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All rights reserved 2009 John Wiley & Sons A/S
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 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
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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.
184
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 (Table 3).
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
Discussion
ordinal scaled data of caries experience 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 reported (11).
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
was set at 5%. 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
Results
exposed. 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
(Table 2). black stain might be the result of traditional dietary
The group of 627 children where DMFS was habits.
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), Hypothesis 3 is therefore rejected.
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
185
Heinrich-Weltzien et al.
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
33 [29–37]
% Caries
[95% CI]
0.7* ± 1.6
1.6 ± 3.0
1.5 ± 2.8
on bacterial adhesion, high levels of Actinomyces
x ± SD
34 [30–38]
*Caries prevalence and caries experience between black stain and no black stain, significance level: P < 0.05.
% Caries
[95% CI]
1.7 ± 1.8
1.6 ± 1.8
x ± SD
5.0 ± 7.1
4.6 ± 6.9
(x ± SD)
80 [77–83]
76 [73–79]
% Caries
[95% CI]
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