What Are Tonsils?
Tonsils are fleshy tissue lumps at the back of our throat that act as an immune defense in the oral cavity.
What Are Tonsilloliths?
Tonsilloliths or tonsil stones are calcifications that usually form around or within the crypts of the palatal tonsils. Of the three sets of tonsils, one is the palatal tonsil, and the other two are pharyngeal tonsils or adenoids and the lingual tonsils. These stones can also be found in the throat or roof of the mouth, common occurrence locations.
Tonsils are easily prone to their crevices being filled by bacterial contamination of other foreign bodies, dead cells, mucus, etc., that can become trapped within them. When this entrapment occurs, the debris becomes concentrated as white formations in these pockets. Tonsilloliths are formed due to debris accumulation. They are generally soft and maybe sometimes rubbery. This often occurs in people who suffer from chronic inflammation in their tonsils or repeated bouts of tonsillitis.
How Are Tonsilloliths Manifested?
They are often associated with post-nasal drip. In the cases of tonsilloliths, patients express irritation, discomfort, and halitosis caused commonly due to the presence of tonsillolith (at the region of the right pharynx at the tonsillar crypt), with halitosis or bad breath being the most common symptom due to the release of volatile sulfur compounds produced by bacterial accumulation.
What Is the Etiology and Pathogenesis of Tonsilloliths?
Tonsilloliths usually occur rarely in children as compared to adults. The size of tonsilloliths ranges from visible size to pea-size. Patients with tonsillolith have increased halitosis, bad breath, or oral malodor and also feel the foreign body sensation causing oral discomfort. Tonsilloliths are not described by traditional research as just calcification but rather as an aggregated bacterial biofilm.
The mechanism of tonsillolith formation is due to the three-dimensional structure of the pathogenic bacterium, with the most dormant bacteria being in the center to serve as a constant nidus or reservoir for the biofilm. However, the exact cause and the pathogenesis of tonsillolith remains elusive.
Biofilm forms when bacteria adhere to the surface in a moist environment by secreting a slimy, glue-like substance. Biofilm is held together by molecules known as extracellular polymeric substances. The establishment of biofilm is an important event in the formation of tonsilloliths in the tonsillar crypt. The intracellular adhesion protects these pathogenic bacteria against significant components of the human innate immune system. Cell to cell signaling and communication remains enabled and enhances the biofilm composed of calcium salts either alone or in combination with other mineral salts.
Chemical analysis of tonsilloliths suggests that it is majorly composed of calcification of calcium salts such as calcium carbonate (CaCO3) and other chemical components like magnesium, chloride, sodium, potassium, sulfates, nitrates, silica, iron, fluoride, etc. Also, one more possible type other than the typical tonsil stones is giant tonsilloliths. Giant tonsilloliths can often be mistaken for other oral disease manifestations like peritonsillar abscesses or tonsillar tumors that must be diagnosed differently by the dentist or physician.
What Is the Differential Diagnosis of Tonsillolith?
The differential diagnosis must, however, be established through scanning and radiography. The following are the conditions to be ruled out while confirming the presence of tonsilloliths:
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Acute and chronic tonsillitis.
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Tonsillar hypertrophy.
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Phleboliths.
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Granulomatous lesions.
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Calcification granuloma or calcified granulomatous lesions.
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Certain Malignancies.
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Enlargement of the styloid process.
What Is the Radiographic Presentation of Tonsillolith?
CT scan is a valuable modality that may reveal the tonsillar zone, outlining these non-specific areas of calcifications in detail. Tonsillitis usually appears in the midline of the mandibular ramus on the dental panoramic radiographs, where the posterior surface of the tongue crosses the mandibular ramus in the palatoglossus or the palatopharyngeal spaces.
The appearance resembles a cluster of multiple, small radiopacities with ill-defined margins. Tonsillitis should be the first differential diagnosis, especially when numerous opaque lesions with ill-defined borders are superimposed on the palatal uvula or the mandibular ramus.
These are most commonly detected on an OPG or panoramic radiography in routine dental checkups or by your dental surgeon. A correct diagnosis by the dentist will eliminate the need for further evaluations, including radiography and clinical examination.
Halitosis - A Major Effect of Tonsilloliths:
Tonsilloliths have the potential to cause oral halitosis. Foul-smelling compounds such as volatile sulfur compounds and sulfur-derived gases were produced during bacterial metabolism. A characteristic sulfur smell is present when the produced gases reach a particular concentration.
In the cases of tonsilloliths, patients express irritation, discomfort, and halitosis. Irritation and discomfort can be commonly caused in these patients due to the presence of tonsillolith (at the region of the right pharynx at the tonsillar crypt), with halitosis or bad breath being the most common symptom due to the release of volatile sulfur compounds produced by bacterial accumulation.
How Is a Tonsillolith Manage
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Surgical resection of tonsils is not recommended by the dental surgeon or the physician until indicated due to persistent discomfiture.
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Affected people can remove tonsils stones using a cotton swab or finger.
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The dentist may recommend chlorhexidine mouthwash rinse for the same.
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Oral irrigators are also effective. Dental surgeons do not recommend most electric oral irrigators for tonsillitis removal because they are too forceful in action and are more likely to cause trauma, discomfort, and rupture to the tonsils, resulting in further complications of swelling, infection, and malodor. Irrigators and manually pressurized tonsil stones removers available commercially may help these patients better pick out the masses.
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The manual pump-type tonsil stone remover remains influential and can adjust the water pressure depending on the number of pumps.
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Lukewarm or mildly hot salty water rinsing remains the most simple yet effective method that can be done multiple times a day. This may help alleviate the discomfort of tonsillitis, which often accompanies tonsils stones. Vigorous gargling each morning can also keep the tonsils crypt clear of all but the most persistent or very large tonsilloliths.
Conclusion:
Tonsilloliths or tonsil stones are thus a usually self-limiting condition, though a very orally disturbing and potentially long-term condition if left untreated and hence needs proper oral hygiene, irrigation, and mouth rinsing along with oral management of malodor and discomfort by the dental surgeon.