Dental caries vaccination

1. CARIES VACCINE
KHUSHBOO SINHMAR
MDS finalYear
DEPTT. OF PEDODONTICS
& PREVENTIVE DENTISTRY

2. CONTENTS
Introduction
Concept of vaccination
Properties of a vaccine
Window of infectivity
Immunity
Molecular pathogenesis of caries
Effective molecular targets
Types of vaccine

3. Routes of protective response
Adjuvants and delivery system
Active and passive immunization
Advantages
Limitations
Conclusion
References

4. INTRODUCTION

5. • The traditional way of managing dental caries was by a
surgical approach of drill and fill.
• 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.

6. VACCINE
• Term Vaccine is derived from EDWARD JENNER’s in 1796.
• Vaccine- Immunobiological substance designed to produce
specific protection against given disease. It stimulates the
production of a protective antibody and other immune
mechanisms.
Prepared from live modified organisms, inactivated or killed
organisms, cellular fractions, toxoids or combinations of these.

7. MILESTONES IN CARIES VACCINE
DEVELOPMENT
1. Mid 1930’s  LACTOBACILLI
2. 1965 : Discovery of a mucosal immune system
3. 1967: Discovery of GTF - Guggerheim and Schroelder
4. 1967 : Wagner -1st to successfully vaccinate rats against
caries S. fecalis was used as immunogen.
5. 1969: Bowen- successful vaccination of monkeys through
the administration of S.mutans intravenously.

8. 6. 1970`s – Lehner- S.C, monoclonal antibodies
7. 1976 - Bowen -possibility of developing a vaccine against
dental caries
8. 1978: Russell and Lehner - Antigen I/II
9. 1979 : Russell– GBpA, GBpB and GBpC
10. 1980: Start of passive immunization

9. • Types:
1. Live – BCG, Polio, Measles
2. Inactivated or killed vaccines - Cholera Vaccine
3. Toxoids – Diptheria, Tetanus
4. Cellular Fractions – Meningococchal Vaccine
5. Combination

10. PROPERTIES THAT CARIES VACCINE
SHOULD POSSESS
• Safe for relevant population
• Cheap in comparison to current control measures
• Stable under field condition
• Ease of delivery preferably single dose

11. • Possible combination with established vaccine
• Acceptable adjuvant to boost immune response
• Interfere with early colonization.
• Non-inflammatory response.
• Persistent response.

12. “WINDOW OF INFECTIVITY”
It is the time period in which the initial acquisition of S. mutans
takes place on either a permanent tooth or primary tooth.
Source - Maternal. (Kohler et al., 1984; Caufield et al., 1993)
- Environmental conditions. (Mattos- Graner et al.,
2001)

13. Children who do not become infected by 3yrs. appear to
remain uninfected for several yrs., possibly until eruption of
the secondary dentition.{Caufield et al,1993; Smith et
al,1998}
This suggests that a long-term benefit could ensure if mutans
streptococcal colonization could be impeded in early childhood
by measures such as immunization.

14. IMMUNITY

15. Immunity- host’s resistance towards injury caused by microbes
or products.
Antigen – any substance which stimulates production of
antibody with which it reacts specifically and in an observable
manner.
Antibody – substance which appears in serum/tissue fluids
which react with the antigen specifically and in an observable
manner.

16. THE PRIMARY RESPONSE
 When an antigen is administered for the first time to an 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 first 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.

17.  Meanwhile, if the antigenic stimulus was sufficient, 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.

18. • An important outcome of the primary antigenic challenge is
the education of the reticuloendothelial 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

19. 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.

20.  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.

21. MOLECULAR PATHOGENESIS OF CARIES

22. • Lamont and Co workers (1991) – S. mutans antigen I/II
adherence to pellicle is mediated through an acidic, mucin-like
glycoprotein (agglutinin) found in parotid and submandibular
saliva.
• Atleast 2 binding regions of Ag I/II involved in adhesive
activities( Crowley et al 1993, Nakai et el 1993, Kelly et el
1995)

25. • Glucans accumulation of S.
+ mutans in biofilm
(GTFs + GBPs)

28. NEXT PHASE OF PATHOGENESIS
• Accumulated Strep.mutans most prolifically produce lactic
acid.(Gibbons &Van Houte, 1975)
• If this increase in lactic acid synthesis can’t be sufficiently
buffered, Dental caries ensues.

