Bhat et al

International Journal of Public Health Dentistry

RESEARCH ARTICLE

Black tooth stain and dental caries among Udaipur school children
Surekha Bhat

Abstract Background: Black stain is defined as dark pigmented exogenous substance in lines or dots parallel to the gingival margin and firmly adherent to enamel at the cervical third of the tooth crown in the primary and permanent dentition. Aim: This study was conducted to evaluate the association and correlation between the presence of black extrinsic tooth stains with dental caries and caries experience at the tooth surface level in Udaipur schoolchildren. Materials and methods: The target population consisted of 1472 (264 with black stain and 1208 without black stain) children aged 9.31.9 years. Clinical examinations were performed by two dentists calibrated for the WHO criteria for caries diagnosis. The studentt test was used to compare the prevalence of caries (DMFT and DMFS) between groups of children with and without black tooth stains. Spearmans correlation test was used to analyze the relationship between the presence of black stains and caries severity. Results: Black stains were observed in 18% of the children. The Caries prevalence (DMFT and DMFS) in the total sample was statistically significant, lower in children with black stains as compared to children without black stains (p=0.000). A negative correlation was observed between the presence (r = -0.36; p<0.001) and severity (r =-0.36; p<0.001) of black stains and DMFT. Conclusion: The presence of black stain is associated with lower levels of caries. The interplay between black stain, caries, general caries activity, oral microflora and diet remains unclear and urges further research. Key words: Black Tooth Stain, Dental Caries, Schoolchildren. Received on: 12/09/2010 Introduction Accepted on: 14/11/2010 an association with chromogenic bacteria such as Actinomyces and Prevotella melaninogenica 3-6 has been reported . However, a possible interaction between the microbiota related to the extrinsic pigmentation and the cariogenic microbiota remains obscure. Black stains may be clinically diagnosed as pigmented dots, lines with incomplete coalescence of dots or 7 continuous lines , which go beyond the cervical third and contour the crown around the gingival 5 third, not extending to the proximal areas . Koch 8 et al. used the following criteria for the diagnosis of black stains: presence of dark dots forming a linear discoloration parallel to the gingival margin at the smooth surfaces of at least two permanent teeth. There is no consensus in the literature concerning the 8 prevalence of black stain among age groups , but the presence of black stain has been commonly associated with a low caries 7,8 experience . There was no as such literature available in India to find the association of black stains with dental caries. Hence, this study was conducted to evaluate the association and correlation between the presence of black extrinsic tooth stains with dental caries and caries experience

Tooth discoloration is a frequent dental finding associated with clinical and esthetic problems. It differs in etiology, appearance, composition, location, severity and degree of 1 adherence . Basically, there are two types of tooth discolorations: those related to intrinsic factors such as congenital or systemic influence and inherited conditions, or those caused by extrinsic factors, related to metallic or nonmetallic stains. Attraction of materials to the tooth surface plays a critical role in the 2 deposition of extrinsic dental stain . Studies focusing on black extrinsic dental stains are scarce in recent scientific literature. This particular type of pigmentation has been considered to be a special form of dental plaque that differs from other types because it contains insoluble iron salt and a high content of calcium 3-5 5 and phosphate . According to Reid et al. , the black material is a ferric salt, probably ferric sulfide, formed by the reaction between the hydrogen sulfide produced by bacteria action and iron in the saliva or gingival exudates. Although its origin remains somewhat obscure,
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International Journal of Public Health Dentistry 1:1 (2010)11-15. Celesta software Pvt Ltd

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International Journal of Public Health Dentistry

at the tooth schoolchildren.

