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Pediatrics International (2013) 55, 355–359 doi: 10.1111/ped.12066

Original Article

Prevalence of black stain and associated risk factors in preschool

Spanish children

Jose Manuel Garcia Martin,1 Manuel Gonzalez Garcia,1 Juan Seoane Leston,2 Santiago Llorente Pendas,1
Juan Jose Diaz Martin1 and Maria Jose Garcia-Pola1
1
School of Medicine, Oviedo University, Oviedo and 2Faculty of Dentistry, USC, Santiago de Compostela, Spain

Abstract Background: In pediatric clinical practice, it is common to be asked about the presence of black stains on teeth in
children and teenagers. According to controversial etiology, it is known to be related to a low rate of caries. The aim of
this study was to determine the prevalence of black stain and associated risk factors in Spanish preschool children.
Methods: A total of 3272 children aged 6 years old (3058 non-emigrant and 214 immigrant children) living in Oviedo
(Spain), were enrolled in the present study.
Results: The prevalence of black stain was 3.1% in the whole group. The index of primary decayed, missing, and filled
teeth (dmft index) associated with black stain was 0.35 ⫾ 1.123. A statistical association between black stain and the
consumption of iron supplements was noted.
Conclusions: The regular consumption of foods rich in iron and the use of iron supplements during pregnancy and early
childhood, could favor the development of chromogenic microbiota. The prevalence of black stain did not differ
significantly between non-emigrant and immigrant children in Spain.

Key words black stain, chromogenic bacteria, dental caries, iron supplements, preschool children.

In pediatric clinical practice, it is common to be asked about the
presence of black stains on teeth in children and teenagers.
This is called black stain and, according to Reid et al., it has
been defined as: pigmented dark lines parallel to the gingival
margin or an incomplete coalescence of dark dots rarely extend-
ing beyond the cervical third of the crown.1
Its formation is attributed to the colonization of the membrane
of Nasmyth by chromogenic bacteria belonging to the following
families: Porphyromonas, Prevotella and Actinomyces, which
require vitamin K and hemin for development.2,3
Traditionally, the presence of secondary black stain is related
to the presence of chromogenic bacteria, with a low rate of dental
caries.4,5
The reported prevalence of black stain varies from study to
study, according to subject age and country of origin.
In Europe, it ranges from 1.6% (UK),6 4.45% (Poland),7 6.3%
(Italy),4 to 7.54% (Valencia, Spain).8 In South America, it ranges
from 6.5% (Peru)9 to 14.8% (Brazil).10 On the Asian continent, it
varies from 16% (Philippines)11 to 18% (India).12
According to the International Organization for Migration,
a substantial amount of immigrants have joined the Spanish
native population. Thus, in the last census conducted in 2010, it
was estimated that they exceeded 14% of the total number of
inhabitants.13
Correspondence: Maria Jose Garcia-Pola Vallejo, PhD, School of
Medicine, Oviedo University, c/ Julian Clavería s/n. 33006 Oviedo,
Spain. Email: mjgarcia@uniovi.es
Received 2 May 2012; revised 13 January 2013; accepted 1
February 2013.
So far, no study has been carried out on the prevalence of
black stain in a large group of subjects of the same age, which
would integrate different races and habits and which would
permit identification of the contributions of the various habits and
lifestyles to the production of black stain.
The purpose of this paper was therefore to evaluate the preva-
lence of black stain on teeth in two groups of 6-year-old children:
one of Spanish origin and the other of emigrant origin, as well as
the influence of certain sanitary determinants, eating habits and
oral hygiene.
Methods
The study includes 3272 6-year-old children, 3058 native chil-
dren (G1) and 214 immigrant children (G2) who had dental
check-up at the Vallobin Heath Centre – La Florida, in Oviedo
(Spain), between January 1998 and March 2011.
The dental check-up was performed in a dental office and
performed by only one dentist.
A record was prepared with the following data: sex, country
of origin, presence of black stain, index of primary decayed,
missing, and filled teeth (dmft index), oral simplified debris
index, number of previous visits to the dentist, duration of ges-
tation, mode of delivery at birth, birthweight, type of feeding
(breast milk; formula; mixed), record of iron supplement con-
sumption during gestation and childhood, and survey of eating
habits and oral hygiene, including consumption of meat, fish,
vegetables, legumes, fresh fruits, dairy products, bread, pasta and
rice, eggs, type of soft drinks with or without sugar, natural

© 2013 The Authors

Pediatrics International © 2013 Japan Pediatric Society
356 JM Garcia Martin et al.

juices, artificial juices, and the use of toothpaste with fluoride,

0.977

0.473
P
without fluoride, mouthwash with or without fluoride.

1
Children born outside Spain, but who had lived ⱖ3 years in

2.1 ⫾ 3.554
0.65 ⫾ 1.852
0.55 ⫾ 2962
Spain, were not included in the study.

