tongue cleaning

Tongue cleaning and mouthwash against halitosis

1. Tongue Cleaning: Why It Matters and How To Do It

In about 90% of cases, bad breath (halitosis) is due to insufficient oral hygiene. In particular, the excessive microflora residing on the tongue is most frequently called into question.

Like that which feast on plaque, tartar, and gum pockets, lingual microflora produces volatile sulfur compounds (especially hydrogen sulfide and methyl mercaptan) and other substances responsible for the bad odor, such as some short-chain fatty acids.

For this reason, simple tooth brushing is not enough to combat bad breath; attention should also be paid to sites that are difficult to clean with common oral hygiene practices, such as the surface of the tongue.

Cleaning the tongue is not only a formidable ally in the fight against halitosis; the lingual patina is in fact a reserve of microorganisms capable of influencing the bacterial flora of the entire oral cavity. A clean tongue, therefore, means a slowdown in the formation of bacterial plaque and its accumulation, which consequently reduces the risk of tooth decay and gingivitis.

The tongue Cleaning (brushing) can be carried out using the classic toothbrush or – preferably – using a special tool called a lingual scraper. The cleaning technique with the toothbrush involves positioning the instrument horizontally, keeping the handle perpendicular to the centerline of the tongue, which must be extruded (i.e. made to come out of the mouth, so as to be able to reach the posterior areas of the lingual dorsum, where there is the greatest number of bacteria). The toothbrush should be brought down with a slight pressure towards the tip of the tongue. It is preferable to use a soft bristle toothbrush in order not to stress the taste buds too much, located on the sides and at the base of the tongue; it is also possible to use the rubber back part of the brushes specially designed to facilitate lingual cleaning.

The scraper, on the other hand, must be passed back and forth over the surface of the tongue with a light but firm movement, always proceeding from the inside to the tip of the tongue.

2. Mouthwashes: are they effective against alitosis?

The effectiveness of mouthwashes in the treatment of halitosis is rather debated, mainly due to possible methodological errors in published studies and conflicts of interest deriving from research funding by manufacturers.

If the toothbrush acts mechanically through the rubbing action of the bristles, the mouthwash intervenes above all chemically. The mechanical washing action of the rinses, in fact, could also be obtained using simple tap water, so the alleged additive advantages of mouthwashes derive from their particular chemical composition.

The active ingredients contained in mouthwashes can be of different types; some, such as chlorhexidine, have a certain antiseptic action, useful for directly decreasing the bacterial load of the microbial flora. Other products – like most of the commercial mouthwashes available at the supermarket – only exert an odor masking action, thanks to the content of aromatic substances such as menthol; the effectiveness of these products is clearly short-lived and even – although essential oils are attributed a certain antibacterial activity – alcohol-based ones could worsen halitosis due to their dehydrating effect.

Other substances contained in mouthwashes – such as zinc salts – are able to neutralize the volatile sulfur compounds responsible for bad odor.

Antiseptic agents, such as triclosan, cetylpyridinium chloride, and chlorhexidine, are slightly more effective, but have side effects; chlorhexidine, in particular, tends to stain the teeth and for this reason, spray products against halitosis are available to be applied directly on the surface of the tongue, thus reducing the contact of chlorhexidine with the teeth.

3. Causes of Halitosis: What does Bad Breath depend on?

Bad breath can have various causes; however, in most cases, it is linked to oral problems.

In one study, 406 patients with halitosis were analyzed, equally distributed between the two sexes:

✓ In 86% of the patients, the bad breath was due to oral causes; specifically, among the oral causes, the most common was linked to the lingual patina, followed by gingivitis and finally by periodontitis.
✓ In 5% of cases, the bad breath was due to ENT pathologies.
✓ In 3% of cases, the bad breath was due to the addition of oral cavity problems with otolaryngological diseases.
✓ In only 1% of patients, the cause of halitosis lay in the gastrointestinal tract.
✓ A precise cause of the disorder could not be determined in 5% of patients.
✓ These results have been confirmed by other studies, so today it is believed that only 5-8% of cases of halitosis can be attributed to non-oral causes.

Therefore, the widespread opinion that bad breath mainly depends on gastrointestinal disorders is absolutely unfounded. Almost always the problem depends “only” on poor oral hygiene. For example, tooth brushing alone is not enough; especially in the presence of halitosis, it is also important to take care of the brushing of the tongue, in order to break down the microorganisms responsible for the production of the volatile sulfur compounds at the base of halitosis.

