Black hairy tongue (BHT)- Causes, Pathophysiology and Treatment

Definition

Black hairy tongue is a temporary, harmless and fairly common condition in which the top of the tongue looks hairy. However, the substance on the tongue is not really hair and it’s not always black- it can be brown, green, white or other colors. Little bumps on the top of the tongue, called filiform papillae, grow and collect food and bacteria, which provide the color. The papillae are usually about 1 millimeter (1/32 inch) long and they’re supposed to fall off, like a layer of skin being shed, before they grow. The shedding process is called desquamation. If the papillae don’t fall off, they can grow as long as 18 millimeters (3/4 inch).

Black hairy tongue affects about 13 percent of people at some point in their lives, according to the American Academy of Oral Medicine. It happens in all population groups but is more common in men and in older people.

Pathophysiology

Precipitating factors for hairy tongue include poor oral hygiene, the use of medications such as broad-spectrum antibiotics (particularly tetracyclines), and therapeutic radiation of the head and the neck. All cases of hairy tongue are characterized by 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 tongues have been measured at more than 15 mm in length.

Anatomy of tongue

Risk factors of Black hairy tongue

There are many risk factors for the black hairy tongue, such as:

  • Poor oral hygiene
  • Smoking tobacco
  • Drinking a lot of coffee or tea
  • Using antibiotics (which may disrupt the normal balance of bacteria in the mouth)
  • Being dehydrated
  • Taking medications that contain the chemical bismuth (such as pepto-bismol for upset stomach)
  • Not producing enough saliva
  • Regularly using mouthwash that contains peroxide, witch hazel, or menthol
  • Getting radiation therapy to the head and neck

Causes

Black hairy tongue typically results when projections on the tongue called papillae grow longer because they don’t shed dead skin cells like normal. This makes the tongue look hairy. Debris, bacteria or other organisms can collect on the papillae and result in discoloration.

Although the cause of black hairy tongue can’t always be determined, possible causes or contributing factors include:

  • Changes in the normal bacteria or yeast content of the mouth after antibiotic use
  • Poor oral hygiene
  • Dry mouth (xerostomia)
  • Regular use of mouthwashes containing irritating oxidizing agents, such as peroxide
  • Tobacco use
  • Drinking excessive amounts of coffee or black tea
  • Excessive alcohol use
  • Eating a soft diet that doesn’t help to rub dead skin cells from your tongue

Black hairy tongue symptoms

Other than the appearance of the tongue, most people with the black hairy tongue don’t have any symptoms or feel any discomfort.

  • The exception is when there is too much growth of the yeast Candida albicans, which can cause a burning sensation on the tongue. This burning sensation is called glossopyrosis.
  • Some people complain of a tickling feeling in the back of the roof of the mouth, a metallic taste in their mouth, or nausea.
  • In more severe cases, the condition may lead to a gagging feeling. Sometimes, food getting caught inside the extra-long papillae can cause bad breath.

Complications            

  • Typically, BHT is a self-limiting disorder and the development of this condition commonly precipitates only aesthetic concern in affected people.
  • Patients should be reassured about the benign nature of the condition to address anxiety and promote recognition and treatment.
  • In rare instances, patients may report irritation, nausea, and gagging sensation mainly due to the size of unusually elongated papillae. Others may experience a disabling metallic taste, general dysgeusia, and perceived halitosis.
  • Microbial or fungal superinfection is an important consideration in management patients with BHT and proper recognition and treatment may preclude progression to glossopyrosis or burning mouth syndrome.

Diagnosis of Black hairy tongue

Diagnosis of black hairy tongue is based on appearance and possible causes or contributing factors. It also includes eliminating other conditions that may cause a similar appearance to the tongue, such as:

  • Normal variations in tongue color (pigment)
  • Foods or medications that have stained the tongue
  • Fungal or viral infections
  • Oral lesions that occur on the tongue, such as oral hairy leukoplakia
  • Blackened tongue (pseudo-black hairy tongue) from using products containing bismuth, such as Pepto-Bismol

Treatment and medications

Black tongue treatment

If black tongue does not clear on its own within a few days, a person should seek medical treatment.

A doctor or dentist may recommend the following treatments for a person who presents with a black tongue:

Antibiotics: These medications will help treat bacterial infections of the tongue.

Switching medications: A person who develops black tongue as a result of antibiotic use may need to switch antibiotics.

Antifungal treatment: These medications can help treat fungal causes of a black tongue.

Other medications or supplements: Anecdotal evidence suggests that certain medications — including salicylic acid, retinoids, and B complex vitamins — may ease symptoms of black tongue. However, people should not use these treatments without first talking to a doctor.

Surgical treatment: If other treatment options do not work, a doctor or dentist can perform a procedure to remove the long, thread-like growths on the tongue. This clipping procedure is safe and effective. However, black tongue may return following the procedure.

Hairy tongue treatment

Hairy tongue is often only temporary, and usually it isn’t a sign of a more serious problem. However, some of the main causes of hairy tongue are the result of lifelong habits, such as smoking, so it may be necessary for you to actively try to treat the condition.

The most common strategies for treating hairy tongue include the following:

Have good oral hygiene: Properly brushing, flossing, and rinsing your mouth can prevent hairy tongue.

Scrape your tongue: You can purchase specialized tongue scrapers to help you clean your tongue and remove dead FP.

Discontinue the responsible medications: In some cases, once you stop using a medication, the hairy tongue will disappear. Ask your doctor if it’s okay to stop using the medicine you suspect might be causing hairy tongue. You may also be able to find an alternative medicine with your doctor’s help.

Stop bad habits: Smoking, excessive alcohol use, and some drugs can lead to hairy tongue. Cut back or stop altogether to restore a healthy mouth.

Consider what you’re eating and drinking: Dark-colored liquids and foods can dye the FP on your tongue. These include black tea and coffee. Opt for more clear liquids like water.

If these treatments aren’t successful, you can talk with your doctor about more aggressive treatments. These include:

  • Prescription antifungal medicines
  • Over-the-counter (OTC) antiseptic mouthwash, such as Listerine or Orajel
  • Surgical treatment to trim the FP

Lifestyle and home remedies

To practice good oral health and to remove the tongue discoloration:

Brush your tongue: Give your tongue a gentle brushing whenever you brush your teeth to remove dead cells, bacteria and food debris. Use a soft-bristled toothbrush or a flexible tongue scraper.

Brush after eating: Brush your teeth at least twice a day and ideally after every meal, using fluoride toothpaste.

Floss at least once a day: Proper flossing removes food particles and plaque from between your teeth.

Visit your dentist regularly: Get professional teeth cleanings and regular oral exams, which can help your dentist prevent problems or spot them early. Your dentist can recommend a schedule for you.

Maintain good nutrition: Drink plenty of water and eat a balanced diet that contains fresh fruits and vegetables.

Prevention of Black hairy tongue

It’s important to note that a black hairy tongue is not a condition that has a specific medical treatment. At most, doctors recommend a strong mouth wash able to remove any the bacteria and yeast present in the filiform papillae. If one happens to have this condition, there are a few things one can do to deal with it. These include:

Proper dental hygiene- You need not brush their teeth after every meal but brushing of teeth should be done at least twice a day. At both times and at the end of brushing, make sure to brush the tongue thoroughly as this will remove any organic debris on the tongue.

Tongue scraping- It is possible to get your hands on specialized tongue scrapers that will aid you in cleaning the tongue. However you should stick to major brands to avoid potentially harmful products

Avoid harmful habits such as smoking, chewing tobacco, drinking alcohol and taking coffee-doing so avoids the more potent tongue discolouring agents.

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