Total
We used the criterion proposed by Theilade et al. to detect the
presence of black stain.14 The WHO criteria were used to calcu-
late the dmft index15 and the simplified debris index of Green and
Vermillion.16

Without stain

0.59 ⫾ 1.740
2.11 ⫾ 3.495
0.70 ⫾ 1.957
The frequency of consumption of specified food was classi-

Female
fied into three categories: ⱕ3 times/month, ⱕ6 times/week and
ⱖ1 times/day. As for the oral hygiene habits: brushing teeth with
toothpaste with or without fluoride and mouthwash with or
without fluoride ⱕ6 times/week, 1 time/day and ⱖ2 times/day.

0.51 ⫾ 1.501
2.1 ⫾ 3.633
0.61 ⫾ 1.750
The consumption of iron supplements in the previous 6

Male
months was not recorded.
The children’s caregivers were given a document with infor-

dmft
mation, and informed consent to be included in the study as well
as the survey of eating habits and oral hygiene.

dmft index, index of primary decayed, missing, and filled teeth; G1, native group (n = 3058); G2, immigrant group (n = 214).
0.36 ⫾ 1.144

0.35 ⫾ 1.123
Data were collected in a database created ad hoc for the study

Total
and analyzed on a PC with SPSS (Statistical Productor Service
Solutions) version 18.0 (University of Oviedo). Data are given as
mean ⫾ SD and 95% confidence interval. Comparisons between

0
means were performed using Student’s unpaired t-test. Chi-

0.49 ⫾ 1.186

0.47 ⫾ 1.162
With stain
squared test was used to analyze qualitative variables. Two-tailed

Female
P < 0.05 was deemed statistically significant.

Results

0
The sample consisted of 3272 children: 1721 boys and 1551 girls.

0.26 ⫾ 1.094
0.27 ⫾ 1.113
The ratio of boys to girls in each group was 1.1 in G1 and 0.94
Male
in G2.
The prevalence of black stain was 3.1% in the total sample

0
(G1, 3.1%; G2, 1.9%). The prevalence of black stain did not
differ significantly between the two groups (P = 0.416), nor was
Total
Table 1 Prevalence of black stain, and dmft index vs presence of black stain

96.7

96.8
(%)

there any statistically significant association between sex and

98

black stain.
Without stain

The dmft index for the whole group was 0.64 ⫾ 1.834. The
Female

45.7
50.4
(%)

dmft index associated with black stain was 0.35 ⫾ 1.123 in the
46

whole group, 0.36 ⫾ 1.144 in G1 and 0 in G2. The association

between black stain and dmft index was not deemed statistically
Male

47.6
50.8
(%)
51

significant in the whole group (P = 0.969), nor in G1 (P = 0.977)

Gender

or G2 (P = 1; Table 1).
Total
(%)

For 74.3% of the children in the whole group and 76% of the
3.1
1.9
3.1

children with black stain, this was the first time they had come to
With stain

a dental check-up performed by a dentist.

Female
(%)
1.3
0.9
1.3

No statistically significant relationship were found between

simplified debris index, mode of delivery, type of feeding (breast
milk; formula; mixed), black stain and dmft index.
Male
(%)
1.7
0.9
1.7

Ten per cent of the children with black stain had been low-
birthweight premature babies.
A statistically significant association was seen in the whole
0.54 ⫾ 1.606
2.07 ⫾ 3.532
0.64 ⫾ 1.834
dmft index

group with regard to premature delivery (P = 0.05) and low

birthweight (P = 0.007), and in G1 for premature delivery (P =
0.003) and low birthweight (P = 0.003).
A total of 11% of the children with black stain had consumed
iron supplements, while 2.7% of the children without black stain
Total
G1
G2

consumed iron supplements.

© 2013 The Authors

Pediatrics International © 2013 Japan Pediatric Society
 Black stain prevalence and risk factors 357

There was a statistically significant association between the

0.024
0.050
0.015
0.000
0.000
0.001
0.016

0.049
0.018
0.011
P
presence of black stain and consumption of iron supplements in
the whole group (P = 0.000), and in G1 (P = 0.000) and G2 (P =
0.030). There was also a statistically significant association

92.3
73.4
74.8
50.3
56.2
69.8
80.9

43.1

39.7
88.3
Without stain
between the previous use of iron supplements by the mother

%
during pregnancy and the detection of black stain, in the whole
group (P = 0.006) and in G1 (P = 0.003).