As well as mechanically, the tongue and teeth can also be “cleaned” chemically; in particular, rinses and gargles based on antiseptic chemicals, such as chlorhexidine, or capable of masking bad odors, such as menthol, can help improve the situation. However, it should be emphasized that the effective anti-halitosis action of mouthwashes is debated.

The correct use of the toothbrush must then be combined with the use of dental floss to also clean the spaces between tooth and tooth, where the bristles of the toothbrush do not reach. Periodic visits to the dentist allow you to remove any deposits of tartar, preventing gingivitis and periodontitis; The dentist can also assess whether the patient’s oral hygiene is actually adequate or whether it needs to be improved.

4. Why Does My Breath Smell Bad When You Wake Up?

In the vast majority of cases, the origin of bad breath lies in the oral cavity and in the metabolic activity of the bacteria that populate it. Therefore, attributing morning bad breath to what you ate the previous evening is almost always wrong; However, meals rich in foods that provide sulfur, such as garlic, onion, leeks, broccoli, and spices such as curry, are an exception. In fact, whether it comes from the sulfur absorbed in the intestine and eliminated with the breath, or whether it comes from the oral cavity, the bad smell is largely determined by volatile sulfur compounds (the bacteria in the mouth produce these substances by metabolizing amino acids containing sulfur present in the saliva and food residues). It should also be remembered that bingeing on very sulfur-rich foods can cause bad breath problems for up to 72 hours after a meal.

Food aside, bad breath on waking generally depends on the physiological decrease in salivary flow at night. During sleep, low saliva secretion is indeed important to avoid frequent swallowing movements. Unfortunately, this oral dryness impoverishes the mouth of important protection against halitosis, represented precisely by saliva; this, in fact, cleanses the teeth by removing food debris, bacterial residues, and epithelial cells, as well as buffering acidity.

For what has been said, in the morning, especially at the lingual level, there is an important presence of microorganisms that produce substances responsible for halitosis.
In addition to facilitating bacterial proliferation and bad breath, the reduction of nocturnal salivary flow facilitates the onset of carious processes, so proper oral hygiene before bed is very important.

5. Bad Smell Breath and Pee after Eating Certain Foods


Bad smell pee after eating asparagus? Bad breath after a nice homemade bruschetta rubbed with garlic? The fault lies entirely with sulfur, present in some amino acids (hence called sulfurates) and in some compounds (such as allicin in garlic) present in these foods.

The same sulfur contributes to characterize the smell of cabbage and spoiled eggs.

The icing on the cake, sulfur is also responsible for bad-smelling flatulence eliminated after taking such foods.

6. Saliva substitutes: what are they?

The natural aging process, some systemic diseases (eg Sjogren’s syndrome), certain radiotherapy interventions, and the intake of particular drugs, can cause a marked reduction in salivation, generating problems of oral dryness and an increased incidence of dental diseases.

Numerous local agents are available for the treatment of dry mouth (called xerostomia). Among these, some stimulate the function of the residual salivary glands (sialagogues), while others act as real saliva substitutes. For example, simple chewing gum is able to significantly increase the production of saliva, also exerting an antibacterial and pH rebalancing action if it contains substances such as xylitol and chlorhexidine. There are also systemic drugs, such as pilocarpine, capable of stimulating the production of saliva. However, when the number of functioning salivary glands is greatly reduced, all of these stimulant products are ineffective. In this case, the use of saliva substitutes becomes particularly suitable.

Modern saliva substitutes are water-based products containing substances – such as hydroxyethylcellulose, carboxymethylcellulose, and electrolytes – capable of reproducing the consistency and lubricating action of saliva; the latter, however, also contains antibacterial substances, such as lysozyme, so when possible the use of sialagogues is generally preferred.

Saliva substitutes generally come in the form of nebulizers or rinse solutions. They are considered palliatives of limited efficacy and require several daily administrations (at least three or four). As an alternative to these products, the habit of frequently sipping water, both during meals and during the rest of the day, certainly has a beneficial effect. Compared to water, it has been seen that the relief given by the wetting action of the saliva substitutes lasts about twice as long.

7. Apples and Oral Hygiene: Are Apples Good for Your Teeth?

A historic advertisement aimed at promoting oral care products has long associated the bite of an apple with the concept of health and beauty of the teeth. But can apples really be valuable allies for the health of our teeth?

In this regard, some details are very important; in the advertisement in question, for example, a green and crunchy apple (presumably of the granny smith variety) was used, eaten with the peel.

This type of apple is characterized by a lower sugar content than other varieties; moreover, if eaten while still unripe, its sugar content is lower than that of ripe fruit.

