Are Tonsil Stones and Bad Breath Connected?
Most infections of the upper respiratory tract system (URIs) can lead to bad breath. These include any acute infection that involves the nose, sinuses, pharynx or larynx. Tonsillitis and sinusitis are examples of upper respiratory tract infections.
Sometimes URIs become chronic or can reoccur very frequently with the consequence that bad breath becomes very persistent too.
Chronic or recurrent URIs are in fact one of the causes of chronic fetid tonsillitis (or chronic caseous tonsillitis), otherwise known as tonsilloliths, and commonly named tonsil stones. However, tonsil stones and bad breath are often present in very healthy individuals with no history of chronic or recurrent URIs.
In this post I will talk about about what tonsil stones are and how they form, and I will explain the relationship between tonsil stones and bad breath. The causes of tonsil stones and contributing factors will be discussed in detail.
What Are Tonsil Stones (Tonsilloliths) and How Do They Form?
The tonsils are naturally filled with crevasses (called tonsillar crypts) where bacteria, fungi, dead cells, mucous, food particles, and other foreign objects get trapped. This leads to the formation of tonsil stones – technically known as tonsilloliths or chronic fetid (caseous) tonsillitis – which form when all this trapped debris hardens, as it calcifies.
Tonsil stones are in fact formed like pearls, layer after layer. They start maybe with a small lump of food or a bit of mucous which gets trapped in one of the crypts; then successive layers are created on top of this initial lump (stratification).
In the case of a lump of food for instance, the process starts with digestive enzymes present in saliva breaking down the trapped food. While the carbohydrates will melt away, harder bits will remain inside the crypt. Bacteria will then start colonising the area, as they will feel very attracted to these remains, and so they will form another layer on top of the broken down food.
More layers may be added, such as layers made of dead cells that used to form the lining of the mouth for instance. The next layer may come from mucous, then more layers of bacteria will add on top …. and so on. In addition, white cells present inside the tonsils will also attack this mix of materials and surround it. The tonsillolith can this way grow bigger and bigger indefinitely – particularly if there is plenty of room for it – unless it is removed, swallowed, coughed up, etc.
Tonsil stones are a therefore a concentrically laminated pattern, composed of many different substances and organisms. But what is important to notice here is the fact that tonsil stones are absolutely crammed with bacteria; literally layer upon layer! And this is the main reason why tonsil stones smell so putrid; in particular, the anaerobic bacteria which create volatile organic compounds are responsible for most of the unpleasant odours.
In fact, several studies show that tonsilloliths are actually a living biofilm (similar to dental plaque). There are both aerobic and anaerobic layers of bacteria present in them, which calcify over time. The consistency evolves from a soft gel to a hardened stone, as layers are formed and the materials calcify.
The characteristic pungent smell is mostly due to the volatile compounds produced by the anaerobic bacteria located near the nucleous. Recent studies have shown that the anaerobic bacteria deep inside the tonsillolith are metabolically active: this means that a tonsil stone is really “alive” and keeps producing nasty smells indefinitely, as long as the anaerobic bacteria inside the nucleus (where there is very little oxygen) are active.
Note that giant tonsilloliths such as the one displayed on this photo are rare. However, smaller tonsil stones are very common and they produce the same foul odours as the big ones. Most people are not aware that their tonsil crypts are full of debris (not necessarily hardened yet in the form of a calcified stone) which is causing their halitosis.
What Causes Tonsil Stones?
Most people with healthy tonsils have very small tonsil stones forming more or less regularly inside their tonsil crypts (rarely larger than about 1mm in diameter). Usually these are not numerous nor big in size and are hidden pretty deep somewhere inside the labyrinthine net of nooks and cranies that form the tonsils. These are benign and harmless and will rarely be felt or cause any health problems.
These small tonsilloliths can be accidentally released when laughing, singing, talking, coughing or performing any activity that involves squeezing the tonsils. In fact, most people end up swallowing them without noticing. Usually, the small size of the crypts and the fact that any small stones that may form are likely to be eventually released and swallowed, guarantees that no large tonsilloliths can ever form.