Total
There was a statistically significant association between the

0
1
1
1
2
2
1

0
0
detection of black stain and the consumption of certain types of

X, frequency (food consumption: 1, ⱕ3 times/month; 2, ⱕ6 times/week; 3, ⱖ1 time(s)/day; oral hygiene: 1, ⱕ6 times/week; 2, 1 time/day; 3, ⱖ2 times/day).
food, and oral hygiene habits (Table 2).

86
68
84
47
93
86
92

35

48
97
%
With stain
Discussion
The prevalence of black stain in this study was 3.1%. This is

0
1
1
2
2
2
1

2
0
higher than in the UK (1.6%),6 and lower than Poland (4.45%),7
Italy (6.3%),4 Valencia (7.54%),8 the Philippines (16%),11 and

0.886
0.051
0.845
0.706
0.671
0.399
0.608

0.700
0.028
India (18%),12; this may be due to the difference in age of the

P
cohorts.

–
In the present study, 74.3% of the G2 children (214 children),
came from South American countries. The present G2 children

7.43
Without stain

62.9
58.6
54.3
55.7

39.3
90.3
had a 1.9% prevalence of black stain, which contrasts with the

50
80

100
data previously observed for some countries of South America.

Group 2
Gasparetto et al. observed black stain in 14.8% of 263 Bra-
zilian children aged between 6 and 12 years old.10

1
1
1
1
2
2
1

2
0
Another study carried out in Peru reported a prevalence of
6.5% in the mixed dentition of 185 children.9

47.1

97.9
In the present study, both the prevalence of black stain
With stain
%

50
75
50
75
75
100

100

50
observed in the whole group (3.1%) and in the G1 (native) chil-
dren, are the lowest observed and are closer to those obtained in
European countries. In contrast, the prevalence observed in G2
X

1
2
1
1
1
1
1

2
0
(1.9%), consisting of emigrant children, differs from the high
values observed in the non-European countries.

0.000
0.000
0.013
0.000
0.000
0.000

0.002

0.070
0.028
These differences could be justified, not just by the qualitative 0.011
P

characteristics (racial origin and age of the group studied), but

also by the quantitative characteristics, such as the size of the
group.
99.3
44.3
65.1
43.3
57.5
70.8
58.6

57.9

39.3
90.3
Without stain
%

Thus, if we compare the data on group size and homogeneity

of the age of the group, we find only five studies in which the
Group 1

subject group is larger than 1000 children.4,7,8,11,12 The present

study has the largest group (3272 children), followed by a study
X

0
1
1
1
2
2
1

2
0

of Polish children with a sample size of 3125,7 which almost

duplicates the next most numerous group studied with 1748
97.9
64.6
78.1

95.8
88.5

40.6

97.9

Filipino children.11
%
With stain

49

74

50

As for the age of the children studied, there is no uniformity,

and it ranges between 4 and 12 years old. To date, there has been
X

no study carried out on a homogeneous age group.

0
1
1
2
2
2
1

2
0
Table 2 Survey of eating habits

The dmft index found in the present group was 0.64 ⫾ 1.834,
which is close to that observed in a study carried out nationwide
Mouthwash with fluoride
Toothpaste with fluoride

in 2007 in Spain in preschool children aged 4 years old, in which

Soft drinks with sugar

the dmft index obtained was 0.76, and in which immigrant chil-
dren were also included.17
Food consumption

Dairy products

Natural juices

As for the association between the presence of black stain and

Fresh fruits
Vegetables

Oral hygiene

caries in the current study, we observed that the children with

Legumes

black stain had a dmft index of 0.35 ⫾ 1.123, lower than that
Bread
Eggs

observed in children without black stain, whose dmft index was

0.65 ⫾ 1.852.

