
coating. Heavy-thick coating was
scored if no pink color could be observed under the coating. Each section
of the tongue should be covered for
more than 1/3 to obtain a score different than 0. Furthermore the presence or
absence of fissures on the tongue was
also recorded.

Agreement of the assessment of tongue

coating

In order to develop a method for the

training of examiners in scoring the extent of discoloration and thickness of
tongue coating, it was evaluated
whether the clinical slides could be used
for this purpose. To determine the
agreement between the assessment

Microbiology

Patients were asked to rinse with 10 ml

of sterile saline (0.85% NaCl) for 20 s
after which they expectorated the rinse
in a vial (Adapted from Ramberg et al.
1994). Subsequently this vial was vortexed thoroughly for 20 s. In total 100
ml of this solution were pipetted into a
bijou after which another 100 ml of
RTF at double concentration were
added to obtain a concentration of
RTF as described by Syed & Loesche
(1972). Additionally, 20 ml of Fildes extract were added as suggested by Petit
et al. (1991). This bijou was vortexed
for 20 s again. Before assessment the
sample was dispersed by aspirating the
suspension five times through a tuberculin syringe (1 ml Terumo syringe
with a 0.4512 mm neolus needle), and
vortexed again for 20 s, to give an homogeneous sample. One drop of the
suspension was placed on a Thoma
bright line counting chamber with
squares covering 1/400 mm2 and coverslipped. At each assessment a minimum
of 100 bacteria was counted in random
squares. Using a phase contrast microscope the total number of bacteria were
counted. A differentiation was made
into cocci, rods, motile microorganisms
and spirochaetes as described by
Listgarten & Hellden (1978). The number of squares needed to reach 100
microorganisms was counted as well, in
order to calculate the number of microorganisms/ml of the sample.
Statistical analysis

Discoloration and thickness scores for

each of the 9 sections on the tongue sur-

Tongue coating and salivary bacterial counts

Table 2. Descriptives of the study population
Healthy/gingivitis
n
mean age (SD) (years)
range of age (years)
gender . female (%)
. of smokers (%)

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%)

p0.001 (Mann-Whitnney test).

973

the appearance of the tongue, %s of

agreement between different assessments and different examiners were calculated. p-values 0.05 were used as
statistically significant. SPSS was used
to do the statistical analysis.
Results
Study population

faces were analysed. For each section

the % distribution of the scores in the
study population was calculated. A
subject was furthermore classified on
the highest score of discoloration and
thickness in one or more of the 9 sections. For each subject the number of
sections showing this highest score was
determined and a mean was calculated.
For the microbiological analysis, the
total number of bacteria per ml was calculated as follows: the number of bacteria were divided by the number of
squares that had been necessary to
reach approximately 100 micro-organisms, this represents the mean number
of bacteria per square. The squares of
the Thoma chamber are 1/400 mm2 in
surface and 0.02 mm in depth. Therefore the mean number of bacteria per
square were multiplied by 20106 to
obtain the number of bacteria per ml
suspension fluid. As compensation for
the dilution with RTF and fildes extract
this number was multiplied by 2.2 to
obtain the number of bacteria per ml of
sample. %s of cocci, rods, motile microorganisms and spirochaetes were determined as well. Non-parametric MannWhitnney tests were used to test for
differences between groups. Normal

tongue appearance is characterized by

a pink or white thin coating as highest
score in each subject (Chen 1987). Discolored coated tongue appearance is
characterized by white discoloration
and thick coating or yellow to black
discoloration with a thin or thick
coating. Statistical analysis was performed by dividing the study population into normal tongue appearance
and discolored coated tongue appearance. c2 tests were used to test the hypothesis that there were differences in
tongue appearance between the healthy/
gingivitis and periodontitis group. A
logistic regression analysis was done,
the dependent variable was tongue appearance (normal or discolored coated)
and the independent variables were: age
(in years); periodontal status, gender,
drinking habit of coffee, tea or wine;
general health status; consumption of
licorice, spices; smoking habit; use of
chlorhexidine or listerine, dental floss,
interdental brush, toothpicks and number of times of toothbrushing per day;
awareness of halitosis; presence of fissures and percentages of cocci, rods,
motile micro-organisms and spirochaetes. For the assessment of the
agreement of the method to describe

Fig. 3. Distribution of the prevalence of discoloration on each section

of the tongue.

Table 2 shows a general description of

the study population. The mean age
was 41 years with a range from 1971
years. 51% was female and consequently 49% was male. There were more
smokers in the periodontitis group
compared to the healthy/gingivitis
group. Sex and age were equally distributed among the 2 groups.
Appearance of the tongue

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-

Fig. 4. Distribution of the prevalence of thickness of coating on each

section of the tongue.

974

Gomez et al.

