|Year : 2019 | Volume
| Issue : 5 | Page : 763-766
|Recurrent black stains and periodontal disease
Ratika Lihala1, Deepika Jayaprakash1, Praveen Jayaram1, AN Savitha1, Anirban Chatterjee1, M Rajini2
1 Department of Periodontics and Implantology, The Oxford Dental College and Hospital, Bengaluru, Karnataka, India
2 Department of Microbiology and Implantology, The Oxford Dental College and Hospital, Bengaluru, Karnataka, India
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|Date of Submission||17-May-2017|
|Date of Decision||17-Jul-2018|
|Date of Acceptance||05-Sep-2018|
|Date of Web Publication||18-Dec-2019|
| Abstract|| |
Objectives: The objective of this study was to identify the anaerobic pigment-forming bacteria present in black stain and correlate its occurrence with dental caries incidence and periodontal destruction. Materials and Methods: A total of 50 healthy subjects with the chief complaint of recurrent black stains were selected based on the inclusion and exclusion criteria. decayed/missing/filled surfaces score, community periodontal index, Gingival Crevicular Fluid (GCF), black stain score, and microbial analysis were done. Results: The data presented indicate that black stain has a constant microflora, dominated by various gram-negative rods, gram-positive cocci and rods (P ≤ 0.1). However, the incidence of gram-positive rods decreased with the increase in plaque score and probing depths and decrease in black stain score. Conclusions: Presence of black stains is predominated by various gram-positive and negative rods, and gram-positive cocci. Increase in the plaque score decreases the severity of black stains, thereby increasing the probability of periodontal destruction and dental caries incidence in adult subjects. Further studies are required to corroborate the results.
Keywords: Black stains, caries, chromogenic bacteria, periodontal disease
|How to cite this article:|
Lihala R, Jayaprakash D, Jayaram P, Savitha A N, Chatterjee A, Rajini M. Recurrent black stains and periodontal disease. Indian J Dent Res 2019;30:763-6
|How to cite this URL:|
Lihala R, Jayaprakash D, Jayaram P, Savitha A N, Chatterjee A, Rajini M. Recurrent black stains and periodontal disease. Indian J Dent Res [serial online] 2019 [cited 2020 May 28];30:763-6. Available from: http://www.ijdr.in/text.asp?2019/30/5/763/273421
| Introduction|| |
Over the years, several attempts have been made to solve the mystery of the occurrence of black stains appearing as black line on the lingual and palatal surfaces of teeth along the gingival margin [Figure 1]. These black stains have been found to be recurrent in nature and are firmly attached to the teeth. They are considered special form of dental plaque with a tendency for calcification. Traditionally, these stains have been found to occur along the gingival margins of primary teeth. Generally, these stains are believed to disappear once the permanent teeth erupt or once the child reaches adulthood. However, occasionally these stains persist into adulthood. Several authors have found that the appearance of these black stains is associated with low prevalence of dental caries, thus making them “caries resistant.”
The earliest attempt to characterize the structure and composition of these black stains were made by Bibby in the 1930s. Several years later, Theilade and Slots found that these black stains were associated with the presence of a higher proportion of Actinomyces spp. All of the earlier studies involved patients in the pediatric age group while evaluating primary teeth for the presence of black stains. None of these studies evaluated the stains in adult patients. While the prevalence of caries was evaluated in the previous studies, none of the studies evaluated the periodontal status in these patients. The present study aimed to find correlation between recurrent black stains, incidence of caries, and periodontal attachment loss in adult patients. It also aimed to investigate the microflora of recurrent black stains along the gingival margin of adult patients.
| Materials and Methods|| |
A total of 50 patients with a history of recurrent black stains visiting the Department of Periodontics at The Oxford Dental College were enrolled in the study. The age of these patients ranged from 18 to 40 years.
- Patients who had undergone repeated scaling with a complaint of recurrent stains.
- Systemically healthy patients.
- Patients with a history of smoking or any other habits which may cause tooth staining.
At the first visit, analysis of the tooth staining was done using the “black stain scoring” (BSS) system described by Shourie. Decay/Missing/ Filled Surfaces (DMFS) was used to evaluate the extent of dental caries, while community periodontal index (CPI) was used to evaluate the periodontal destruction.