© 2013 The Authors

Pediatrics International © 2013 Japan Pediatric Society
358 JM Garcia Martin et al.
Most authors report the association of the presence of black
stain with a low index of caries. Thus, Sutcliffe noted that in
children who had black stain the DMFT index was 3.06 ⫾ 0.50,
and for those without black stain the DMFT index was 5.67 ⫾
0.13.6 Paredes and Paredes found that 32.5% of the children in
their group had caries, and that among those, only 6.9% had
black stain.8 Koch et al. found a DMFT index of 1.87 ⫾ 2.47
associated with black stain, and a DMFT index of 2.39 ⫾ 2.62 for
lack of black stain.4 In Peru, Mayta-Tovalino and Torres-Quevedo
observed a DMFT index of 1.33 ⫾ 1.073 associated with black
stain, and a DMFT index of 3.39 ⫾ 2.391 for lack of black stain.9
Gasparetto et al. observed that only 28.1% of his group did not
have any caries, and among the group without caries, 84% were
associated with black stain.10 Heinrich-Weltzien et al. observed a
DMFT index associated with black stain of 1.5 ⫾ 2.1, and a
DMFT index of 2.5 ⫾ 2.5 for lack of black stain.11 In India, Bhat
found a DMFT index of 1.12 ⫾ 1.41 associated with black stain,
and a DMFT index of 1.77 ⫾ 1.87 for lack of black stain.12
Given the results of the other studies listed here, even though
a statistically significant association was not obtained in the
present study, the present observed trend of a low index of caries
associated with black stain, is corroborated by the other studies.
And even though there was no statistically significant rela-
tionship between level of oral hygiene and the presence of black
stain, it is worth noting that 74.3% of the group had not previ-
ously had a dental check-up, and the percentage of children with
black stain who had come for the first time was 76%.
These data contrast with the recommendations of the main
dental associations, which advise having the first dental check-up
performed by a dental health professional during the first year.18
On the basis of the present results, however, the dental health of
three out of four of the present children had been examined by
professional pediatricians. Professional pediatricians periodi-
cally examine most of the children during the early years and are
frequently asked by their parents about the dental problems of
their children.19,20
In the present study we did not find any statistically significant
relationship between the level of oral hygiene and black stain in
the whole group, neither in G1 nor in G2 (P = 0.478). This agrees
with the findings in the Sutcliffe and in the Mayta-Tovalino and
Torres-Quevedo studies.6,9
There was a statistically significant relationship, however,
between the presence of black stain and the consumption of iron
supplementation during pregnancy (P = 0.006), and in child-
hood (P = 0.000). In the Mayta-Tovalino and Torres-Quevedo
study a similarly statistically significant relationship was found
(P = 0.027).9
Even though there was no statistically significant association
between the consumption of iron supplementation and dmft
index, we detected caries in only one of the children with black
stain and who had taken iron supplementation.
In experimental studies carried out on animals, it was
observed that a diet that includes iron supplements reduces the
acidogenic capacity of the dental plaque21 and is associated with
a lower number of caries.22 Shaoul et al. have observed severe
dental caries in children with iron deficiency.23
© 2013 The Authors
Pediatrics International © 2013 Japan Pediatric Society
As for the interpretation of the data on eating habits, the
present study may have some limitations due to information and
interpretation biases, with regard to the information the chil-
dren’s parents were asked about, as well as the bias in recall of
this information.
We emphasize the present finding of a statistically significant
relationship between black stain and the consumption of
food with a high iron content as well as beverages containing
vitamin C.
Just as there are foods that can have cariostatic effects, exert-
ing a modulating effect on the cariogenic bacteria and the com-
position of the saliva,24 the consumption of specific foods rich in
iron, such as vegetables, legumes, dairy products and eggs is
likely to favor the growth and colonization of the oral cavity by
the involved bacteria in the development of black stain. Thus, in
their studies, Surdacka, and Reid and Beeley found in the com-
position of the saliva of the children who had black stain a
significant increase of various microelements such as calcium
and phosphates. Moreover, they observed that the chemical com-
position of the saliva in children and teenagers with black stain
was associated with a low susceptibility to dental caries, consid-
ering that the high levels of phosphate could contribute to
increase the buffering capacity of the saliva acidity against the
dental plaque.25,26
The interplay between black stain, caries, oral microflora and
diet remains unclear and requires further research.
In the survey on hygiene habits, we found a statistically sig-
nificant relationship between the presence of black stain and the
following hygiene habits: teeth brushing with fluoride toothpaste
and with fluoride rinse.
An adequate supply of fluoride, above all while using tooth-
paste and fluoride mouthwashes, provides both the saliva and the
plaque with an abundance of that ion, which can reduce the
acidogenic capacity of the dental plaque,27 which in turn can
favor the development of another type of microbiota, as well as
the chromogenic.
Conclusions
Regular consumption of foods rich in iron and use of iron sup-
plements during pregnancy and early childhood could favor the
development of chromogenic microbiota.
The prevalence of black stain did not differ significantly
between non-emigrant and immigrant children in Spain.
References
1 Reid JS, Beeley JA, MacDonald DG. Investigations into black
extrinsic tooth stain. J. Dent. Res. 1977; 56: 895–9.
2 Watts A, Addy M. Tooth discoloration and staining: A review of the
literature. Br. Dent. J. 2001; 190: 309–16.
3 Saba C, Solidani 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:
219–24.
4 Koch MJ, Bove M, Schroff J, Perlea P, Garcia-Godoy F, Staehle
HJ. Black stain and dental caries in schoolchildren in Potenza,
Italy. ASDC J. Dent. Child. 2001; 68: 353–5.
5 Slots J. The microflora of black stain of human primary teeth. Scan.
J. Dent. Res. 1974; 82: 484–90.

