“Hairy tongue” is a clinical term describing an abnormal coating on the dorsal surface of the tongue. The incidence of this condition ranges from 0.5% in the United States to 12.8% among Israeli male geriatric patients and 57% among imprisoned Greek drug addicts.Hairy tongue results from the defective desquamation of cells that make up the secondary filiform papilla. This buildup of keratin results in the formation of highly elongated hairs, which is the hallmark of this entity.
The cause of black hairy tongue is unknown; however, there are several initiating or contributing factors. These include tobacco (heavy smoking) and psychotropic agents.Other predisposing factors include broad-spectrum antibiotics such as penicillin and the use of systemic steroids.The use of oxidizing mouthwashes or antacids and the overgrowth of fungal or bacterial organisms have also been associated with this condition. Radiation therapy for head and neck malignancies is
considered a major factor as well. Importantly, poor oral hygiene can exacerbate this condition. The common etiologic factor for all of these influences may be the alteration of the oral flora by the overgrowth of yeast and chromogenic bacteria.
(See Chapters 4 and 7 for a more thorough discussion of this entity and its treatment.)
Hairy tongue usually involves the anterior two-thirds of the dorsum of the tongue, with a predilection for the midline just anterior to the circumvallate papillae. The patient presents with elongated filiform papillae and lack of desquamation of the papillae. The tongue therefore appears thickened and matted. Depending on the diet and the type of organisms present, the lesions may appear to range from yellow to brown to black or tan and white. Although the lesions are usually asymptomatic, the papillae may cause a gag reflex or a tickle in the throat if they become especially elongated (Figure 5-45). They may also result in halitosis or an abnormal taste. A biopsy is usually unnecessary. Treatment consists of eliminating the predisposing factors if any are present. Cessation of smoking or discontinuation of oxygenating mouthwashes or antibiotics will often result in resolution. Improvement in oral hygiene is also important, especially brushing or scraping of tongue, in addition to other good oral hygiene practices. Podophyllin resin (a keratolytic agent) has been used in treatment, but there are some questions about its safety. However, a 1% solution of podophyllin resin is available for the treatment of hairy tongue. The efficacy of tooth brushing can be enhanced by a prior application of a 40% solution of urea. Topical tretinoin has recently been tried as treatment of this entity.Oral Submucous Fibrosis
Oral submucous fibrosis (OSF) is a slowly progressive chronic fibrotic disease of the oral cavity and oropharynx, characterized by fibroelastic change and inflammation of the mucosa, leading to a progressive inability to open the mouth, swallow, or speak.These reactions may be the result of either direct stimulation from exogenous antigens like Areca alkaloids or changes in tissue antigenicity that may lead to an autoimmune response. It occurs almost exclusively in inhabitants of Southeast Asia, especially the Indian subcontinent.
The inflammatory response releases cytokines and growth factors that promote fibrosis by inducing the proliferation of fibroblasts, up-regulating collagen synthesis and down-regulating collagenase production.
ETIOLOGYEven though the etiopathology is incompletely understood, several factors are believed to contribute to the development of OSF, including general nutritional and vitamin deficiencies and hypersensitivity to certain dietary constituents such as chili peppers, chewing tobacco, etc.However, the primary factor is the habitual use of betel and its constituents, which include the nut of the areca palm ( Areca catechu), the leaf of the betel pepper ( Piper betle), and lime (calcium hydroxide). Approximately 200 million persons chew betel regularly throughout the western
Pacific basin and south Asia.
Only three drugs (nicotine, ethanol, and caffeine) are consumed more widely than betel. When betel is chewed, it produces mild psychoactive and cholinergic effects. Betel use is also associated with oral leukoplakia and squamous cell carcinoma.
OSF is regarded as a premalignant condition, and many cases of oral cancer have been found coexisting with submucous fibrosis.
Cases of submucous fibrosis have been reported in many Western countries, especially in individuals who have immigrated from the Indian subcontinent.
CLINICAL FEATURES
The disease first presents with a burning sensation of the mouth, particularly during consumption of spicy foods. It is often accompanied by the formation of vesicles or ulcerations and by excessive salivation or xerostomia and altered taste sensations. Gradually, patients develop a stiffening of the mucosa, with a dramatic reduction in mouth opening and with difficulty in swallowing and speaking. The mucosa appears blanched and opaque with the appearance of fibrotic bands that can easily be palpated. The bands usually involve the buccal mucosa, soft palate, posterior pharynx, lips, and tongue. OSF usually affects young individuals in the second and third decades of life but may occur at any age. Histologic examination reveals severely atrophic epithelium with complete loss of rete ridges. Varying degrees of epithelial atypia may be present. The underlying lamina propria exhibits severe hyalinization, with homogenization of collagen. Cellular elements and blood vessels are greatly reduced.
TREATMENT AND PROGNOSIS
OSF is very resistant to treatment. Many treatment regimens have been proposed to alleviate the signs and symptoms, without much success. Submucosal injected steroids and hyaluronidase, oral iron preparations, and topical vitamin A and steroids are some of the agents that have been used.