Table 3. % of subjects per group of age according to thickness of coating (score 0

none, score 1thin and score 2thick)

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)

ance and a discolored coated tongue

appearance based on the combination
of the outcome discoloration and coating (see statistical analysis). The results
show that there was a trend that among
periodontitis patients a discolored
coated appearance of the tongue was
more prevalent (59% versus 43%) (c2
test p0.07). Further analysis showed
that age was a significant factor in relation to the prevalence of the tongue
coating (OR1.05, p0.05). Table 3
shows a further analysis of the thickness of coating in relation to different
age categories. These results indicate an
increase in score 2 (thick coating) after
the age of 40 as compared to the
younger age groups.
Bacterial load

Fig. 5 shows the discoloration scores

for each patient in relation to the salivary bacterial load. The mean number
of bacteria per ml in relation to a pink
appearance of the tongue (score 0) was
948106. For a white (score 1) and yellow (score 2) appearance the mean
number of bacteria were 855106 and
900106 respectively. Statistical analy-

Periodontitis

Total

mean number of micro-organisms 106/ml (SD)

total
860 (181)
918 (148)
cocci
793 (159)
803 (120)
rods
56 (37)
95 (44)
motile
9.5 (14)
13 (30)
spirochaetes
2.1 (5)
8.1 (11)

886
797
73
11
4.8

(169)
(142)
(45)
(23)
(9)

mean % of the flora (SD)

cocci
92 (4)
rods
6 (3)
motile
1 (1)
spirochaetes
0.2 (0.6)

90
8
1
0.5

(6)
(4)
(2)
(1)

88
10
1
0.9

(6)
(4)
(3)
(1)

p0.0001 (Mann-Whitnney test).

sis did not detect a relationship between

discoloration and total bacterial load.
Explorative analysis revealed a qualitative difference, where the number of
rods per ml was lower in subjects with
a white coating as compared to no
discoloration (p0.004) or yellow
discoloration (p0.007). The prevalence of no (score 0), thin (score 1) and
thick (score 2) coating in each patient
in relation to the number of bacteria in
each salivary sample is shown in Fig. 6.
The mean number of bacteria per ml
with score 0, 1 and 2 was 948106,
863106 and 895106 respectively.
Statistical analysis did not reveal a relationship between coating thickness
and total bacterial load. Further analysis revealed a qualitative difference
where the number of rods per ml was
lower in subjects with a thin coating as
compared to no coating (p0.01).
Among normal appearance and discolored coated appearance the mean
total number of bacteria per ml was
similar (891106 versus 881106). The

Fig. 5. Bacterial load in relation to discoloration of the tongue in

samples taken from saliva: discoloration 0 (pink) n10, discoloration
1 (white) n49, discoloration 2 (yellow) n67.

number of motile micro-organisms was

lower in the patients with discolored
coated appearance compared to patients with a normal appearance (p
0.03).
Healthy/gingivitis periodontitis patients

Table 4 shows the microbiological data

divided into healthy/gingivitis and periodontitis patients. The mean number of
bacteria per ml was 886106. There was
no difference between the 2 groups of
patients.
Cocci formed proportionally the
main part of the salivary flora, followed
by rods which represented 8%. Motiles
represented 1% and spirochaetes 0.5%.
Although the difference was small, the
presence of spirochaetes as well as rods
was higher in periodontitis patients
(Mann-Whitney test p0.0001).
Table 5 shows the prevalence of
tongue coating and discoloration in
healthy/gingivitis and periodontitis patients. The results show that a total

Fig. 6. Bacterial load in relation to thickness of coating in samples

taken from saliva: coating 0 (no coating) n10, coating 1 (light-thin)
n50, coating 2 (heavy-thick) n66.

975

Tongue coating and salivary bacterial counts

Table 5. Appearance of the dorsum of the tongue in relation to periodontal health status
Healthy/gingivitis

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]

% subjects with tongue coating (thickness)*

0no coating
6%
1thin coating
46% [3.4]
2thick coating
48% [2.7]

11%
32% [3.4]
57% [3.3]

8%
40% [3.4]
52% [2.9]

% of subjects with normal appearance of tongue versus

discolored coated appearance n. subjects
normal appearance
57%
41%
(n40)
(n23)
discolored coated appearance
43%
59%
(n30)
(n33)

50%
(n63)
50%
(n63)

in periodontitis patients is more frequently found in the distal 2/3 of the

tongue, whereas in healthy/gingivitis
subjects the distal 1/3 is more frequently covered by a white coating.
The % of subjects without a coating
was also low (8%). A thin coating was
seen in 40% of the patients and a
thick coating in 52%.

Fissures and tongue coating

The presence of fissures in the study

population was 27%. There were no differences in bacterial load between subjects with fissures and without fissures.
Neither were presence or absence of
coating related to the fissures.