6 Sutcliffe P. Extrinsic tooth stains in children. Dent. Pract. Dent.
Rec. 1967; 17: 175–9.
7 Surdacka A. Black stain and caries in children and adolescents in
schools. Czas. Stomatol. 1987; 40: 763–9.
8 Paredes V, Paredes C. Black stain: A common problem in pediat-
rics. An. Pediatr. (Barc) 2005; 62: 258–60.
9 Mayta-Tovalino FR, Torres-Quevedo JC. Extrinsic black stains on
teeth and its association with tooth decay in children in mixed
dentition. Rev. Estomatol. Herediana 2008; 18: 16–20.
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: 157–61.
11 Heinrich-Weltzien R, Monse B, van Palenstein Helderman W.
Black stain and dental caries in Filipino schoolchildren. Commu-
nity Dent. Oral Epidemiol. 2009; 37: 182–7.
12 Bhat S. Black tooth stain and dental caries among Udaipur school
children. Int. J. Public Health Dent. 2010; 1: 11–15.
13 International Organization for Migration. IOM, World Migration
Report 2010. [Cited 12 January 2012.] Available from URL: http://
www.publications.iom.int.
14 Theilade J, Slots J, Fejerskov O. The ultrastructure of black stain
on human primary teeth. Scand. J. Dent. Res. 1973; 81: 528–32.
15 World Health Organization. Oral Health Surveys: Basic Methods,
4th edn. World Health Organization, Geneva, 1997.
16 Greene JC, Vermillion JR. The simplified oral hygiene index. J.
Am. Dent. Assoc. 1964; 68: 7–13.
17 Bravo M, Llodra JC, Cortes FC et al. Encuesta de Salud Oral de
Preescolares en España 2007. RCOE 2006; 12: 143–68.
18 American Academy on Pediatric Dentistry Clinical Affairs Com-
mittee; American Academy on Pediatrics Dentistry Council on
Black stain prevalence and risk factors 359
Clinical Affairs. Policy on dietary recommendations for infants,
children and adolescents. Pediatr. Dent. 2008–2009; 30 (7 Suppl.):
47–8.
19 Bottenberg P, Van Melckebeke L, Louckx F, Vandenplas Y.
Knowledge of Flemish paediatricians about children’s oral health:
Results of a survey. Acta Paediatr. 2008; 97: 959–63.
20 Balaban R, Aguiar CM, Da Silva Araújo AC, Dias Filho EB.
Knowledge of paediatricians regarding child oral health. Int. J.
Paediatr. Dent. 2011; 17: 1–6.
21 Miguel JC, Bowen WH, Pearson SK. Effects of iron salts in
sucrose on dental caries and plaque in rats. Arch. Oral Biol. 1997;
42: 337–83.
22 Emilson CG, Krasse B. The effect of iron salts on experimental
dental caries in the hamster. Arch. Oral Biol. 1972; 7: 1439–
43.
23 Shaoul R, Gaitini L, Kharouba J, Darawshi G, Maor I, Somri M.
The association of childhood iron deficiency anaemia with severe
dental caries. Acta Paediatr. 2012; 101: 76–9.
24 Moynihan P. Foods and dietary factors that prevent dental caries.
Quintessence Int. 2007; 38: 320–24.
25 Surdacka A. Chemical composition of the saliva in children
and adolescents with black tartar. Czas. Stomatol. 1989; 42: 525–
33.
26 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.
27 World Health Organization. Fluorides and oral health. Re-
port of a WHO Expert Committee on Oral Health Status and
Fluoride Use. World Health Organ. Tech. Rep. Ser. 1994; 846:
1–37.
© 2013 The Authors
Pediatrics International © 2013 Japan Pediatric Society