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Community Dent Oral Epidemiol 2009; 37: 182–187 Black stain and dental caries in RoswithaHeinrich-Weltzien1,Bella 1Department of Preventive Dentistry,University Hospital of Jena, WHOCollaborating Centre ‘Prevention of OralDiseases’, Jena, Germany, 2Department ofEducation, Health and Nutrition Centre, City Heinrich-Weltzien R, Monse B, van Palenstein Helderman W. Black stain and dental caries in Filipino schoolchildren. Community Dent Oral Epidemiol 2009; 37: 182–187. Ó 2009 The Authors. Journal compilation Ó 2009 John Future Scenarios, Radboud UniversityNijmegen Medical Centre, The Netherlands Abstract – Black stain is defined as dark pigmented exogenous substance inlines or dots parallel to the gingival margin and firmly adherent to the enamel atthe cervical third of the tooth crowns in the primary and permanentdentition. Objectives: This study was conducted to assess the prevalence ofblack stain on teeth of Filipino children and to determine a possible associationbetween black stain and caries levels. The study was designed to test thefollowing hypotheses: (i) the prevalence of black stain does not differ betweenchildren from schools with oral health intervention programs and those fromschools without an intervention program, (ii) the prevalence of black stain doesnot differ in children attending easily accessible and remote schools, (iii) cariesprevalence and caries experience do not differ in children with and withoutblack stain and (iv) the caries distribution at the surface level does not differ inchildren with and without black stain. Methods: In total, 32 elementary schoolswere included. 19 schools with a comprehensive school-based preventive oralhealth program, seven schools with a basic preventive program and six controlschools. All sixth graders of these schools (n = 1748) aged 11.7 ± 1.1 years wereclinically examined for black stain. DMFT was assessed in 1121 children byseven calibrated dentists using WHO criteria. DMFS was scored in 627 childrenby two calibrated dentists. Results: Black stain was found in 16% of thispopulation. The prevalence of black stain did not differ significantly betweenchildren attending schools with different oral health intervention programs.
Thus, hypothesis 1 was accepted. The prevalence of black stain was significantlyhigher (P < 0.05) in remote than in more accessible schools. Thus, hypothesis 2 was rejected. Children with black stain had significantly lower (P < 0.05) caries prevalence and caries experience than children without black stain. Thus, Roswitha Heinrich-Weltzien, Department of hypothesis 3 was rejected. No difference was found in the DMFS pattern of Preventive Dentistry, University Hospital of occlusal, smooth and proximal surfaces between children with and without Jena, Bachstr. 18, D-07743 Jena, GermanyTel: +49 3641 9 34801 black stain. Thus hypothesis 4 was accepted. Conclusions: The presence of black stain is associated with lower levels of caries, but a difference in the distribution e-mail: roswitha.heinrich-weltzien@med.uni- of caries in black stain children was not noticed. The interplay between black stain, caries, oral microflora and diet remains unclear and urges further In the fifties and sixties of the last century, most Black stain may be clinically diagnosed as pig- children in the Western world suffered from a high mented dark lines parallel to the gingival margin caries burden and children with no or few caries (1–5) or as an incomplete coalescence of dark dots lesions were uncommon. After empirical observa- rarely extending beyond the cervical third of the tions that children with black stained teeth had less crown (6). This particular type of pigmentation has caries, epidemiological studies in the 1950s and been considered to be a special form of dental 1960s demonstrated that the occurrence of black plaque because it contains an insoluble ferric salt, stain on primary and permanent teeth in children probably ferric sulphide, and a high content of was associated with low caries experience (1–3).
calcium and phosphate (6–8). Actinomyces and Black stain and dental caries in Filipino schoolchildren Prevotella melaninogenicus have been reported as the predominant microorganisms in black stain (6, 9,10). However, a possible interaction between the In July and August 2003 this cross-sectional study microbiota related to the extrinsic pigmentation was carried out in rural areas in Misamis Oriental and the cariogenic microbiota remains obscure.
