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Mutans Streptococci: Acquisition and Transmission

Robert J. Berkowitz, DDS1

Abstract
Dental caries is an infectious and transmissible disease. The mutans streptococci (MS) are
infectious agents most strongly associated with dental caries. Earlier studies demonstrated
that infants acquire MS from their mothers and only after the eruption of primary teeth.
More recent studies indicate that MS can colonize the mouths of predentate infants and
that horizontal as well as vertical transmission does occur. The purpose of this paper was
to demonstrate that these findings will likely facilitate the development of strategies to
prevent or delay infant infection by these microbes, thereby reducing the prevalence of
dental caries. (Pediatr Dent 2006;28:106-109)
KEYWORDS: MUTANS STREPTOCOCCI, ACQUISITION, TRANSMISSION

Acquisition 10 primary teeth. Berkowitz and coworkers4 reported that

The mouth of a normal predentate infant contains only MS were detected in 9 of 40 (22 %) infants who had only
mucosal surfaces exposed to salivary fluid flow. Mutans primary incisor teeth. In addition, these organisms were not
streptococci (MS) could persist in such an environment detected in 91 normal predentate infants, but were detected
by forming adherent colonies on mucosal surfaces or by in 2 of 10 infants with acrylic cleft palate obturators. In
living free in saliva by proliferation and multiplying at a a subsequent study, Berkowitz and colleagues 5 reported
rate that exceeds the washout rate caused by salivary fluid that these organisms were not detected in 16 predentate
flow. The oral flora averages only 2 to 4 divisions per day1 infants, but were detected in 3 of 43 (7%) infants (mean
and swallowing occurs every few minutes. Because of this, age=8.9 months) with 1 to 5 primary incisor teeth and in
it is reasonable to assume that bacteria cannot maintain 12 of 42 (29%) infants (mean age=13.8 months) with 6 to
themselves freew in saliva by proliferation, but instead must 8 primary incisors. Likewise, Stiles and coworkers6 could
become attached to an oral surface. not detect MS in 43 normal predentate children, but iso-
Previous studies, reviewed by Gibbons and Van Houte,2 lated these organisms in 12 of 56 (22%) of infants (median
have demonstrated that MS have a feeble capacity to be- age=approximately 14 months) with 6 to 8 primary incisors
come attached to epithelial surfaces. Therefore, it seemed and in 1 of 38 (3%) of infants (median age=approximately
unlikely that these organisms could colonize in the mouth 9 months) with 2 to 4 primary incisors.
of a normal infant before the teeth erupt. Earlier clinical Catalanotto and colleagues7 failed to isolate these organ-
studies reported that MS could not be detected in the isms from predentate children or children that harbored
mouths of normal predentate infants,3-10 but could after only primary incisors; MS were isolated only after the
the insertion of acrylic cleft palate obturators or eruption eruption of the first primary molars. Caufield and cowork-
of primary teeth. ers8 reported that 25% of their infant population (N=46)
A longitudinal investigation by Carlsson and coworkers3 acquired MS by 19 months of age. Extrapolations of
reported that MS were detected in 5 of 25 (20%) infants Caufield and colleagues’ data from a figure depicting the
12 months to 16 months old. In addition, these organisms cumulative probability of MS acquisition as a function of
were not detected in any of the 25 subjects during their age indicated that approximately 5% of their study popula-
first year of life. Although Carlsson and colleagues did not tion acquired these organisms by approximately 9 months
report the stage of dental development, the age range of of age. Approximately 15% of the subjects were colonized
12 to 16 months is compatible with an infant having 6 to by approximately 12 months of age. Karn9 and coworkers
assessed MS prevalence in a population of 149 inner city
infants who were enrolled in a WIC Program. Evidence
1
Dr. Berkowitz is professor and Chair, Division of Pediatric Dentistry, of MS was seen as early as 10 months of age. For children
Eastman Department of Dentistry, School of Medicine and Dentistry,
University of Rochester, Rochester, NY.
12 months old, 25% had detectable MS levels; in the 15-
Correspond with Dr. Berkowitz at [email protected] month-old age group, 60% were colonized.