Fig. 7. % of subjects per section of the tongue with white coating as

highest discoloration.

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.

p0.001 (Mann-Whitnney test).

pinkish appearance of the tongue

(score 0) was not a common finding.
In this study population the highest
discoloration score was yellow (score
2). No score 3 and 4, being either
brown or black were observed. A
white appearance (score 1) was found
in 39% and yellow in 53% of the
study population. The area of the
tongue with a white appearance was
larger (mean number of sections 4.9
versus 2.9) in periodontitis as compared to healthy/gingivitis patients
(p0.001). Fig. 7 shows the distribution among the study population
whose highest score for discoloration
was white in periodontitis and
healthy/gingivitis patients. As is obvious from this figure, the white coating

Table 6. % of agreement between different

assessment of appearance of the dorsum of
the tongue; within and between examiners
(PMS, BR)

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%

In vivo (clinical) assessment versus

assessment using slides

For the analysis of agreement between

clinical and scoring on slides, 103 slides
were used. 23 slides were rejected for
further evaluation since these patients
were unable to stick out their tongue
sufficiently to make an adequate slide
for an assessment of the tongue surface
from the tip to the vallate papilla. It
would therefore not be possible to score
the dorsum of the tongue completely on
those slides. Fig. 8 illustrates the percentage of agreement between analysis
using slides and clinical analysis on
each section of the tongue, for discoloration and coating. The highest percentage of agreement (92%) was obtained in the front one third of the
tongue. The lowest percentage was 60%

Fig. 8. % of agreement for coating and for discoloration per section of

the tongue between slides and clinical assessment within the principal
investigator (SMG).

976

Gomez et al.

obtained in the middle one third for

coating and in the base third for discoloration (61%). On average there was a
73% of agreement over all 9 sections.
The results for the % of agreement
between and within the examiners are
shown in Table 6. The % of agreement
within the examiners for discoloration
and coating was comparable for each
examiner. On average approximately
70% agreement was obtained between
the 2 assessments one week apart. The
% of agreement between the examiners
for the assessment of discoloration was
lower as compared to the thickness of
coating. On average 50% agreement
was found for discoloration and 58%
for thickness of coating.

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:

none visible; 1: less than one third of

tongue dorsum surface covered; 2: less
than two thirds; and 3: more than two
thirds. Chen (1987) classified the tongue
coating by color (white, yellow, grey and
black) and by quality of the tongue (dry,
slippery, dry and rough, prickly, partially furred, completely furred). As is
obvious from the previous, several
methods to assess the tongue coating
have been proposed, but none of them
seem to provide an exact method to score
it. The assessment of the tongue coating
in the present study was a modification
of the method described by Miyazaki et
al. (1995) and describes the discoloration, thickness and extent of the coating.
The results showed that the highest accumulation of coating is located in the
back, especially in the middle section of
the tongue, and that it is rarely free of
coating. This finding agrees with Christensen (1998) who suggests that the section of the tongue with more debris and
food accumulation is the back of the
tongue, consequently if cleaning of the
tongue is undertaken one has to focus on
the most posterior aspect of the tongue.
Colour was not related to bacterial load.
However a relationship between yellow
appearance of the tongue and coffee intake was found.
In the present study, the appearance
of the tongue was dichotomized in
normal appearance and discolored
coated appearance. A trend was observed among the periodontitis patients
to have a higher prevalence of a discolored coated appearance as compared
to healthy/gingivitis patients. Further
analysis revealed that this difference can
be due to the fact that the extent of surface of the tongue covered by a white
coating is higher among periodontitis
patients. This finding is in agreement
with the study of Yaegaki & Sanada
(1992b) who calculated the wet weight
of the tongue coating that could be removed. They also found a considerably
thicker layer of tongue coating in periodontitis patients.
By performing a logistic regression
model of which the dependent variable
was the appearance of the tongue (i.e.
normal or discolored coated) it was
found that age increases the probability
of the presence of a discolored coated
tongue as suggested by several authors
(Massler 1980, Ralph 1987). Also in a
survey in 5403 subjects it was found
that the proportion of subjects with a
pinkish tongue or a thin white tongue
coating, which is considered a normal