31. ADHESINS:
• Adhesins form the two principal human pathogens of
- S. mutans (variously identified as antigens I/ II, Pac, or P1)
-S. sobrinus( Spa-A or Pag) and has been purified.
• Antigens I/II (Ag I/II)
• Found in the culture supernatant as well as in the S. mutans
cell surface.

32.  Contains an alanine-rich tandem-repeating region in the N-
terminal third and a proline rich repeat region in the center of
the molecule.

33.  These regions have been associated with the adhesin activity
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.

34. GLUCOSYLTRANSFERASE (GTFs):
1. Water insoluble glucan synthesizing enzyme: GTF-I
2. Water insoluble and water-soluble glucan
synthesizing en-zymes: GTF-S-I
3. Water soluble glucan synthesizing enzymes: GTF-S

35. Three genes
encoding for
GTF activity

36.  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.
 Streptococcus sobrinus produces a water soluble glucan-
synthesizing enzyme GTF-S.

37. GLUCAN BINDING PROTEIN (GBP):
 S. mutans secretes at least three distinct proteins with
glucan binding activity: GBP-A, GBP-B, and GBP-C.
 GBP-B has been shown to induce a protective
immune response to experimental dental caries.

38. TYPES OF VACCINES
• SUBUNIT VACCINE
• RECOMBINANT VACCINE
• CONJUGATE VACCINE

39. SUBUNIT VACCINES
• Contain structural elements of the Ag I/II adhesin family,
GTF-S or GBP-B
• These vaccines contain single or multiple copies of epitopes of
domains associated with salivary binding, catalytic processes
or glucan binding activities.

40. • These homologous sequences may induce cross reactive
responses influencing colonization, attachment or
accumulation of commensal microbiota.
• Hence subunit vaccines are designed to exclude sequences
bearing the potential for induction of unwanted antibody
responses

41. Recombinant Vaccine
• Produced through recombinant DNA technology.
• Involves inserting the DNA encoding an antigen that
stimulates an immune response into bacterial or mammalian
cells, expressing the antigen in these cells and then purifying it
from them.

42. Conjugate Vaccine
• These vaccines combine a weak antigen with a strong antigen
so that immune system has a strong response to the weak
antigen.
• S.mutans polysaccharides are conjugated with protein or
peptide components.
• Weak antigen- polysaccharide
• strong antigen- peptide/protein

43. only polysachharide coating
B cells independent of T cells
stimulation
Weak immune response
With peptide/protein
coating
B cells dependent of T cells
Strong immunogenic
memory
Strong immune response
IMMUNE RESPONSE

44. COMMON MUCOSAL IMMUNE SYSTEM:
• Mucosal applications of dental caries vaccines are generally
preferred for the induction of Secretory-IgA antibodies.
• Several routes which have been used for induction are as
follows.

45. • Several mucosal routes used to induce protective immune
responses to dental caries vaccine antigens:
• Oral
• Intra Nasal
• Tonsillar
• Minor salivary gland
• Rectal

46. Oral
• Relied on oral induction of immunity in the GALT.
• Smith DJ (2002): applied antigen by oral feeding, gastric
intubation, or in vaccine containing capsules or liposome.

47. Intranasal
• Intranasal instillation of antigen, the NALT, has been used to
induce immunity to bacterial antigens including those
associated with mutans Streptococcus colonization and
accumulation.

48. TONSILLAR ROUTE:
• The tonsillar tissues contain the required elements of immune
induction of S-IgA and IgG.
• Palatine tonsils, especially the nasopharyngeal tonsils have
been suggested to contribute precursor cells to mucosal
effector sites, such as salivary glands.

49. • MINOR SALIVARY GLAND-
They populate the lips, cheeks and soft palate.
• They have been suggested as potential routes for mucosal
induction, given their short, broad secretory ducts that facilitate
retrograde access of bacteria & their products & give the
lymphatic tissue aggregates.

