Background

• Hairy tongue, also known as black hairy tongue or lingua villosa, is a benign and usually temporary condition characterized by the elongation and discoloration of the papillae on the surface of the tongue. Despite its name, hairy tongue does not involve actual hair growth on the tongue. Instead, the condition results from an accumulation of dead skin cells, bacteria, and other debris on the tongue’s papillae, causing them to appear elongated and discolored. 
• Hairy tongue is considered a cosmetic concern rather than a medical problem and is harmless. It is usually painless and does not cause any significant discomfort or health issues.  
• Several factors contribute to the development of hairy tongue, including poor oral hygiene, tobacco use (smoking or chewing), excessive consumption of certain substances (such as coffee, tea, or alcohol), and the use of certain medications (like antibiotics or medications that contain bismuth). 

Epidemiology

• Prevalence: Hairy tongue is considered a common condition. The exact prevalence can vary across different populations and regions. 
• Age and Gender: Hairy tongue can affect individuals of all ages, but it is more commonly observed in adults. There is no significant gender predilection, and it can occur in both males and females. 
• Risk Factors: The risk factors can increase the likelihood of developing hairy tongue, including: 

• Poor oral hygiene 
• Tobacco use (smoking or chewing) 
• Excessive consumption of substances like coffee, tea, or alcohol 
• Use of medications, particularly antibiotics or those containing bismuth 

Geographic Variation: The prevalence of hairy tongue may vary in different geographic regions due to differences in dietary habits, tobacco use, and oral hygiene practices. 

Anatomy

Pathophysiology

• Keratin Accumulation: Hairy tongue is characterized by the elongation and discoloration of the filiform papillae on the dorsum (top surface) of the tongue. These papillae normally contain keratin, a protein that helps protect the tongue’s surface. In hairy tongue, there is an abnormal accumulation of keratin on the filiform papillae, leading to their elongation and the appearance of “hair-like” projections. 
• Impaired Shedding: Under normal circumstances, the filiform papillae on the tongue go through a continuous cycle of growth and shedding. Old, keratinized cells at the tips of the papillae are shed, making way for new cells to emerge. In hairy tongue, this shedding process may be impaired, resulting in the retention of keratinized cells and elongation of the papillae. 
• Discoloration: Hairy tongue can also be associated with discoloration, giving the papillae a dark appearance. This discoloration may be due to various factors, such as the accumulation of food particles, tobacco or other substances, or the presence of certain bacteria or fungi on the tongue’s surface. 
• Contributing Factors: Several factors may contribute to the development of hairy tongue, including poor oral hygiene, smoking or tobacco use, excessive consumption of substances like coffee, tea, or alcohol, and the use of certain medications, particularly antibiotics or those containing bismuth. 

Etiology

Poor Oral Hygiene: 

• Inadequate oral hygiene can lead to the accumulation of bacteria, food particles, and dead cells on the tongue’s surface. This buildup may contribute to the elongation and discoloration of the filiform papillae, giving rise to hairy tongue. 

Impaired Tongue Cleaning Mechanisms: 

• The normal shedding process of the filiform papillae may become impaired due to various factors, including smoking, tobacco use, certain medications, and chemical irritants. This can result in the accumulation of keratinized cells and the appearance of hairy tongue. 

Consumption of Certain Substances: 

• Excessive intake of substances like coffee, tea, alcohol, or certain medications (e.g., antibiotics) may contribute to the development of hairy tongue. 

Tobacco Use: 

• Smoking or tobacco use has been associated with an increased risk of developing hairy tongue. 

Use of Certain Medications: 

• Some medications, particularly antibiotics and those containing bismuth (commonly used for digestive issues), have been linked to the development of hairy tongue. 

Dietary Factors: 

• Poor dietary habits, including a lack of roughage or fiber in the diet, may affect the normal cleaning mechanisms of the tongue and contribute to hairy tongue. 

Factors Affecting Salivary Flow: 

• Conditions that lead to reduced salivary flow, such as xerostomia (dry mouth), can affect the natural cleansing of the tongue, potentially contributing to hairy tongue. 

Microbial Factors: 

• Certain bacteria or fungi present in the oral cavity may play a role in the development of hairy tongue, though the exact relationship is not fully understood. 

Genetics

Prognostic Factors

Oral Hygiene Practices: 

• Maintaining good oral hygiene, including regular brushing of the tongue, can help prevent and improve hairy tongue. 

Lifestyle and Dietary Habits: 

• Reducing the consumption of substances that can contribute to hairy tongue, such as tobacco, coffee, tea, and alcohol, may have a positive impact on the condition. 

