Practice Essentials
Hairy tongue (lingua villosa) is a commonly observed condition of defective desquamation of the filiform papillae that results from a variety of precipitating factors. [1] 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). [2, 3]
In most cases, lesions are noted as part of an intraoral examination,though 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. Patients occasionally notice the condition of the tongue during tooth brushing and present to the office with concerns regarding potential malignancy. (See Presentation.)
Maintenance of good oral hygiene in addition to gentle mechanical debridement of the dark tongue surface matter optimally controls the condition. In most 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. Lifestyle changes may be necessary if specific life issues are thought to be potentially causative. Surgical removal of the papillae is the treatment of last resort if less complicated therapies are ineffective. (See Treatment.)
Pathophysiology
Precipitating factors for hairy tongue include poor oral hygiene, the use of medications such as broad-spectrum antibiotics (particularly tetracyclines), and therapeutic irradiation of the head and the neck. [4] 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 long, whereas filiform papillae in hairy tongue have been measured at more than 15 mm in length.
Etiology
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. [5, 6, 7] Medications, such as lorazepam and similar agents, [8, 9, 10, 11] lithium, [12] and linezolid, [13, 14, 15] have been implicated. [16] Other medications that have been reported to induce black hairy tongue include doxycycline, penicillin lozenges, mepazine, oral tetracycline, olanzapine, oral erythromycin, vancomycin, and meropenem. [17, 18]
Epidemiology
United States and international statistics
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. [1] There may also be geographical disparity depending on the relative contribution of identified etiologic factors.
Age-, sex-, and race-related demographics
The incidence and the prevalence of hairy tongue increases with age, possibly because a higher percentage of the older population engages in activities (eg, using tobacco or drinking coffee or tea) that predispose to the condition.
Although hairy tongue is reported more often in males, it is not uncommon in females, especially those who drink coffee or tea or who use tobacco.
No racial predilection is associated with hairy tongue.
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.
Hairy tongue is rarely symptomatic, though 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.
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 healthcare provider.
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Brown hairy tongue in middle-aged woman who drinks coffee. Note how condition is limited to mid-dorsal part of tongue, becoming more prominent toward posterior part.
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Brown hairy tongue in middle-aged man who smokes cigarettes. Condition is limited to posterior two thirds of dorsal surface of tongue.
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Close-up view of brown hairy tongue in middle-aged man who smokes cigarettes. Condition is limited to posterior two thirds of dorsal surface of tongue.
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Patient is middle-aged woman who drank coffee and smoked cigarettes for many years. Chief complaint was tickling sensation in oral pharynx during swallowing. Slight greenish cast to tongue was due to use of mouthwash immediately prior to appointment.
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Male geriatric patient was pipe smoker for many years. He was unaware of presence of hairy tongue until it was brought to his attention during routine dental examination.
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Male geriatric patient was pipe smoker for many years. He was unaware of presence of hairy tongue until it was brought to his attention during routine dental examination. Photo was taken 1 month after initial examination. During intervening 4 weeks, patient did not decrease his pipe smoking, but he gently brushed dorsal surface of tongue when brushing his teeth. Hairy tongue has completely resolved.
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Middle-aged woman with hairy tongue that is brown.
