REVIEW ARTICLE

Dental caries vaccine

KM Shivakumar, SK Vidya1, GN Chandu2

Department of Preventive
and Community Dentistry,
ABSTRACT
1
Department of Oral and
Maxillofacial Pathology, Sharad
Pawar Dental College and
Hospital, Datta Meghe Institute
of Medical Sciences (Deemed
University), Sawangi (Meghe),
Wardha Maharashtra, 442 004,
2
Department of Preventive and
Community Dentistry, College
of Dental Sciences, Davangere,
Karnataka - 577 004, India
Received : 26-10-07
Review completed : 27-10-07
Accepted : 09-08-08
PubMed ID : 19336869
DOI: 10.4103/0970-9290.49066
Dental caries is one of the most common diseases in humans. In modern times, it has reached
epidemic proportions. Dental caries is an infectious microbiologic disease of the teeth that results
in localized dissolution and destruction of the calcified tissue. Dental caries is a mulitifactorial
disease, which is caused by host, agent, and environmental factors. The time factor is important
for the development and progression of dental caries. A wide group of microorganisms are
identified from carious lesions of which S. mutans, Lactobacillus acidophilus, and Actinomyces
viscosus are the main pathogenic species involved in the initiation and development of dental
caries. In India, surveys done on school children showed caries prevalence of approximately
58%. Surveys among the U.S. population showed an incidence of 45.3% in children and 93.8%
in adults with either past or present coronal caries. Huge amounts of money and time are spent
in treating dental caries. Hence, the prevention and control of dental caries is the main aim of
public health, eventually the ultimate objective of public health is the elimination of the disease
itself. Recently, dental caries vaccines have been developed for the prevention of dental caries.
These dental caries vaccines are still in the early stages.
Key words: Dental caries, dental caries vaccine, streptococcus mutans

Dental caries is an infectious microbiologic disease of the
teeth that results in localized dissolution and destruction
of the calciÞed tissue.[1,2] Dental caries is one of the most
common diseases in humans.[3,4] In modern times, it has
reached epidemic proportions. The prevalence of dental
caries in developed countries varies greatly and can
reach over 90%. The rate of Caries has been increasing in
developing countries with the increase in the popularity
of highly refined sugars. The development of dental
caries requires the presence of cariogenic bacteria that are
capable of producing acid and a sugar present in the diet
which favors the colonization of these bacteria to form
acid.[3,5] Dental caries appears to be a major public health
problem which if left untreated can cause considerable
pain, discomfort, and treatment costs are very high. Dental
caries results from the interaction between the host, the
host’s diet, and the microßora on the tooth surface bounded
by the time factor.[6] A wide group of microorganisms are
identiÞed from carious lesions of which Streptococcus
mutans ( S. mutans) , Lactobacillus acidophilus , and
Actinomyces viscosus are the main pathogenic species
involved in the initiation and development of dental
caries.[7,8] S. mutans has been implicated as a causative
organism of dental caries. [4,9] S. mutans accounts for
seven distinct species isolated from animals and humans;
Streptococcus cricetus, Streptococcus ferus, Streptococcus
Address for correspondence:
Dr. Shivakumar KM,
E-mail: kmshivakumar@rediffmail.com
99
macacae, Streptococcus rattus, Streptococcus downey,
S. mutans, and Streptococcus sobrinus. S. mutans and
Streptococcus sobrinus are exclusively isolated from
humans and S. mutans is the most prevalent species.[10]
The traditional way of managing dental caries was by a
surgical approach of “drill and Þll”. This approach has
slowly evolved into a more conservative mode. Various
preventive measures have been implicated for the
prevention of dental caries, among which is immunization
of the population against the disease. [7] Many studies
have been conducted on the development of an effective
vaccine to prevent the occurrence of dental caries. A
review of literature pertaining to a dental caries vaccine
is presented.
VACCINES
Vaccines are an immuno-biological substance designed
to produce speciÞc protection against a given disease. It
stimulates the production of a protective antibody and other
immune mechanisms. Vaccines are prepared from live
modiÞed organisms, inactivated or killed organisms, extracted
cellular fractions, toxoids, or a combination thereof.[11]
THE IMMUNE RESPONSE
a) The primary response
When an antigen is administered for the Þrst time to an
Indian J Dent Res, 20(1), 2009
Dental caries vaccine
animal or human, there is a latent period of induction of
3 to 10 days before antibodies appear in the blood. The
antibody that is elicited Þrst is entirely of the IgM type.
The IgM antibody titer rises steadily during the next 2 to
3 days, reaches a peak level, and then declines almost as
fast as it developed. Meanwhile, if the antigenic stimulus
was sufÞcient, the IgG antibody appears in a few days. IgG
reaches a peak in 7 to 10 days and then gradually falls over
a period of weeks or months. An important outcome of the
primary antigenic challenge is the education of the reticulo-
endothelial system of the body. Both B and T lymphocytes
produce what are known as “memory cells” or primed cells.