Medication Use: 

• In some cases, discontinuing or adjusting the dosage of medications associated with hairy tongue, such as antibiotics or medications containing bismuth, may lead to improvement. 

Salivary Flow: 

• Conditions that affect salivary flow, such as xerostomia (dry mouth), may influence the development of hairy tongue. Managing underlying salivary flow issues may help improve the condition. 

Tongue Cleaning Habits: 

• Proper tongue cleaning habits, such as using a tongue scraper or a soft toothbrush, may help reduce the appearance of hairy tongue. 

Age and Sex: 

• Some studies have suggested that hairy tongue is more common in older individuals and males, but further research is needed to confirm these associations. 

Underlying Health Conditions: 

• Certain health conditions, such as immunosuppression or gastrointestinal disorders, may be associated with hairy tongue. Addressing and managing these underlying conditions may impact the course of hairy tongue. 

Clinical History

Age Group: 

• Hairy tongue can occur at all ages, but it is more commonly observed in adults, particularly in those over the age of 40. 

Appearance: 

• The most notable feature of hairy tongue is the presence of elongated and discoloured papillae on the dorsal (upper) surface of the tongue. These papillae can range in colour from white, yellow, brown, to black, depending on the cause and extent of staining. 
• The elongated papillae give the tongue a furry or “hairy” appearance, hence the name “hairy tongue.” 

Physical Examination

Tongue Appearance: 

• The most apparent finding is the elongation and discoloration of the papillae on the surface of the tongue. The tongue may appear yellow, brown, black, green, or white, depending on the specific cause of the condition. 

Furry or Hairy Texture: 

• The elongated papillae can give the tongue a rough or hairy texture, which is more prominent towards the back of the tongue. 

Location and Distribution: 

• The hairy appearance is often concentrated on the dorsal (top) surface of the tongue, especially in the posterior region. The anterior part of the tongue near the tip is usually unaffected. 

Colour Variation: 

• The colour of the elongated papillae may vary depending on factors such as diet, smoking, and oral hygiene practices. For example, the papillae may appear dark or black due to the accumulation of food debris, tobacco, or certain substances. 

No Pain or Discomfort: 

• Hairy Tongue is typically a painless condition and does not cause any discomfort, aside from mild sensitivity to certain foods or beverages. 

Foul Breath (Halitosis): 

• In some cases, the elongated papillae can trap food particles and bacteria, leading to bad breath (halitosis). 

Age group

Associated comorbidity

• Hairy tongue is often associated with certain factors that contribute to its development, including poor oral hygiene, smoking or tobacco use, excessive consumption of substances like coffee, tea, and alcohol, and the use of certain medications. 

Associated activity

Acuity of presentation

• Hairy tongue usually develops gradually over time and is not considered an acute condition. The changes in papillae length and discoloration can be noticeable over weeks to months. 
• In some cases, the appearance of hairy tongue may cause concern or discomfort for individuals, leading them to seek medical advice or dental consultation. 

Differential Diagnoses

• Oral Thrush (Oral Candidiasis): A fungal infection caused by Candida species that can lead to white or cream-colored patches on the tongue and oral mucosa. Unlike hairy tongue, oral thrush lesions can be wiped off, and they may cause discomfort or pain. 
• Geographic Tongue (Benign Migratory Glossitis): A benign condition characterized by irregular, map-like patches on the tongue’s surface. The patches may appear white, pink, or red and can change in shape and location over time. 
• Leukoplakia: A white patch that cannot be wiped off, often caused by chronic irritation, smoking, or tobacco use. It can occur on the tongue or other parts of the oral mucosa. 
• Oral Lichen Planus: An inflammatory condition that can affect the tongue and oral mucosa, leading to white, lacy patches or red, raised areas. 
• Syphilis: It is caused by Treponema pallidum, which can cause a painless ulcer or chancre on the tongue. 
• Chemical or Medication-Induced Staining: Discoloration of the tongue can occur due to certain medications, chemicals, or substances like coffee, tea, or tobacco. 
• Black Hairy Tongue: A variation of hairy tongue where the elongated papillae appear black or brown due to pigment-producing bacteria or substances. 
• Oral Squamous Cell Carcinoma: Although rare, oral cancer can present as a persistent white or dark spot on the tongue. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment paradigm for hairy tongue typically involves a step-by-step approach, starting with conservative measures and progressing to more specific interventions if needed. The following is a general treatment paradigm for hairy tongue: 

Conservative Measures: 

• Oral Hygiene: Encourage good oral hygiene practices, including regular brushing of the tongue’s surface and tongue scraping to remove debris and dead cells. 
• Saliva Stimulants: If reduced salivary flow is a contributing factor, use saliva stimulants to promote saliva production and maintain oral hygiene. 

