How is black hairy tongue managed and treated?

From the Guidelines

Black hairy tongue is primarily managed through improved oral hygiene and elimination of contributing factors, with the most crucial step being gentle brushing of the tongue daily with a soft toothbrush or tongue scraper to physically remove the elongated papillae and accumulated debris. This condition results from defective desquamation of the filiform papillae on the tongue surface, allowing them to elongate and trap bacteria, yeast, and food debris, which creates the characteristic dark, furry appearance. Management involves:

• Brushing the tongue from back to front, using mild toothpaste or a mixture of baking soda and water
• Rinsing mouth with an alcohol-free mouthwash, such as rinsing upon awakening and at least four times a day after brushing, for ∼1 min with 15 ml mouthwash; gargling; and then spitting out, as recommended by the ESMO clinical practice guidelines 1
• Avoiding eating and drinking during the first half hour after rinsing
• Identifying and discontinuing contributing factors, including tobacco use, excessive coffee or tea consumption, oxidizing mouthwashes, and medications like antibiotics (particularly linezolid and tetracyclines)
• Maintaining adequate hydration and practicing good oral hygiene, which can help resolve most cases within days to weeks. Pseudo black hairy tongue, on the other hand, may require a different approach, but the fundamental principle of improving oral hygiene and addressing underlying causes remains the same.

From the Research

Black Hairy Tongue

• Black hairy tongue (BHT) is a benign medical condition characterized by elongated filiform lingual papillae with a typical carpet-like appearance of the dorsum of the tongue 2.
• The prevalence of BHT varies geographically, typically ranging from 0.6% to 11.3% 2, 3.
• Known predisposing factors include smoking, excessive coffee/black tea consumption, poor oral hygiene, trigeminal neuralgia, general debilitation, xerostomia, and medication use 2, 4.

Pseudo Black Hairy Tongue

• Pseudo-BHT is included in the differential diagnosis of BHT, along with acanthosis nigricans, oral hairy leukoplakia, pigmented fungiform papillae of the tongue, and congenital melanocytic/melanotic nevi/macules 2.
• The clinical presentation of pseudo-BHT may be similar to BHT, but the diagnosis relies on visual observation, detailed history taking, and occasionally microscopic evaluation 2.

Management and Treatment

• Treatment of BHT involves identification and discontinuation of the offending agent, modifications of chronic predisposing factors, patient reassurance of the benign nature of the condition, and maintenance of adequate oral hygiene with gentle debridement to promote desquamation 2, 4.
• Gentle brushing of the tongue is a common treatment approach, and many anecdotal reports exist demonstrating the use of medications or other products to treat this condition 4, 5.
• Complications of BHT, such as burning mouth syndrome, halitosis, nausea, gagging, and dysgeusia, typically respond to therapy, and the prognosis is excellent with treatment of underlying medical conditions 2, 3.