appearance of the tongue, decreases

with age (Chen & Hu 1986).
In the present study, saliva samples
were used to assess the bacterial load in
the oral cavity. It has been suggested
that saliva samples are a good indication of bacteria present on the tongue
(Krasse 1954). There is a relationship
between the presence of micro-organisms on the tongue and in saliva (Lindquist et al. 1989). The results of the
present study showed no differences in
bacterial load in patients with normal
appearance of the tongue compared to
discolored coated appearance of the
tongue, neither were differences found
with presence or absence of fissures on
the tongue. The mean total bacterial
counts in this study were 886106 per
ml of sample, which are different to the
results found by Ramberg et al. (1994).
The reason for this disagreement may
be that Ramberg et al. (1994), as far as
it can be interpreted, did not compensate for the dilution of the sample with
the transport media. On the other hand
they used microbiologic culturing, a
method with which it is not possible to
detect all micro-organisms present in
the sample.
Although the results of the salivary
samples revealed no differences in total
bacterial load in the healthy/gingivitis
and in the periodontitis group, there
were qualitative differences. Counts of
rods and spirochaetes were higher in the
group of periodontitis patients as compared to healthy/gingivitis patients. The
0.51% of spirochaetes in saliva
samples was low but in agreement with
results from Petit et al. (1994) who
found 0.5% of spirochaetes in saliva of
periodontitis patients. Timmerman et
al. (1998), in a group of untreated subjects, did not find differences in prevalences of spirochaetes in samples taken
from saliva in subjects with attachment
loss as compared to those from the
same community but without attachment loss. They studied a population
that has never visited a dentist for dental treatment, and hardly use oral hygiene methods. The present study population regularly visited a dentist and
was used to toothbrushing.
Quirynen et al. (1998) studied the difference in microbial load, using samples
taken from the tongues in patients with
presence of tongue coating compared to
absence of this coating and presence of
fissures compared to smooth tongues.
In agreement with the present data they
found no differences in total bacterial

Tongue coating and salivary bacterial counts

load in relation to the presence or absence of coating. Contrastingly, De Boever & Loesche (1995), found significant differences in total CFU in
samples taken from the tongue in patients with fissured tongues as compared to patients with smooth tongues.
They also found differences in total
CFU in patients with presence of
tongue coating as compared to patients
without tongue coating. However their
study population was small (n16).
In conclusion the method which was
developed for the present study to assess tongue appearance indicated that
most discoloration and coating is
located in the back especially in the
middle section. There was a relationship
between age and the presence of a discolored coated appearance. Furthermore, in the group of periodontitis patients the extent of a white coating on
the dorsum of the tongue is greater. No
relationship between the presence of
coating and salivary bacterial load
could be detected. There appeared to be
no difference in bacterial load between
the healthy/gingivitis and the periodontitis group within the present
study population.
Zusammenfassung
Zungenbelag und Bakteriengehalt im Speichel
bei gesunden bzw. Gingivitis-Personen und Parodontitis-Patienten
Hintergrund: Die papillare Struktur des Zungenruckens bildet eine einheitliche okologische Oberflache, die eine groe Oberflache
vermittelt, was die Akkumulation von oralem Belag und Mikroorganismen favorisiert.
Diese Mikroorganismen der Zunge konnen
die Flora der gesamten Mundhohle beeinflussen. Die normale Erscheinung des Zungenruckens ist eher pinkfarben oder hat einen dunnen, weien Belag. Fur die vorliegende Studie wurde eine Memethode
entwickelt, um die Erscheinung des Zungenruckens in Beziehung zum Ausma der Farbe und der Dicke des Zungenbelags zu beschrieben.
Ziel: Der Zweck der Studie war die Untersuchung der Verfarbung und der Belagbildung
auf der Zunge bei gesunden bzw. GingivitisPersonen und Parodontitis-Patienten. Weiterhin sollte die Beziehung zwischen der Erscheinung der Zunge und dem bakteirellen
Gehalt in Speichelproben bestimmt werden.
Material und Methoden: 2 Gruppen von Patienten wurden untersucht, 70 gesunde bzw.
Gingivitis-personen und 56 Parodontitis-Patienten. Nach der Beurteilung der Zunge
wurde von jedem Patienten eine Speichelprobe genommen und mit einem Phasenkontrastmikroskop untersucht.
Ergebnisse: Die Ergebnisse zeigten, da die

meiste Verfarbung der Zunge am distalen Teil

gefunden wurde. Die mittlere Anzahl der
Bakterien pro ml Speichel in Beziehung zu
einer pinkfarbigen, weien und gelben Erscheinung der Zunge was 948, 855 oder 900
(106). Die mittlere Anzahl der Bakterien
pro ml Speichel in Beziehung zu keinem, zu
dunnem oder zu dickem Belag war 948, 863
oder 895 (106). Die Analyse zeigte keine
Beziehung zwischen Verfarbung, Belagsdicke
und totalem Bakteriengehalt. Die mittlere
Anzahl von Bakterien pro ml bei gesunden
bzw. Gingivitis-Personen war 860 und bei Parodontitis-Patienten 918 (106).
Zusammenfassung: Es konnte kein Beziehung
zwischen der Erscheinung der Zunge und
dem bakteriellen Gehalt entdeckt werden. Es
gab keine Differenzen im bakteriellen Gehalt
zwischen den gesunden bzw. Gingivitis-Personen und den Parodontitis-Patienten innerhalb der vorliegenden Studienpopulation.

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