These cells are responsible for the immunological memory
that is established after immunization.[11,12]
b) Secondary (Booster response)
The response to a booster dose differs in a number of ways
from the primary response. The secondary response also
involves the production of IgM and IgG antibodies. A
collaboration between B and T cells is necessary to initiate
a secondary response. There is a brief production of the IgM
antibody and a much larger and more prolonged production
of the IgG antibody. This accelerated response is attributed
to immunological memory. The immune response (primary
and secondary) and immunological memory are the basis of
vaccination and revaccination.[11,12]
MECHANISM OF ACTION OF VACCINE
Saliva contains approximately 1–3% of immunoglobulin
concentration, a majority of which is secretary IgA. However,
saliva also contains the humoral immunoglobulin IgG and
IgM from the gingival sulcular ßuid. In addition, cellular
components of the immune system such as lymphocytes,
macrophages, and neutrophils are also present in gingival
sulcus. Some of the possible ways antibodies might control
bacterial growth are listed below:[13,14]
i. The salivary immunoglobulin may act as a speciÞc
agglutinin interacting with the bacterial surface
receptors and inhibiting colonization and subsequent
caries formation. They might also inactivate surface
glucosyltransferase, which would then reduce the
synthesis of extra cellular glucans resulting in reducing
plaque formation.
ii. The salivary glands produce secretory IgA antibodies
by direct immunization of the gut associated lymphoid
tissue (GALT), from where sensitized B-cells may be
home to the salivary glands. The salivary IgA antibodies
have, of course, direct access to the tooth surface. They
may prevent S. mutans from adhering to the enamel
surface or they may prevent formation of dextran by
inhibiting the activity of glucosyltransferase (GTF).[3]
iii. The gingival crevicular mechanism involves all the
humoral and cellular components of the systemic
immune system, which may exert its function at the tooth
Indian J Dent Res, 20(1), 2009
Shivakumar, et al.
surface. There is now sufÞcient evidence to postulate
what may happen after subcutaneous immunization
with S. mutans. The organism is phagocytosed and
undergoes antigenic processing by macrophages. In the
lymphoid tissue, T and B-lymphocytes are sensitized by
the macrophages preventing the antigen HLA Class-
II complex and releasing IL-I. This induces the CD-4
helper and CD-8 cytotoxic suppressor cell response
with the activation of IL-2 receptors and the release of
IL2. The interaction between the cells play an essential
part in modulating the formation of IgG, IgA, and IgM
classes of antibodies and B-lymphocytes.[3,15,16]
STUDIES
a) Animal studies
Rodents are attractive as experimental laboratory animals
because they are inexpensive and easy to maintain. Rapid
decay of their teeth can be induced by S. mutans when
present during the provision of a sugar containing diet.
The ability to establish large experimental groups and to
arrive at an accurate diagnosis of caries by examination
of the tooth surface also makes rodents a good choice for
laboratory animals.[17] Immunization experiments with cells
of S. mutans both in rats and monkeys have consistently
resulted in a signiÞcant decrease in dental caries. PuriÞed
components of S. mutans have been used only to a limited
extent. Protection has been induced by immunization
with GTF in rats. Recently, immunization with puriÞed
protein antigen I/II, which resides in the cell wall of S.
mutans, has induced protection against caries. The latter
utilizes only one subcutaneous injection of the antigen with
adjuvant, unlike all other experiments, which have not been
performed in rhesus monkeys and have used from 5 to 15
injections. Immunization with whole cells of S. mutans or
with puriÞed I/II antigen produces a reduction of about 70%
in both smooth surface and Þssure caries when compared
with controls.[18] In gnotobiotic rats, ingestion of whole
S. mutans selectively produces S-IgA. The appearance of
S-IgA correlated with a reduced incidence of the caries
vaccine.[17,19]
The Þrst report of successful immunization of monkeys against
caries was by Bowen who injected whole cells S. mutans into
Macaca fascicularis monkeys.[7] Rats and monkeys have been
largely used in immunization studies. The principal design
in most of the experiments has been to Þrst immunize the
animals with an antigen from S. mutans incorporated in an
adjuvant as frequently as is necessary to attain high antibody
levels, and follow this by implanting the same organism in the
mouth and placing the animals on a high sucrose diet. Some
of the experiments have been designed to aim for salivary
immunity and others have been designed to aim for systemic
immunity.[3] There have been reports of the successful use of
GTF as an anticaries vaccine in rats and hamsters, but neither
crude preparations, nor a highly puriÞed GTF conferred any
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Dental caries vaccine
protection on monkeys.[20]
b) Human studies
As dental caries fulÞlls the criteria of an infectious disease,
the possibility of preventing it by vaccination has been
pursued. The rationale is that immunization with S. mutans
should induce an immune response, which might prevent
the organism from colonizing the tooth surface, and thereby
prevent decay. As a vaccine would be administered before
the deciduous dentition has erupted at about 6 months of
age, it would prevent the disease in children who show the
greatest incidence of caries. The vaccine could be given
at the same time as the vaccines against diphtheria and
tetanus. Immunity could be boosted at intervals thereafter to
provide life-long protection. The existing delivery system of
immunization could be used, without any Þnancial burden
being incurred.[3] Currently, clinical trials are underway to
test the use of a pill of S. mutans for control of caries. There
have been some conßicting results thus far in human studies.
