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Everyday bad breath has any number of causes. We have all had the unpleasant experience of bad breath after eating onions or garlic. We have all had the experience of bad breath when it just is not possible to brush, or when we have cough, colds, or flu. These kinds of bad breath are easy to treat. Tonsil stones lead to bad breath of an entirely different order of magnitude.

Tonsil stones are caused by tonsillitis. More specifically, they are caused by infections of the tonsils with Streptococcus bacteria. Little kids between 2 and 5 who get tonsillitis most commonly have viral infections. Children over the age of 2, teens, and adults who get tonsillitis most commonly have Streptococcus infections. Tonsil stones almost never occur before the age of 20.

A tonsil stone is the remnant of the immune system's battle against the Streptococcus germ. Strep bacteria have the ability to protect themselves from the immune system by mobilizing a protein called fibrin from the bloodstream.

As its name suggests, fibrin undergoes a series of chemical reactions to become protein fiber known as fibrinogen. This filamentous protein forms a blood clot around the bacteria that protects them from white blood cells from the blood stream. It also enables them to live in their preferred anaerobic, low-oxygen environment.

Strep are not truly anaerobic bacteria but rather facultative anaerobes, able to live in either an oxygenated or oxygen-free environment. Medications designed to neutralize the anaerobic bacteria of the mouth, such as an oral rinse swished in the mouth, an oxygenating rinse, oxygenating tablets, oxygenating toothpaste, and any other product designed to make the mouth an oxygen-rich environment are of limited use.

The newly formed stone at first is soft and pliable, about the size of a grain of rice up to size of a pea. The typical tonsil stone is between 1 and 5 mm (approximately 1/20 to 1/4 of an inch) in width. The sulfur-producing bacteria inside the stone dissolve tissue and release malodorous gases. These sulfur gases themselves are toxic, killing tissue around the stone, which is then consumed by different bacteria which 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 are dead. White blood cells known as macrophages are attracted to the tough, fibrous outer layer of the stone. They are never able to penetrate it, but they die trying.

Still more macrophages follow them, and also die on the outer layer of the stone. Macrophages come along to consume the dead macrophages and likewise become impacted at the edge of the stone. A continuous assault by the immune system for months, years, and even decades after the bacteria inside the stone are dead provides a continuing source for decay and bad breath. All you may see is white spots on tonsils, but decay goes on all around the stone.

Do you have tonsil stones? Some years ago I gave a lecture on this topic, so my answer here is going to be unusually complete. Here are 10 ways to tell:

The best scientific information is that about 1 in 15 people has the tonsil stones. Since many more than 1 in 15 people has bad breath, usually bad breath is caused by some other condition. Here are ten easy questions to determine whether you may have tonsil stones.


1. You get intense bad breath after eating onions and garlic.

While hellacious halitosis after eating odor-causing foods does not rule out the possibility of having tonsil stones, it is far more likely that intense and temporary bad breath is caused by the food itself.

It isn't just onions and garlic that can cause bad breath. One of the most commonly overlooked offenders is asafetida, an herb that once was known as devil's dung. It is an important ingredient in Worcestershire sauce. Fermented fish, fermented cabbage as either sauerkraut or kimchi, pickled fish, pickled eggs, and many cheeses also cause bad breath. They break into food particles that get caught on the teeth or gums or that lodge in crevices in the tongue and tonsil until they are washed away with drink or swallowed with food. Cooking bits and pieces of garlic and onions with fat, such as butter, coats them so that they release fewer odor-causing gases, but also makes them stick to your tongue and teeth and cause bad breath longer.

Sipping water with your meal rinses away the offending food particles. Eating crusty foods carries them into your stomach. Once all the particles of these foods are in your stomach, they no longer cause bad breath, although they may contribute to the scent of flatulence. Even if you don't do anything about garlic breath and related food breath issues at all, the odor dissipates on its own in about six hours.

If you need to freshen your breath faster than that, keep a supply of Oxyfresh Fresh Mint Mouthrinse with Zinc on hand. The chlorine dioxide it contains won't damage your teeth, tongue, or gums but it can neutralize food odors almost immediately. Mints and lemon drops mask food odors but don't remove them. Breath spray is also a short-term fix, just an hour or so.

2. You usually don't have bad breath but you seem to have "caught" bad breath on a trip.

Stomach infections often cause bad breath. Probably most intense odors are the "purple burps" that accompany infection with a parasite known as Giardia. It's usually contracted by drinking water from seemingly pristine mountain streams. Giardiasis is something you need a doctor to treat.

Bad breath is also a side effect of stomach infections with the bacterium Helicobacter pylori. This is the "bug" that is associated with peptic ulcer disease. Intense bad breath after burping, especially after a trip to Central America, is a sign you have drunk water contaminated with Helicobacter. Your doctor can tell you for sure and prescribe an appropriate antibiotic. In the mean time, you can chew tablets of a supplement called DGL (deglycyrrhizinated licorice that has had a chemical that can cause high blood pressure removed) to kill the bacteria. DGL has to be mixed with saliva by chewing to release a chemical that kills the germs.

Sinus infections and post nasal drip also cause bad breath. Cure them, and you cure bad breath. Use of nasal sinus drops and sprays, however, can backfire because sinusitis and bad breath come back with a vengeance as soon as you miss even one dose.

3. You brush after every meal but you still have bad breath.

Brushing after every meal never cures bad breath. Only about 30% of the bad breath bacteria that live in the mouth are found on the oxygen-rich surfaces of the teeth. Another 30% live on the gums and the remaining 40% live in crevices and crepitations on the tongue. Brushing may remove enough bacteria that bad breath is not noticed, but bacteria constantly flow back to the teeth to start the process of growth all over again.