province, Northern Mindanao, Philippines. In total, There is no consensus in the literature concerning 32 schools were included. At the time of evaluation the prevalence of black stain among age groups 19 schools had participated for 5 years in a com- (5, 11, 12), but the presence of black stain has been prehensive school-based preventive program (dai- commonly associated with a low caries experience ly tooth brushing, application of FluorprotectorÒ (5, 11). Neither the older studies nor the more recent varnish three times a year, manual restorative ones have established whether the observed lower treatment in the permanent dentition and extrac- caries experiences in children with black stain is the tion of nonrestorable teeth (13). At the time of result of fewer lesions on smooth surfaces, in evaluation seven schools had participated for fissures, or both. It was suggested that information 2 years in a basic preventive program (daily tooth of this kind may elucidate a possible connection brushing and emergency oral treatment on de- between black stain and low caries activity (8).
mand). Six other schools were assigned to serve as The present study was conducted within the control for the intervention program. The control frame of oral health care programs in public schools were exposed to regular school dental elementary schools in Northern Mindanao, Philip- services which included an annual examination pines which were carried out in cooperation and a classroom talk on dental health. The schools between the Philippine Department of Education were selected by the Department of Education and and the German NGO ‘Committee of German comprised rural schools, accessible by four-wheel Doctors’. During the 5 years of the programs, the drive even in rainy season. All sixth graders health personnel involved developed the impres- (n = 1748) of these 32 schools were examined for sion that schoolchildren with black stain on their black stain, 966 from the 19 schools with the primary or permanent teeth were ‘more caries comprehensive preventive program, 468 children resistant’ than their peers. The frequent occurrence from the seven schools with the basic preventive of black stain associated with no or low caries program and 314 children from the six control experience was particularly conspicuous in school- schools (Table 1). A sub-sample of the total sample children attending schools in villages located in consisting of four remote schools with a compre- poor and remote mountainous areas who main- hensive preventive program contained 134 chil- tained traditional nutrition behaviour with limited schoolchildren was assessed by seven calibrated It was therefore decided to conduct a study not dentists scoring DMFT whereas two calibrated only to assess possible associations between black experienced dentists scored DMFS according to stain, caries prevalence and experience at the tooth WHO criteria (14) in 627 children. Children were surface level, but also to assess possible effects of assigned to the different examiners by the teachers different intervention programs on the prevalence according to the numbering in the school record of black stain and to determine the occurrence of book. After brushing their teeth the children were black stain and the association with caries in examined outdoors in the schoolyards lying in a supine position on school benches. Examination This study was designed to test the following was performed under direct sunlight.
hypotheses: (i) the prevalence of black stain does The criterion for scoring black stain was the not differ between children from schools with oral presence of firmly adherent black dots generally health intervention programs and those from forming linear discolouration parallel to the gingi- schools without an intervention program, (ii) the val margin and occasionally covering up to one prevalence of black stain does not differ in children third or more of the clinical tooth crown (Fig. 1) (8).
attending easily accessible and remote schools, (iii) Black stain was recorded as absent or present in the caries prevalence and caries experience do not differ in children with and without black stain and Calibration of the examiners was performed by (iv) the distribution of caries at the surface level a WHO consultant epidemiologist over a 3-day does not differ in children with and without black period. Calibration of caries scoring was based on a theoretical and practical training at a local school Table 1. Number of schools, number of schoolchildren, their mean age and the prevalence of black stain in the differentintervention groups Table 2. Prevalence of black stain in the total sample and in a sub-sample with remote schools and caries prevalence andcaries experience (DMFT) of children with and without black stain *Caries prevalence and caries experience between black stain and no black stain, significance level P < 0.05.
**Prevalence of black stain between total sample and sub-sample with remote schools, significance level P < 0.05.
Fig. 1. Clinical manifestation of blackstain: Upper (a) and lower (b) jaw of a12-year-old caries free child withcontinuous pigmented lines limitedto half of the cervical third of thetooth surfaces and on the oral smoothsurfaces of the incisors. First (c) andfourth (d) quadrant of a 12-year-oldchild with low caries experience (2DMFT) and presence of pigmented dots extending beyond half of thecervical third of the tooth surfaces.
that was not included in the survey sample.