Some workers have actually reported a negative correlation
between S-IgA and caries prevalence. However, this result
could be the result of the experimental design. It has been
shown that ingestion of capsules containing S. mutans
stimulates the production of S-IgA. Stimulation of serum
immunoglobulin in humans has also produced mixed results
and no correlation could be made between caries experience
and serum immunoglobulin stimulation.[8,13]
ANTIGENIC COMPONENTS OF STREPTOCOCCUS
MUTANS
S. mutans posses various cell surface substances including
adhesins, GTFs, and glucan binding proteins (GBP). These
substances are used for vaccine preparation. Most of the
recent experimental efforts have been directed toward these
compounds.[21]
Adhesins: Adhesins form the two principal human
pathogens of S. mutans (variously identiÞed as antigens I/
II, Pac, or P1 and Streptococcus sobrinus, Spa-A or Pag) and
has been puriÞed. Antigens I/II (Ag I/II) are found in the
culture supernatant as well as in the S. mutans cell surface.
This 185-KDa protein composed of a single polypeptide
chain of approximately 1600 residues. Ag I/II contains an
alanine-rich tandem-repeating region in the N-terminal
third and a proline rich repeat region in the center of the
molecule. These regions have been associated with the
adhesin activity of Ag I/II. The proline-rich central portion
contains an adhesin epitope basing their conclusions on
adhesin inhibition assays involving the recombinant fragment
of Ag I/II. The antibody directed to the intact Ag I/II molecule
or to its salivary binding domain blocked adherence of S.
mutans of saliva-coated hydroxyapatite. Immunization of
mice with synthetic peptide (residue 301-319) from the
101
Shivakumar, et al.
alanine rich region of Ag I/II suppressed tooth colonization
with S. mutans.[14,22]
GLUCOSYLTRANSFERASE
S. mutans has three forms of glucosyltransferases (GTFs):
• Water insoluble glucan synthesizing enzyme: GTF-I
• Water insoluble and water-soluble glucan synthesizingen-
zymes: GTF-S-I
• Water-soluble glucan synthesizing enzymes: GTF-S
The genes encoding GTF-I, GTF-SI, and GTF-S are called
the GTF-B, GTF-C, and GTF-D genes, respectively. All three
GTF genes are important for smooth surface caries formation
in the pathogen-free rat model system. Streptococcus
sobrinus produces a water insoluble glucan-synthesizing
enzyme GTF-S. The GTF-I gene encoding GTF-I and the
GTF-S and GTF-T genes encoding two GTF-S enzymes have
been cloned.[21,23,24] S. mutans and Streptococcus sobrinus
each synthesize several GTFs.[25]
Glucan binding protein (GBP): S. mutans secretes at least
three distinct proteins with glucan binding activity: GBP-A,
GBP-B, and GBP-C. Of the three S. mutans GBPs, only
GBP-B has been shown to induce a protective immune
response to experimental dental caries. GBP-A has a
sequence of 563 amino acids. The molecular weight is 59.0
Kda. The carboxy-terminal 2/3rd of GBP-A sequence has
signiÞcant homology with a putative glucan binding region
of S. mutans GTFs. The C-terminal region contains 16
repeating units, which represent the full glucan-binding
domain of this protein. GBP-A has a greater afÞnity for water
soluble glucan than for water insoluble glucan.
Dextranases: Dextran is an important constituent of early
dental plaque. Dextranase is an enzyme produced by mutans
Streptococcus. They destroy dextran and thus the bacteria
can invade dextran-rich early dental plaque. Dextranase,
when used as an antigen, can prevent the colonization of
the organism in early dental plaque.[7]
ROUTES OF IMMUNIZATION
In general, 4 routes of immunization have been used with
S. mutans:
1. Oral
2. Systemic (subcutaneous)
3. Active gingivo-salivary
4. Passive dental immunization
Common mucosal immune system
Mucosal applications of dental caries vaccines are generally
preferred for the induction of secretory IgA antibodies
in the salivary compartment, since this immunoglobulin
Indian J Dent Res, 20(1), 2009
Dental caries vaccine
constitutes the major immune component of major and
minor salivary gland secretions. Many investigators have
shown that exposure of an antigen to a mucosally associated
lymphoid tissue in the gut, nasal, bronchial, or rectal site
can give rise to immune responses not only in the region
of induction but also in remote locations. This has given
rise to the notion of a “common mucosal immune system”.
Consequently, several mucosal routes have been used to
induce protective immune responses to dental caries vaccine
antigens.[22,26]
1. Oral route
Many of the earlier studies relied on oral induction of
immunity in the GALT to elicit protective salivary IgA
antibody responses. In these studies, an antigen was applied
by oral feeding, gastric intubation, or in vaccine containing
capsules or liposome.[22] Killed S. mutans was administered
to germ-free rats in drinking water for 45 days before
implantation of live S. mutans and then throughout the
experimental period. A signiÞcant reduction in caries was
related to an increased level of salivary IgA antibodies to
S. mutans, as the serum antibody titer was minimal. Oral
immunization with S. mutans did not induce signiÞcant
secretory IgA in monkeys. Daily administration of 10[11] cells
of S. mutans in capsules produced a small increase in secretory
IgA. The oral route failed to reduce caries signiÞcantly, as
compared with subcutaneous immunization. The rise
in secretory antibodies produced was small and of short
duration, even after secondary immunization. Experiments
in humans of the ingestion of S. mutans in gelatins capsules
resulted in an increase in secretory IgA antibodies in saliva,
although for a limited time only. Immunological memory
in secretory IgA responses is rather limited and this may
curtail the value of oral immunization.[3] Although the oral
route was not ideal for reasons including the detrimental
effects of stomach acidity on antigen, or because inductive
sites were relatively distant, experiments with this route
established that induction of mucosal immunity alone was
sufÞcient to change the course of infection with S. mutans
and disease in animal models and in humans.[22,26-28]
2. Intranasal route
More recently, attempts have been made to induce
protective immunity in mucosal inductive sites that are in
closer anatomical relationship to the oral cavity. Intranasal
installation of the antigen, the nasal associated lymphoid
tissue (NALT), has been used to induce immunity to
many bacterial antigens including those associated with
mutans Streptococcal colonization and accumulation.