The consumption of the apple with the peel is also very important; in fact, just like the bristles of the toothbrush and the dental floss, chewing the apple peel contributes to the mechanical cleaning of the dental and periodontal apparatus.

Another characteristic of the green apple is the high concentration of malic acid, responsible for the sour taste of the fruit. Like all acidic substances, malic acid helps whiten teeth; however, it can also damage the surface of the enamel and the underlying dentin, which can cause problems for people with sensitive and poorly mineralized teeth. However, it should be added that apples are often indicated as foods with a moderate content of fluorine, a known mineral with a preventive effect against the fragility of the enamel and caries.

A mouth rinses with water after consuming an apple can still help bring the oral pH back to normal, preventing damage to the enamel and completing the cleansing action of the fruit.

8. Gums that Bleed in Pregnancy

During pregnancy, the gums are also “bombarded” by high levels of progesterone, the hormone that blocks ovulation, creating many problems for pregnant women.

Progesterone also has a pro-inflammatory action, so it predisposes to the appearance of gingivitis, that is, an inflammation of the gums, whose bleeding is the characteristic symptom of this condition.

Furthermore, the hormonal interactions of pregnancy favor an increase in periodontal pathogenic species, weaken the immune defenses, acidify saliva and increase vascularization at the gingival level. For this reason, during gestation it is not uncommon to notice variations in the color of the gums from pale pink to dark pink; gums which in pregnant women also tend to be more swollen and prone to bleeding. To worsen the situation there is also the tendency to eat small and frequent meals, often sweet, either to counteract the sense of nausea or for the typical “cravings” of pregnancy.

It is no coincidence that there is a saying that each child would cost a mother a tooth.

Beyond the idioms and this natural predisposition to gingivitis, it should be noted that healthy gums are unlikely to bleed during pregnancy. When pregnant women notice bleeding while brushing or flossing, it most likely means that the gums were somehow predisposed before pregnancy; essentially there was already some underlying inflammation that was amplified by hormonal changes.

In case of gum bleeding during pregnancy, it is therefore important to have a dental visit, for professional hygiene and to receive advice on proper oral hygiene at home. This recommendation becomes even more important considering that in the literature there are many studies that show a significant correlation between gingival – periodontal pathologies, and gestational complications such as premature birth. For example, a pregnant woman with periodontitis has been shown to be 7.5 more likely than the average to give birth to a premature and underweight baby.

9. History of Oral Hygiene

Thinking of how devastating dental problems could be in the days when modern treatments did not exist, it is easy to understand how the history of man is imbued with the most disparate remedies to prevent and combat dental problems.

On a Babylonian tablet dating back to 1800 BC. the first suggestive theory on the onset of caries is imprinted; according to legend, a worm born in the mud would have begged Poseidon to allow him to live between the teeth and gums of man, where residues of food and drink abound. Obtained divine permission, the worm settled in the human mouth, starting to dig burrows and caves.

As early as 400 BC Hippocrates urged not to believe the story of the worm and recommended cleaning the teeth and gums every day to avoid cavities and toothache. But how to treat oral hygiene with the scarce means available in those times? Coal, alum, animal bones, mollusk shells, barks, and various types of plant extracts were the most used ingredients to prepare pastes and mouthwashes for rinses.

In ancient Mesopotamia, for example, people brushed their teeth with a mixture of bark, mint, and alum. In ancient India, instead, a mixture based on extracts of barberry and pepper was used. In Egypt, during the twelfth dynasty, the princesses used verdigris, incense, and a paste based on sweet beer and flowers such as crocus. All cultures of antiquity knew toothpicks, made of wood, rachis, or other materials.

Hippocrates himself, for cleaning his teeth, recommended a mixture of salt, alum, and vinegar as a mouthwash.

In the literature of Pliny the Elder (23 – 79 AD) the uses of various plants for the well-being of the oral cavity are reported; mastic leaves, for example, rubbed against aching teeth, and their decoction was considered useful for inflamed gums and falling teeth. The dried resin of the mastic grown on the island of Chios was and still is considered excellent refreshing chewing, which perfumes the breath giving a feeling of freshness and cleanliness. The thorns of the plant were used as toothpicks and in their absence, the use of goose feathers or different birds was recommended.

In Arab countries, the Siwak, a root or wood stick obtained from the arak plant (Salvadora persica) was and still is very popular as a toothpick; the Maya of Central America, on the other hand, chewed the “Chicle”, given by the latex of the Sapodilla tree (Manilkara zapota), which has long represented an ingredient in modern chewing gum.

Pliny himself indicated olive oil as an effective mouthwash against tooth infections.

