The purpose of this study was to investigate theeffects of oral care using simple tools and methodson the cleanliness of the oral cavity in the elderly.Enrolled were 84 elderly subjects with a mean (±S.D) age of 85.1±7.0 years in a nursing home. Theywere given tongue and oral mucosa cleaning (theoral care) after lunch every day or every other dayfor two consecutive weeks by the authors. Theeffect of the oral care was studied in terms ofCandida scores in tongue coating, concentration ofvolatile sulfur compounds (VSC) which are themain causative substance of bad breath, andchange in tongue coating scores. The above para-meters were measured five times; just before theoral care program, weekly during, and at the end ofthe oral care program. The groups of patients, whowere given the oral care, especially the group ofpatients cared with sponge brushes every day,showed a significant reduction in Candida scoresbut not in VSC concentration and tongue coatingscores. The present method of oral care provedeffective in cleaning the tongue and oral mucosa,

and the Candida scores appeared to be a reliableindicator for evaluation. It is suggested that thisway of oral care is simple, easy and useful not onlyfor the elderly at a nursing home but for thehouse-bound elder people who will rapidlyincrease in the near future in Japan.

Key words: the elderly in the nursing home, oralcare, Candida

Introduction

The importance of oral care has been suggested toimprove not only oral functions but also the quality oflife (QOL) of the elderly1-2. This is one of the basic dailylife supports that nurses and caregivers could providefor enhanced cleanliness. It is sometimes difficult,however, to find a time for good oral cares becausethey are busy to take care of their meals and voiding3.The tongue could be a reservoir for bacteria in elderlysubjects and those whose awareness levels are dete-riorating, and automatic depuration was declined withreduced amount of saliva4. As a result, bacteria grow inthe oral cavity and the subjects become susceptible tocomplications such as aspiration pneumonia5.

Nevertheless, tongue cleaning has not becomecommon yet. Elderly subjects and disabled persons

Original Article

Effects of Tongue and Oral Mucosa Cleaning on Oral Candida Species andProduction of Volatile Sulfur Compounds in the Elderly in a Nursing Home

Hiromi Yonezawa1, Kinuko Takasaki2, Kayo Teraoka3, Tsugio Asaka3, Chifumi Sato4, and Kyoko Tsuchiya3

1) Aoba Public Health & Welfare Center, Yokohama2) Department of Gerontological Nursing and Health Care System in Nursing Science, Graduate School ofAllied Health Sciences, Tokyo Medical and Dental University3) Department of Health Science Politics, Section of Health Care Economics, Graduate School, Tokyo Medicaland Dental Univesity4) Department of Analytical Health Science in Nursing Science, Graduate School of Allied HealthSciences, Tokyo Medical and Dental University

J Med Dent Sci 2003; 50: 1–8

Corresponding Author: Hiromi Yonezawa, RN.Aoba Public Health & Welfare Center, 31-4 Ichigao,Aoba-ku, Yokohama 225-0024, JapanTel: 81-45-978-2450Fax: 81-45-978-2416Received: November 12, 1999; Accepted July 10, 2000

who are not independent in their oral care due to phys-ical and mental dysfunction find it difficult to use tooth-brushes. In Western countries, a disposable spongewith a handle (sponge brush) is widely used for its con-venience6-7. The tool is not widely used in Japan partlybecause of unknown clinical effects8-10. There are nodetailed studies that report the effects of tongue andoral mucosa cleaning in elderly subjects. The purposeof the present study was to compare simple tools andmethods of oral care to obtain specific indications forelderly subjects, and to study the effects of tongue andoral mucosa cleaning (the oral care) in terms ofCandida scores and physiological indices.

Materials and Methods

Subjects and study periodThe subjects were those who were living in a skilled

nursing home in J ward, Tokyo (150 beds) and satisfythe following inclusion criteria; 1) those over 65 years ofage and who needed to be cared, 2) those who couldtake food orally, 3) those who were not under treatmntof antibacterial, antifungal drugs, steroids or anydrugs which affects saliva secretion, for one monthbefore study and 4) those with stable systemic condi-tions without fever. Informed consent was obtainedfrom 120 subjects and 100 out of them were partici-pated in the research. The analysis was made on 84subjects excluding 3 who had been hospitalized duringthe study period, 4 who had stayed home or who hadbeen out, 3 who had refused to be included after entryand 6 whose samples were not sufficient (effective rateof 84.0%). The study period was between June andOctober 1998.

