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Dermatologic Clinic: Plaque On Tongue

A 60-year-old Black man with hypertension and type 2 diabetes presents with a 1-month history of a yellowish, green furry plaque on his tongue. He states that he drinks several cups of coffee and eats oatmeal daily. He does not have any pain with the plaque but does endorse a slight burning sensation. He also notes his food has tasted differently lately, and he wonders if it could be related to the changes on his tongue.

Hairy Tongue

Hairy tongue, first documented in 1835 by Rayer, was initially observed in an adult male patient.¹ The condition affects both genders and is estimated to impact approximately 0.5% to 5.0% of the population.2 However, the prevalence varies significantly, with some studies indicating rates as low as 8.3% in children and as high as 57% among individuals addicted to drugs or incarcerated.3 Other reports suggest an overall prevalence of 13% in the general population.⁴ Such variability in prevalence can be attributed to differences in study design, population characteristics, and diagnostic methods. Although hairy tongue appears unrelated to the patient's race, global variations may exist due to differences in dietary habits, oral hygiene, and bacterial diversity.5

Hairy tongue is characterized by hypertrophy of the papillae, which gives the tongue a hairy appearance. This occurs because of a lack of stimulation, leading to excessive papillae growth beyond the usual 1 mm, with dead cells and debris accumulating on the tongue's surface. The accumulation of keratin on the dorsum of the tongue, which is not naturally broken down due to insufficient chewing, is thought to contribute to the condition.⁶ Hairy tongue is not typically linked to underlying diseases, but several risk factors have been identified, including a history of tobacco use, frequent consumption of coffee or tea, HIV, and intravenous drug use.²

Risk Factors

Several risk factors contribute to hairy tongue, such as smoking, poor oral hygiene, chronic antibiotic use, consumption of hot beverages, and oxidizing mouthwashes.⁶ Epidemiologic data indicate that men are approximately 3 times more likely to develop hairy tongue than women, primarily because of higher smoking rates and poorer oral hygiene.⁴ Furthermore, the condition is found more frequently in older adults, with a prevalence of 40% in individuals over 60 years of age.⁴ Certain neurologic disorders affecting tongue movement or chewing also increase the risk. Diet consisting mainly of liquid or soft foods may prevent keratin breakdown due to less mechanical abrasion of the tongue, thereby causing hairy tongue.

Clinical Examination

Clinically, hairy tongue appears as a furry, hair-like layer on the dorsal midportion of the tongue, without affecting the lateral regions.⁶ The elongated papillae can present in various colors, including black, brownish-black, yellow-green, or even unpigmented.⁴ These color variations often arise from external factors such as tobacco use, food residues, or bacteria.⁶ While typically asymptomatic, hairy tongue can cause discomfort, with some patients experiencing symptoms like a metallic taste, burning sensation, halitosis, or a gagging feeling when the tongue touches the palate.

Dermoscopic analysis of hairy tongue reveals yellow-brownish to black-hair elongation of the filiform papillae.⁵ Histologically, there is thickening of the filiform papillae due to hyperkeratosis, with bacterial and yeast overgrowth, sometimes accompanied by non-specific inflammation.⁷ Trapped debris and Candida pseudohyphae may also be observed.⁸

The differential diagnosis of hairy tongue includes various conditions such as oral hairy leukoplakia, pigmented fungiform papillae, and acanthosis nigricans.⁴ Oral hairy leukoplakia appears as white patches on the tongue, often triggered by Epstein Barr Virus (EBV), particularly in individuals with compromised immune systems, such as those with HIV or AIDS.⁸ Pigmented fungiform papillae present as isolated dark lesions, primarily on the sides and tip of the tongue, predominantly in individuals with darker skin. Acanthosis nigricans in the oral cavity manifests as multiple dark, well-defined papillary lesions, sometimes extending to the lips, often linked to underlying malignancies.⁴

