Approach Considerations
Owing to the striking color, patients benefit from reassurance that they have a benign condition. Maintenance of good oral hygiene in addition to gentle mechanical debridement of the dark tongue surface matter optimally controls the condition. [27] Reducing the lingual coating prevents bacterial colonization of the tongue. If medications are the cause of the black hairy tongue, then consideration could be given to changing to a similar medication or reassurance that the condition will resolve with discontinuation.
Patients with poor oral intake and mastication, such as those with trigeminal neuralgia, have been reported to have an increase development of black hairy tongue. Treatment of the condition that is producing the minimal mastication and tongue movement reduces the development of black hairy tongue. [28]
Frank discussion with the patient about lifestyle changes may be necessary if specific life issues thought to be potentially causative are revealed by the history. For example, individuals using oxidizing mouthwashes containing sodium perborate, sodium peroxide, or hydrogen peroxide over the long term should be advised to change this potentially contributing behavior. Excessive tea drinking may also need to be curtailed. [29]
To rule out other causes, a punch biopsy is a simple approach. Because of a generous blood supply, the tongue heals quickly and does not easily become infected.
Medical Care
In the majority of 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. [30]
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.
Note the transition in the images below.
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.
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. Photo 1 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.
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. A punch biopsy may be performed as a mechanism of establishing the diagnosis, if in doubt.
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; other consultations may be needed if one or more prescribed medications need to be changed or curtailed.
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.
Long-Term Monitoring
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.
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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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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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Close-up view of 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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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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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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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. Photo 1 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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Middle-aged woman with a hairy tongue that is brown.