Brushing your teeth the wrong way can even make bad breath worse. Toothbrushes that have hard bristles can wear grooves into dental enamel. These grooves become a home for bacteria. Even a soft toothbrush can cause dental damage and increase bad breath if brushing is too vigorous. Always brush your teeth, not your gums, only down to the gum line. Brushing below the gum line only kills gum tissue that can decay and cause bad breath.

4. You use mouthwash and other bad breath remedies every day and you still have bad breath.

What the mouthwash companies don't tell you about the products that kill "millions of germs on contact" is that you have trillions of germs in your mouth. The most common brands of mouthwash contain between 24 and 26% alcohol. That's enough alcohol to make your mouth burn and to kill tissue in the linings of your mouth and surfaces of your gums and tongue. Alcohol dissolves the protein "glue" that holds cells in place, and once they are cut off from nutrients and oxygen, they die.

The most common bacteria that cause bad breath are only killed by 46% alcohol or more. This means that the mouthwash feels as if it must be working, but it is only providing more dead tissue for bacteria to use as food. As bacteria digest the proteins in the cells that are killed by mouthwash, they release more hydrogen sulfide (rotten egg odors) and more of the aptly named chemicals cadaverine and putrescine.

Harsh mouthwash never works for relieving halitosis, but there are brands of mouthwash that kill bacteria without killing oral tissue. Oxygenating mouthwashes are better than alcohol-based mouthwashes. One of the best is Oxyfresh.

5. You floss every day and you still have bad breath.

If you floss every day, congratulations! Dr. Michael B. Bonner, a dentist and author of several books about dental care, cites studies that find that only 4% of North Americans floss every day and only 2% floss two or more times a day. Most people don't floss at all. The problem is that most people who do floss use a technique that makes bad breath worse.

The objective of brushing and flossing isn't getting food particles off gums. The objective of both brushing and flossing is getting food particles off teeth. The correct way to floss is to loop a piece of floss around a tooth and to pull back and forth, left and right, to remove food particles that are stuck between teeth. Running the string up and down between teeth only forces food particles into the gums, and damages the gums, producing more tissue that bacteria will decay.

6. You scrape your tongue every week and you still have bad breath.

Tongue scraping gets rid of the 40% of halitosis bacteria that live on the tongue. Actually, it's a misstatement to referring to scraping the tongue. The objective of tongue scraping is not to rub your tongue raw, but to lift and remove the white or yellow biofilm that can cause a massive accumulation on your tongue between meals.

7. You make a point of using a lot of toothpaste when you brush but you still have bad breath.

About 20% of men and about 25% of women have a genetic variation that makes them uniquely sensitive to a toothpaste and mouthwash ingredient known as sodium lauryl sulfate or SLS. If you live in the UK or Australia, this ingredient is usually listed as sodium dodecyl sulphate, or SDS. Both are the same chemical. This chemical makes toothpaste foamy so it covers the entire tooth. In susceptible people, however, it can also irritate the tongue and gums so that tiny bits of tissue die and combine with the food debris that feeds bacteria.

There are toothpastes that do not contain SLS and some that include ingredients that actually fight bad breath. Bioenhanced Grapefruit Seed Extract coats the gums with antioxidant bioflavonoids that stimulate the production of collagen. This collagen glues cells in place on the surface of the gum, making them harder for bacteria to attack.

Green tea extract also provides antioxidant polyphenols that reduce inflammation on the gums. There is green tea extract in Dr. Sharp's Green Tea Whitening Toothpaste and in Crest with Fluoride, although many people choose to avoid the fluoride. A chemical ingredient called MSM (methylsulfonylmethane) encourages the production of collagen in the gums, making them stronger and resistant to bad breath bacteria.

8. You have not been to see your dentist in a year or more and you have bad breath.

People who don't get their teeth cleaned on a regular basis, preferably twice a year or more, tend to get a condition called gingivitis. A plaque of live and dead bacteria builds up in the sulcus, the pocket between the gums and the teeth.

The plaque itself is not harmful, but when the immune system attacks the bacterial plaque with inflammation, the result can be swollen gums, bleeding gums, painful gums, loose teeth, a bad taste in the mouth in the morning, and constant bad breath along with a constant sense of discomfort. Gingivitis is a condition of having inflammation, not a condition of having plaque—but failure to have the teeth scaled at the dentist's office to remove the plaque can lead to gingivitis.

Gingivitis is not a slow-moving disease. Permanent damage to the gums and teeth can occur in as little as a week. Bad breath combined with any of the other symptoms of the disease listed above is a reason to make an appointment with your dentist right away.

9. You don't eat your fruits and veggies and you have a problem with bad breath.

The gums need vitamin C to make collagen. One of the first symptoms of vitamin C deficiency is bad breath with bleeding gums that can be followed by loose teeth, and other symptoms all over the body.

It doesn't take a lot of vitamin C to prevent deficiency symptoms. As little as two pieces of fruit per week may be enough to save your teeth, although optimal health requires considerably more C. Nearly everyone benefits from up to 500 mg of vitamin C per day. Higher doses have special applications.

10. You have a problem with your dental work.

Crowns come loose. Braces and dentures don't always fit. Fillings fall out. Even work by the best dental specialist usually doesn't last a lifetime. Shifts and breakages of crowns, fillings, and braces, and dentures that have to be removed and replaced every day can trap food particles that decay and cause breath odor.

About 94% of people who have bad breath have one of these easily controllable causes of bad breath. But if you have chronic bad breath and none of these conditions applies to you—or perhaps even if they do—you may have tonsil stones.


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