Calibration of scoring black stain was restricted The collected data were entered in Microsoft Excel to training with typical clinical images. To check worksheets and analysed using the spss statistical for each examiner’s reliability, re-examination of software (spss, version 11.05). Cohen’s kappa (j) every 20th subject throughout the study was was used to measure the intra- and inter-examiner Black stain and dental caries in Filipino schoolchildren reliability of the examiners. For caries scoring at the sentative subgroup for the analysis of caries at the DMFT and DMFS level the j values ranged from surface level and black stain. The distribution of 0.92 to 0.97 for intra-examiner reliability and from DMFS between occlusal, smooth and proximal 0.87 to 0.97 for inter-examiner reliability. The surfaces was not statistically significant different j-values computed for black stain scoring ranged in the black stain and nonblack stain group from 0.98 to 1.00 for intra-examiner reliability and from 0.96 to 1.00 for inter-examiner reliability.
About 95% confidence intervals (CI) were calcu- lated for all the principal outcomes in percentages.
For statistical testing of differences between theordinal The data revealed that the prevalence of black stain (DMFT ⁄ DMFS) in children belonging to different in the whole group of Filipino schoolchildren was intervention groups and in children with and 16% (Table 1) and therefore higher than that without black stain Mann–Whitney-U-test (15) recorded in Italian (6%) (5) and Spanish children and one-way anova were used. The 627 children (8%) (12). Only in Brazilian children, a comparable for whom DMFS was recorded were included with high prevalence of black stain (15%) has been their DMFT in the overall DMFT value of the total sample of 1748 children. The prevalence of black The caries prevalence (72%) and caries experi- stain in the different groups and the prevalence of ence (2.3 DMFT) of this sample of children (Table 2) caries in children with and without black stain was were lower than the reported 82% caries preva- compared by the contingency table test of inde- lence and 2.9 DMFT in the recent national oral pendence (chi-square test). The level of significance health survey for 12-year olds (16). The lower levels of caries prevalence and caries experience in thepresent sample are probably because of regionalcircumstances and the preventive intervention programs to which the majority of children wereexposed. No statistical significant difference was The mean age of the total sample of Filipino observed in the prevalence of black stain between children was 11.7 ± 1.1 years and the overall prev- children exposed to the three different intervention alence of black stain was 16% (Table 1). The programs (Table 1). Thus hypothesis 1 is accepted.
prevalence of black stain did not differ significantly The finding of a higher prevalence of black stain in between the three different intervention groups remote schools than in accessible schools (Table 2) (P = 0.09). The prevalence of black stain was rejects hypothesis 2. The obviously lower caries statistically significant higher in the remote schools prevalence and caries experience of children in as compared with the total sample, 45% versus remote schools is associated with distinctive fea- 16%, respectively (Table 2). The caries prevalence tures of rural poverty. Traditional nutrition, sus- and caries experience in the total sample were tainable community structures, limited cash on statistically significant, lower in children with black hand and as a consequence limited exchange of stain as compared with children without black goods and food and also limited exposure to stain (Table 2). A similar pattern was found in the Western lifestyle through television are specific remote schools where the level of caries prevalence characteristics of these deprived communities. It and caries experience was lower in the black stain can only be speculated that the low caries preva- group as compared with the nonblack stain group lence and experience and the high prevalence of black stain might be the result of traditional dietary assessed, 247 children from schools with compre- For the whole group of Filipino schoolchildren, hensive intervention, 251 children from schools the presence of black stain was associated with with basic intervention and 129 children from lower caries prevalence and caries experience. This control schools did not differ significantly from finding is in accordance with the literature (5, 11).
the total sample with regard to age (11.6 years), prevalence of black stain (15%) and a DMFT value The present study is the first to present the of 2.2 ± 2.6. The group of children where DMFS presence of black stain in association with caries was assessed can therefore be considered a repre- distribution on occlusal, smooth and proximal surfaces. No difference in DMFS pattern was found in black stain children compared with those with- out black stain. Hypothesis 4 is therefore accepted.
