What the research says
Smelly white balls in your throat are tonsil stones. Here's what they're made of and why they smell
When your throat hurts, you look at it in the mirror, and sometimes you spot little white balls with a strong smell in your tonsils. People also ask about them online when they have a cold. Australia's government health service, healthdirect, explains that these are small, hard lumps that form in tiny pits in the tonsils. Below we look at what tonsil stones are made of, how often they're found, why they smell, and where bad breath most often comes from.
01The problem
Lots of people find smelly white balls in their throat, but it's awkward to ask about them
It usually starts the same way. You cough or sneeze, and a tiny white ball flies out of your throat with a smell so bad you don't want to tell even the people closest to you. Others notice these lumps in the mirror while looking at a sore throat.
Doctors often see lumps like these on scans. Doctors in Japan reviewed CT scans of 2,873 patients at their clinic and found these lumps in the palatine tonsils, the small soft tissues at the back of the throat, in 1,145 of them, almost 40%. A single tonsil had anywhere from 1 to 18 of them, from 1 to 10 millimeters in size.
ENT (ear, nose and throat) doctors in Scotland write that these lumps usually cause minimal symptoms. Australia's healthdirect adds that small ones usually don't cause problems, while large ones can cause bad breath or discomfort.
The smell is what worries people most. To understand where it comes from, let's first look at what these lumps are and where they grow.
What people say online
- “The nastiest smelling thing ever is this tiny white ball that comes up from somewhere deep in my throat. Rarely, but it never misses”
- “I've had these stones for about 5 years. They don't really bother me and my throat hardly ever hurts. But they give me bad breath, and it messes with my head”
- “I looked up pictures of tonsil stones online. It looks like you've got teeth growing in your throat”
- “It's weird that nobody talks about this, and nobody knows if it's normal or not”
02Made of
What are tonsil stones made of
Tonsils are small soft tissues at the back of the throat. Their surface has tiny pits, and according to healthdirect, that's where the lumps form. Doctors call them tonsilloliths, and in everyday speech they're called tonsil stones.
The service gives a short list of what these lumps are made of. They contain calcium, bits of food, bacteria and dead cells.
Scientists took a closer look at the stones. They were carefully removed from 16 adults who were having their tonsils taken out, and studied in two labs. In structure, the stones turned out to be similar to dental biofilm, the same plaque that forms on teeth. It's a community of bacteria that grow together and stick to each other.
So a tonsil stone isn't a stone in the usual sense. It's more like plaque that grew in a pit in the tonsil instead of on a tooth.
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See the toothpaste03How common
Are tonsil stones normal, and does everyone get them
There's no single exact number for how many people have tonsil stones, because the studies vary a lot. All of them looked at scans of clinic patients, not of everyone in a population.
In the Japanese study of 2,873 patients, stones were found in almost 40%. Another Japanese study compared two kinds of scans in the same 482 patients. CT found stones in 46.1%, but a panoramic dental X-ray found them in only 7.3%. A lot depends on how you look.
In Turkey, 416 dental CT scans found stones in 29.6% of participants. And in the Dominican Republic, they were found in only 5.85% of 209 dental patients.
The same studies checked what tonsil stones are linked to. In the Japanese study, the older the patients were, the more often they had stones, with the most at ages 50 to 69. In the Turkish study, age was more strongly linked to stones than smoking. In the Dominican study, only one factor was significantly linked to them, a past case of tonsillitis, which is inflammation of the tonsils.
The stones don't stay put forever. Doctors compared 326 sets of scans where each patient had a first scan and at least two follow-ups. Over that time, 12.1% of the stones disappeared. The authors suggest this is how the tonsils keep clearing out foreign material, but for now that's just their guess. The studies themselves didn't settle whether tonsil stones are normal. But they're found in a lot of people, and ENT doctors in Scotland write that they usually cause minimal symptoms.
04The smell
Why do tonsil stones smell
The smell seems to be linked to the bacteria living inside the stone. In the study of stones from 16 adults that we described above, the center of a stone had about ten times less oxygen than the fluid around it.