Collection of Data

Information was collected from clinical charts, nursingcharts and interview of staffs (nurses and certified careworkers). Physiological indices (Candida scores, con-centrations of volatile sulfur compounds (VSC) andtongue coating scores) were measured. Informationitems were sex, age, main diagnosis, activities ofdaily living (ADL), mental status, types of food intake,hydration, dysphagia, number of remaining teeth,denture, frequency and methods of oral cleaning etc.The N type activities of daily living scale for elderly peo-ple (N-ADL) developed by Kobayashi et al.11 and the Ntype mental scale for elderly people (NM scale) devel-

oped by Kobayashi et al.11 were used to evaluate ADLand mental status.

Methods and the period of the oral careTo demonstrate the difference among care methods,

the subjects were randomly assigned into fourgroups; control, A, B and C (Fig. 1). The control groupreceived no special care at any point in time. The groupA was given daily oral care using sponge brushes fortwo weeks. The group B was given the oral care usingsponge brushes every other day for two weeks (total 7days). The group C received continuous oral care usingbrushes for oral mucosa (mucosa brush) for twoweeks. Kruskal-Wallis test was conducted onCandida scores, VSC and tongue coating scores toidentify the difference among the four groups beforeoral care. Non-parametric test proved that no statisti-cally significant difference was present in sex, agegroup, N-ADL and NM scales attributes amonggroups. Eleven items of types of food and oral functions(Table 1)12-14 were also studied using non-parametricmethod since they were suspected to relate to oralindices. There were no significant differences either.

The care was given according to the precedingresearch by Tamamoto et al.4 and the tongue and oralmucosa was cleaned using a sponge brush Toothette(Halbrand, U.S.A) or a mucosa brush Dentoerack

H. YONEZAWA et al. J Med Dent Sci2

Fig. 1. Grouping and methods of care. ▼;Collection of samples andevaluation (Candida, VSC, Tongue coating Score) ; ▽;Collection ofsamples and evaluation (Candida and tongue coating score);

Care every day, Care every other day, No care.

510S (Lion,Tokyo). Brushing it from back to front 10times (approx. for 15 sec) cleaned the tongue.Rubbing lingual and labial side of upper and lowergums as well as the palate at certain light pressure for

5 sec each cleaned oral mucosa. Neither water nortoothpaste was used. The same researchers visited thesame subjects every day including weekend, andgave the oral care. The control group was also visited

3TONGUE AND ORAL MUCOSA CLEANING

Table 1. Types of Food and Oral Functions

and given oral instruction only. Besides, the staffs andthe elderly subjects were asked to continue theirusual oral care. The room was air conditioned at25–28 °C in this nursing home. The care was givenafter lunch for two consecutive weeks between 3rd and16th of August 1998. The orders of subjects cared werechanged each time.

Collection of samples and evaluationCandida scores of the tongue: Stomastat (Sankin

Kogyo, Tokyo) was used. Samples of tongue coatingwere collected from the right of central groove of thetongue using a sterilized swab. They were then culturedat 37 °C for 24 hours. The samples were comparedwith the color samples provided by the manufacturerand determined as negative (–)＜102 /ml of saliva, falsepositive (±), about 7×102 /ml of saliva, positive (+)＞7×105 13. For the analysis, scores of 1, 2 and 3 weregiven for negative, false positive and positive, respec-tively.

Oral malodor test: Using sterile microspatula, onescrape of tongue coating was collected from the right ofcentral groove of the tongue. The sample was immedi-ately suspended in 2.5 ml of Todd Hewitt Broth(DIFCO) with L-methionine in a sterile centrifugaltube. The tube was then sealed and stored at4 °C.The tongue coating sample was displaced withmixed gas (N2: CO2: H2 = 8: 1: 1) for 48 hours and cul-tured at 37 °C under anaerobic condition for 24 hours.After culture, the samples were agitated for 10 secusing a mixer and 0.5 ml of gas phase samples wereapplied to a gas chromatography (detector FDP) tomeasure produced CH3SH and H2S concentrations.The sum of CH3SH and H2S was defined as VSC con-centration13,16.