Protective immunity after infection with cariogenic mutans
streptococci could be induced in rats by the intranasal
route with many S. mutans antigens or functional domains
associated with these components. Protection could be
demonstrated with S. mutans Ag I/II, the SBR of Ag I/II,
a 19-mer sequence within the SBR, the glucan binding
domain of S. mutans, GBP-B, and Þmbrial preparations from
Indian J Dent Res, 20(1), 2009
Shivakumar, et al.
S. mutans with antigen alone or combined with mucosal
adjuvants.[22,23,27]
3. Tonsillar route
The ability of tonsillar application of antigens to induce
immune responses in the oral cavity is of great interest. The
tonsillar tissue contains the required elements of immune
induction of secretory IgA responses although IgG, rather
than IgA, response characteristics are dominant in this
tissue. Nonetheless, the palatine tonsils, and especially the
nasopharyngeal tonsils, have been suggested to contribute
precursor cells to mucosal effector sites, such as the salivary
glands. In this regard, the experiments have shown that
topical application of formalin-killed Streptococcus sobrinus
cells in rabbits can induce a salivary immune response, which
can signiÞcantly decrease the consequences of infection with
cariogenic Streptococcus sobrinus. Interestingly, repeated
tonsillar application of a particulate antigen can induce the
appearance of IgA antibodies producing cells in both the
major and minor salivary glands of the rabbit.[22]
4. Minor salivary gland
The minor salivary glands populate the lips, cheeks, and soft
palate. These glands have been suggested as potential routes
for mucosal induction of salivary immune responses, given
their short, broad secretory ducts that facilitate retrograde
access of bacteria and their products and give the lymphatic
tissue aggregates that are often found to be associated with
these ducts. Experiments in which Streptococcus sobrinus
GTF was topically administered onto the lower lips of young
adults have suggested that this route may have potential for
dental caries vaccine delivery. In these experiments, those
who received labial application of GTF had a signiÞcantly
lower proportion of indigenous S. mutans/total Streptococcal
ßora in their whole saliva during a 6-week period following
a dental prophylaxis, compared with a placebo group.[22]
5. Rectal
More remote mucosal sites have also been investigated for
their inductive potential. For example, rectal immunization
with non oral bacterial antigens such as Helicobacter pylori
or Streptococcus pneumoniae, presented in the context
of toxin-based adjuvant, can result in the appearance of
secretory IgA antibodies in distant salivary sites. The colo-
rectal region as an inductive location for mucosal immune
responses in humans is suggested from the fact that this site
has the highest concentration of lymphoid follicles in the
lower intestinal tract. Preliminary studies have indicated
that this route could also be used to induce salivary IgA
responses to mutans streptococcal antigens such as GTF. One
could, therefore, foresee the use of vaccine suppositories as
one alternative for children in whom respiratory ailments
preclude the intranasal application of the vaccine.[22]
Systemic route of immunization
Subcutaneous administration of S. mutans was used
102
Dental caries vaccine
successfully in monkeys and elicited predominantly
serum IgG, IgM, and IgA antibodies. The antibodies Þnd
their way into the oral cavity via gingival crevicular ßuid
and are protective against dental caries. Whole cells, cell
walls, and the 185 KD Streptococcal antigen have been
administered on 2 to 4 occasions. A subcutaneous injection
of killed cells of S. mutans in Freund’s incomplete adjuvant
or aluminium hydroxide elicits IgG, IgM, and IgA classes of
antibodies. Studies have shown that IgG antibodies are well
maintained at a high titer, IgM antibodies progressively fall
and IgA antibodies increase slowly in titer. The development
of serum IgG antibodies takes place within months of
immunization, reaching a tire of up to 1:1280 with no
change in antibodies being found in the corresponding
sham-immunized monkeys. Protection against caries
was associated predominantly with increased serum IgG
antibodies.[3]
Active gingivo-salivary route
There has been some concern expressed regarding the side
effects of using these vaccines with the other routes. In
order to limit these potential side effects, and to localize the
immune response, gingival crevicular ßuid has been used
as the route of administration. Apart from the IgG, it is also
associated with increased IgA levels.[29]
The various modalities tried were as follows:
• Injecting lysozyme into rabbit gingival, which elicited
local antibodies from cell response
• Brushing live S. mutans onto the gingiva of rhesus
monkeys, which failed to induce antibody formation
• Using smaller molecular weight Streptococci antigen,
which resulted in better performance probably due to better
penetration.[29]
Passive immunization
As the name suggests, passive immunization involves passive
or external supplementation of the antibodies. This carries
the disadvantage of repeated applications, as the immunity
conferred is temporary.