50. • RECTAL
• This region as an inductive location for immune responses in
humans is suggested as this site has the highest concentration
of lymphoid follicles in the lower intestinal tract.
• Hence the use of vaccine suppositories as an alternative in
children in whom respiratory ailments preclude intranasal
route may be considered.

51. • Rectal immunization with non-oral bacterial antigens such as
Helicobacter pylori (Kleanthous et al., 1998) or Streptococcus
pneumonia (Hvalbye et al., 1999), presented in the context of
toxin-based adjuvant, can result in the appearance of secretory
IgA antibody in distant salivary sites.
Naik S et al.Indian Journal of Mednodent and Allied Sciences 2014;2(2): 198-203.

52. SYSTEMIC ROUTE
• This route was used successfully and
elicited predominantly IgG, IgM and IgA
antibodies.
• The antibodies find their way into the oral
cavity via GCF and are protective against
dental caries.
• The development of serum IgG antibodies
takes place within months of
immunization. Protection against caries
was associated predominantly with
increased serum IgG antibodies.

53. ACTIVE GINGIVO-SALIVARY ROUTE
• In order to limit the potential side effects and to localize the
immune response, gingival crevicular fluid has been used as the
route of administration. It induces both IgA and IgG antibodies.

54. • Schroeder, et al. 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.
Schroeder HE, Moreillon MC, Nair PN. Architecture of minor salivary gland duct/lymphoid follicle
associations and possible antigen recognition sites in the monkey Macacafascicularis. Arch Oral Biol
1983;28:133-43.

55. SYNTHETIC PEPTIDES
• Antigen derived from animals/ humans has potential for
hypersentivity.
• Chemically synthesized peptides hold an advantage in that this
reaction can be avoided.
• Give antibodies in GCF and saliva.

56. CHOLERA AND E.COLI HEAT LABILE
ENTEROTOXINS :
• Cholera toxins (CT)- powerful mucosal immuno-adjuvant
-ADP- bacterial toxin.
• Adjuvant effects of CT include increased mucosal epithelial
cell and macrophage production of pro-inflammatory
cytokines.
• Can greatly enhance mucosal immune response.

57. LIPOSOMES
• Phospolipid membrane
vesicles are used to contain
and deliver drugs and
antigens.
• IgA antibody response was
higher with liposome
containing compared to
protein vaccine alone.

58. New Fusion Anti-caries DNA Vaccine
• Researchers at Wuhan Institute of Virology, China, tried to
develop a new DNA vaccine which showed promising results
in preventing dental caries.
• S. mutans have two important virulence factors: cell surface
protein PAc and Glucosyltransferases (GTFs).

59. • GTFs have two functional domains: an
• N-terminal catalytic sucrose-binding domain (CAT) and
• C-terminal glucan-binding domain (GLU).
• A fusion anti-caries DNA vaccine, encoding two important
antigenic domains, PAc and GLU, of S. mutans, was successful
in reducing the levels of dental caries caused by S. mutans in
gnotobiotic animals

60. Microcapsules and microparticles
• Microcapsules and microparticles of polylactide-coglycolide
(PLGA) used as local delivery systems.
•Advantages: ability to control the rate of release, evade
preexistent antibody clearance mechanisms and degrade
slowly without eliciting an inflammatory response

61. • Shiroza T et al in 1987-The S sobrinus recombinant enolase
(rEnolase) is used as a target antigen. rEnolase plus an alum
adjuvant was delivered into the oral cavity of rats. It increased
the levels of salivary IgA and the IgG antibodies which were
specific for this recombinant protein. These results indicated
that rEnolase could be a promising and a safe candidate for
testing in the trials on vaccines against dental caries in humans
Shiroza T, Ueda S, Kuramitsu HK. Sequence analysis of the gtfB gene from Streptococcus mutans. J
Bacteriol. 1987;169:4263–70

62. • Studies conducted by Katz, et al 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.
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.

