Evaluation of the Association between Smoking and Tonsillolith Characteristics using Cone-Beam Computed Tomography

Tonsilloliths are calcified concretions within tonsillar crypts whose relationship with smoking remains poorly understood. This study investigated the association between smoking and tonsillolith characteristics using cone-beam computed tomography (CBCT).

This retrospective cross-sectional study evaluated 416 dental CBCT scans obtained between 2021 and 2023. Scans were evaluated for the presence, size, number, laterality, and anatomical localization of tonsilloliths by a single oral and maxillofacial radiologist, with a second radiologist consulted in cases of diagnostic uncertainty. Demographic characteristics and smoking status were obtained from medical records. Statistical analyses included the chi-square or Fisher's exact test, independent-samples t-test or Mann-Whitney U test, and one-way ANOVA with Bonferroni post hoc correction (α = 0.05).

Tonsilloliths were detected in 29.6% of participants (123/416). Smoking was not significantly associated with tonsillolith prevalence, size, or number (p > 0.05). Among patients with tonsilloliths, smokers showed significantly higher frequencies of unilateral (p = 0.041) and lingual (p = 0.036) tonsilloliths than non-smokers. Age was significantly associated with both prevalence and size (p < 0.001 and p = 0.037, respectively), with higher prevalence in older groups. No significant sex differences were found.

Smoking was not associated with the overall prevalence, size, or number of tonsilloliths, but unilateral and lingual tonsilloliths were more frequent among smokers. Age was the strongest factor associated with tonsillolith formation, exerting a greater influence than smoking. Further prospective, multicenter studies with detailed smoking exposure data are needed to validate these findings.