Diagnosis

Diagnosis of hairy tongue is usually based on visual inspection of the mouth.⁴ Microscopic examination may show papillae exceeding 3 mm in length, and cultures may be performed to identify associated bacterial or fungal infections.⁴ Although not always required, a tongue biopsy can be helpful if the lesions are characteristic of black hairy tongue.⁴

Treatment

Treatment for hairy tongue is generally simple and primarily involves improving oral hygiene. Tongue scraping using a toothbrush or a dedicated tongue scraper is effective for removing elongated papillae.⁶ Good oral hygiene, combined with regular tongue cleaning, is key to managing the condition.² Lifestyle changes, such as reducing excessive tea or coffee consumption and avoiding oxidizing mouthwashes, may also be beneficial. In cases where these conservative measures fail, surgical intervention using electrodesiccation or scissors may be considered as a last resort.²

Outcome

The patient was recommended to switch to a new toothbrush and use a tongue scraper to remove the hyperkeratosis. He was also educated on cutting back on his coffee consumption and was recommended to eat a balanced diet.

This article originally appeared on Clinical Advisor

10 Signs Your Tongue Can Say About Your Health

An unhealthy tongue may look red, smooth, or black. Other signs of tongue health include soreness and enlarged and swollen papillae, or the small bumps on your tongue. Tongue changes are sometimes the first signs that something is amiss. Symptoms of many acute and chronic infections and illnesses can appear on your tongue.