63. . Immunization of mice with synthetic peptides (residues 301-
319) from the alanine-rich region of antigen I/II suppressed
tooth colonization with S. mutans (Takahashi et al., 1991)
Smith D. DENTAL CARIES VACCINES: PROSPECTS AND CONCERNS. Crit Rev Oral Biol Med 2002;
13(4):335-349.

65. PASSIVE IMMUNIZATION
• It involves passive or external supplementation of the
antibodies. Several approaches tried were:

66. • Passive antibody administration has also been examined for
effects on indigenous mutans streptococci. Mouthrinses
containing bovine milk (Filler et al., 1991) or hen egg yolk
IgY (Hatta et al., 1997) antibody to S. mutans cells led to
modest short-term decreases in the numbers of indigenous
mutans streptococci in saliva or dental plaque.
Smith D. DENTAL CARIES VACCINES: PROSPECTS AND CONCERNS. Crit Rev Oral Biol Med
2002; 13(4):335-349.

67. 1. Monoclonal antibodies:
- Monoclonal antibodies to S.mutans cell surface Ag I/II have been
investigated.
- Topical application in humans brought a marked reduction in the
implanted S.mutans.

68. 2. Bovine milk: -
-Systemic immunization of cows with a vaccine using whole
S.mutans led to the products containing polyclonal IgG Abs.
- This milk was then added to the diet of a rat model which
reduced caries
- Also used in mouth rinse which resulted in lower percentage
of S.mutans in plaque.

69. 3. Egg-yolk antibodies:
- Vaccines used were formalin killed whole cells & cell
associated GTFs.
- Caries reduction has been found with both these treatments.

70. 4. Transgenic plants:
- Caries vaccine from a genetically modified (GM) tobacco
plant.
- Colorless, tasteless and can be painted onto the teeth.
- It is the first plant derived vaccine from GM plants.

71. • Jimson S et al in 2013 -The suppressive effects of lozenges
which contained egg yolk antibodies (immunoglobulin Y
[IgY]) against the Streptococcus mutans cell-associated
glucosyltransferase (CA-gtf) was studied in healthy young
adults. The results of the study showed that the lozenges
which contained anti–CA-gtf IgY could suppress the oral
colonization by mutant Streptococci in healthy young adults.
Jimson S et al.JClin Diagn Res 2013;7(6):1250–1253.

72. PROSPECTS AND CONCERNS
• For populations under normal risk of infections Immunization
for dental caries should begin early in the second year of life.
• If bacterial colonization of the dental bio-film is complete after
eruption of all primary teeth and if through immunization we
can prevent S mutans colonization prior to this period then
benefit of early immunization extends until secondary teeth
begin to erupt.

73. ADVANTAGES
• Could be given at the same time as vaccines against diptheria
and tetanus.
• Parents can decide whether to have their child vaccinated.
• Immunity could be boosted thereafter to provide life long
protection.
• No additional financial burden being incurred.

74. LIMITATIONS
• Provides partial protection.
• The immune system must respond to the bacteria on a daily
basis and not on periodic bases.
• No stimulation of immunoglobulin synthesis.
• Immunization could also cause an increase in caries incidence.

75. CONCLUSION
• Both passive and active immunization approaches have
demonstrated success in animal models and human clinical
trials. The efficacy of active immunization with subunit
vaccines from S.mutans has been proved to prevent dental
caries in animal models.
• The primary target of such a vaccine would be young children,
who are at high risk at this disease.

76. • Risk-free and more effective approach to prevent human
dental caries should be developed.
• Recent advances in research on mucosal vaccines will lead to
a safe and effective vaccine

77. References
• DJ Smith – Dental Caries Vaccines: Prospects and Concerns. Crit Rev Oral
Biol Med 2002 ; 13 : 335-349.
• AC Krithika, D Kandaswamy and V Gopi Krishna – Caries Vaccine – I ;
Today’s Myth!. JPHD 2004 : 4 ; 21 – 25.
• Shivakumar KM, Vidya SK, Chandu GN. Dental caries vaccine. Indian J
Dent Res. 2009 Jan-Mar;20(1):99-106.
• Tandon S. Textbook of Pedodontics. 1st ed. Paras Publishing; 2001.

78. THANK YOU