Following this, a sample of the stain was scraped using a sterile curette [Figure 2], after which the sample was immediately transferred to a test tube containing thioglycolate broth to check for the presence of Actinomyces spp. The test tube was then sealed and the sample was incubated for 42 h. The appearance of a cloudy supernatant would confirm the presence of Actinomyces spp [Figure 3]. The samples of the stains were also evaluated for the presence of gram-positive and negative cocci and rods using a gram stain.
|Figure 3: Cloudy appearance post-48 h incubation of sample in thioglycolate broth|
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In the current study, the clinical parameters were continuous variables, whereas the microbiological parameters were binary variables, that is, present (noted as 1) or absent (noted as 0). Since a correlation was to be established between continuous and binary variables, a linear regression analysis was run (y = a + bx).
| Results|| |
The sample pool consisted of patients with non-significant association of age and gender. A strong association was obtained between the black stain score, CPI, and decayed/missing/filled surfaces (DMFS) score. A negative correlation was obtained with regards to severity of black stains and DMFS (i.e., P < 0.03) and CPI scores (P < 0.001) [Table 1] and [Table 2]. As per the regression equation (y = a + bx), the value of BSS (y) was 2.33 (a) when the value of DMFS was 0 (bx), and with every per-unit change in DMFS, the value of BSS decreased by 0.065. Similarly, the value of BSS (y) was 2.77 (a) when the value of CPI score was 0 (bx), and with every per unit change in CPI score, the value of BSS decreased by 0.835.
|Table 1: Correlation between black stain scores and decayed/missing/filled surfaces|
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|Table 2: Correlation between black stain scores and community periodontal index|
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All the stain sample slides showed presence of gram-positive cocci and gram-negative rods [Figure 4]. A positive correlation was obtained in relation to presence of gram-positive rods and severity of black stain scores (P < 0.02) [Table 3]. A negative correlation was obtained in relation to presence of gram-positive rods and CPI scores (P < 0.04) [Table 4]. However, no significant correlation was established between presence of gram-positive rods and prevalence of caries.
|Figure 4: Section of gram staining showing presence of gram-positive rods and cocci and gram-negative rods and cocci.|
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|Table 4: Correlation between gram-positive rods and community periodontal index scores|
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| Discussion|| |
The dental plaque has a well-defined structure formed by bacterial cells ordered in groups or columns of microcolonies. The microbial composition of this plaque varies significantly between individuals. The nature of the microbiota determines the possibility of occurrence of two of the most frequent dental diseases (dental caries and periodontal disease). A rare occurrence of dental plaque with black stains has been highlighted by various authors in the primary and mixed dentition, usually associated with low caries incidence in children. Studies have also found that the occurrence of these black stains tends to decrease with age and following the eruption of permanent teeth. Limited knowledge has been generated regarding the presence of these black stains and occurrence of dental disease in adults.
The earlier studies, conducted in young children, found an inverse relationship between dental caries and the occurrence of black stains. Shmuly found a similar trend wherein the presence of black stains correlated with decreased caries incidence in young adults. The present study agrees with the previous studies. A negative correlation was seen with black stain score and the severity of caries incidence (P < 0.03). This could be attributed to the fact that black stains have the tendency to get calcified and the occurrence of black stain is characterized by low caries activity. Considering the multifactorial nature of caries, the hypothesis that the microbial composition of black stain might be associated with lower caries experience is questionable, as shown by Costa et al., wherein a higher prevalence of Streptococcus mutans was seen despite low caries incidence.
To the best of our knowledge, ours is the first study that examines the association between black stain and periodontal disease prevalence exclusively in an adult population presenting with recurrent black stains along the gingival margins of the teeth. A negative correlation was seen with black stain score and severity of periodontal destruction (P < 0.001). CPI was used to measure the severity of periodontal destruction, according to which index teeth were selected for each sextant of the upper and lower arches and were scored from 0 to 4 according to severity of periodontal destruction. As the purpose of the study was only to identify the presence of periodontal destruction, no attempt was made to determine the extent of periodontal destruction or the activity of the disease.
The current study utilized gram staining and anaerobic culture method to analyze the types of microorganisms in the black stain samples. Gram staining was used for initial screening of the samples while thioglycolate broth was used to culture Actinomyces. Previous studies on black stains have indicated predominance of gram-positive rods and coccoid species in the microflora of these deposits. The presence of gram-positive rods increased with the increase in black stain scores. Similarly, in the present study, predominance of gram-positive rods was seen, which increased with the increase in black stain scores (P < 0.02) and decreased with severity of periodontal destruction (P < 0.04).
