Community Dent Oral Epidemiol 2009; 37: 182–187  2009 The Authors.

Journal compilation
All rights reserved  2009 John Wiley & Sons A/S

Roswitha Heinrich-Weltzien1, Bella

Black stain and dental caries in Monse2 and Wim van Palenstein
Helderman3

Filipino schoolchildren
1
Department of Preventive Dentistry,
University Hospital of Jena, WHO
Collaborating Centre ‘Prevention of Oral
Diseases’, Jena, Germany, 2Department of
Education, Health and Nutrition Centre, City
Heinrich-Weltzien R, Monse B, van Palenstein Helderman W. Black stain of Division Cagayan de Oro, Cagayan de
and dental caries in Filipino schoolchildren. Community Dent Oral Epidemiol Oro, Philippines, 3WHO Collaborating
2009; 37: 182–187.  2009 The Authors. Journal compilation  2009 John Centre for Oral Health Care Planning and
Wiley & Sons A/S Future Scenarios, Radboud University
Nijmegen Medical Centre, The Netherlands
Abstract – Black stain is defined as dark pigmented exogenous substance in
lines or dots parallel to the gingival margin and firmly adherent to the enamel at
the cervical third of the tooth crowns in the primary and permanent
dentition. Objectives: This study was conducted to assess the prevalence of
black stain on teeth of Filipino children and to determine a possible association
between black stain and caries levels. The study was designed to test the
following hypotheses: (i) the prevalence of black stain does not differ between
children from schools with oral health intervention programs and those from
schools without an intervention program, (ii) the prevalence of black stain does
not differ in children attending easily accessible and remote schools, (iii) caries
prevalence and caries experience do not differ in children with and without
black stain and (iv) the caries distribution at the surface level does not differ in
children with and without black stain. Methods: In total, 32 elementary schools
were included. 19 schools with a comprehensive school-based preventive oral
health program, seven schools with a basic preventive program and six control
schools. All sixth graders of these schools (n = 1748) aged 11.7 ± 1.1 years were
clinically examined for black stain. DMFT was assessed in 1121 children by
seven calibrated dentists using WHO criteria. DMFS was scored in 627 children
by two calibrated dentists. Results: Black stain was found in 16% of this
population. The prevalence of black stain did not differ significantly between
children attending schools with different oral health intervention programs.
Thus, hypothesis 1 was accepted. The prevalence of black stain was significantly
higher (P < 0.05) in remote than in more accessible schools. Thus, hypothesis 2 Key words: black stain; dental caries;
was rejected. Children with black stain had significantly lower (P < 0.05) caries deprived communities
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, Germany
Tel: +49 3641 9 34801
black stain. Thus hypothesis 4 was accepted. Conclusions: The presence of black Fax: +49 3641 9 34802
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 jena.de
black stain, caries, oral microflora and diet remains unclear and urges further Submitted 15 January 2008;
research. accepted 19 November 2008

In the fifties and sixties of the last century, most
children in the Western world suffered from a high
caries burden and children with no or few caries
lesions were uncommon. After empirical observa-
tions that children with black stained teeth had less
caries, epidemiological studies in the 1950s and
1960s demonstrated that the occurrence of black
stain on primary and permanent teeth in children
was associated with low caries experience (1–3).
Black stain may be clinically diagnosed as pig-
mented dark lines parallel to the gingival margin
(1–5) or as an incomplete coalescence of dark dots
rarely extending beyond the cervical third of the
crown (6). This particular type of pigmentation has
been considered to be a special form of dental
plaque because it contains an insoluble ferric salt,
probably ferric sulphide, and a high content of
calcium and phosphate (6–8). Actinomyces and