Pliny was also among the first to report the use, to effectively rinse teeth and gums, of a natural and extremely organic mouthwash: urine. Thus, in addition to cleaning clothes, the use of urine aged a few days to whiten teeth was quite widespread among the ancient Romans.

Among the peoples of Muslim origin, the care of oral hygiene also assumed a religious significance, since from 600 AD the word of Mohammed imprinted in the Koran recommended: “Keep your mouth clean because praise to God passes through it!” For its part, The Holy Roman Church promised: “Whoever prays to the holy martyr and virgin Apollonia will not be struck by toothache on that day.” Thus it was that, in the thirteenth and fourteenth centuries, Apollonia became the patron saint of those who suffered from toothache.

In the history of oral hygiene, an important role is played by mouthwashes. Ancient Egyptian, Chinese, Greek, and Roman cultures were already steeped in recipes and folk remedies for dental care and breath freshening. Ingredients included materials such as charcoal, vinegar, fruit, and dried flowers; it seems that the Egyptians used a highly abrasive mixture of pulverized pumice and wine vinegar. The Romans, as mentioned, preferred urine, mainly used as a mouthwash due to the presence of ammonia.

The first evidence of a real toothbrush with bristles, similar to today’s one, dates back to 1500 in China. The fibers, however, are natural (pig hair attached to a bone or a bamboo stick), was too soft, and easily deteriorated, becoming a receptacle for bacteria. Meanwhile in Europe, in the Middle Ages, the fashion of not washing was raging, supported by medical and religious influences; the Sun King, who took no more than two baths in his entire life, was already completely toothless at a young age. At that time, fans, so much appreciated by noblewomen, were the ideal remedy to spare the interlocutor the sight of smiles disfigured by caries and the pestilential smell of one’s breath. If on the one hand the bad smells of the clothes were camouflaged by essences of civet, animal musk, and amber, the toothache was tried to remedy with equally unique recipes, passed off as miraculous remedies by the merchants of the time. “A porridge of wolf and dog dung, mixed with rotten apples, helps in case of toothache” or: “Fallen teeth grow back if you massage your jaw with hare’s brains” or “The best thing is to fight tooth worms with a mixture of roasted hare’s head and finely chopped sheep’s hair ».

With the advent of the first microscopes, the tooth worm theory was definitively shelved. Antony van Leeuwenhoek discovered bacteria by observing residues of plaque and tartar taken from his teeth under the microscope. After observing the bactericidal effects of alcohol, Leeuwenhoek tested the partial ineffectiveness of brandy and vinegar mouth rinses, concluding that the mouthwash probably did not reach the microorganisms or did not stay in contact long enough to kill them.

An important step forward was made around the mid-1800s when fluoride-based candies sweetened with honey were put on the market. In the same period began the production of toothbrushes and pastes containing fluorine and sodium salts similar to today’s toothpaste. In 1872, Samuel B. Colgate invented the first modern toothpaste based on mineral salts and refreshing essences. In 1938 America produced the first “Dr. West’s Miraculous Wisp Toothbrush” with synthetic fibers (nylon).

10. Mouthwash: when it can represent a danger

The correct use of mouthwashes can represent useful support to normal oral hygiene methods (toothbrush, toothpaste, and dental floss), although it is still an auxiliary tool. In other words, when used alone, mouthwash cannot be considered sufficient to achieve adequate oral hygiene.

This premise hides the first potential danger linked to the use of mouthwash: the user – dazzled by advertising messages that insistently emphasize its usefulness in preventing plaque – could neglect the correct use of wire and toothbrush, in the mistaken belief that good oral hygiene is guaranteed by the simple use of mouthwash.

Therefore, it is worth reiterating that mouthwash should be used only and exclusively after brushing the teeth. Furthermore, mouthwashes cannot be considered a substitute for adequate home oral hygiene with a toothbrush and dental floss, whose combined use must in any case be accompanied by professional cleaning every 6-8 months.

