Tonsil Stones: The Cause of Your Bad Breath?

Tonsil stones at a glance:
Tonsil stones cause persistent bad breath that never goes away and that can’t be covered up by mints, flossing, brushing, or drugstore mouthwashes. Also known as tonsilloliths or tonsil lithiases (the plural of lithiasis, or stone), these calcified aggregations of dead bacteria and mucus collect in the back of the throat in the palatine or pharyngeal tonsils, where in extreme cases they appear as white or off-white “stones” the size of a grain of rice or larger. Most stones, however, remain too small to be seen and instead make themselves known mainly through their offensive odor.

No Ordinary Halitosis

Tonsil stones can be an exasperating problem and if you’ve reached this page, it’s probably because you’re desperate for a solution to the most frustrating symptom of tonsil stones: horrible bad breath.

So let’s start by looking at what distinguishes tonsil stones breath from ordinary, run-of-the-mill halitosis.

Everybody has bad breath at some time. We’ve all had the unpleasant experience of bad breath after eating onions or garlic. And we’ve all had the experience of bad breath when it just isn’t possible to brush, or when we have a cough, a cold or the flu.

This kind of bad breath – sometimes called situational bad breath – is relatively easy to treat. A mint or a burst of breath spray usually does the trick.

Tonsil stones, however, cause bad breath of an entirely different order of magnitude.

That’s because they result from an infection of the tonsils with Streptococcus bacteria, an infection called tonsillitis that may have occurred many years before the actual symptoms of a stone become noticeable.

It All Starts with the Tonsils

An understanding of tonsil stones requires some understanding of the tonsils themselves and how they become infected with the Streptococcus germ.

Tonsils are made up of stratified non-keratinized squamous cell tissue. They grow much like the skin with a basal layer generating cells in strata that resembles rows of bricks. Newer cells push older cells to the surface, and dying cells slough off as the newer cells replace them.

The difference between tonsil tissue and skin is that the outermost layer of tissue in the tonsils is non-keratinized. So instead of being tough, it’s soft. The tonsils are squamous, which is to say the layers of cells stick together.

There are two palatine tonsils on either side of the back of the mouth, just below mucus-producing glands in a small expanse of mucus tissue. There are also pharyngeal tonsils (also called adenoids), tubal tonsils in the throat and lingual tonsils at the base of the tongue. Of these, the palatine and lingual tonsils are lined with long tonsil crypts that can collect bacteria, food particles and mucus.

The palatine tonsils — the tonsils we can see — serve as the immune system’s first line of defense against inhaled disease organisms. The two palatine tonsils act a lot like flypaper, but instead of catching flies they trap bacteria in their sticky coating of mucus. The gooey mixture of bacteria and mucus hitches a ride with food on the way to the stomach.

The palatine tonsils reach their maximum size relative to the width of the throat at about the age of seven, when children are most likely to have a tonsillectomy, the surgical procedure to remove tonsil stones. They continue to grow until puberty, although the mouth and throat grow faster. After puberty, the palatine tonsils gradually recede into the lining of the mouth and are almost undetectable unless they become infected.

What Causes Tonsil Stones: The Role of Tonsillitis

Think of a tonsil stone as a remnant of the immune system’s battle against the Streptococcus bacteria,  a battle fought many years earlier in response to bacterial tonsillitis. Even after the body fights off this initial infection, a tonsil stone can take years or even decades to develop, which is why tonsil stones almost never occur before the age of twenty.

Nearly everyone has tonsillitis at some time during childhood. This inflammatory infection of the tonsils causes a painful sore throat, often accompanied by difficulty in talking, eating and swallowing. The tonsils can become so swollen that they block off the air passages at the back of the throat, sometimes causing a real danger of suffocation in children.

Infants and children under the age of two almost never get tonsillitis. Children between two and six are the age group mostly likely to get viral infections. Children over the age of six, teens and adults who get tonsillitis most commonly have Streptococcus infections. In adults, tonsillitis is relatively rare after the age of forty.

If you’ve ever had tonsillitis, you know that an infection of the tonsils with Streptococcus is often difficult to fight off.

Strep bacteria have the ability to protect themselves from the immune system by mobilizing a protein in the bloodstream called fibrin to make fibrinogen. This filamentous protein forms a clot around the bacteria that protects them from white blood cells known as macrophages. These macrophages normally hunt down and consume harmful bacteria.

This macrophage-proof fibrinogen shell is the start of a tonsil stone.

Protected from the immune system, the Strep bacteria at the heart of the newly formed stone thrive in the anaerobic (low-oxygen) environment of the tonsillar crypts. Inside the stone, these bacteria dissolve tissue and produce foul-smelling sulfur byproducts like hydrogen sulfide gas (rotten egg smell) or chemicals like cadaverine and putrescine (think cadaver and putrefy).

These byproducts are themselves toxic, killing tissue around the stone, which is then consumed by other kinds of anaerobic bacteria in and around the tonsillolith. These let off even more stinky sulfides.

Eventually, the bacteria inside the stone consume all the tissue available to them and die, but the immune system continues to try to get rid of them even after they’re dead. Macrophages continue to attack the tough, fibrous outer layer of the stone. They never succeed in penetrating it, but they die trying.

More macrophages follow them and also die on the outer layer of the stone, adding a new layer of white or yellowish-white material that eventually calcifies and hardens. Even more macrophages come along to consume the dead ones, continuing the cycle that gradually builds the stone.