106 Berkowitz Mutans Streptococci: Acquisition and Transmission Pediatric Dentistry – 28:2 2006
 Japanese investigators10 studied acquisition of MS in Vertical transmission
a population of 39 children in a Hiroshima day nursery. Vertical transmission is the transmission of microbes from
They reported that the cumulative probability of detecting caregiver to child. The major reservoir from which infants
MS was 20% in children harboring 10 teeth and 40% in acquire MS is their mothers. The early evidence for this
children harboring 12 teeth. Collectively, these observa- concept comes from bacteriocin typing studies20-22 where
tions indicated that MS are not detected in the mouths MS isolated from mothers and their infants demonstrated
of predentate infants and infrequently colonized the oral identical bacteriocin typing patterns. More advanced
cavity until the later stages of primary incisor emergence technology that utilized chromosomal DNA patterns or
(approximately 10 to 12 months old). Accordingly, the identical plasmids provided more compelling evidence to
concept that MS required a nonshedding oral surface for substantiate the concept of vertical transmission.23-27
persistent oral colonization became a basic tenet of oral Successful infant colonization of maternally transmitted
microbial ecology. MS cells may be related to several factors which, in part,
More recent clinical investigations11-13 have demonstrated include magnitude of the innoculum,28 frequency of small
that MS can colonize in the mouths of predentate infants. dose inoculations,29 and a minimum infective dose.30 A
Tanner and coworkers11 have demonstrated that the fur- study conducted by Berkowitz and coworkers28 reported
rows of the tongue appear to be an important ecological that, when mothers harbored greater than 105 colony
niche. Utilizing DNA probe technology, they reported forming units (cfu) of MS per mL of saliva, the frequency
that MS were present in 55% of plaque samples and in of infant infection was 58%. When mothers harbored 103
70% of tongue scraping samples of 57 children aged 6 cfu of MS per mL of saliva or more, however, the frequency
to 18 months living in Saipan. Wan and colleagues12,13 of infant infection was 9 times less (6%). These data clearly
reported that MS can be routinely detected prior to tooth demonstrate that mothers with dense salivary reservoirs of
emergence. In their study of 172 predentate 6-month-old MS are at high risk for infecting their infants early in life.
infants, they found that 50% of the preterm and 60% Accordingly, Kohler and colleagues31 demonstrated that
of the full-term children harbored MS in mouth swab a reduction of the salivary level of MS in highly infected
samples. The authors concluded that the detection of these mothers can inhibit or delay the establishment of these or-
organisms in repeated samples was indicative of colonization. ganisms in their infants. Only 3 of 28 babies (11%) whose
The recent studies11-13 on acquisition of MS raise doubts that a mothers were in the experimental group and had their MS
nonshedding oral surface is required for colonization. reservoirs suppressed by treatment of active caries lesions
and topical chlorhexidene gels were infected by the age of 23
Early acquisition of mutans streptococci months. In contrast, 17 of 38 babies (45%) in the control
and dental caries group whose mothers’ levels of MS were not suppressed,
Early acquisition of MS is a major risk factor for early child- were infected by 23 months of age.
hood caries14 and future caries experience.15-19 Alaluusua and A recent study by Li and colleagues 32 reported that
Renken15 performed longitudinal assessment for MS and neonatal factors may also affect risk for early acquisition of
dental caries in children aged 2 to 4 years. Children who MS via vertical transmission. Infants delivered by caesarian
harbored MS in their plaque at age 2 had the most caries by section acquired MS 11.7 months earlier than did vaginally
age 4. The mean decayed, missing, and filled primary tooth delivered infants (P=.038). This observation indicates that
surface (dmfs) scores in these children was 10.6, whereas medical history assessment of the pediatric dental patient
in children in whom colonization occurred later the mean should include mode of delivery to identify infants at po-
dmfs score was 3.4 at age 4 (P<.005). Similar observations tential risk for early MS infection.
were made by Kohler and colleagues,16 who reported that
89% of children with MS colonization by 2 years of age Horizontal transmission
had experienced dental caries by 4 years of age with a mean Horizontal transmission is the transmission of microbes be-
dfs score of 5.0. tween members of a group (eg, family members of a similar
In contrast, 25% of children not infected with MS prior age or students in a classroom). More recent reports33-35
to 2 years of age had experienced dental caries by 4 years of indicate that vertical transmission is not the only vector by
age (mean dfs score=0.3). In another longitudinal study,17 which MS are perpetuated in human populations. Hori-
Grinderfjord and coworkers evaluated 786 children at 1 zontal transmission also occurs. This is important given the
year of age for caries risk factors that included MS infec- socioeconomic changes in Western culture over the past 2
tion, fluoride exposure, dietary habits, and oral hygiene. to 3 decades. For example, the use of a daycare center or a
The children were re-examined at 3½ years of age for the nanny may provide another vector for acquisition of these
presence of dental caries. The presence of MS at 1 year of organisms. Mattos-Graner and coworkers33 isolated Strep-
age was the most effective predictor of caries at 3.5 years tococcus mutans strains from cohorts of Brazilian nursery
of age. These observations, coupled with the findings school children (12 to 30 months of age) and genotyped
of Fujiwara et al18 and Roeters et al,19 clearly illustrate them by arbitrarily primed polymerase chain reaction and
that early infection with MS is a significant risk factor for restriction fragment length polymorphism analysis. Of 24
future development of dental caries. children with 2 to 5 S mutans isolates, 29% carried 2 or

