What is the best course of action for a patient with a black lesion on their tongue, considering potential referral to a dentist (dental specialist) or ENT (Ear, Nose, and Throat) specialist?

Black Tongue Lesion: Referral to Dentist or ENT

For a black tongue lesion, refer to an ENT specialist (otolaryngologist) for urgent evaluation and biopsy within 2 weeks, as the lateral tongue is a high-risk site for malignancy and tissue diagnosis is mandatory to exclude oral squamous cell carcinoma. 1

Immediate Triage: Rule Out Malignancy First

The primary concern with any persistent black or pigmented tongue lesion is malignancy, particularly primary oral melanoma or squamous cell carcinoma. 2 The lateral tongue represents a high-risk anatomic location for malignant transformation, and non-homogeneous lesions require urgent tissue diagnosis. 1

Red Flags Requiring ENT Referral (Within 2 Weeks):

• Non-homogeneous appearance (mixed colors, irregular borders, raised areas) 1
• Lateral tongue location - high-risk site for oral cancer 1
• Patient age >40 years - single most important demographic risk factor 3
• Ulceration, induration, or firmness on palpation 3
• Persistent lesion >2-3 weeks despite conservative management 1
• Associated symptoms: ipsilateral otalgia, dysphagia, odynophagia, unexplained weight loss, or blood in saliva 3
• Cervical lymphadenopathy - firm, fixed nodes >1.5 cm 3

When Dentist Referral Is Appropriate

Refer to a dentist or oral medicine specialist only if the lesion appears benign AND meets criteria for black hairy tongue (lingua villosa nigra):

Benign Black Hairy Tongue Characteristics:

• Elongated filiform papillae on dorsum of tongue giving hairy appearance 4, 5
• Symmetric distribution on midline dorsal tongue (not lateral) 4
• Easily scraped or brushed - pigment accumulation from bacteria, food, fungi 4
• Recent antibiotic use (especially ceftriaxone), proton pump inhibitors, or poor oral hygiene 5
• Young patient or clear predisposing factor (vitamin C supplementation in infants) 4

Critical Diagnostic Algorithm

Step 1: Attempt to Scrape the Lesion

• If the black discoloration can be wiped or scraped away, consider candidiasis or black hairy tongue 1
• If the lesion cannot be removed and is firm or indurated, this suggests leukoplakia, melanoma, or carcinoma requiring biopsy 1

Step 2: Assess Location and Morphology

• Lateral tongue, ventral tongue, or floor of mouth = high-risk sites → ENT referral 1
• Dorsal midline tongue with hairy appearance = likely benign black hairy tongue → dentist referral 4

Step 3: Document Risk Factors

• Tobacco and alcohol use - synergistic risk for squamous cell carcinoma 3
• Recent medication changes - antibiotics, PPIs, bismuth-containing products 5
• Immunosuppression - HIV, transplant, chemotherapy 6

Step 4: Pre-Referral Laboratory Testing (If ENT Referral)

Before ENT consultation, obtain: 1

• Full blood count - rule out leukemia, anemia
• Coagulation studies - ensure no surgical contraindications for biopsy
• Fasting blood glucose - assess risk for invasive fungal infection

Common Pitfalls to Avoid

Do not assume a black tongue lesion is benign without histologic confirmation - primary oral melanoma is rare but highly aggressive, and early diagnosis is critical for survival. 2 The lateral tongue is a high-risk site for oral squamous cell carcinoma. 1

Do not delay biopsy for empiric antifungal treatment - if candidiasis is suspected, attempt to scrape the lesion first; persistent lesions after 2 weeks of antifungal therapy require biopsy. 1

Do not prescribe multiple courses of antibiotics without definitive diagnosis - this delays cancer diagnosis and worsens outcomes. 3

Do not rely on clinical appearance alone to distinguish between benign pigmentation, leukoplakia, lichen planus, and early malignancy - histopathology is essential. 1

Immediate Management Pending Specialist Evaluation

• Document lesion size, exact location, and obtain photographs if possible 1
• Counsel on tobacco and alcohol cessation if applicable 1
• Gentle tongue brushing with soft toothbrush if black hairy tongue suspected 4
• Schedule biopsy within 2 weeks for non-homogeneous lesions or any concerning features 1

Summary: Dentist vs. ENT Decision

Choose ENT if:

• Lateral tongue location 1
• Cannot be scraped away 1
• Patient >40 years old 3
• Ulceration, induration, or asymmetry 3
• Any red flag symptoms 3

Choose Dentist if:

• Dorsal midline tongue 4
• Hairy appearance with elongated papillae 4
• Recent antibiotic/PPI use 5
• Young patient with clear benign etiology 4