surface

level

in

Udaipur

Materials and Methods This cross sectional survey was conducted in schools of Udaipur city, Rajasthan, India. The survey was conducted between November 2008 and January 2009. The list of schools in the city was obtained from District Educational Board office. The list comprised of 64 schools. Thirty schools were selected by simple random sampling technique. All the schools children available on the day of visit were included in the study. The sample consisted of 1472 childrens (708 males and 764 females) aged 6 to 12 years attending 30 schools (23 private and 7 government schools). The study design was approved by the Ethics Committee of the Pacific Dental College and Hospital. The goals of the study were explained in detail to the parents or caretakers of the patients who met the inclusion criteria. The patients caretaker signed an informed consent form. The clinical examinations were performed by two dentists who had been previously trained and calibrated for the World Health Organization criteria for caries 9 diagnosis . The intra- and inter-examiner agreements for dental caries diagnosis were evaluated using the kappa test, with kappa values above 0.82. A clinical examination was performed under natural light with plane mouth mirrors in the school environment. DMFT and DMFS were recorded together with the presence or absence of black stains. Only the permanent dentition was evaluated. The clinical diagnosis of the black stains was performed according to 7 8 the criteria of Shourie and Koch et al. , and an additional criterion was created for classification based on the extension of the tooth surface area affected by the black stain. Score 1 corresponded to the presence of pigmented dots or thin lines with incomplete coalescence parallel to gingival margin; score 2 corresponded to continuous pigmented lines, which were easily observed and limited to half of the cervical third of the tooth surface; score 3 corresponded to the presence of pigmented stains extending beyond half of the cervical third of the tooth 10 surface as used by Gasparetto et al. . Statistical analysis Data analysis was done using SPSS version 11.5 (SPSS, Inc., Chicago, IL, USA)

and Data was descried using frequency, percentage, mean and standard deviation. Statistical significance for the association between occurrence black stain and dental caries (DMFT and DMFS) was carried out using the Student t test. The correlation between caries severity and the presence of black stains was analyzed using Spearmans correlation test. The level of significance set was p<0.05. Results A total of 1472 children formed the study sample which consisted of 264 children with black stain and 1208 children without black stain with mean age of the total sample of Udaipur city children was 9.3 1.9 years. The overall prevalence of black stains was 18% (50.8% females and 49.2% males). Caries prevalence (DMFT) in the total sample was statistically significant, lower in children with black stains (1.12 1.41) as compared to children without black stains (1.77 1.87) (p=0.001) (Table 1).
Children Subjects N (%) 1208(82) Age (years SD) 9.6 1.9 9.5 1.8 9.4 1.9 % Caries 60.1 DMFT (x SD) 1.77 1.87 0.001* With black stain Total 264(18) 1472 45.1 50.2 1.12 1.41 1.56 1.77 Pvalue

Without black stain

Table 1: Prevalence of black stain in total sample and caries experience (DMFT) of children with and without black stains. *significant at p<0.05 (p=0.001) using studentt test.

When children were observed for DMFS, it was seen that children with black stains (1.16 1.72) had significantly lower total mean DMFS value than children without black stains (1.76 2.38) (p=0.001), but when comparing mean DMFS value at surface level it was found that no significant difference existed between DMFS value in occlusal (0.47 0.708 with black stains and 0.54 0.70 among without black stains) and smooth surface level (0.27 0.605 with black stains and 0.33 0.77 among without black stains), while statistically significant difference was observed at proximal surface level (0.14 0.38 with black stains and 0.49 0.79 among without black stains) (p=0.001)(Table 2).

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International Journal of Public Health Dentistry

DMFT Scores* Children With black stain* (N = 264) Without black stain (N =1208) 0 145(54.9) 482(39.9) 1 24(9.1) 71(5.9) 2 38(14.4) 354(29.3) 3 33(12.5) 70(5.8) 4 24(9.1) 78(6.5) 5 0 77(6.4) 6-8 0 76(6.3)

Table 2: Caries experience (DMFS) and distribution of DMFS at surface level of children with black and without black stains. *significant at p<0.05 (p=0.001) using student t Test

Children

Subjects N (%) 264(18)