Tongue coating scores: The visual scores developedby Kojima et al.17 was used to study the coat of thetongue. It is four steps. The score 1 is about 1/3 of thethin tongue coating. The score 2 is about 2/3 of the thintongue coating or about 1/3 of the thick tongue coating.The score 3 classifies about 2/3 and more of the thintongue coating or about 2/3 of the thick tongue coating,the score 4 in about 2/3 and more of the thick tonguecoating.

Sample collection and determination of tonguecoating scores was performed at 3 o’clock in theafternoon for all subjects. The VSC concentration wasmeasured 3 times and Candida scores and tonguecoating scores were measured 5 times as shown inFig. 1.

Analytical methodsStatistical analysis package SPSS was used for

analyzing the data. Friedman test, Kruskal-Wallis test orMann-Whitney U-test was performed. Multiple com-parison was performed using Bonferroni. The valueshown here indicates average ±standard deviation.

Results

Subjects characteristicsBasic attributes: As shown in Table 2, there were

more female than male with the ratio of 8:2. Seventy-five (89.3%) subjects were over 75 years of age. N-ADL score were 20.1 ±13.6 and many needed care inall of ADL. NM scale was 25.3 ±15.4 and more thanhalf (55.9%) of the subjects were moderate to severe.

Types of food and oral function: Table 1 summarizesthe types of food they took and their oral functions.Fifty-two (61.9%) had gruel or chopped meals. Sixty-three subjects (75.0%) had no remaining teeth of theirown. Thirty-eight subjects (45.2%) used denture and 24of them (63.2%) wore the denture at night as well. Fororal cleaning frequency, 30 (35.7%) cleaned every day(once or more) and 45 (53.6%) cleaned rarely. Of thosewho cleaned their mouth everyday or sometimes, 29used toothbrushes and 11 only rinsed their mouth.

Physiological indicesThe oral conditions were evaluated for three para-

meters before beginning of oral care. For Candidascores, 22 were positive (26.2%), 41 were false positive(48.8%) and 21 were negative (25%). The VSC con-centration was 68.2 ±13.5 ng/ml. The tongue coatingscore was 2 in 29 subjects (34.5%), and 4 in only 5(6.0%). The relationship between these and otherscores were studied using Kruskal-Wallis test, showingno relation of Candida scores, VSC concentration andtongue coating scores with other parameters. Therewas also no strong relationship observed among thethree physiological indices.

Change in physiological indices by difference oforal care

Change over time by difference of oral care:Friedman test was conducted for Candida scores. Nodifference in Candida scores was observed in thecontrol group and groups B and C, while significant dif-ference was noticed in the group. Multiple comparisonshowed that the group A presented significant differ-

H. YONEZAWA et al. J Med Dent Sci4

ence in week 2 and 1 week after the oral care as com-pared to the precare condition. In the groups B and C,the Candida scores tended to be lower at any pointthan the precare scores, however, they were significant.Four groups were compared at each timepoint (Table3). After 1 week, a significant difference wasobserved between the control and the group A as wellas the control and the group B. After 2 weeks, thegroups A and C showed significant difference from thecontrol. The VSC concentration (Table 4) and thetongue coating scores (Table 5) showed no significantdifference between each group.

Comparisons of oral care effectsThe Candida scores, VSC concentrations, tongue-

coating scores were compared before and after the oral

care. A decrease in the scores was considered‘improvement’, no change as ‘no change’ and anincrease in scores as ‘deterioration’. Consolidatedresults of the groups A, B and C were compared withthe control. Candida scores improved more among theoral care group at weeks 1 and 2 as shown in Fig 2. Utest between the oral care group and control showedsignificance at week 1 (Z= –5.2, p＜0.001) and week 2(Z= –4.2, p＜0.001). As for the VSC concentration andthe tongue coating scores, more subjects tended toimprove at weeks 1 and 2 in the oral care groups thanthe control, but it was not significant.

