AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Hairy tongue (lingua villosa) is a commonly observed condition of defective desquamation of the filiform papillae that results from a variety of precipitating factors. The condition is most frequently referred to as black hairy tongue (lingua villosa nigra); however, hairy tongue may also appear brown, white, green, pink, or any of a variety of hues depending on the specific etiology and secondary factors (eg, use of colored mouthwashes, breath mints, candies).

Pathophysiology

Precipitating factors for hairy tongue include poor oral hygiene, the use of medications (especially broad-spectrum antibiotics), and therapeutic radiation of the head and the neck. All cases of hairy tongue are characterized by a hypertrophy and elongation of filiform papillae, with a lack of normal desquamation. Normal filiform papillae are approximately 1 mm in length, whereas filiform papillae in hairy tongue have been measured at more than 15 mm in length.

Frequency

United States

The prevalence of hairy tongue varies widely, from 8.3% in children and young adults to 57% in persons who are addicted to drugs and incarcerated. Hairy tongue has been reported with greater frequency in males, those who use tobacco, those who heavily drink coffee and tea, patients infected with HIV, and those who are HIV negative and use intravenous drugs.

Mortality/Morbidity

Hairy tongue is rarely symptomatic, although overgrowth of Candida albicans may result in glossopyrosis (burning tongue). Patients frequently complain of a tickling sensation in the soft palate and the oral pharynx during swallowing. In more severe cases, patients may actually complain of a gagging sensation. Retention of oral debris between the elongated papillae may result in halitosis.

Race

No racial predilection is associated with hairy tongue.

Sex

Although hairy tongue is reported more often in males, it is not uncommon in females, especially those who drink coffee or tea and/or those who use tobacco.

Age

The incidence and the prevalence of hairy tongue increases with age, possibly because a higher percentage of the population engage in activities (eg, using tobacco, drinking coffee or tea) that predispose to the condition.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

Because hairy tongue is usually asymptomatic, the history is often irrelevant.

• In most cases, lesions are noted as part of an intraoral examination, although patients may complain of a tickling or gagging sensation.
• Most patients with hairy tongue have a positive history of coffee or tea drinking, often in addition to tobacco use.
• Although hairy tongue has been reported with increasing prevalence in persons who are HIV positive and in persons who are HIV negative and use intravenous drugs, it is not considered to be of any diagnostic or predictive value and probably represents a manifestation of social habits (eg, using tobacco, drinking coffee or tea).
• Patients occasionally notice the condition of the tongue during tooth brushing and present to the office with concerns regarding potential malignancy.

Physical

• Hairy tongue clinically appears as an elongation of the filiform papillae on the dorsal surface of the tongue.
• Papillae, which are normally minimally keratinized and appear pinkish white, often retain pigments from food, beverages, and candies, resulting in the varying colors associated with the condition (eg, black, brown, white, green, pink). The tongue has a thick coating in the middle, with a greater accentuation toward the back.
• Bacterial and fungal overgrowth play a role in the color of the tongue.
• In extreme cases of hairy tongue, a blast of compressed air results in the papillae "waving in the breeze."

Causes

• The basic defect in hairy tongue is a hypertrophy of filiform papillae on the dorsal surface of the tongue, usually due to a lack of mechanical stimulation and debridement. This condition often occurs in individuals with poor oral hygiene (eg, lack of tooth brushing, eating a soft diet with no roughage that would otherwise mechanically debride the dorsal surface of the tongue).
• Contributory factors for hairy tongue are numerous and include tobacco use and coffee or tea drinking. These factors account for the various colors associated with the condition.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Other Problems to be Considered

Oral hairy leukoplakia

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• Culture of the tongue's dorsal surface may be taken if a superimposed oral candidiasis or other specific oral infection is suspected.
• Cytologic smears stained with Gram stain or periodic acid-Schiff stain may reveal candidal organisms.
• Potassium hydroxide preparations are useful for rapid diagnosis of oral candidiasis, as are latex agglutination-based card tests (eg, CandidaSure).