DMFS* (x SD) 1.16 1.72*

DMFS Occlusal (x SD) 0.470.708

DMFS Smooth (x SD) 0.27 0.605

DMFS*Proximal (x SD) 0.14 0.386* 0.49 0.792

With black stain

Without black 1208(82) 1.76 2.38 0.54 0.700 0.33 0.775 stain Table 3: DMFT index distribution of children with and without black extrinsic tooth stains (N=1472). *significant at p<0.05, negative correlation was observed (r= -0.36; p=0.001)

In the present study, children with black stains (N=264), it was found that the highest percentage 42.4% was classified as score 3 (N=112), followed by 33.4% for score 2 (N=88) and 24.2% for score 1(N=64). Statistical analysis (Spearmans correlation test) showed that negative correlation between the severity of the black stains (scores) and DMFT (r = -0.36; p=0.001) was observed. In addition, the presence of black extrinsic tooth stains was negatively correlated to the severity of caries (DMFT scores) (r = -0.36; p=0.001) (Table 3). Discussion In the present study, prevalence of black stains among schoolchildren was 18%, which is in consistent with the study conducted by Koch 8 et al. (19.9%) among school children from Switzerland (aged 7- 15 years), Gasparetto A et 10 al. (15%) among Brazilian schoolchildren, 11 Heinrich-Weltzien et al among Filipino 12 schoolchildren, Sutcliffe in 1967 reported 21% of black stains in a population of nearly one thousand children aged 11 to 13 years and 8 higher than reported by Koch et al. (4.6%) among schoolchildren aged six to ten years of age in Germany. The data revealed that the prevalence of caries in this study was lower among the children with black stains (45.1%) than those of without black stains (60.1%), this finding is in accordance with study done by Gasparetto A et 10 8 12 al. , Koch et al. and Sutcliffe .

In relation to presence of black stains to caries distribution on occlusal, smooth and proximal surfaces. The mean DMFS values was found to be statistically significant between children with black stains and those without black stains but at surface level no difference in DMFS pattern for smooth and occlusal surface was found between the groups, except at proximal surface level significant difference was observed between both the groups. This finding is in contrast to the study conducted by Heinrich11 Weltzien et al. , where no difference was observed for mean value of DMFS and value DMFS at all the surface level. This finding reflects that the occurrence of black stains on smooth 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 rather than a localized effect. It has been assumed that the presence of black stain is associated with low cariogenic oral microflora with predominance of actinomycetes and low numbers of 3,6,13 streptococci . However, the mechanism of biological interaction between the microbiota related to the extrinsic pigmentation and the cariogenic microbiota is not completely understood. The morphologic studies of black 3 stains reported by Theilade et al. and Reid et 5 al. confirmed that this kind of stain is a special type of dental plaque characterized by its flora 4 and its tendency to calcify. According to Reid 6 and Slots , the predominant organisms in black

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International Journal of Public Health Dentistry 1:1 (2010)11-15. Celesta software Pvt Ltd

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International Journal of Public Health Dentistry

stains are Actinomyces and Prevotella melaninogenicus. The tendency towards calcification within the black material promotes a high level of calcium and phosphate that contributes to a reduction in the enamel dissolution and an increase in the buffering capacity. Following recent immunological studies and investigations on bacterial adhesion, high levels of Actinomyces naeslundii in biofilms on teeth correlated with low caries experience and 14,15 low mutans streptococci adhesion . Thus, bacterial composition of biofilms on teeth has an influence on susceptibility and resistance to 15 dental caries . If black stain is indeed associated with biofilms on teeth with low cariogenic potential, the question is whether this is caused 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 16 8 microflora . According to Koch et al. , the microbiota of black stain might be an interesting model of replacement of oral pathogens and further studies in populations of different age ranges evaluating the hypothesis that black stains are protective against caries would seem justified. This study showed, significant difference between the presence of black stain and caries prevalence and a significant negative correlation was found between the presence of black stains and the severity of the disease, as evaluated by means of the DMFT scores. A DMFT > 3 was seen for 9.1% of the children with stains and 19.2% of the children without stains. No child with black stains presented DMFT above 4, whereas this condition was observed in 12.7% of the children without stains. Another interesting finding was that the amount or extension of staining was significantly correlated to DMFT scores, i.e., less caries was observed among those children with the largest areas affected by the stains (score 3). The reason why some individuals with black stain exhibits less caries prevalence has not been clearly demonstrated whether it is due to their dietary habits, general lower caries activity, presence of microbiota or biofilms, or increase in deposition of calcium and phosphate ion. So, the phenomenon of black stain is an interesting clinical model to unravel the interplay of general caries activity, diet, microflora and dental caries. Hence it requires further investigations to find out the exact association.
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Authors Affiliations: Dr. Surekha Bhat, MDS, Associate Professor, Department of conservative dentistry, Pacific Dental College, Udaipur, Rajasthan, India.