182 doi: 10.1111/j.1600-0528.2008.00458.x


Prevotella melaninogenicus have been reported as the
predominant microorganisms in black stain (6, 9,
10). However, a possible interaction between the
microbiota related to the extrinsic pigmentation
and the cariogenic microbiota remains obscure.
There is no consensus in the literature concerning
the prevalence of black stain among age groups
(5, 11, 12), but the presence of black stain has been
commonly associated with a low caries experience
(5, 11). Neither the older studies nor the more recent
ones have established whether the observed lower
caries experiences in children with black stain is the
result of fewer lesions on smooth surfaces, in
fissures, or both. It was suggested that information
of this kind may elucidate a possible connection
between black stain and low caries activity (8).
The present study was conducted within the
frame of oral health care programs in public
elementary schools in Northern Mindanao, Philip-
pines which were carried out in cooperation
between the Philippine Department of Education
and the German NGO ‘Committee of German
Doctors’. During the 5 years of the programs, the
health personnel involved developed the impres-
sion that schoolchildren with black stain on their
primary or permanent teeth were ‘more caries
resistant’ than their peers. The frequent occurrence
of black stain associated with no or low caries
experience was particularly conspicuous in school-
children attending schools in villages located in
poor and remote mountainous areas who main-
tained traditional nutrition behaviour with limited
access to sugar containing foods.
It was therefore decided to conduct a study not
only to assess possible associations between black
stain, caries prevalence and experience at the tooth
surface level, but also to assess possible effects of
different intervention programs on the prevalence
of black stain and to determine the occurrence of
black stain and the association with caries in
remote schools.
This study was designed to test the following
hypotheses: (i) the prevalence of black stain does
not differ between children from schools with oral
health intervention programs and those from
schools without an intervention program, (ii) the
prevalence of black stain does not differ in children
attending easily accessible and remote schools, (iii)
caries prevalence and caries experience do not
differ in children with and without black stain and
(iv) the distribution of caries at the surface level
does not differ in children with and without black
stain.
Black stain and dental caries in Filipino schoolchildren
Methods
In July and August 2003 this cross-sectional study
was carried out in rural areas in Misamis Oriental
province, Northern Mindanao, Philippines. In total,
32 schools were included. At the time of evaluation
19 schools had participated for 5 years in a com-
prehensive school-based preventive program (dai-
ly tooth brushing, application of Fluorprotector
varnish three times a year, manual restorative
treatment in the permanent dentition and extrac-
tion of nonrestorable teeth (13). At the time of
evaluation seven schools had participated for
2 years in a basic preventive program (daily tooth
brushing and emergency oral treatment on de-
mand). Six other schools were assigned to serve as
control for the intervention program. The control
schools were exposed to regular school dental
services which included an annual examination
and a classroom talk on dental health. The schools
were selected by the Department of Education and
comprised rural schools, accessible by four-wheel
drive even in rainy season. All sixth graders
(n = 1748) of these 32 schools were examined for
black stain, 966 from the 19 schools with the
comprehensive preventive program, 468 children
from the seven schools with the basic preventive
program and 314 children from the six control
schools (Table 1). A sub-sample of the total sample
consisting of four remote schools with a compre-
hensive preventive program contained 134 chil-
dren (Table 2). The caries status of 1121
schoolchildren was assessed by seven calibrated
dentists scoring DMFT whereas two calibrated
experienced dentists scored DMFS according to
WHO criteria (14) in 627 children. Children were
assigned to the different examiners by the teachers
according to the numbering in the school record
book. After brushing their teeth the children were
examined outdoors in the schoolyards lying in a
supine position on school benches. Examination
was performed under direct sunlight.
The criterion for scoring black stain was the
presence of firmly adherent black dots generally
forming linear discolouration parallel to the gingi-
val margin and occasionally covering up to one
third or more of the clinical tooth crown (Fig. 1) (8).
Black stain was recorded as absent or present in the
dentition.
Calibration of the examiners was performed by
a WHO consultant epidemiologist over a 3-day
period. Calibration of caries scoring was based on
a theoretical and practical training at a local school
183
Heinrich-Weltzien et al.