Several approaches tried were:
• Monoclonal antibodies
Monoclonal antibodies to S. mutans cell surface antigen I/
II have been investigated. The topical application in human
subjects brought a marked reduction in the implanted S.
mutans. Thus, by bypassing the system, less concern exists
about the potential side effects.[3,29]
• Bovine milk and whey
Systemic immunization of cows with a vaccine using whole
S. mutans led to the bovine milk and whey containing
polyclonal IgG antibodies. This was then added to the diet
103
Shivakumar, et al.
of a rat model. The immune whey brought a reduction in
the caries level. This whey was also used in a mouth rinse,
which resulted in a lower percentage of S. mutans in the
plaque.[3,29]
• Egg-yolk antibodies
The novel concept of using hen egg-yolk antibodies against
the cell-associated glucosyltransferase of S. mutans was
introduced by Hamada. Vaccines used were formalin killed
whole cells and cell associated GTFs. Caries reduction has
been found with both these treatments.[3]
• Transgenic plants
The latest in these developments in passive immunization
is the use of transgenic plants to give the antibodies.
The researchers have developed a caries vaccine from a
genetically modiÞed (GM) tobacco plant. The vaccine,
which is colorless and tasteless, can be painted onto the teeth
rather than injected and is the Þrst plant derived vaccine
from GM plants.[30]
The advantages are listed below:
• The genetic material can be easily exchanged.
• It is possible to manipulate the antibody structure so
that while the speciÞcity of the antibody is maintained,
the constant region can be modiÞed to adapt to human
conditions, thus avoiding cross reactivity.
• Large scale production is possible as it would be quite
inexpensive.[29]
ADJUVANTS AND DELIVERY SYSTEMS FOR
DENTAL CARIES VACCINES
Various new approaches have been tried out to potentiate
aspects of the immune response to induce sufficient
antibodies to achieve a protective effect to overcome the
existing disadvantages.
Synthetic peptides: Any antigen derived from animals or
humans has the potential for hypersensitivity reaction.
The chemically synthesized peptides hold an advantage
in that this reaction can be avoided. This has been found
to enhance the immune response. In humans, synthetic
peptides elicited both IgG and T-cell proliferative responses,
and the antibodies were both anti-peptide and anti-native.
The synthetic peptides give antibodies not only in the GCF
but also in the saliva. The synthetic peptide used is derived
from the Glucosyltransferase enzyme.[23,29]
Coupling with Cholera Toxin Subunits: Cholera toxin (CT)
is a powerful mucosal immunoadjuvant, which is frequently
used to enhance the induction of mucosal immunity to a
variety of bacterial and viral pathogens in animals systems.
Mucosal application of a soluble protein or peptide antigen
Indian J Dent Res, 20(1), 2009
Dental caries vaccine
alone rarely results in elevated or sustained IgA responses.
However, the addition of small amounts of CT or the closely
related E. coli heat-labile enterotoxins (LT) can greatly
enhance mucosal immune responses to intragastrically or
intranasally applied mutans Streptococcal antigens or to
peptides derived from these antigens. The coupling of the
protein with the nontoxic unit of the cholera toxin was
effective in suppressing the colonization of S. mutans.[22,24,29]
Fusing with salmonella: The avirulent strains of salmonella
are an effective vaccine vector; fusion using recombinant
techniques have been used.[29]
Microcapsules and microparticles: Combinations of antigens
in or various types of particles have been used in an attempt
to enhance mucosal immune responses. The microcapsules
and microparticles made of poly lactide-co-glycolide (PLGA)
have been used as local delivery systems because of their
ability to control the rate of release, evade preexistent
antibody clearance mechanisms, and degrade slowly without
eliciting an inßammatory response to the polymer.[29]
Liposomes: Liposomes, which are bilayered phospholipids
membrane vesicles manufactured to contain and deliver
drugs and antigens, have been used to enhance mucosal
responses to mutans Streptococcal carbohydrate and
GTF. Liposomes are thought to improve mucosal immune
responses by facilitating M cell uptake and delivery of
antigen to lymphoid elements of inductive tissue.[22,29]
RISKS OF USING CARIES VACCINE
All vaccines, even if properly manufactured and
administered, seem to have risks. The most serious is that
sera of some patients with rheumatic fever who show
serological cross-reactivity between heart tissue antigens
and certain antigens from hemolytic Streptococci. [31]
Experiments from antisera from rabbits immunized with
whole cells of S. mutans and with a high molecular weight
protein antigen of S. mutans were reported to cross react
with normal rabbit and human heart tissues. Polypeptides
(62-67 KDA) immunologically cross-reactive with human
heart tissue and rabbit skeleton muscles myosin are found
in the cell membrane of S. mutans and Streptococcus
ratti.[32] On the other hand, demonstrations showed that
rabbit antiserum to high molecular weight, Todd-Hewitt
broth components reacted with monkey cardiac muscle
with S. mutans coated with medium components. Heart
cross-reactive antibodies do not develop in rhesus monkeys
or rabbits immunized with puriÞed Ag I/II from S. mutans.