Since the dominant occurrence of black stain onsmooth surfaces was not particularly associated with less caries on these surfaces, one can speculate that the lower caries experience in children with black stain reflects a general lower caries activity It has been assumed that the presence of black stain is associated with low cariogenic oral micro- flora with a predominance of actinomycetes and low numbers of streptococci (8–10). Followingrecent immunological studies and investigations on bacterial adhesion, high levels of Actinomyces naeslundii in biofilms on teeth correlated with low caries experience and low mutans streptococci adhesion (17, 18). Thus, bacterial composition ofbiofilms on teeth has an influence on susceptibilityand resistance to dental caries (18). If black stain is indeed associated with biofilms on teeth with low cariogenic potential, the question is whether this iscaused by the diet. It has been suggested that the composition of the microflora on the teeth might be the expression of dietary habits and that a low caries experience is more likely caused by dietary habits than by a specific microflora (19). The phenomenon of black stain is an interesting clinical model to unravel the interplay of diet, microflora and dental caries and this urges further investiga- 1. Pedersen PO. Farvede belægninger i mælketandsætter og deres forold til cariesforkomster. Tandlægebladet 2. Commerell C. Zum Problem der Kariesresistenz.
Dtsch Zahna¨rztl Z 1955;10:1418–20.
3. James PMC. Dental caries prevalence in relation to calculus, de´bris and extrinsic dental staining. Adv Fluorine Res Dent Caries Prev 1965;3:153–8.
4. Shourie KL. Mesenteric line or pigmented: a sign of comparative freedom from caries. J Am Dent Assoc 5. Koch JM, Bove M, Schroff J, Perlea P, Garcia-Goddoy F, Staehle H-J. Black stain and dental caries in schoolchildren in Potenza, Italy. J Dent Child 6. Reid JS, Beeley JA, MacDonald DG. Investigations into black extrinsic tooth stain. J Dent Res 7. Reid JS, Beeley JA. Biochemical studies on the composition of gingival debris from children with black extrinsic tooth stain. Caries Res 1976;10:363–9.
Black stain and dental caries in Filipino schoolchildren 8. Theilade J, Slots J, Fejerskov O. The ultrastructure of 14. World Health Organisation. Oral Health Surveys.
black stain on human primary teeth. Scand J Dent Basic Methods, 4th edn. Geneva: WHO; 1997.
15. Cohen ME. Analysis of ordinal dental data: evalua- 9. Slots J. The microflora of black stain on human tion of conflicting recommendations. J Dent Res primary teeth. Scand J Dent Res 1974;82:484–90.
10. Saba C, Solidana M, Berlutti F, Vestri A, Ottolenghi 16. Monse B, Yanga-Mabunga S. Urgent oral health L, Polimeni A. Black stains in the mixed dentition: a needs of Filipino children: The results of the 2006 PCR microbiological study to the etiopathogenic National Oral Health Survey. Developing Dentistry bacteria. J Clin Pediatr Dent 2006;30:219–24.
11. Gasparetto A, Conrado CA, Maciel SM, Miyamoto 17. Levine M, Owen WL, Avery KT. Antibody response EY, Chicarelli M, Zanata RL. Prevalence of black to Actinomyces antigen and dental caries experience: tooth stains and dental caries in Brazilian schoolchil- Implications for caries susceptibility. Clin Diagn Lab 12. Paredes Gallardo V, Paredes Cencillo C. Tincio´n cromo´gena: un problema habitual en la clı´nica Ka¨llesta˚l C, Stro¨mberg N. The association of bacterial pedia´trica. An Pediatr (Barc) 2005;62:258–60.
adhesion with dental caries. J Dent Res 2001;80: 13. Monse-Schneider B, Heinrich-Weltzien R, Schug D, Sheiham A, Borutta A. Assessment of manual 19. van Palenstein Helderman WH, Matee MIN, van der restorative treatment (MRT) with amalgam in high- Hoeven JS, Mikx FHM. Cariogenicity depends more caries Filipino children: results after 2 years. Com- on diet than the prevailing mutans streptococcal munity Dent Oral Epidemiol 2003;31:129–35.
species. J Dent Res 1996;75:535–45.

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