Although it is quite difficult to determine exactly why some people are prone to the formation of large tonsil stones, there are indeed a few factors that play a significant role. There are factors that may increase the speed at which tonsil stones form and other factors that may not only encourage tonsil stone formation but also impair adequate elimination of the calcified matter before it becomes too large.
Here is a list of what causes tonsil stones to form (main predisposing factors):
1.- Large or scarred tonsil crypts: The bigger and the more scarred the tonsil crevasses are, the higher the probability that larger tonsil stones will form. Hence, if your tonsil crypts are enlarged and permanently damaged – for whatever reason, usually because of recurrent bouts of tonsillitis or other upper respiratory tract infections that affect the tonsils (past or present) – and the openings of the crypts are quite exposed, then it is quite likely that you regularly produce larger than average tonsil stones.
The same applies when the crypts are not necessarily big but very numerous; the tonsils may have a higher than average amount of pits, folds and tunnels, where debris, mucous, etc can easily get trapped.
2.- Chronic or frequent throat infections: Irrespectively of whether the recurrent infections (tonsillitis, strep throat, etc) are causing permanent enlargement or scarring of the tonsils, when there is a chronic infection present, the tonsils are not able to function adequately. Pus, inflammation, crypt enlargement, presence of excessive amounts of bacteria, etc, all create an environment more prone to tonsil stone formation.
3.- Excessive mucous production: Sinus problems, rhinitis and post-nasal drip can lead to the production of large amounts of mucous, which can then drip down the back of the throat and easily get inside the tonsil pockets as well. Mucous attracts bacteria, and so tonsilloliths can rapidly form when large amounts of mucous and bacteria regularly make their way inside the crypts.
4.- Under-active salivary glands / Dry mouth: Saliva has many functions, but one of them is to help clean the mouth, to wash away debris. When saliva levels decrease, either chronically or temporarily, debris in the mouth sticks more easily and it can build up in the tonsils. Tonsils are not moisturised as they should be and all these factors are thought to increase the risk of tonsil stone formation.
5.- Acid reflux disease (GERD): Acids in the stomach that regurgitate back into the esophagus can sometimes reach the tonsillar area. This may increase the risk of tonsil stone formation. Note that this is very rare (even in severe cases of acid reflux, food particles or acids do not normally reach the tonsillar area).
6.- Tonsils not functioning properly due to sickness or allergies: The main function of the tonsils is to help the body get rid of foreign bodies and germs at an early stage, just as they enter the system. They do so by filtering foreign viruses, bacteria, debris, etc, and subsequently attacking them via the white cells.
In most cases, if the tonsils are working adequately and are not scarred with large crypts, foreign bodies and micro organisms will either be eliminated or get killed by the white cells inside the tonsils.
Even when small tonsil stones are formed, these will eventually make their way out of the body when accidentally coughed, swallowed (down the stomach and eventually expelled), etc.
In addition, healthy tonsils are quite likely involved in the regulation and control of the amounts and types of bacteria present in the mouth.
If the functionality of the tonsils is impaired somehow – for whatever reason, be it temporary or chronic – adequate filtering, break down and elimination of trapped matter and micro organisms inside the tonsils is not carried out effectively and gradually large tonsil stones can form inside the crypts.
7.- Consumption of dairy: I am not of the opinion that avoiding certain foods altogether is a solution to any problem – unless there is of course an allergy or intolerance of some kind involved. However, there seems to be anecdotal evidence that consumption of dairy products can increase the frequency of build-up of tonsil stones in the crypts.
Unfortunately there is not much research done in this area yet and I would advise you not to make any radical changes in your diet unless you have spoken to your family doctor or a dietician first.
If you suspect a dairy allergy or intolerance consult with your doctor straight away. Sensitivities or intolerances (without being necessarily an allergy as such) can cause the palatine tonsils or adenoids to enlarge and swell, as well as increased mucous production (and congestion), post nasal drip etc. This in turn can increase the chances of getting large tonsil stones inside the crypts.