It is possible that increased production of heart-reactive
antibody in rabbits immunized with mutans streptococci
results in injury of heart tissue as a consequence of binding
of this low molecular weight Streptococcal polypeptide.
Because of the potential of Streptococcal whole cells to
induce heart reactive antibodies, the development of a
Indian J Dent Res, 20(1), 2009
Shivakumar, et al.
sub-unit vaccine for controlling dental caries has been the
focus of intense research interest. Glucosyltransferase was
also tested for cross-reactivity with human heart tissue and
the results were negative.[21,33] Further research showed that
the C-terminal part of Ag I/II contains an epitope, which is
cross-reactive with human IgG and, although the clinical
signiÞcance of this observation is unknown, it appears that
this potentially harmful epitope should be excluded from a
caries vaccine. The human IgG cross-reactive region is also
present in other mutans streptococci such as Streptococcus
sobrinus as well as in non mutans streptococci.[33]
PUBLIC HEALTH ASPECTS
Although the prevalence of tooth decay has declined
according to a national epidemiologic survey by the United
States national institute of dental research, this oral disease is
still a signiÞcant health problem that affects approximately
50% of the 5 to 17 year old children in the U.S. In fact, by
the age of 17, only 16% remain free of caries. Interestingly,
25% of children and adolescents aged 5 to 17 years old
account for 80% of caries in permanent teeth, indicating
the existence of high-risk groups. Meanwhile, in many
developing countries in Central and South America, Africa,
Asia, as well as in certain European countries, dental caries
is on the rise. Despite the wide spread use of ßuoride (e.g.,
in toothpaste and drinking water) to which the decline of
caries between the 1970s and 1980s is mainly attributed,
this disease still remains among the most prevalent and
costly in industrialized and in developing countries. Indeed,
developing countries without a water ßuoridation system
and where access to dental health education and treatment
may not be available to everyone are in great need of a
vaccine. An effective, safe, and readily deliverable vaccine
may not only help against pain and health issues associated
with caries but also save the billions of dollars that are
currently spent in the U.S. for restorative treatment.[33]
An important question is whether the search for a caries
vaccine is justiÞed from a public health point of view. This
question is especially critical as we already have effective
means to control the disease. Given that S. mutans is not the
only cariogenic microorganism and that a series of factors
inßuence the development of the disease, the question arises
as to what extent successful vaccination against S. mutans
could reduce the incidence of dental caries.[31] Considerable
caries reduction could be attained if colonization of S. mutans
could be prevented or reduced at the time of eruption of
both deciduous and permanent teeth. Thus, a successful
vaccination directed against S. mutans could be a valuable
adjunct to other caries-preventive measures. Some other
studies also suggest that vaccination could be a supplement
to antimicrobial treatment in individuals with high levels of
S. mutans. In third-world countries, a rapid increase in caries
has been observed both in children and adolescents. The low
dentist to population ratio and the lack of organized dental
health care limit the possibilities of utilizing conventional
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caries-preventive methods. Therefore, it was thought that
vaccination against dental caries could be of great value as
a preventive adjunct in some societies and as a major public
health measure in others. It ought to be stressed, however,
that a thorough analysis of the need, cost beneÞts, and risk-
beneÞts of a vaccine against dental caries in various societies
and subgroups has to be performed.[31]
DISCUSSION
Loesche[34] stated that dental caries is one of the most
widespread diseases of mankind. S. mutans is the primary
etiologic agent of dental caries that are transmissible. It is
also said that a strong association exists between the level of
colonization with S. mutans and dental caries, although other
organisms such as Lactobacilli have also been implicated
in this disease. Adding to this, the studies conducted by
CauÞeld, et al.[35] stated that under normal circumstances of
diet, children become permanently colonized with S. mutans
between the middle of the 2nd year and the end of the 3rd year
of life. This period is called the window of infectivity. Many
studies were conducted on active immunization. Childers,
et al.[36] immunized adults orally by using enteric coated
capsules Þlled with crude Streptoccoccus mutans Gs-5 GTF
antigen preparation contained in liposome, resulting in the
production of parotid salivary IgA antibodies. Similarly,
the studies by Childers, et al.[37] have shown that nasal
immunization with dehydrated liposome containing GTRF
preparation induced significant IgA antibody response
in nasal washes. However, the studies by Smith, et al.[38]
reported that mucosal immunization with GTF could
influence the re-emergence of mutans Streptococci in
adults after a dental prophylaxis. Although the oral route
was not ideal for reasons such as the detrimental effects of
stomach acidity on antigens or because inductive sites were
relatively distant, experiments with this route established
that induction of mucosal immunity alone was sufÞcient
to change the course of mutans Streptococci infection and
disease in animal models by Michalek, et al.[39] and humans
by Smith, et al.[38] Most recently, attempts have been
made to induce protective immunity in mucosal inductive
sites closes to the oral cavity. Studies conducted by Katz,
et al.[40] have demonstrated that intranasal immunization
of rats with AgI/II - CTB induced a protective salivary
immune response, which was associated with a reduction
in Streptococci mutans colonization and Streptococci
mutans induced caries. The studies by Brandtzaed[41] have
shown that tonsillar application of antigens to the palatine
tonsils i.e., nasopharyngeal tonsils may contribute precursor
cells to mucosal effectors sites such as salivary glands. The
experiments performed by Schroeder, et al.[42] have shown
that Streptococcus sobrinus GTF was topically administered
on the lower lips of young adults and suggested that this
route may have potential for dental caries vaccine delivery.