Japanese scientists analyzed the genes of bacteria from the stones of 6 people. Inside they found anaerobic bacteria, meaning bacteria that live without oxygen. The authors write that all the groups of these bacteria they found are apparently linked to making volatile sulfur compounds, or sulfur gases. The authors think a stone may be a source of bad breath.
But the smell isn't always there, and not for everyone. A clinic in Brazil examined 49 patients who complained of bad breath and had chronic caseous tonsillitis. That's what doctors call long-lasting inflammation of the tonsils. A device that measures sulfur gases in the breath showed raised levels in only 8 of them.
In 6 of those 8 (75%), a tonsillolith, or stone, was found in the tonsil, compared with only 6% of the patients whose breath the device didn't flag. The study was small, and its patients came from people referred for laser treatment of the tonsils. So its conclusion can't be applied to everyone.
05Tongue
Why you have bad breath even after brushing
Tonsil stones aren't the only cause of bad breath, and bad breath is common. Researchers pooled 13 studies, and the overall share of people with bad breath in them was 31.8%.
Cochrane, an international organization that reviews medical research, writes in a 2019 review where bad breath usually comes from. It's caused by too many bacteria or tiny bits of food in the mouth, most often on the back of the tongue. The UK's National Health Service (NHS) advises cleaning not only your teeth but your tongue too.
A bad breath clinic in Belgium saw a similar picture when it looked at 2,000 patients. A cause in the mouth was found in 76% of them, most often a coated tongue, in 43%. Causes in the ear, nose and throat and everything else outside the mouth together were found in only 4%. Another 16% were diagnosed with imagined bad breath, when a person believes their breath smells.
Lots of products for bad breath have been tested. The same Cochrane review gathered 44 trials with 1,809 participants, but the evidence was low or very low certainty, and the authors couldn't conclude that any one product works better than the others.
The NHS starts with the basics. According to the NHS, the best way to prevent bad breath is to keep your teeth, tongue and mouth clean.
06Myths
What people believe about tonsil stones, and what's actually known
- Myth
Tonsil stones poison your whole body
FactIn a consensus statement, ENT doctors in Scotland write that there's no evidence tonsil stones lead to long-term health problems. They usually cause minimal symptoms.
Source 10 - Myth
Bad breath comes from your stomach
FactThe Cochrane review names the mouth itself as the main source of bad breath, most often the back of the tongue. At a bad breath clinic in Belgium, a cause outside the mouth, including the ear, nose and throat, was found in only 4% of 2,000 patients.
Source 12 - See the toothpaste
- Myth
If you have tonsil stones, you definitely have bad breath
FactAt a clinic in Brazil, out of 49 patients with chronic caseous tonsillitis who complained of bad breath, the device found raised sulfur gas levels in only 8.
Source 09 - Myth
Gum and mints get rid of bad breath
FactIn a Canadian experiment with 15 men, gum and mints didn't lower sulfur gas levels in mouth air at any point it was measured.
Source 14 - See the toothpaste
- Myth
You should squeeze out tonsil stones yourself
FactWe don't recommend it. ENT doctors in Scotland list the ways to remove stones described in medical literature and write that none of them is backed by level 1 evidence, the most reliable kind of research. If the stones cause constant bad breath, pain or trouble swallowing, healthdirect advises seeing a doctor.
Source 10
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See the toothpaste07What to do
What to do if white balls with a bad smell come out of your throat
Brush your teeth and gums twice a day
The UK's NHS advises gently brushing your teeth and gums at least twice a day for 2 minutes with fluoride toothpaste.
Clean your tongue once a day
The NHS advises gently cleaning your tongue once a day with a tongue scraper or tongue cleaner. The Cochrane review names the back of the tongue as the most common source of bad breath.
Clean between your teeth
The NHS advises cleaning between your teeth once a day with interdental brushes or floss.
