DEAR DOCTOR, Sometimes when I brush my teeth and rinse my mouth, I notice small white bits that I’m told are tonsil stones. They have an unpleasant smell. What causes them? How bad can they get and how do I get rid of them? IVAN DEAR IVAN, Tonsil stones (tonsilloliths) are hard, white or yellow formations located within or around tonsils. They may range from size of a rice grain to that of a grape or even bigger. The tonsils are made of crevices, tunnels and pits called tonsil crypts. Dead cells, mucus saliva, food particles can get trapped in these crevices and build up. Bacteria and fungi feed on this, resulting in unpleasant odour. Over time, this debris may harden like a stone, hence the name ‘tonsil stones’. The stones may be single or multiple. Poor dental hygiene is the most common cause of tonsil stones. Not brushing the teeth at all, brushing inadequately or with a worn out tooth brush, can lead to residual food particles sticking around teeth and gums. This leads to formation of plaque and debris over which bacteria build up. If not corrected, this increases in volume and hardens, resultant inflammation can spread to tonsils. Chronic inflammation of the tonsils or repeated acute tonsillitis can lead to it. Tonsils form protective barrier within the mouth, they trap microbe and foreign particles, and prevent them from passing further. Hence, frequent infections of the nose, throat or air sinuses, frequent cold with post nasal drip, can also result in formation of tonsilloliths. Smoking damages the protective inner lining of oral cavity, making one more vulnerable to repeat tonsillitis and tonsil stones formation. Pain during swallowing is one of the early manifestations of tonsilloliths. It also leads to sore throat, bad breath, ongoing cough and swollen tonsils. On physical examination, white or yellow debris is seen over the tonsils. Due to anatomical connection with ears, infection and inflammation may spread to ear, causing ear pain and or discharge. There may be associated high fever. Intensity of symptoms depends on size and number of tonsilloliths. Untreated persistent tonsilloliths can result in chronic throat infection and inflammation of the throat. The resultant throat pain can affect nutrition of a person. Large sized tonsil stones may disrupt the surrounding tissues over and surrounding the tonsils, thus damaging the tonsils. This lowers the immunity of the person, making one vulnerable to infections. Persistence of streptococcal infection of the throat can cause damage to kidneys or heart as complications. Therefore, the best strategy is to prevent formation of tonsil stones. Drinking hot water, hot saline gargles, are useful in preventing tonsil stones. Drinking adequate amount of water keeps the throat well-hydrated. This prevents breach in protective mucosa of the throat, thus preventing invasion by microbes. Stopping smoking is a good strategy. Treatment consists of antibiotics, anti-inflammatory drugs. Big tonsilloliths and those causing serious problems have to be removed surgically. Dr. Rachna Pande is a specialist in internal medicine rachna212002@yahoo.co.uk