The use of thioglycolate broth for the growth of Actinomyces species has been advocated by several authors in the past. The appearance of a cloudy supernatant in the broth has been shown to be suggestive of predominance of Actinomyces species., Amongst the gram-positive rods, Actinomyces species have been associated predominantly in earlier studies evaluating the microflora of black stains. These bacteria have also been found to be associated with the initial phase of development of supragingival plaque and calculus, which explains the predominance of Actinomyces with low incidence of periodontal destruction in the current study.
Even though gram staining is the most simple and inexpensive method for rapid diagnosis, a risk of misdiagnosis due to false-positive results is also present. Misidentification between gram-positive and Negative bacteria may also exist. This limitation was partly taken care of by the use of thioglycolate broth for the culture of Actinomyces. However, a separate culture for gram-positive rods like streptococcus was not done in the current study.
The black color of these stains has been attributed to the formation of ferric sulfide and presence of more of carbon and phosphate. Some Actinomyces strains produce hydrogen sulfide, which can result in ferric sulfide formation in the presence of iron in saliva or gingival exudates. However, the mineral content of the stain samples and the iron content in diet as well as in the oral fluids was not assessed, which was another limitation of the current study.
Within the limitations of the study, it was seen that like caries, the severity of periodontal destruction increases with decrease in black stains and a positive correlation is seen with prevalence of gram-positive rods and severity of black stains.
| Conclusions|| |
Black stain appears to have a characteristic and relatively stable microflora. These organisms are predominantly gram-positive rods, cocci, and gram-negative rods. Increase in the plaque score decreases the severity of black stains, thereby increasing the probability of periodontal destruction and dental caries incidence in adult subjects.
The authors acknowledge the help of Mr. Tushar Lihala (M. Sc. Quantitative Economics) for statistical analysis; Department of Oral Pathology, The Oxford Medical College, Bengaluru, for sample storage and testing; and patients visiting the Department of Periodontology, The Oxford Medical College, Bengaluru, for agreeing to be a part of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bibby BG. A study of a pigmented dental plaque. J Dent Res 1931;11:855-72.
Reid JS, Beeley JA, MacDonald DG. Investigations into black extrinsic tooth stain. J Dent Res 1977;56:895-9.
Slots J. The microflora of black stain on human primary teeth. Scand J Dent Res 1974;82:484-90.
Shourie KL. Mesenteric line or pigmented plaque; a sign of comparative freedom from caries. J Am Dent Assoc 1947;35:805-7.
Socransky SS, Manganiello AD, Propas D, Oram V, van Houte J. Bacteriological studies of developing supragingival dental plaque. J Periodontal Res 1977;12:90-106.
Gasparetto A, Conrado CA, Maciel SM, Miyamoto EY, Chicarelli M, Zanata RL, et al.
Prevalence of black tooth stains and dental caries in Brazilian schoolchildren. Braz Dent J 2003;14:157-61.
Shmuly T, Zini A, Yitschaky M, Yitschaky O. Can black extrinsic tooth discoloration predict a lower caries score rate in young adults? Quintessence Int 2014;45:439-44.
Theilade J, Slots J, Fejerskov O. The ultrastructure of black stain on human primary teeth. Scand J Dent Res 1973;81:528-32.
Costa MT, Dorta ML, Ribeiro-Dias F, Pimenta FC. Biofilms of black tooth stains: PCR analysis reveals presence of streptococcus mutans. Braz Dent J 2012;23:555-8.
Ellen RP. Genus Actinomyces and other filamentous bacteria. In: Nisengard RJ, Newman MG, editors. Oral Microbiology and Immunology. 2nd
ed. Philadelphia: W. B. Saunders Company; 1988. p. 151-9.
Sidaway DA. A microbiological study of dental calculus. I. The microbial flora of mature calculus. J Periodontal Res 1978;13:349-59.
Reid JS, Beeley JA, MacFarlane TW. A study of the pigment produced by bacteroides melaninogenicus. J Dent Res 1976;55:1130.
Li Y, Zhang Q, Zhang F, Liu R, Liu H, Chen F, et al.
Analysis of the microbiota of black stain in the primary dentition. PLoS One 2015;10:e0137030.
Dr. Praveen Jayaram
Department of Periodontics and Implantology, The Oxford Dental College and Hospital, Bengaluru - 560 068, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]
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