There is also a widespread belief that mouthwash can cure bad breath and make teeth whiter. In the first case, we recall how many commercial products (the so-called cosmetic mouthwashes sold at the supermarket) have an effect that is mainly masking halitosis rather than curative; this is because they contain substances (mostly essential oils) that exert a masking effect on bad odors; in fact, the antibacterial activity of xylitol and essential oils contained in mouthwashes is low, both due to the reduced concentrations and above all due to the low contact time with teeth and oral mucosa. In the presence of bad breath, therefore, the mouthwash does not cure the cause of the problem, but simply cancels the effects. The real results in the fight against halitosis are obtained by eliminating the bacteria that produce these odors, and to do so nothing is more effective than the mechanical action of the toothbrush, dental floss, and scrapers for cleaning the tongue. The chemical killing of these bacteria can be obtained with medicated mouthwashes (sold in pharmacies), based on antiseptic substances. However, these products have important side effects; the best known is linked to chlorhexidine, an antibacterial active ingredient present in medicated mouthwashes recommended in the presence of chronic gingivitis, very aggressive carious diseases, and important problems of the periodontium; in fact, chlorhexidine tends to dirty the teeth and tongue with yellow-brown spots that require outpatient hygiene to be removed. Furthermore, inappropriate use of chlorhexidine creates bacterial resistance and inflammation of the mucous membranes. Other antiseptic agents, such as triclosan, have even been banned for use in mouthwashes in some countries due to potential side effects.

Returning to cosmetic mouthwashes, one of the greatest risks associated with their use derives from the presence of ethyl alcohol among the ingredients. Ethanol is added above all to enhance the flavor of the product rather than for the real antibacterial properties. However, the presence of alcohol can induce side effects, since ethanol tends to dry and irritate the oral mucosa, causing irritation and hypersensitivity stomatitis. Furthermore, according to some studies, the alcohol contained in mouthwashes increases the risk of cancer of the mouth and oral cavity.

All these warnings should suggest the importance of submitting any oral disorders to a dentist, to identify the causes and possibly choose the most suitable mouthwash for your needs.

11. Cetylpyridine and Oral Health

Cetylpyridine (CPC) is a chemical compound with antiseptic properties, better known as cetylpyridinium chloride (INCI Cetylpyridinium chloride). Due to its chemical and functional characteristics, CPC is a cationic disinfectant belonging to the group of quaternary ammonium salts.

In the United States, cetylpyridinium was used as an anti-plaque mouthwash as early as 1940. This active ingredient has in fact proved effective in the disinfection of the oral cavity and in the prevention of caries and gingivitis, thanks to its bactericidal activity against a wide spectrum of bacteria in the cavity. oral, especially gram-positive ones. For the same reason, cetylpyridinium is also useful in case of bad breath problems of oral origin.

Cetylpyridinium chloride acts by binding to the bacterial wall and causing its lysis, thus causing cellular components to escape with metabolic alterations up to the death of the microbe. The ability to bind to bacterial cell membranes depends on the cationic (positively charged) surface of the CPC; therefore, in the formulation of products containing cetylpyridinium, it is necessary to respect this characteristic making it stable. Some anionic detergents, widely used in the formulation of toothpaste, such as Sodium-lauryl-sulfate (SLS), interact with CPC, inactivating its positive charge and consequently limiting its antiseptic activity. For this reason, some authors recommend waiting at least 30 minutes between brushing teeth with toothpaste and using a cetylpyridinium-based mouthwash.

Recently, the use of cetylpyridinium is finding a certain space in medicated products for oral hygiene, in combination with chlorhexidine (CHX). This combination would make it possible to reduce the doses of chlorhexidine necessary to produce the desired antibacterial effect, thus also limiting the side effects of the latter in terms of dental discoloration.

Cetylpyridinium chloride is used in concentrations between 0.03% and 0.1%. At therapeutic concentrations, it has no toxic effects. Among the undesirable effects, dental pigmentations and, in sporadic cases, local irritation with a burning sensation in the oral cavity have been described. However, it seems that the risk of dental stains is considerably lower than using chlorhexidine.

Cetylpyridine is also present in hand sanitizers, medicated intimate hygiene products, deodorants, and pharmaceutical products (e.g. sore throat tablets, or acne products).

12. Dental Health and Cardiovascular Diseases

Several studies have linked poor oral hygiene to a staggering number of diseases. Poorly cared for teeth, therefore, can have negative repercussions on our entire health.

The most certain link is that between poor mouth health and cardiovascular disease. Chronic inflammation, in fact, releases a whole series of inflammatory cytokines in the bloodstream that favor the formation and/or rupture of atherosclerotic plaques, in turn, responsible for fearful cardiovascular diseases such as heart attack, ischemic stroke, and heart disease. ischemic. Not surprisingly, recent research has shown that if the health of the gums improves, it also slows down the formation of atherosclerotic plaques and vice versa.

However, the relationship between poor oral hygiene and other diseases still needs to be clarified. For example, some studies have shown a correlation between chronic inflammation of the gums (chronic gingivitis) and Alzheimer’s disease, while on the oncological front, periodontal disease could, perhaps, increase the risk for certain types of cancer, such as that of the colon or pancreas.

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