Photo Rounds

Discoloration of the tongue

A 60-year-old man sought care at his family physician (FP)’s office smelling of alcohol and tobacco. He complained of a black discoloration of his tongue and an occasional gagging sensation. He acknowledged that on a daily basis, he smoked one to 2 packs of cigarettes and drank 6 to 8 beers. On physical exam, his teeth were stained and his tongue shows elongated papillae with brown discoloration.

What's your diagnosis?


This patient had a black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction. BHT is a benign disorder of the tongue characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. In addition, there is defective desquamation of the papillae on the dorsal tongue, resulting in a hair-like appearance. These papillae, which are normally about 1 mm in length, may become as long as 12 mm. The elongated filiform papillae can then collect debris, bacteria, fungus, or other foreign materials.

In a literature review of reported cases of drug-induced BHT, 82% were caused by antibiotics. Dry mouth (xerostomia) from medications, tobacco, and radiation therapy can also lead to BHT. Patients may be asymptomatic. However, the accumulation of debris in the elongated papillae may cause taste alterations, nausea, gagging, halitosis, and pain or burning of the tongue.

The diagnosis is made by visual inspection. Patients with BHT have a black, brown, or yellow discoloration of their tongue, depending on foods ingested, tobacco use, and the amount of coffee or tea consumed. In this case, the FP recommended that the patient avoid predisposing risk factors (eg, tobacco, alcohol). She also recommended regular tongue brushing (using a soft toothbrush or tongue scraper) and an appointment with a dentist.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Gonsalves W. Black hairy tongue. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:226-231.

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