Kleanthous, et al.[43] conducted experiments through rectal
immunization with non oral bacteria antigens such as
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Shivakumar, et al.
H. pylori resulting in secretory IgA antibodies in distant
salivary sites. Filler, et al.[44] conducted experiments on
passive immunization and showed that passive immune
protection can be achieved with antibodies to GTF or GBPs
mouth rinses containing bovine milk or hen egg yolk .
Childers, et al.[45] reported that the antibody to S. mutans
cells lead to a modest, short-term decrease in the number
of Streptococci mutans in saliva or dental plaque.
CONCLUSION
Clearly, there is strong evidence that S. mutans and
Streptococcus sobrinus are closely associated with dental
caries. Fluoride treatment used abroad has successfully limited
caries progression, but was not sufÞcient to control this
infectious disease even when used together with professional
tooth cleaning and dietary counseling in populations highly
exposed to these cariogenic microbiota. Active and passive
immunization strategies, which target key elements in the
molecular pathogenesis of mutans Streptococci, hold promise.
Integrating these approaches into broad-based public health
programs may yet forestall dental caries disease in many of
the world’s children, among whom those of high risk might
derive the greatest beneÞt. Despite the encouraging decline
in dental caries observed in recent years in many populations,
millions of children remain at risk of experiencing extensive
tooth decay and it is particularly distressing that many
of those suffering will be among the least likely to obtain
satisfactory treatment. Along with established methods
of caries prevention, caries vaccines have the potential of
making a highly valuable contribution to disease control.
In the meantime, basic research on the mode of action of
caries vaccine and the search for new, more effective, and
possibly polyvalent vaccines must continue if we are to fully
explore their potential for helping us in the struggle against
dental caries. Regardless of the mechanism by which immune
protection against dental caries is achieved, further advances
to make immunization against caries practical will depend
upon clinical trials aimed at establishing whether the Þndings
from animal experiments can be transferred to humans.
Particular goals for such studies include determining whether
appropriate immune responses can be safely generated in
humans, especially in susceptible age groups and whether
such responses will afford desirable levels of protection.
Although several methods such as topical or systemic use
of ßuorides, Þssure sealants, and dietary control have been
developed to prevent dental caries, the efÞcacy of these
methods is not enough to eradicate dental caries in humans;
however, there are a few studies on the efÞcacy of caries
vaccines in humans.
REFERENCES
1. Clifford MS. The art and science of Operative dentistry. 4th ed. Mosby
Publications; 1995.
Indian J Dent Res, 20(1), 2009
Dental caries vaccine
2. Hajishengallis G, Russel MW, Michalek SM. Comparison of an adherence
domain and a structural region of S. mutans antigen I/II in protective
immunity against dental caries in rats after intranasal immunization.
Infect Immun 1998;66:1740-3.
3. Lehner T. Immunology of dental caries. Immunology of oral diseases.
3rd ed. Blackwell scientific publications; 1992.
4. Smith DJ, Godiska R. Passive immunization approaches for dental caries
prevention. Conference Proceedings. Egg Symposium; 2004. p. 1-6.
5. Winston AE, Bhaskar SN. Caries Prevention in the 21st century. J Am
Dent Assoc 1998;129:1579-87.
6. Kruger C, Pearson SK, Kodama Y, Vacca Smith A, Bowen WH, Hammarstrom
L. The effects of Egg-derived antibodies to Glucosyltransferase on
dental caries in rats. Caries Res 2004;38:9-14.
7. Krithika AC, Kandaswamy D, Gopikrishna V. Caries vaccine-I today’s
myth. J Indian Assoc Public Health Dent 2004;4:21-5.
8. Russel MW, Childers NK, Michalek SM, Smith DJ, Taubman MA. A caries
vaccine? The state of science of immunization against dental caries.
Caries Res 2004;38:230-5.
9. Guo JH, Jia R, Fan MW, Bian Z, Chen Z, Peng B. Construction and
Immunologic characterization of a fusion anti-caries DNA vaccine
against Pac and Glucosyltransferase - I of S. mutans. J Dent Res
2004;83:266-70.
10. Mattos-Graner RO, Smith DJ. The vaccination approach to control
infections leading to dental caries. Braz J Oral Sci 2004;3:595-608.
11. Park K. Text book of preventive and social medicine. 17th ed. Bhanotidas
Publication; 2004.
12. Warren L, Ernest J. Medical microbiology and immunology. 6th ed.
Lange Medical Publishing Division; 2000.
13. Newman, Nisengard. Oral microbiology and immunology. W.B.
Saunder’s Company; 1988.
14. Bowen WH. Vaccine against dental caries: A personal view. J Dent Res
1996;75:1530-9.
15. Wilton JM. Future control of dental disease by immunization: Vaccines
and oral health. Int Dent J 1984;34:177-83.
16. Lehner T, Challacombe SJ, Caldwell J. Immuologic basis for vaccination
against dental caries in Rhesus monkeys. J Dent Res 1976;55:C166-80.
17. Russel RR, Johnson NW. The prospects for vaccination against dental
caries. Br Dent J 1987;10:29-33.
