A 60-year-old man who smokes presents to the physician’s office smelling of alcohol. He complains of a black discoloration of his tongue and a gagging sensation on occasion. He admits to smoking
1 to 2 packs per day along with drinking at least 6 to 8 beers per day. The patient brushes his teeth infrequently and has not seen a dentist for a long time.
On physical exam, his teeth are stained and his tongue shows elongated papillae with brown discoloration . See picture below:
Diagnoses include black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction.
Black Hairy Tongue:
Black hairy tongue (BHT) is a benign disorder of the tongue characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. In addition, there is defective desquamation of the papillae on the dorsal tongue resulting in a hair-like appearance
Also known as : Hyperkeratosis of the tongue and lingua villosa nigra.
Risk factors include:
• Tobacco (smoking and chewing).
• Alcoholism and drug abuse (especially drugs that are smoked).
• Poor oral hygiene.
• Medications (especially antibiotics and those causing dry mouth).
• Oxidizing mouthwashes (containing peroxide).
• Cancer, especially with radiation therapy.
• Drinking black tea or coffee.
Clinical Features: Patients may be asymptomatic. However, the accumulation of debris in the elongated papillae may cause taste alterations, nausea, gagging, halitosis, and pain or burning of the tongue. The lesion is restricted to the dorsum of the tongue, anterior to the circumvallate papillae, rarely involving the tip or sides of the tongue.
Diagnosis: The diagnosis is made by visual inspection and clinical history of smoking and poor oral hygiene.
Consider performing a KOH preparation to rule out associated candidiasis.
Differential Diagnosis: Black tongue can occur with:
• Ingestion of bismuth subsalicylate or minocycline. Although the tongue has a black coating, the papillae are not elongated. Without the hypertrophy of papillae this is not a Black Hairy Tongue.
• Hairy leukoplakia—Appears as faint white vertical keratotic streaks typically on the lateral side of the tongue .
Do not confuse BHT with oral hairy leukoplakia, an Epstein- Barr virus–related condition typically affecting the lateral tongue bilaterally in immunocompromised patients, especially those with HIV infection.
• Oral candidiasis—White plaques typically found on the buccal mucosa, tongue, and palate when removed has an erythematous base. The white color should make this easy to distinguish from BHT
1. Avoidance of predisposing risk factors (e.g., tobacco, alcohol, and antibiotics).
2. Stop the offending medication in drug-induced BHT whenever possible.
3. Regular tongue brushing using a soft toothbrush or tongue scraper.
4, If candidiasis is present, an oral antifungal is indicated. If there is no liver disease, the preferred regimen for oral candidiasis is fluconazole 100 mg daily for 14 days. An alternative is clotrimazole troches 5 times a day for 14 days. Nystatin is less effective.
5, Patients with poor oral hygiene should be referred to a dentist.