Pediatric Dentistry – 28:2 2006 Mutans Streptococci: Acquisition and Transmission Berkowitz 107
more matching genotypes. The presence of matching geno- 2. Alter saliva-sharing activities, such as tasting food
types of S mutans among children attending one nursery before feeding and sharing toothbrushes.
school strongly suggests horizontal transmission. 3. Twice daily tooth-brushing of the dentate infant
Van Loeveren and colleagues34 reported data which with an appropriate amount of an American Dental
bacteriocin typed isolates of MS obtained from children 5 Association-approved fluoridated toothpaste.
years of age and their parents. The results showed that, even 4. Avoid decay-promoting feeding behaviors.
when a child acquires MS after the age of 5, there may be 5. Oral health evaluation of the infant by a dental profes-
similarity between MS in mother, father, and child—in- sional should occur before the first birthday.
dicating that horizontal transmission can occur between In summary, dental caries is an infectious and transmis-
family members. Emauelson and Wang35 genotyped isolates sible disease. Detailed knowledge regarding the acquisition
of MS from 18 Chinese families consisting of a mother, and transmission of infectious agents facilitates a more com-
father, and 3-year-old child without any other siblings. A prehensive approach toward prevention. MS are important
key observation in their study was that identical genotypes organisms in the initiation and pathogenesis of dental caries.
were found between some fathers and their first-born child. Recent evidence demonstrates that these bacteria are found
The homology of genotypes between spouses was another in the mouths of predentate infants and are acquired via
important observation. These findings also support the vertical and horizontal transmission from human reservoirs.
concept that horizontal transmission may occur among This information should facilitate the focusing of clinical
family members. interventions that prevent or delay infant infection, thereby
reducing the prevalence of dental caries.
Clinical significance
Knowledge regarding the natural history of an infectious Conclusions
disease facilitates a more comprehensive approach toward Based on this paper’s findings, the following conclusions
its prevention (eg, HIV and yellow fever), Studies by Kohler can be made:
and colleagues,16,31 discussed earlier, utilized this concept 1. Primary oral infection by mutans streptococci (MS)
to inhibit and/or reduce dental caries in young preschool may occur in predentate infants.
Swedish children by reducing the risk of vertical transmis- 2. Infants may acquire MS via vertical and horizontal
sion of MS via suppression of oral MS reservoirs in their transmission.
highly infected mothers. More recently, Söderling and 3. Improvements in the prevention of dental caries
colleagues36 demonstrated that habitual xylitol consump- may likely be realized through intervention strategies
tion (via chewing gum) by mothers was associated with that focus on the natural history of this infectious
a statistically significant reduction of the probability of disease.
vertical transmission of MS at 2 years of age. In a follow-up
study,37 Söderling’s group reported that, at the age of 5, the References
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Pediatric Dentistry – 28:2 2006 Mutans Streptococci: Acquisition and Transmission Berkowitz 109