18. Lehner T. Future possibilities for the prevention of caries and
periodontal disease. Br Dent J 1980;149:318-25.
19. Bowen WH. Do we need to be concerned about dental caries in the
coming millennium? Crit Rev Oral Biol Med 2002;13:126-31.
20. Russel RR, Beighton D, Cohen B. Immunization of monkeys (Macaca
fascicularis) with Antigens purified from S. mutans . Br Dent J
1982;152:81-4.
21. Koga T, Oho T, Shimazaki Y , Nakano Y. Immunization against dental
caries. Vaccine 2002;20:2027-44.
22. Smith DJ. Dental caries vaccines: Prospects and concerns. Crit Rev Oral
Biol Med 2002;13:335-49.
23. Moro I, Lehner T. Symposium report: Sixth International congress of
mucosal immunology; Dental caries vaccine. J Dent Res July 23rd 1990.
p. 1863-4.
24. Russell RR. The application of molecular genetics to the microbiology
of dental caries. Caries Res 1994;28:69-82.
25. Luo Z, Smith DJ, Taubman MA, King WF. Cross sectional analysis of
serum antibody to oral streptococcal antigens in children. J Dent Res
1998;67:554-60.
26. Russell MW, Hajishengallis G, Childers NK, Michalek SM. Secretory
Immunity in defense against cariogenic Mutans streptococci. Caries
Res 1999;33:4-15.
Indian J Dent Res, 20(1), 2009
Shivakumar, et al.
27. Curtis R 3rd. 1984 Kreshover lecture: Genetic analysis of S. mutans
virulence and prospects for an anticaries vaccine. J Dent Res
1986;65:1034-45.
28. Bowen WH, Cohen B, Cole M, Colman G. Immunization against dental
caries: Summary. J Dent Res 1976;55:C164-5.
29. Tandon S. Textbook of Pedodontics. 1st ed. Paras Publishing; 2001.
30. News. Genes ‘n’ Greens: The future of oral medicine? Br Dent J
2002;192:674.
31. Krasse B, Emilson CG, Gahnberg L. An anticaries vaccine: Report on
the status of research. Caries Res 1987;21:255-76.
32. Harris R. Vaccines for dental caries. Aust Dent J 1983;28:115-6.
33. Hajishengallis G, Michalek SM. Current status of a mucosal vaccine
against dental caries. Oral Microbiol Immunol 1999;14:1-20.
34. Loesche WJ. Role of S. mutans in human dental decay. Microbiol Rev
1986;50:353-80.
35. Caufield PW, Cutter GR, Dasanayake AP. Initial acquisition of Mutans
Streptococci by infants: Evidence for a discrete window of infectivity.
J Dent Res 1993;72:37-45.
36. Childers NK, Zhang SS, Michalek SM. Oral immunization of humans
with dehydrated liposomes conataining S. mutans Glycosyltransferase
induces salivary immunoglobulin A2 antibody responses. Oral
Microbiol Immunol 1994;9:146-53.
37. Childers NK, Tong G, Mitchell S, Kirk K, Russell MW, Michalek SM.
A controlled clinical study of the effect of nasal immunization with a
S. mutans antigen alone or incorporated into liposomes on induction
of immune responses. Infect Immun 1999;67:618-23.
38. Smith DJ, Taubman MA. Oral immunizaqtion of humans with
Streptococcus sobrinus glucosyltransferase. Infect Immun 1987;55:
2562-9.
39. Michalek SM, McGhee JR, Mestecky J, Arnold RR, Bozzo L. Ingestion
of S. mutans induces secretory IgA and caries immunity. Science
1976;192:1238-40.
40. Katz J, Harmon CC, Buckner GP, Richardson GJ, Russsell MW, Michalek
SM. Proctective salivary immunoglobulin A responses against S. mutans
infection after intranasal immunization with S. mutans antigen I/II
coupled to the B Subunit of Cholera toxin. Infect Immun 1993;61:
1964-71.
41. Brandtzaeg P. The B-cell development in tonsillary lymphoid follicles.
Acta Otolaryngol Suppl 1996;523:55-9.
42. Schroeder HE, Moreillon MC, Nair PN. Architecture of minor salivary
gland duct/lymphoid follicle associations and possible antigen
recognition sites in the monkey Macaca fascicularis. Arch Oral Biol
1983;28:133-43.
43. Kleanthous H, Myers GA, Geoorgakopoulos KM, Tibbitts TJ, Ingrassia
JW, Gray HL, et al. Rectal and intranasal immunizations with
recombinant urease induce distinct local and serum immune responses
in mice and protect against Helicobacter pylori infection. Infect Immun
1998;66:2879-86.
44. Filler SJ, Gregory RL, Michalek SM, Katz J, McGhee JR. Effect of immune
bovine milk on S. mutans in human dental plaque. Arch Oral Biol
1991;36:41-7.
45. Childers NK, Tong G, Li F, Dasanayake AP, Kirk K, Michalek SM. Humans
Immunized with S. mutans antigens by Mucosal Routes. J Dent Res
2001;81:48-52.
How to cite this article: Shivakumar KM, Vidya SK, Chandu GN. Dental
caries vaccine. Indian J Dent Res 2009;20:99-106.
Source of Support: Nil, Conflict of Interest: None declared.
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