Bad breath, or halitosis, is one of the great unmentionables, despite the fact it affects a huge number of people - as many as seven million Britons - who spend more than £150 million each year on mouthwash alone trying to get rid of it.
The problem is often linked to smoking and not brushing your teeth properly - this causes the bacteria in the mouth linked to bad breath to flourish.
But for many people, no amount of brushing or sweet-smelling products seems to make a difference. That's because their problem is triggered by a little known but surprisingly common condition - tonsil stones. We tend to associate stones with the kidneys or gall bladder, but it seems stones can also form on our tonsils, where they appear as small white spots.
Experts say tonsil stones are little understood by many doctors - indeed patients are often told there's nothing wrong with them or that what they see on their tonsils is simply the remains of last night's dinner. In fact, the problem affects thousands of people - it's particularly common in those who've suffered from tonsillitis or who have a dry mouth as a result of medication such as painkillers.
The tonsils are sacs of lymphatic tissue on either side of the throat. They are part of the body's immune system and contain lymphocytes - cells that prevent and fight infections. The tonsils are meant to function like nets, trapping incoming bacteria and virus particles passing through your throat and preventing them travelling through the body.
Their location makes them the front line of defence against infections of the throat and upper airways. However, it also means they become a potential trap for food particles. Tonsil stones, or tonsilloliths, as they are also known, are actually lumps of calcified food, mucus and bacteria, explains Anastasia Rachmanidou, a consultant ear, nose and throat surgeon at University Hospital Lewisham, South-East London.
'Once bits of debris get trapped, they attract bacteria, harden and start to decay, which is why sufferers can have bad breath,' she says.
They can also suffer from a bad 'metallic' taste in the mouth. Adults are more at risk simply because they have bigger tonsils; the tonsils have a naturally pitted surface like the moon and, as we grow, these pits or crypts also get bigger, making them more likely to harbour food.
Anyone who's had tonsillitis is also at risk, as the illness can scar the tonsil. Taking certain prescription medicines, such as high blood pressure tablets, painkillers and antidepressants, can also cause the problem, as a side-effect is dry mouth - if you don't have enough saliva to wash food and bacteria away, this can trigger tonsil stones or exacerbate them.
Though many clinicians are unfamiliar with tonsil stones, the problem is widespread. French researchers found that in a sample of 515 scans, 31 people - about 6 per cent - had calcified matter in their tonsils.
Drink plenty of water to flush out hidden bacteria
A Brazilian study found tonsilloliths were present in 75 per cent of tonsillitis patients who had bad breath and in only 6 per cent with normal breath. Some experts say the numbers affected could rise. 'They are already not uncommon and it's possible we will see even more of them as we no longer take out tonsils as much as we used to,' explains Mr Gerald Brookes, a consultant at the London Clinic and the Royal National Throat, Mouth and Ear Hospital.
The difficulty, he says, is that the condition is often missed because the small white spots on the tonsils are also characteristic of a throat infection. 'It is very common for patients who see this small white bead to think this, especially if the stone gives them a little localised soreness around the throat.'
However, some won't suffer any soreness - instead, they might notice it as a maddening feeling that something is stuck at the back of their throat. Tonsil stones can cause a variety of symptoms and will not always be visible to the naked eye (if hidden in the folds of the tonsils, they might be detectable only with a CT or MRI scan).
Depending on the location or size of the tonsil stone, it may also be difficult or painful to swallow foods or liquids. And because of shared nerve networks, the patient may feel referred pain in their ear, even though the stone itself is not touching the ear. So, occasionally, someone with tonsil stones, says Mr Brookes.
Often the stones, which tend to be between two to five millimetres in size, spontaneously come off, says dentist Dr Phil Stemmer, from the Teeth For Life clinic. 'They can just get swallowed or can be spat out.' If you have particularly craggy tonsils, it is possible to smooth the nooks that trap food in the tonsils, adds Ms Rachmanidou.
Doing this requires a laser, a procedure known as laser resurfacing, to take off the top layer of tissue. In this way, the edges of the pits are flattened out, so they can no longer trap any material. Without surgery, there is very little else to prevent the problem if you have craggy tonsils. However, good oral hygiene, brushing your teeth, flossing and using a non-alcoholic mouthwash twice-a-day will help to flush the food away.
Also, it might be possible to remove tonsil stones by flushing them out with warm salt water. This can be done by emptying a nasal spray bottle and filling it with warm water and half a teaspoon of salt to spray onto the tonsils.
Or you can buy an oral irrigation device such as the Waterpik Ultra Cordless Water Jet WP450 (£34.99, available at www.chemist direct.co.uk).
'Pushing the tongue out hard and so pushing the muscles at the side of the throat may also help dislodge the stones, too,' adds Mr Brookes.
Drinking plenty of water is also important, as this keeps the saliva moving throughout the oral cavity and flushes out hidden bacteria. Even chewing on a dry cracker every day may also help rub away the tonsil stones. A more drastic option is to have the tonsils removed.
However, dentist Phil Stemmer says this is not something he would routinely recommend.
'Apart from the fact that a tonsillectomy is an operation under general anaesthetic, the tonsils are very important to prevent infection. And like any operation, there can be complications, such as bleeding.'
But it's vital to get any white spots on your tonsils checked out by your GP, insists Ms Rachmanidou.
'Though very rare, a lesion, spot or white patch can be a sign of cancer, so your GP will want to refer you to a specialist just to be sure,' she says.
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