This continuous assault by the immune system for months, years and even decades after the bacteria inside the stone are dead provides an ongoing source of decay and bad breath. All you may see is white spots on tonsils, but decay goes on all around the stone.

Tonsil Abscesses and Tonsil Stones

Tonsils can also become abscessed. This condition is known as a peritonsillar abscess. Unlike tonsillitis, a peritonsillar abscess is a disease not of children but of young adults. It almost never occurs before the age of twenty or after forty. And it can even occur in people who had their tonsils removed as children.

Abscesses of the tonsils usually are not caused by infection with more than one kind of microorganism and Streptococcus bacteria usually predominate. At first, the glands behind the tonsils try to protect the tonsils by producing copious amounts of mucus. The sticky mucus traps the bacteria, which are swallowed along with food for digestion.

If the production of mucus fails to get rid of the bacteria, the linings of the tonsils become inflamed. Inflammation destroys both tonsil tissue and bacteria, but we’ve already noted that Streptococcus bacteria can evade the immune system by secreting chemicals that gather protein from the bloodstream to build a wall of fibrin. As the abscess forms, the bacteria are able to protect themselves inside their tough protein casing.

A peritonsilar abscess is almost always painful, even more painful than tonsillitis. By the time people who develop such an abscess get to the doctor, they usually look and feel sick. There can be fever, earache and loss of appetite.

More serious symptoms may include trismus, or difficulty in opening the mouth. Sufferers may have muffled speech, a condition the medical literature sometimes calls “hot potato mouth”. The tonsil itself may also swell back and toward the middle of the mouth in the direction of the dumbbell-shaped uvula at the back of the mouth. In the most extreme cases, death occurs when the airway is blocked.

Eventually, most people are able to fight off the effects on a peritonsillar abscess. Just as with tonsillitis, the immune system persistently attacks the abscess and white blood cells die by the billions on the tough outer coating. Layer by layer, the abscess, dead white blood cells and mucus calcify, creating a tonsil stone.

How Common Are Tonsil Stones?

Since most of us have never heard of tonsil stones, it would be easy to assume that they are a relatively rare condition. Because large tonsil stones are rare, and because they form in adult tonsil tissue that has receded into the palate, they frequently go undiagnosed.

Even so, the calcification of a mature tonsil stone can be as large as 1” (25 mm) across. But tonsil stones more commonly present as tiny white spots on the tonsil, ranging in size from a grain of rice up to the size of a pea. This makes them large enough to generate powerful bad breath odor, but too small to be noticed on visual inspection. Tonsil stones are most commonly caught during a pre-surgical exam.

In one study, a French research team led by an ear, nose and throat specialist (ENT) gave 515 volunteers MRIs to look for tonsil stones. The study found that 33 people in the group (about 1 in 15 or 6.4%), ranging in age from twenty to seventy-seven, had at least one stone.

Most of the volunteers in the French study remembered having tonsillitis anywhere from one to fifty-five years before the exam. Most had also experienced uncontrollable bad breath their entire lives as a result of the undiagnosed and nearly invisible stone.

On this side of the Atlantic, Dr. Harold Katz, a California-based dentist, bacteriologist, bad breath authority and founder of the California Breath Clinics, reports a similar profile for his patients. He estimates that amongst Americans about 7% (roughly 1 in 14) of the general population, or almost 22 million people, suffer from tonsil stones and the bad breath they cause.

Link Between Tonsil Stones, Bad Breath and Anaerobic Bacteria

Katz is not the only medical professional to have noticed the link between persistent, debilitating bad breath and tonsil stones.

A study reported on by the National Institutes of Health (NIH) found that the presence of a tonsil stone increased the risk of abnormal halitometry, a method used to measure the levels of volatile sulfur compounds (VSCs) that cause bad breath, by tenfold!

It has been known for some time that anaerobic bacteria living in the oral cavity are the source of the VSCs responsible for many kinds of chronic bad breath.

The word “anaerobic” means “living in the absence of air or free oxygen”. In a nutshell, anaerobic bacteria thrive in an oxygen-poor environment, where they divide and multiply, producing metabolic waste products like the VSCs that make bad breath smell so bad.

Another study on the NIH website documented the existence of seven different types of anaerobic bacteria inside tonsil stones. These bacteria were found to belong to the genera eubacterium, fusobacterium, magasphaera, porphyromonas, prevotella, selenomonas and tannerella.

All of the bacteria are associated with the production of bad-smelling volatile sulfur compounds.

Treatment Options

According to Dr. Harold Katz, increasing oxygen levels inside the mouth is one of the most effective ways to kill these anaerobic bacteria and neutralize the volatile sulfur compounds they produce.

Katz, who has made frequent television appearances on America’s morning news shows, has reported good success treating tonsil stones and the horrible odor they cause with a non-invasive over-the-counter program of specially formulated oxygen-rich oral rinses and nasal sinus drops.

The best time to use these oxygenating products is when a newly formed stone has not completely calcified and is still soft and pliable. Used early enough in the life cycle of the stone, oxygenating products may be enough to dissolve it.

The products are also very helpful in reducing the activity of Strep bacteria that escape the developing stone and in keeping new stones from forming. The products also kill over twenty other species of bacteria that feed on and around the developing stone and that release most of the gases responsible for “everyday” bad breath.

This treatment regimen works well for most people, although some may require more invasive treatments like curettage, laser ablation or even a complete tonsillectomy to alleviate their problems with tonsil stones.