8.- Unhealthy diet: High consumption of foods such as refined sugars, trans fats, etc can lead to a compromised immune system. The tonsils are part of the immune system, and so they will not function adequately if your immune system as a whole is weak. Tonsils that do not do their job properly, as discussed above, can end up producing frequent and / or large tonsil stones.
9.- Unhealthy mouth: Having an infected tooth, large amounts of plaque or tartar, periodontal disease or any other type of infection in your mouth means that large amounts of harmful bacteria are present inside the oral cavity; the oral flora is very unbalanced.
These excessive amounts of bacteria will quickly colonise the tongue and the tonsils as well. Therefore, an unhealthy oral flora may be a contributing factor to the formation of tonsil stones, since a poor chemical balance in the mouth may make them grow at a faster pace.
In the same way, having poor oral hygiene can have the same effect on how healthy your tonsils are. Both food particles and bacteria can quickly build up inside the tonsils if the mouth is not properly cleaned after each meal.
10.- Pregnancy: There is anecdotal evidence that a significant amount of women see the frequency of tonsil stone production increased during pregnancy, or even start producing large tonsil stones for the first time.
There may be several factors involved that can encourage tonsillolith buildups during pregnancy. Increased intake of dairy, post-nasal drip due to hormone changes, inadequate cleaning of the oral cavity (brushing teeth, tongue, etc) due to increased gag reflex, frequent vomiting, and “pregnancy gingivitis” due to hormonal changes may be some factors that increase the risk of tonsil stone formation.
Note: not all the above predisposing factors need apply. For instance, you may be very healthy, have excellent oral hygiene, with no allergies, sinus or post-nasal drip problems, nor any chronic throat infections at present.
However, you may have larger than average tonsil crypts with exposed openings, and perhaps you tend to eat a lot of dairy as well; these two factors may be sufficient to guarantee the frequent formation of tonsil stones and the presence of chronic bad breath as a consequence.
Tonsil Stones and Bad Breath – Research Shows There is a Clear Link:
Although there are some people who suffer from tonsil stones and report no bad breath at all, it has been shown that there is a clear link between tonsillolith presence in the tonsils and chronic halitosis:
“Forty-nine patients with halitosis and chronic caseous tonsillitis (CCT), 17 male (35%) and 32 female (65%), were selected among patients referred for CO(2) laser cryptolysis. Anamnesis, physical examination and VSC halitometry were carried out. (…) A tonsillolith was present in 75% of the patients with abnormal halitometry and only 6% of patients with normal halitometry values. (…) The presence of a tonsillolith represents a tenfold increased risk of abnormal VSC halitometry and can be considered as a predictable factor for abnormal halitometry in patients with CCT.”
Source: “Relationship Between the Presence of Tonsilloliths and Halitosis in Patients with Chronic Caseous Tonsillitis”, Br Dent J. 2008 Jan 26;204(2):E4. Epub 2007 Nov 23, Rio AC, Franchi-Teixeira AR, Nicola EM. Dental Surgeon/Doctoral Student in Medical Sciences, Department of Otolaryngology, Faculty of Medical Sciences, State University of Campinas-UNICAMP, Campinas, São Paulo 13083-970, Brazil.
Therefore, it is reasonable to think that the more tonsil stones your tonsils contain at any given time and the larger they are, the higher the risk of suffering from bad breath.
It is clear that tonsil stones and bad breath go hand in hand, and so it is important that you determine whether your tonsils are prone to gathering debris, so you can establish if you suffer from tonsil stones and bad breath.
If you would like to know:
- What tests you can do at home to find out if you suffer from tonsil stones (even when it appears there are none!), and
- The little known proven techniques and tools you can use regularly to remove them safely and effectively as well as what you need to do to prevent their formation, click here to download this extensive (152-page) step by step guide, which contains no less than 25 pages exclusively dedicated to tonsil stones and bad breath.