All of these therapies are essentially palliative. In severe cases, surgical intervention is the only treatment, but the fibrous bands and other symptoms often recur within a few months to a few years.
The use of an oral stent as an adjunct to surgery to prevent relapse has also been studied.
OSF is considered to be a premalignant condition. In a 17-year follow-up study in India, oral cancer developed in 7.6% of patients with submucous fibrosis. The malignant transformation rate for submucous fibrosis was 4 to 13%
(See Chapters 4 and 7 for a more thorough discussion of this entity and its treatment.)
Hairy tongue usually involves the anterior two-thirds of the dorsum of the tongue, with a predilection for the midline just anterior to the circumvallate papillae. The patient presents with elongated filiform papillae and lack of desquamation of the papillae. The tongue therefore appears thickened and matted. Depending on the diet and the type of organisms present, the lesions may appear to range from yellow to brown to black or tan and white. Although the lesions are usually asymptomatic, the papillae may cause a gag reflex or a tickle in the throat if they become especially elongated (Figure 5-45). They may also result in halitosis or an abnormal taste. A biopsy is usually unnecessary. Treatment consists of eliminating the predisposing factors if any are present. Cessation of smoking or discontinuation of oxygenating mouthwashes or antibiotics will often result in resolution. Improvement in oral hygiene is also important, especially brushing or scraping of tongue, in addition to other good oral hygiene practices. Podophyllin resin (a keratolytic agent) has been used in treatment, but there are some questions about its safety. However, a 1% solution of podophyllin resin is available for the treatment of hairy tongue. The efficacy of tooth brushing can be enhanced by a prior application of a 40% solution of urea. Topical tretinoin has recently been tried as treatment of this entity.Oral Submucous Fibrosis
Oral submucous fibrosis (OSF) is a slowly progressive chronic fibrotic disease of the oral cavity and oropharynx, characterized by fibroelastic change and inflammation of the mucosa, leading to a progressive inability to open the mouth, swallow, or speak.These reactions may be the result of either direct stimulation from exogenous antigens like Areca alkaloids or changes in tissue antigenicity that may lead to an autoimmune response. It occurs almost exclusively in inhabitants of Southeast Asia, especially the Indian subcontinent.
The inflammatory response releases cytokines and growth factors that promote fibrosis by inducing the proliferation of fibroblasts, up-regulating collagen synthesis and down-regulating collagenase production.
ETIOLOGYEven though the etiopathology is incompletely understood, several factors are believed to contribute to the development of OSF, including general nutritional and vitamin deficiencies and hypersensitivity to certain dietary constituents such as chili peppers, chewing tobacco, etc.However, the primary factor is the habitual use of betel and its constituents, which include the nut of the areca palm ( Areca catechu), the leaf of the betel pepper ( Piper betle), and lime (calcium hydroxide). Approximately 200 million persons chew betel regularly throughout the western
Pacific basin and south Asia.
Only three drugs (nicotine, ethanol, and caffeine) are consumed more widely than betel. When betel is chewed, it produces mild psychoactive and cholinergic effects. Betel use is also associated with oral leukoplakia and squamous cell carcinoma.
OSF is regarded as a premalignant condition, and many cases of oral cancer have been found coexisting with submucous fibrosis.
Cases of submucous fibrosis have been reported in many Western countries, especially in individuals who have immigrated from the Indian subcontinent.
CLINICAL FEATURES
The disease first presents with a burning sensation of the mouth, particularly during consumption of spicy foods. It is often accompanied by the formation of vesicles or ulcerations and by excessive salivation or xerostomia and altered taste sensations. Gradually, patients develop a stiffening of the mucosa, with a dramatic reduction in mouth opening and with difficulty in swallowing and speaking. The mucosa appears blanched and opaque with the appearance of fibrotic bands that can easily be palpated. The bands usually involve the buccal mucosa, soft palate, posterior pharynx, lips, and tongue. OSF usually affects young individuals in the second and third decades of life but may occur at any age. Histologic examination reveals severely atrophic epithelium with complete loss of rete ridges. Varying degrees of epithelial atypia may be present. The underlying lamina propria exhibits severe hyalinization, with homogenization of collagen. Cellular elements and blood vessels are greatly reduced.
TREATMENT AND PROGNOSIS
OSF is very resistant to treatment. Many treatment regimens have been proposed to alleviate the signs and symptoms, without much success. Submucosal injected steroids and hyaluronidase, oral iron preparations, and topical vitamin A and steroids are some of the agents that have been used.
All of these therapies are essentially palliative. In severe cases, surgical intervention is the only treatment, but the fibrous bands and other symptoms often recur within a few months to a few years.
The use of an oral stent as an adjunct to surgery to prevent relapse has also been studied.
OSF is considered to be a premalignant condition. In a 17-year follow-up study in India, oral cancer developed in 7.6% of patients with submucous fibrosis. The malignant transformation rate for submucous fibrosis was 4 to 13%