Table 1. Number of schools, number of schoolchildren, their mean age and the prevalence of black stain in the different
intervention groups
Schools Subjects Age % Black stain
Intervention group (N) (N) (yrs ± SD) [95% CI]
Comprehensive intervention 19 966 11.8 ± 1.1 16% [14–18]
Basic intervention 7 468 11.6 ± 1.1 18% [15–21]
No intervention 6 314 11.5 ± 0.9 12% [9–15]
Total 32 1748 11.7 ± 1.1 16% [14–18]

Table 2. Prevalence of black stain in the total sample and in a sub-sample with remote schools and caries prevalence and
caries experience (DMFT) of children with and without black stain
Total sample Remote schools
Subjects Subjects
N (%) Age % Caries DMFT N (%) Age % Caries DMFT
[95% CI] (yrs ± SD) [95% CI] (x ± SD) [95% CI] (yrs ± SD) [95% CI] (x ± SD)
With 278 (16%)** 12.0 ± 1.2 59* [54–64] 1.5* ± 2.1 61 (45%)** 11.9 ± 1.1 52* [41–63] 0.8* ± 1.0
black [14–18] [38–52]
stain
Without 1470 (84%) 11.6 ± 1.0 81 [79–83] 2.5 ± 2.5 73 (55%) 11.9 ± 1.1 74 [65–83] 2.0 ± 2.0
black [82–86] [48–62]
stain
Total 1748 11.7 ± 1.1 72 [70–74] 2.3 ± 2.5 134 11.9 ± 1.1 64 [57–71] 1.5 ± 1.7
*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.

(a) (b)
Fig. 1. Clinical manifestation of black
stain: Upper (a) and lower (b) jaw of a
12-year-old caries free child with
continuous pigmented lines limited
to half of the cervical third of the
tooth surfaces and on the oral smooth
surfaces of the incisors. First (c) and
fourth (d) quadrant of a 12-year-old
child with low caries experience (2
DMFT) and presence of pigmented
(c) (d) dots extending beyond half of the
cervical third of the tooth surfaces.

that was not included in the survey sample. Statistical methods

Calibration of scoring black stain was restricted
to training with typical clinical images. To check
for each examiner’s reliability, re-examination of
every 20th subject throughout the study was
performed.
The collected data were entered in Microsoft Excel
worksheets and analysed using the spss statistical
software (spss, version 11.05). Cohen’s kappa (j)
was used to measure the intra- and inter-examiner

