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Nurs Res. 2013 Nov-Dec;62(6):422-9. doi: 10.1097/NNR.0b013e3182a53b3a.

Toothbrushing versus toothbrushing plus tongue cleaning in reducing halitosis and tongue coating: a systematic review and meta-analysis.

Author information

Ya-Wen Kuo, RN, is Doctoral Student, College of Medicine, Institute of Allied Health Sciences, and National Cheng Kung University, and Supervisor, Department of Nursing, Changhua Christian Hospital, Taiwan. Miaofen Yen, PhD, RN, FAAN, is Professor, College of Medicine, Department of Nursing and Institute of Allied Health Sciences, National Cheng Kung University, Tainan City, Taiwan. Susan Fetzer, PhD, RN, is Professor, College of Health and Human Services, Department of Nursing, University of New Hampshire, Durham. Jiann-Der Lee, MD, is Assistant Professor, College of Medicine, Chang Gung University, and Neurologist, Department of Neurology, Chiayi Branch, Chang Gung Memorial Hospital, Chiayi City, Taiwan.



Halitosis affects people of all ages. Among hospitalized patients, oral care includes toothbrushing and mouth rinses. Tongue cleaning is not included in most guidelines or nursing education curricula.


The aim of this study was to compare the effectiveness of two types of oral care, toothbrushing alone and toothbrushing plus tongue cleaning, on halitosis and tongue coating (TC).


A systematic review and meta-analysis of randomized controlled trials were conducted to compare toothbrushing and toothbrushing plus tongue cleaning during oral care to reduce halitosis and TC. The databases included PubMed, ProQuest, CINAHL, the Cochrane Central Register of Controlled Trials, experts, and bibliographic review. A quality assessment of study reports and methodology was conducted using the CONSORT checklist and the Jadad Scale. The measurement of volatile sulfide compounds (VSCs) evaluated halitosis, whereas TC was measured with assessment indexes.


Seven experimental data sets were obtained from five randomized clinical trials. There were 188 male and 63 female subjects within an age range of 17-80 years. All intervention groups indicate a large effect size of toothbrushing plus tongue cleaning decreases volatile sulfur compounds and TC by 0.745 and 0.922, respectively, compared with toothbrushing only.


The use of toothbrushing plus tongue cleaning compared with toothbrushing alone significantly reduced the indicators of halitosis and TC. However, there is insufficient evidence to recommend frequency, duration, or delivery method of tongue cleaning. Further research is needed to articulate a comprehensive clinical guideline. Oral care is an important nursing intervention. Tongue cleaning should be incorporated into current nursing procedures.

[Indexed for MEDLINE]

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