5TONGUE AND ORAL MUCOSA CLEANING

Table 2. Basic Attributes of Elderly subjects

Table 3. Candida scores by time

H. YONEZAWA et al. J Med Dent Sci6

Table 4. VSC concentration by time

Table 5. Tongue coating scores by time

Fig. 2. Comparison of care effects (Candida scores)

Discussion

In this study, the authors performed tongue and oralmucosa cleaning to find the simplest and most effectiveoral care for elderly subjects. The effects of oral carewere studied using physiological parameters and thereactions and opinions of the subjects.

Oral care tools and effects for elderly subjectsCandida scores were decreased by any of the

methods and the percentage of Candida positive sub-jects was also declined. This result agrees with theother report4 showing that one tongue cleaning effec-tively reduced Candida scores on the tongue.Cleaning of the tongue, which serves as a reservoir ofmicroorganisms, helped reduce Candida scores intongue coating. Candida is one of the normal flora inthe mouth. Immunocompromised resistance of hostmay aquire opportunistic infection, leading to oralcandidiasis18. Prevention and treatment of oral can-didiasis requires antifungal agents and cleaning in themouth. It is important to clean the tongue and oralmucosa because they are reservoirs of microorgan-isms.

Concerning the tools, multiple comparisons showeda significant difference between week 2 and precare inthe group cared with sponge brushes every day for twoweeks. No significant difference, however, wasobserved in the group using mucosa brushes. Theresults were similar to those of Suzuki et al.8 whoreported that sponge brushes have special cleaningeffects avoiding reattachment of microorganisms on thetongue and oral mucosa and that tooth brush may helpreattachment of microorganisms. There is a low risk ofaspiration because sponge brushes need not to be wet.It is the minimum tool to be used in the mouth. It is alsoan advantage that few infectious materials can betransported because of disposable nature. A spongebrush is easier to use for non-professional caregiversand its short handle keeps them from injuring pharynx.As reported, a sponge brush provides relatively stablecleaning effects8,19 and it removes oral residue.Though it does not need to water the sponge, subjectssometimes complain dryness of the mouth. It isbecause of lowered saliva secretion of elderly sub-jects20. To improve the dryness and strange feeling inthe mouth, the sponge could be moisturized if the sub-jects have a low risk of aspiration and advise them torinse their mouth.

Frequency and effects of oral careThe subjects who received the oral care with a

sponge brush every day and every other day werecompared. Daily oral care group maintained theeffects of oral care at week 2 and one week after theoral care. The group cared every other day showed adecreased number of Candida. The difference, how-ever, was not statistically significant in multiple com-parison with the precare data. It was found that dailyoral care with sponge brushes was most effective inthis study.

Indices to measure oral care effectsBefore oral care, 63 (74.0%) of the subjects were

false positive or positive in Candida scores. The figurewas close to the figure for elderly subjects1. The studyrevealed that Candida is a good and stable index toevaluate effectiveness of oral care because its culturemedia is easy to operate. Candida scores revealed oralcare effects but VSC concentrations and tongue coat-ing scores did not. Oral malodor is shown to be affect-ed with time and eating habits11, and is related to thecoat of the tongue and saliva21. In the present study,detailed evaluation of periodontal diseases and salivameasurement was not performed because they weredifficult for elderly subjects who need to be cared. Theevaluation was limited to simple observation and sub-jective complaint of dryness. It is necessary to developsome easy but accurate methods of saliva measure-ment of its quality and quantity. It is also considerednecessary to study intrinsic self-cleaning mechanism ofmouth through mastication and conversation.Determination of Candida attachment on the tonguecoating was made using visual scores since it gaveleast burden to the subjects. There is a report, howev-er, which suggests that it is difficult to accuratelydetermine quantitative change of tongue coatingthrough non-dying macroscopic procedure4. It is moredesirable to perform culture of tongue coatingmicroorganisms,as used in this study.

Limit of the study and future outlookCleaning of the tongue and oral mucosa was per-

formed for two weeks and effects after the oral carewas evaluated. It may be too short, however, to makecomprehensive evaluation, taking into consideration ofdaily living and QOL of the elderly subjects4,22. It is,therefore, necessary to verify long term oral careeffects.