184

reliability of the examiners. For caries scoring at the
DMFT and DMFS level the j values ranged from
0.92 to 0.97 for intra-examiner reliability and from
0.87 to 0.97 for inter-examiner reliability. The
j-values computed for black stain scoring ranged
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 the
ordinal scaled data of caries experience
(DMFT ⁄ DMFS) in children belonging to different
intervention groups and in children with and
without black stain Mann–Whitney-U-test (15)
and one-way anova were used. The 627 children
for whom DMFS was recorded were included with
their DMFT in the overall DMFT value of the total
sample of 1748 children. The prevalence of black
stain in the different groups and the prevalence of
caries in children with and without black stain was
compared by the contingency table test of inde-
pendence (chi-square test). The level of significance
was set at 5%.
Results
The mean age of the total sample of Filipino
children was 11.7 ± 1.1 years and the overall prev-
alence of black stain was 16% (Table 1). The
prevalence of black stain did not differ significantly
between the three different intervention groups
(P = 0.09). The prevalence of black stain was
statistically significant higher in the remote schools
as compared with the total sample, 45% versus
16%, respectively (Table 2). The caries prevalence
and caries experience in the total sample were
statistically significant, lower in children with black
stain as compared with children without black
stain (Table 2). A similar pattern was found in the
remote schools where the level of caries prevalence
and caries experience was lower in the black stain
group as compared with the nonblack stain group
(Table 2).
The group of 627 children where DMFS was
assessed, 247 children from schools with compre-
hensive intervention, 251 children from schools
with basic intervention and 129 children from
control schools did not differ significantly from
the total sample with regard to age (11.6 years),
prevalence of black stain (15%) and a DMFT value
of 2.2 ± 2.6. The group of children where DMFS
was assessed can therefore be considered a repre-
Black stain and dental caries in Filipino schoolchildren
sentative subgroup for the analysis of caries at the
surface level and black stain. The distribution of
DMFS between occlusal, smooth and proximal
surfaces was not statistically significant different
in the black stain and nonblack stain group
(Table 3).
Discussion
The data revealed that the prevalence of black stain
in the whole group of Filipino schoolchildren was
16% (Table 1) and therefore higher than that
recorded in Italian (6%) (5) and Spanish children
(8%) (12). Only in Brazilian children, a comparable
high prevalence of black stain (15%) has been
reported (11).
The caries prevalence (72%) and caries experi-
ence (2.3 DMFT) of this sample of children (Table 2)
were lower than the reported 82% caries preva-
lence and 2.9 DMFT in the recent national oral
health survey for 12-year olds (16). The lower levels
of caries prevalence and caries experience in the
present sample are probably because of regional
circumstances and the preventive intervention
programs to which the majority of children were
exposed. No statistical significant difference was
observed in the prevalence of black stain between
children exposed to the three different intervention
programs (Table 1). Thus hypothesis 1 is accepted.
The finding of a higher prevalence of black stain in
remote schools than in accessible schools (Table 2)
rejects hypothesis 2. The obviously lower caries
prevalence and caries experience of children in
remote schools is associated with distinctive fea-
tures of rural poverty. Traditional nutrition, sus-
tainable community structures, limited cash on
hand and as a consequence limited exchange of
goods and food and also limited exposure to
Western lifestyle through television are specific
characteristics of these deprived communities. It
can only be speculated that the low caries preva-
lence and experience and the high prevalence of
black stain might be the result of traditional dietary
habits.
For the whole group of Filipino schoolchildren,
the presence of black stain was associated with
lower caries prevalence and caries experience. This
finding is in accordance with the literature (5, 11).
Hypothesis 3 is therefore rejected.
The present study is the first to present the
presence of black stain in association with caries
distribution on occlusal, smooth and proximal
185
Heinrich-Weltzien et al.

surfaces. No difference in DMFS pattern was found

29 [20–38]

33 [29–37]
% Caries
[95% CI]
in black stain children compared with those with-
out black stain. Hypothesis 4 is therefore accepted.
Since the dominant occurrence of black stain on

DMFSProximal
smooth surfaces was not particularly associated

0.7* ± 1.8

1.6 ± 3.0

1.5 ± 2.9
with less caries on these surfaces, one can speculate

x ± SD
that the lower caries experience in children with
Table 3. Caries prevalence, caries experience (DMFS) and distribution of DMFS within the dentition of schoolchildren with and without black stain

black stain reflects a general lower caries activity

rather than a localized effect.
It has been assumed that the presence of black
29 [20–38]

33 [29–37]
% Caries
[95% CI]

stain is associated with low cariogenic oral micro-

flora with a predominance of actinomycetes and
low numbers of streptococci (8–10). Following
recent immunological studies and investigations
DMFSSmooth

0.7* ± 1.6

1.6 ± 3.0

1.5 ± 2.8
on bacterial adhesion, high levels of Actinomyces
x ± SD

naeslundii in biofilms on teeth correlated with low

caries experience and low mutans streptococci
adhesion (17, 18). Thus, bacterial composition of
biofilms on teeth has an influence on susceptibility
42 [32–52]

34 [30–38]

*Caries prevalence and caries experience between black stain and no black stain, significance level: P < 0.05.
% Caries
[95% CI]

and resistance to dental caries (18). 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
DMFSOcclusal

composition of the microflora on the teeth might be

1.0* ± 1.6

1.7 ± 1.8

1.6 ± 1.8
x ± SD

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
2.4* ± 4.5

5.0 ± 7.1

4.6 ± 6.9
(x ± SD)

model to unravel the interplay of diet, microflora

DMFS

and dental caries and this urges further investiga-

tion.
53* [44–62]

80 [77–83]

76 [73–79]
% Caries
[95% CI]

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