To assess the relationship of dental extrinsic stains (DES) with levels of trace elements in drinking water sources. A cross-sectional study among the population of Madesha VDC. A sample of 551 residents aged between 4 years and above was examined. A questionnaire was prepared to assess the dietary habits, oral hygiene practices, age, period of residency (POR), followed by clinical examination regarding the presence or absence of DES. Water samples were collected and sent for analysis by AAS method for trace elements. The prevalence of DES was 39%. Twenty-eight water samples had Fe levels that exceeded permissible levels and all samples were negative for other trace elements. Stains were associated with POR and levels of Fe in water (P value 0.001). There was a positive correlation by ward of Fe levels and stain distribution. The results revealed an association between DES with age, POR, and Fe levels in water. The positive correlation between stain distribution by ward and levels of Fe in water indicated the causative role of Fe in stains. Keywords: dental extrinsic stains, metallic stains, trace elements, Fe