Topical Antifungals or Antiseptic Mouthwashes: 

• If there is evidence of fungal or bacterial overgrowth on the tongue’s surface, topical antifungals (e.g., nystatin, clotrimazole) or antiseptic mouthwashes (e.g., chlorhexidine, hydrogen peroxide) can be prescribed to address the underlying infection. 

Retinoids: 

• For cases with significant keratin accumulation on the tongue, topical or systemic retinoids may be used to promote the shedding of excess keratin and restore the normal appearance of the tongue. 

Addressing Underlying Causes: 

• If hairy tongue is a result of an underlying medical condition or medication, it is essential to address and manage the underlying cause or consider alternatives to the medication if possible. 

Follow-up and Maintenance: 

• Regular follow-up visits with a dentist or oral medicine specialist are crucial to assess the progress of the treatment and adjust the plan as needed. 
• Maintain good oral hygiene practices to prevent recurrence. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

non-pharmacological-treatment-of-hairy-tongue

Non-pharmacological treatments for hairy tongue aim to improve oral hygiene and promote the natural shedding of keratin on the tongue’s surface. 

Oral Hygiene Practices: 

• Brushing: Regularly brush your tongue’s surface as part of your daily oral hygiene routine. Use a soft-bristled toothbrush & toothpaste to gently clean the tongue’s surface and remove debris and dead cells. 
• Tongue Scraping: Use a tongue scraper or cleaner to gently scrape the surface of the tongue from back to front. This can help remove accumulated keratin and other debris. 
• Flossing: Floss between your teeth daily to maintain overall oral hygiene and prevent the accumulation of food particles that can contribute to tongue discoloration. 

Saliva Stimulants: 

• Hydration: Drink plenty of water to promote saliva production, which can help cleanse the tongue and reduce the appearance of hair-like projections. 

Dietary Adjustments: 

• Avoid Foods that Stain: Reduce consumption of foods and beverages that can stain the tongue, such as tea, coffee, red wine, and tobacco products. 
• Increase Fiber Intake: Eating a diet rich in fiber can aid digestion and promote regular bowel movements, reducing the risk of constipation, which may contribute to hairy tongue. 

Stop Smoking and Tobacco Use: 

• Smoking and tobacco use can contribute to tongue discoloration and exacerbate hairy tongue. Quitting smoking or avoiding tobacco products can help improve oral health. 

Address Underlying Factors: 

• If hairy tongue is a result of an underlying medical condition, addressing and managing that condition can improve the appearance of the tongue. 
• If medications are contributing to hairy tongue, discuss potential alternatives with your healthcare provider. 

Use of Topical Antifungals in the treatment of Hairy Tongue

Topical antifungal agents, such as Nystatin, Clotrimazole, Ketoconazole, and Fluconazole, are sometimes used in the treatment of hairy tongue. These antifungals help in reducing fungal overgrowth on the tongue’s surface, which can be one of the contributing factors to hairy tongue. 

Nystatin: 

• Nystatin is an antifungal medication that is commonly used to treat oral fungal infections, including oral thrush. It comes in various formulations, including oral suspension and lozenges. 
• For hairy tongue, Nystatin oral suspension may be prescribed. The patient swishes the suspension in the mouth for a certain period before swallowing it or spitting it out. 
• Nystatin may help in reducing fungal colonization on the tongue’s surface, leading to an improvement in the condition. 

Clotrimazole, Ketoconazole, and Fluconazole: 

• Clotrimazole, Ketoconazole, and Fluconazole are other antifungal agents that are used to treat various fungal infections, including oral thrush. 
• While they are not specifically approved for the treatment of hairy tongue, they may be prescribed off-label in certain cases where fungal overgrowth is suspected to contribute to the condition. 

• Topical formulations of these antifungals may be applied directly to the tongue’s surface, as prescribed by a healthcare professional. 

Use of Antiseptic Mouthwashes in the treatment of Hairy Tongue

Antiseptic mouthwashes have antimicrobial properties that can help reduce the bacterial load on the tongue’s surface and improve the condition. Here is how they are used: 

Chlorhexidine Mouthwash: 

• Chlorhexidine is a broad-spectrum antiseptic agent commonly used to treat and prevent oral infections. 
• For hairy tongue, a mouthwash containing 0.12% chlorhexidine gluconate may be prescribed. 
• Patients are instructed to swish the chlorhexidine mouthwash in the mouth for about 30 seconds to 1 minute and then spit it out. It is usually used twice daily or as directed by a healthcare professional. 

