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Those white, smelly, hard bumps in the back of your mouth are usually a peculiar growth known as tonsil stones. Also known as tonsilloliths, tonsil stones grow in the crypts and cracks of your tonsils from a combination of debris from food, bacteria, and a fungus known as Leptothrix buccalis. These stones usually first appear with childhood tonsillitis, although they may linger and grow in adults who have stopped having throat infections. The bacteria, fungus, and debris eventually combine with calcium and become stones, although there are also magnesium and ammonia-based stones. It's the ammonia generated by bacteria that causes intense bad breath.

Sometimes tonsil stones cause halitosis and dysphagia, difficulty swallowing, along with ear pain. Sometimes they are just "there," asymptomatic until an injury dislodges them, months, years, or decades after they formed. Tonsil stones are usually about 5 mm (1/5 inch) wide, although they sometimes grow as much as 40 mm (over 1-1/2 inches) in diameter.

It's usually your dentist who makes the diagnosis of tonsil stones. On X-ray, they can be hard to distinguish from displaced teeth and calcified blood vessels. Your doctor might resort to a CT scan to make a definitive diagnosis. Either way, treatment is usually surgical (which isn't to say many people don't remove them on their own at home).

Should you let your doctor take care of tonsil stones? If your primary concern is bad breath, there are a number of things you can try before surgery:

  • Keep your mouth moist. Frequent sips of water not only keep cracks in your tonsils from opening and emitting odor, they also remove particles of offending foods, such as garlic.
  • Floss your teeth daily. The evidence that flossing prevents cavities is questionable, but it definitely reduces bad breath.
  • Avoid eating foods that provide the raw materials that bacteria use to make cadaverine, putrescine, spermidine and skatol the "smells dead" and "smells like stuff we can't mention in a G-rated answer" chemicals that give you foul breath. Sauerkraut, cheese, pastrami, mortadella, and fish, especially frozen fish sticks, provide the amino acids that bacteria use to make the stinky chemical. If you eat these foods, don't just brush and floss. Gargle to remove food particles from the back of your throat.
  • Clean the back of your tongue so you don't transfer food particles to your tonsils. It may take some practice to overcome your gag reflex.
  • When other measures fail, use mouth wash. Your doctor can usually prescribe "extra strength" mouthwash to tackle the problem. Mouthwash usually relieves bad breath, but most commercial mouthwashes aren't strong enough to kill bacteria. Hydrogen peroxide is, but you really don't want to swallow it, and you should not use it as a mouthwash.

And if all of these measures fail, you'll get better results with medicine that with short-term natural measures like gargling with salt water, gargling with lemon juice or lime juice, eating garlic and onions for their antibacterial properties (not really an ideal remedy for bad breath), removing stones by placing an electric toothbrush on them (which can just open up the tonsils for new infections), or trying to push out the stones with cotton swabs (which usually doesn't remove the stones but does irritate the tissue around them). What your doctor may do for you includes:

  • Antibiotics, which stop current growth of stones but won't remove previously existing stones.
  • Tonsillectomy, the surgical removal of your tonsils and any stones in them.
  • Laser therapy, burning out the stones with carefully calibrated laser light.

If your doctor has done a swab of your throat and sent it to the laboratory to identify the bacteria that are causing tonsillitis, then it can make good sense to give you antibiotics. Without identifying the bacteria that are being treated, antibiotics can be worse than useless. Laser therapy removes existing stones and leaves the tonsils; you will need to practice careful hygiene to keep the stones from coming back. Tonsillectomy is painful and requires recovery time, but it is a permanent way to get rid of the stones.​

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