Procedures

• Distinguishing between oral hairy leukoplakia and hairy tongue is important if patients are found or suspected to be HIV positive. This can be accomplished by a simple mucosal punch biopsy and appropriate immunostaining of the specimen for the presence of Epstein-Barr virus, the causative agent of oral hairy leukoplakia. However, in most cases, the diagnosis is made retrospectively on the basis of the clinical response to mechanical debridement.

Histologic Findings

Histopathologic findings in hairy tongue consist of elongated filiform papillae, with mild hyperkeratosis and occasional inflammatory cells. Finding accumulated debris intermingled among the papillae and candidal pseudohyphae is not unusual. No other specific microscopic findings are associated with this entity.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Medical Care

The treatment of hairy tongue is variable. In many cases, simply brushing the tongue with a toothbrush or using a commercially available tongue scraper is sufficient to remove elongated filiform papillae and retard the growth of additional ones.

Surgical Care

Surgical removal of the papillae by using electrodesiccation, carbon dioxide laser, or even scissors is the treatment of last resort when less complicated therapies prove ineffective.

Consultations

Consultation with or referral to a general dentist may be indicated if the etiology of a patient's hairy tongue appears to be primarily one of poor oral hygiene.

Diet

Patients who are on a continuous soft diet occasionally develop hairy tongue because the consistency of the diet does nothing to mechanically debride the dorsal surface of the tongue during eating and swallowing. If adding more roughage to the patient's diet is not feasible, encourage the patient to cleanse the dorsal surface of the tongue daily by brushing or scraping.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

In most cases, the treatment of hairy tongue does not require pharmacologic intervention. If Candida albicans is present, topical antifungal medications can be used when the condition is symptomatic (eg, glossopyrosis). Topical application of retinoids has been used with some success. Keratolytic agents are effective but may be irritating. Although reportedly successful, the agents listed above (with the exception of treatment of oral candidiasis) are used off label and their application should be limited to selected cases with close monitoring.

Drug Category: Antifungal agents

These agents are used to treat oral candidiasis in association with hairy tongue.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Further Inpatient Care

• If hairy tongue is noted in a patient hospitalized for other reasons, instruct the nursing staff to encourage the patient to gently brush or scrape the tongue as necessary to debride the area. If the lesion persists, a dental consult is appropriate to rule out other clinically similar entities.

Further Outpatient Care

• If hairy tongue is noted in a patient as part of a routine outpatient examination, encourage the patient to gently brush or scrape the tongue as necessary to debride the area. In addition, encourage the patient to consult a dentist.

Complications

• The only complication associated with hairy tongue is an occasional candidal overgrowth, which often results in an uncomfortable glossopyrosis (burning tongue).
• Altered taste sensation is a rare complication.

Prognosis

• The prognosis for hairy tongue is excellent. If the precipitating factors cannot be adequately controlled or compensated for, patients may have to make tongue brushing or scraping part of their daily oral hygiene regimen.

Patient Education

• Education regarding proper oral hygiene procedures is more easily provided to the patient as part of a routine dental appointment; however, encouragement in this regard is appropriate from any health care provider.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  Brown hairy tongue in a middle-aged woman who drinks coffee. Note how the condition is limited to the mid-dorsal part of the tongue, becoming more prominent toward the posterior part.
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Media file 2:  Brown hairy tongue in a middle-aged man who smokes cigarettes. The condition is limited to the posterior two thirds of the dorsal surface of the tongue.
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Media file 3:  Close-up view of the patient in Image 2.
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Media file 4:  This patient is a middle-aged woman who drank coffee and smoked cigarettes for many years. Her chief complaint was a tickling sensation in the oral pharynx during swallowing. The slight greenish cast to her tongue was due to the use of a mouthwash immediately prior to her appointment.
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Media file 5:  This male geriatric patient had smoked a pipe for many years. He was unaware of the presence of his hairy tongue until it was brought to his attention during a routine dental examination.
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Media file 6:  The same patient as in Image 5 one month following his initial examination. While he has not decreased his pipe smoking, he has gently brushed the dorsal surface of his tongue when he brushes his teeth during the intervening 4 weeks. The hairy tongue has completely resolved.
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Media file 7:  Middle-aged woman with a hairy tongue that is brown.
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REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

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Article Last Updated: Dec 15, 2006