Don't pick at your tonsils
ENT doctors in Scotland write that none of the described ways to remove stones is backed by level 1 evidence, the most reliable kind of research.
Know when to see a doctor
If the smell doesn't go away, your throat hurts or it's hard to swallow, see a doctor. If bad breath doesn't go away after a few weeks of caring for your mouth, the NHS advises seeing a dentist.
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See the toothpaste08Sources
What the sources actually say
Tonsil stones are small, hard lumps that can form in tiny pits (pockets) in the tonsils, the small soft tissues at the back of the throat. They are made of calcium, food debris, bacteria and dead cells. Small stones usually don't cause problems, while large ones can cause bad breath or discomfort. See a doctor if the stones cause persistent bad breath, pain or difficulty swallowing.
Tonsilloliths were carefully removed during tonsillectomy from 16 adults and studied in two labs. In structure, the tonsilloliths resembled dental biofilms. Oxygen concentration in the center of a tonsillolith dropped to about one tenth of the concentration in the surrounding fluid.
Palatine tonsilloliths were found in 1,145 of 2,873 patients (39.9%). A single tonsil had from one to 18 stones, 1 to 10 mm in size. The share of people with tonsilloliths grew with age, and they were found most often in patients aged 50 to 69.
482 pairs of computed tomography (CT) scans and panoramic dental X-rays. Tonsilloliths were found in 46.1% on CT and in only 7.3% on panoramic X-rays.
- See the toothpaste
Across 416 dental cone-beam CT scans, tonsilloliths were found in 29.6% of participants (123 of 416). Age was the strongest factor linked to tonsillolith formation, stronger than smoking.
209 dental patients at two university clinics. The share of people with tonsilloliths in this sample was 5.85%. A past case of tonsillitis was the only factor significantly linked to having tonsilloliths.
326 sets of CT scans, a first scan and at least two follow-ups. Over the follow-up period, 12.1% of tonsilloliths disappeared. The authors suggest that tonsilloliths are constantly in an active phase that serves to clear out foreign material.
Bacterial genes from the tonsilloliths of 6 people. The anaerobic bacteria in the tonsilloliths belonged to genera that are apparently linked to producing volatile sulfur compounds, and the results support the idea that a tonsillolith may be a source of bad breath.
- See the toothpaste
49 patients with bad breath and chronic caseous tonsillitis, chosen from people referred for laser treatment of the tonsil crypts. The device showed raised readings in 8 (16.3%). A tonsillolith was found in 75% (6 of 8) of patients with raised readings and in only 6% of those with normal readings.
Tonsil stones usually cause minimal symptoms. There is no evidence that having them leads to long-term health problems. None of the described treatments is backed by level 1 evidence.
13 articles met the selection criteria. The overall share of people with bad breath was 31.8%.
Bad breath is caused by too many bacteria or tiny bits of food in the mouth, most often on the back of the tongue. 44 trials, 1,809 participants. The evidence was low or very low certainty, and no conclusions could be drawn about any product or concentration being better than another.
- See the toothpaste
2,000 patients at a bad breath clinic. A cause in the mouth was found in 76%, most often a coated tongue (43%). Imagined bad breath was found in 16% of cases, and causes in the ear, nose and throat or outside the mouth in 4%.
15 men with mouth sulfur gas levels above the threshold. Gum, mints and a product with parsley seed oil didn't lower volatile sulfur compound levels in mouth air at any point.
The best way to prevent bad breath is to keep your teeth, tongue and mouth clean. Gently brush your teeth and gums at least twice a day for 2 minutes with fluoride toothpaste. Gently clean your tongue once a day with a tongue scraper or cleaner. Clean between your teeth once a day with interdental brushes or floss. See a dentist if bad breath doesn't go away after a few weeks of looking after your mouth yourself.
09Products
Toothpaste from our catalog
- R00523
Atomy Toothpaste 50g, set of 4
Toothpaste with propolis extract and green tea extract. A set of 4 tubes, 50 g each.
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