Your tongue is typically pinkish-red in color. Folic acid or vitamin B12 deficiency can cause your tongue to appear red or glossy. This change could also just be from red foods or beverages or hot soup that burned your mouth.  Keep in mind that you cannot diagnose nutrient deficiencies by looking at your tongue. Other symptoms include: Hyperpigmentation, or skin color changes Impaired vision Mental state changes Dietary changes or supplements can often correct nutrient deficiencies. Before starting any supplements, talk to a healthcare provider or pharmacist. Papillae may become inflamed or swollen, which makes them larger and more noticeable than usual. Transient lingual papillitis (lie bumps) is the result of a lack of sleep, excessive smoking, and stress. These bumps are not usually a cause for concern. You can treat symptoms at home with pain relievers and saline mouthwash. Other bumps that may occur on your tongue include: Canker sores: Painful ulcers caused by allergies, hormones, menstruation, and stress Chancres: Develop with syphilis, which is a sexually transmitted infection (STI) Lymphoepithelial cysts: Bumps that usually grow underneath the tongue Mucocele: A disorder of the salivary glands that causes mucus-filled cysts in your mouth Red sores: Occur with herpes and human immunodeficiency virus (HIV) Squamous papilloma: Typically occur with human papillomavirus (HPV) and are mostly benign, but large lesions can become cancerous A dentist may want to check any bumps and sores on your tongue or elsewhere in your mouth that linger longer than two weeks. Oral cancers typically grow on the lateral and ventral surfaces of the tongue. Glossitis is inflammation and swelling of the tongue that makes it look smooth. Atrophic glossitis, also known as "bald tongue" or "smooth tongue," occurs if you lose some or all papillae. You may have symptoms like pain and taste changes. Research has shown that atrophic glossitis is sometimes the only symptom of celiac disease. This autoimmune disorder, which is triggered by gluten, damages the small intestine. The hallmark symptoms of celiac disease are usually abdominal pain, bloating, constipation, and diarrhea. You might also notice that you lose the little hairs that dot the surface of your tongue. Sjögren's syndrome is another cause of atrophic glossitis. This autoimmune disorder targets the glands in your eyes and mouth that create moisture. An overgrowth of the yeast (fungus) Candida albicans causes oral thrush. This yeast infection looks like a heavy, white coating on your tongue. Conditions that may cause oral thrush include: Diabetes: Oral thrush is common among people with diabetes, especially if their blood glucose (sugar) is not within a healthy range. Some people with diabetes develop a weak immune system. This makes it hard for the body to fight off germs. HIV: Oral thrush is one of the first signs of HIV. A weak immune system, as with diabetes, is often the cause. Sjögren's syndrome: Dry eyes and mouth may lead to oral thrush. Yeast starts to grow out of control if you do not have enough saliva. An uncontrolled growth of cells in your mouth may produce white patches on your tongue that look similar to oral thrush. This condition, known as leukoplakia, can be harmless or lead to certain types of cancer. A healthcare provider may surgically remove the affected area. See a healthcare provider right away if you notice white cauliflower-like masses on your tongue. Hairy-looking growths, or hairy leukoplakia, may appear on the sides of your tongue. Hairy leukoplakia normally goes away on its own. A healthcare provider may prescribe medications to treat them if they are severe or cause pain. Common causes of hairy leukoplakia include: Epstein-Barr virus (EPV), which commonly causes infectious mononucleosis (mono) HIV/AIDS Weak immune system A build-up of dead skin cells commonly causes a black tongue, which is generally not a sign of a severe condition. Dead skin cells may stop shedding due to poor oral hygiene or certain medications, including antibiotics. Smoking and drinking a lot of coffee or tea can also cause a black tongue. Tobacco and caffeine can stain the papillae, which make your tongue look black. A sore tongue might occur with diabetes. Canker sores, which are often a sign of stress, can also cause soreness. Try easing stress with deep breathing, exercise, meditation, and yoga. Here are some ways to alleviate soreness: Take over-the-counter (OTC) pain relievers Gargle with warm salt water Avoid greasy foods in favor of soft and cold foods like yogurt A burning sensation, or burning mouth syndrome, can be a symptom of xerostomia (dry mouth). Dehydration and certain medications commonly cause dry mouth. Other causes of burning mouth syndrome include: Allergies to dental appliances or foods Depression Gastroesophageal reflux disease (GERD), which causes stomach acid to flow backward into the esophagus Nerve damage Nutritional deficiencies  Oral thrush Teeth grinding or jaw clenching Macroglossia causes your tongue to be larger than average. It's most common in people with conditions that are inherited or congenital (present at birth). Examples include Down syndrome and congenital hypothyroidism, or an underactive thyroid gland. Fissures are deep grooves on your tongue in which food particles can become trapped. Common causes include older age, dehydration, and vitamin deficiencies. Conditions like Down syndrome and Sjögren's syndrome, which causes dry eyes and mouth, may also cause fissures. Your tongue may be able to tell you a lot about your overall health. It's important to know what your tongue looks like when it's healthy. A healthy tongue is a pinkish-red color. A moist layer of tissue, or mucosa, lines the surface of your tongue. You will notice papillae, which look like small bumps on the back of your tongue. Your taste buds, which help you taste the salty, sweet, or sour flavors of food, sit among papillae. A healthcare provider can prescribe treatments based on your symptoms and what's causing them. It's essential to see a dentist at least twice per year to make sure your teeth and tongue are healthy. Here are some ways you can clean your tongue at home naturally: Avoid tobacco and caffeine: Avoid smoking and drinking coffee or tea to avoid staining the papillae on your tongue. Brush your tongue: You can clean your tongue using a soft-bristled toothbrush while brushing your teeth. Make sure to brush your teeth at least twice per day with fluoride toothpaste. Eat a nutrient-rich diet: Limit sugary foods and drinks. Use a tongue scraper: This U-shaped tool cleans your tongue. It pulls bacteria and dead skin cells off of it. Reach out to a healthcare provider if symptoms do not improve or if it's hard to breathe or eat. Make sure to keep note of symptoms like pain, swelling, breathing problems, dysphagia (difficulty swallowing), and problems with speaking or moving the tongue. A healthcare provider may order blood tests or a biopsy to check for other conditions. Your tongue helps you taste, eat your food, and talk, and it also provides a snapshot of your overall health. Signs like a red, smooth, black, or sore tongue and bumps or soreness may be signs of several infections and illnesses. Consult a healthcare provider if you notice your tongue is not its normal pinkish color or develops thick, cottage-cheese-looking spots or ulcers.

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