References 1. Hattab FN, Qudeimat MA, Al-Rimawi HS. Dental discoloration: an overview. J Esthet Dent 1999;11:291-310. 2. Nathoo SA. The chemistry and mechanisms of extrinsic and intrinsic discoloration. J Am Dent Assoc 1997;128:6S-10S. 3. Theilade J, Slots J, Fejerskov O. The ultrastructure of black stain on human primary teeth. Scand J Dent Res 1973;81:528-532. 4. Reid JS, Beeley JA. Biochemical studies on the composition of gingival debris from children with black extrinsic tooth stain. Caries Res 1976;10:363-369. 5. Reid JS, Beeley JA, MacDonald DG. Investigations into black extrinsic tooth stain. J Dent Res 1977;56:895-899. 6. Slots J. The microflora of black stain on human primary teeth. Scand J Dent Res 1974;82:484-490. 7. Shourie KL. Mesenteric line or pigmented plaque: a sign of comparative freedom from caries. J Am Dent Assoc 1947;35:805-807. 8. Koch MJ, Bove M, Schroff J, Perlea P, Garcia-Godoy F, Staehle H. Black stain and dental caries in schoolchildren in Potenza, Italy. J Dent Child 2001;68:353-355. 9. World Health Organization. Oral Health Surveys. Basic Methods. Geneva: WHO. 1997. 10. Gasparetto A, Conrado CA, Maciel SM, Miyamoto EY, Chicarelli M, Zanata RL. Prevalence of black tooth stains and dental caries in Brazilian schoolchildren. Braz Dent J 2003;14:15761. 11. Heinrich-Weltzien R, Monse B, van Palenstein Helderman W. Black stain and dental caries in Filipino schoolchildren. Community Dent Oral Epidemiol 2009; 37: 182187. 12. Sutcliffe P. Extrinsic tooth stains in children. Dental Practice 1967;17:175-179. 13. Saba C, Solidana M, Berlutti F, Vestri A, Ottolenghi L, Polimeni A. Black stains in the mixed dentition: a PCR microbiological study to the etiopathogenic bacteria. J Clin Pediatr Dent 2006;30:21924. 14. Levine M, Owen WL, Avery KT. Antibody response to Actinomyces antigen and dental caries experience: Implications for caries

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susceptibility. Clin Diagn Lab Immunol 2005;12:7649. 15. Stenudd C, Nordlund A, Ryberg M, Johansson I, Kallesta l C, Stromberg N. The association of bacterial adhesion with dental caries. J Dent Res 2001;80: 200510. 16. van Palenstein Helderman WH, Matee MIN, van der Hoeven JS, Mikx FHM. Cariogenicity depends more on diet than the

prevailing mutans streptococcal species. J Dent Res 1996;75:53545. Address for Correspondence Dr. Surekha Bhat, MDS, Associate Professor, Department of conservative dentistry, Pacific Dental College, Udaipur, Rajasthan, India

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International Journal of Public Health Dentistry 1:1 (2010)11-15. Celesta software Pvt Ltd