Hydrogen Peroxide Mouthwash: 

• Hydrogen peroxide is another antiseptic agent that can help in reducing bacteria on the tongue’s surface. 
• A common concentration used for mouthwash is 1.5% hydrogen peroxide. 
• Like chlorhexidine, patients swish the hydrogen peroxide mouthwash for a short duration and then spit it out. The frequency of use is usually determined by a healthcare professional. 

Use of systemic Retinoids in the treatment of Hairy Tongue

• Systemic retinoids, such as isotretinoin, are potent medications used for treating severe acne and certain skin disorders. They are derived from vitamin A and have various effects on the skin, including reducing sebum production and promoting cell turnover. While they may have some impact on the appearance of the tongue’s surface, the potential risks and side effects associated with systemic retinoid use may outweigh the benefits for treating hairy tongue. 
• Systemic retinoids can cause a range of adverse effects, such as dryness of the skin, lips, and mucous membranes, as well as musculoskeletal and gastrointestinal issues. Additionally, these medications can have teratogenic effects, meaning they can harm a developing fetus, so they are typically avoided during pregnancy. 
• Due to the lack of strong evidence supporting the use of systemic retinoids in hairy tongue treatment and the potential for significant adverse effects, they are not considered a first-line treatment option. 

tongue-debridement-in-the-treatment-of-hairy-tongue

• Tongue debridement is a procedure used in the treatment of hairy tongue to physically remove the accumulated keratin and debris from the surface of the tongue. It is a form of mechanical cleaning that can be performed by dental professionals or healthcare providers. Tongue debridement can be effective in reducing the visible hair-like appearance of the tongue and improving oral hygiene. 
• During the procedure, a tongue scraper or a special instrument may be used to gently scrape or brush the surface of the tongue. This helps to remove the dead cells, bacteria, and food particles that contribute to the appearance of hairy tongue. The procedure is painless and does not require anesthesia. 
• Tongue debridement is often combined with other treatments, such as good oral hygiene practices and the use of antiseptic mouthwashes, to achieve better results in managing hairy tongue. After debridement, patients are usually advised to maintain regular oral hygiene practices and follow any other recommendations provided by their healthcare provider. 

surgical-care-for-hairy-tongue

Surgical care is rarely required in the treatment of hairy tongue, as it is usually a benign and self-limiting condition. Hairy tongue can often be managed effectively with non-surgical interventions and topical treatments, as mentioned earlier. 

• Laser Ablation: In certain instances, laser therapy may be used to remove or reduce the elongated papillae on the tongue’s surface. Laser ablation can be effective in promoting the shedding of dead cells and improving the tongue’s appearance. 
• Electrosurgery: Electrosurgical techniques involve the use of an electric current to remove or modify the affected tissue. This method can be utilized to trim or reduce the size of the elongated papillae. 

management-of-hairy-tongue

Acute Phase: During the acute phase, the primary focus is on addressing the immediate symptoms and providing relief. The treatment may include: 

• Tongue Debridement: Mechanical cleaning of the tongue surface to remove accumulated keratin and debris. 
• Topical Antifungals: Use of antifungal agents like nystatin, clotrimazole, ketoconazole, or fluconazole to reduce fungal overgrowth. 
• Antiseptic Mouthwashes: Rinsing with chlorhexidine or hydrogen peroxide mouthwashes to control bacterial growth. 

• Systemic Retinoids: In severe cases, systemic retinoids may be prescribed to regulate keratinization. 

Maintenance Phase: After the acute phase, the focus shifts to maintaining oral hygiene and preventing recurrence. The following measures are recommended during the maintenance phase: 

• Good Oral Hygiene: Regular brushing of teeth and tongue to remove plaque and debris. 
• Tongue Cleaning: Continued use of tongue scrapers or brushes to prevent tongue coating buildup. 
• Regular Dental Check-ups: Regular dental visits to monitor oral health and address any early signs of recurrence. 
• Avoidance of Risk Factors: Patients should be advised to avoid tobacco, alcohol, and certain foods that can contribute to hairy tongue. 

Medication

Future Trends

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References

• www.Black hairy tongue syndrome Grigoriy E Gurvits and Amy Tan.ncbi.nlm.nih.gov 
• www.Black hairy tongue etiology and treatment.ntm.in