In conclusion, 1) Candida scores were significantlydecreased in any of the oral care groups as compared

7TONGUE AND ORAL MUCOSA CLEANING

to precare data. 2) Daily cleaning groups, especiallythat using sponge brush showed decrease in Candidascores with statistical significance. 3) Continuedeffects of the oral care were observed even 1 weekafter oral care completion among those who werecleaned every day with a sponge brush. Candidascores of them were much lower than precare level. 4)No significant difference was observed in VSC con-centrations and tongue coating scores. These resultssuggest that it is important for elderly subjects toclean the tongue and the oral cavity every day as a partof daily cleaning.

References1. Kikutani K, Suzuki A, Inaba S et al. Candida on the back of

the tongue of the elderly subjects in the hospitals (inJapanese). J Geriatr Dent 1998;13(1):23-7.

2. Morishita M, Yamamoto S, Kawamura M et al. Study on oralcare of subjects at a nursing institution and a hospital inHiroshima Prefecture (in Japanese). Hiroshima Univ J Dent1997;29(1):124-8.

3. Takasaki K, Nogawa T, Sasaki A et al. Evaluation of nursingassistance to disabled elderly subjects and their families athome (in Japanese). J Pub Health Nurs 1989;45(5):55-61.

4. Tamamoto M. Nakamoto T, Koko M et al. Change in oralCandida flora by tongue cleaning (in Japanese). JProsthodont 1990;34:208-14.

5. Sasaki H. Mechanism of aspiration of elderly people and pre-ventive measures (in Japanese). Geriatric International Res1993;4(2):54-7.

6. Niessen L. On dental care for the person with dementia.Alzheimer’s Disease and Related Disorders AssociationNewsletter 1985;5(3):2-3.

7. Nomura M. Alzheimer’s Disease (4) (in Japanese). DentalHygiene 1989;9:370-1

8. Suzuki A, Kikutani T, Ishida T et al. Cleaning effects of aiddevices for oral care of elderly subjects : Comparison of swaband sponge with a handle (in Japanese). J Geriatr Dent1994;8(2):128-36.

9. Gross A, Barnes GP. Effects of tongue brushing on tonguecoating and dental plaque scores (in Japanese). J Dent Res1975;54:1236.

10. Sakao S. Epidemiological study of oral malodor (inJapanese). Kyushu J Dent 1993;47(6):652-62.

11. Kobayashi T, Higuchi Y, Nishimura T et al. Preparation of men-tal scale (NM scale) and activities of daily living scale (N-ADL)for demented subjects using behavior observation (inJapanese). Clin Psychiat 1988;29:16-26.

12. Teraoka K. Effects of eating function on somatic activities inelderly people (in Japanese). J Oral Dis 1994;61(1):159.

13. Jacobson SE, Crawford JJ, McFall WR. Oral physiotherapy ofthe tongue and palate: relationship to plaque control. J AmDent Assoc 1973;87:134-9.

14. Fujita C. Epidemiological study of oral malodor, saliva andperiodontal health status (in Japanese). Kyushu J Dent1996;50(6):76-88.

15. Hamada T, Kotani H, Nakajima T et al. Easy to use media todiagnose denture induced stomatitis (in Japanese). JProsthodont 1982;26:948-53.

16. Fukushima K. Basic clinical study on components of oral mal-odor among different oral diseases (in Japanese). Jpn J OralSurg 1986;32(7):1192-211.

17. Kojima T. Clinical study of coat of the tongue (in Japanese).Jpn J Oral Surg 1985;31:1659-78.

18. Muramatsu K, Suzuki A, Yamane T, et al. Study on theeffects of oral miconazole for oral candidiasis (in Japanese). JGeriatr Dent 1994;9(3);26-32

19. Suzuki R. Study on aid devices for oral care (in Japanese).Jpn J Nurs (Comprehensive Nursing) 1995;26(7);159-61.

20. Shimoyama K, Unno M, Ohwatari B et al. Oral discomfort ofelderly dental subjects (in Japanese). J Geriatr Dent 1995;9(3):149-56.

21. Yoshida H. Function and components of saliva (inJapanese). Outlook Dent 1993;81:903-11.

22. Horino A, Yoshino K, Yoshida S et al. Study on bacteriologicaleffects of oral cleaning methods (in Japanese). J Nurs1995;59(1):44-6.

H. YONEZAWA et al. J Med Dent Sci8