A 60-year-old man who smokes presents to the physician's office smelling of alcohol. He complains of a black discoloration of his tongue and a gagging sensation on occasion. He admits to smoking 1 to 2 packs per day along with drinking at least 6 to 8 beers per day. The patient brushes his teeth infrequently and has not seen a dentist for a long time. On physical exam, his teeth are stained and his tongue shows elongated papillae with brown discoloration (Figure 37-1). Diagnoses include black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction.