PERSPECTIVE
D.J. Smith
The Forsyth Institute, 245 First Street, Cambridge, MA 02146, USA; dsmith@
forsyth.org
J Dent Res 91(3):225-226, 2012
KEY WORDS: mucosal immunity, Streptococcus mutans,
vaccine(s), adjuvants, dental caries, DNA vaccines.
V accines have long been attractive for broad-based pub-
lic health coverage of infectious diseases, of which dental
caries is one of the most pervasive. We are now in the seventh
decade of vaccine approaches intended to prevent or arrest den-
tal caries. In the 1940s, Lactobacilli were among the principal
bacterial targets. In the latter half of the 20th century, attention
was focused on mutans streptococci (Streptococcus mutans and
S. sobrinus), given their repeated association with dental caries,
especially that of early childhood. Although more recent use of
molecular probes has implicated additional bacteria (e.g., bifi-
dobacteria) in the development of early lesions (Kanasi et al.,
2010), most of the immunologic interest remains with S. mutans.
Protein, recombinant or synthetic peptide, protein-carbohydrate
conjugate, or DNA-based active vaccines—each has been suc-
cessful in experimental systems. However, no vaccines have
been brought to market. Although there are several reasons for
this, including financial risk/reward for development, the ability
to induce and maintain high levels of protective antibody in oral
fluids has been a significant challenge. Several strategies have
been pursued to identify powerful and safe adjuvants that can be
used in the mucosal immune context. In the present issue of the
JDR, Shi and co-workers have evaluated the use of recombinant
flagellin protein as an adjuvant for the intranasal delivery of an
anti-caries DNA vaccine (Shi et al., 2012).
DNA vaccine approaches for dental caries have had a history
of success in animal models. Incorporating message for one or
more of the known S. mutans virulence antigens, investigators
have used such constructs to induce systemic IgG and/or mucosal
IgA antibody responses to S. mutans glucosyltransferases and
adhesins. These responses were associated with reductions in car-
ies lesions in rodents. Since DNA vaccines are relatively weak
immunogens, there has been significant effort, especially by the
Fan group, to identify compounds and conditions that would
increase antibody levels which could also improve the protective
effect. Useful adjuvants appropriate for intranasal (IN) vaccine
delivery have been sought, in part because the IN route has been
shown to enhance regional mucosal antibody levels, including
salivary antibody. This group has had some success using bupiva-
caine (Jia et al., 2004) and chitosan (Xu et al., 2006) adjuvants to
increase salivary IgA antibody responses. Shi and co-workers (Shi
et al., 2012) sought to further enhance salivary IgA and serum IgG
DOI: 10.1177/0022034511425928
Received September 13, 2011; Accepted September 15, 2011
© International & American Associations for Dental Research
Prospects in Caries Vaccine
Development
antibody by including Salmonella-derived flagellin protein, a
ligand of Toll-like receptor 5, at the time of pGJA-P/VAX admin-
istration. The S. mutans-specific sequences of this construct code
for the glucan-binding domain (GLU) of GtfB and the A-P adhe-
sin-associated fragment of the Pac surface protein. Addition of
recombinant flagellin to this intranasally administered DNA vac-
cine enhanced both serum IgG and salivary IgA antibody levels to
the A-P fragment. Anti-GLU antibody responses were not reported.
These authors suggested that flagellin-enhanced antibody
responses to the adhesin were responsible for greater caries reduc-
tions than had been seen with chitosan or bupivacaine, based on
comparison with earlier studies. Direct adjuvant comparison in
follow-up studies could confirm this suggestion.
Investigators have sought to enhance antigen uptake to muco-
sal lymphatic tissues by combining adjuvants with acceptable
delivery vehicles. Delivery systems such as PLGA microparticles,
liposomes, or ISCOMs have resulted in generally modest
increases in salivary IgA antibody activity, although such increases
have sometimes been associated with protection in animal models
for dental caries. Additional chitosan incorporation into, or coat-
ing on, microparticles has been reported to be beneficial to muco-
sal immune induction, possibly by promoting M-cell uptake
(Borges et al., 2007). New methods to target M-cell uptake of
antigens may offer enhancement of mucosal IgA antibody forma-
tion sufficient to sustain protection (Azizi et al., 2010).
Heat-labile enterotoxins (HLT) from Vibrio cholera (LT-I) or
Escherichia coli (LT- II) induce vigorous mucosal (and sys-
temic) immune responses when used as adjuvants for protein
antigens. However, their inherent toxicity precludes the use of
such holotoxins in human vaccines. Even genetically detoxified
mutants of E. coli LT-II have been associated with neurological
issues following their use with intranasally delivered inactivated
influenza vaccine (Lewis et al., 2009), likely a function of LT
binding to neuronal gangliosides. However, work continues to
identify safe HLT subcomponents which retain significant
immunomodulatory characteristics that can be used at the pre-
ferred intranasal site (Liang et al., 2009).
Unlike active vaccines, passive applications of antibody do not
require adjuvants. Experimentally successful passive vaccines for
dental caries have taken many forms, including mouse monoclonal
IgG, bovine or simian IgG, chicken IgY, and tobacco-plant-derived
transgenic SIgA/G antibody (reviewed in Smith and Mattos-
Graner, 2008). The aforementioned transgenic vaccine also showed
some promise in small clinical trials in adults (Ma et al., 1998).
Most of these vaccines were directed to the same glucan-generating
or adhesin targets as their active counterparts. Since passive vac-
225
226  Smith J Dent Res 91(3) 2012
cines do not induce a continuous antibody-secreting host response,
effective delivery of the passive reagents is key to their success.
Intriguingly, single-chain antibody (scFv), directed against a
S. mutans adhesin and expressed on the surface of Lactobacilli, has
been associated with dental caries reductions in a rat model (Kruger
et al., 2005). This approach would offer sustained delivery of anti-
body as long as the probiotic colonizes the host.
Some of the uncertainty about caries vaccine effectiveness
stems from our limited understanding of the influence which the
natural mucosal immune response has on the entry of cariogenic
mutans streptococci into the oral biofilm. Attempts to correlate
host antibody and caries levels have been problematic. Recently,
Nogueira and co-workers (2005) provided suggestive evidence
that salivary IgA antibody to certain virulence antigens delayed S.
mutans colonization in very young children. These potentially
protective responses theoretically could have been provoked
through antigenic stimulation by similar epitopes on earlier-colo-
nizing oral streptococci.
Dental caries vaccines, directed to key components of mutans
streptococcal colonization and enhanced by safe and effective
adjuvants and optimal delivery vehicles, are likely to be forth-
coming. Will these vaccines lower dental caries risk in children?
Effectiveness may be tied to immunization timing and a reduc-
tion in environmental risk factors. For example, one strategy
may be to immunize prior to permanent acquisition of cario-
genic S. mutans early in childhood. Ultimately, clinical trials of
immunologically superior dental caries vaccine formulations
will determine their usefulness for public health applications.
Although scientific, regulatory, and economic hurdles need to be
cleared to reach this goal, the potential benefit continues to
make the race worth running.
Acknowledgments
The author received no financial support and declares no poten-
tial conflicts of interest with respect to the authorship and/or
publication of this article.
References
Azizi A, Kumar A, Diaz-Mitoma F, Mestecky J (2010). Enhancing oral
vaccine potency by targeting intestinal M cells. PLoS Pathog 6:
e1001147.
Borges O, Tavares J, de Souza A, Borchard G, Jungingee HE, Cordeiro-
da-Silva A (2007). Evaluation of the immune response following
a short oral vaccination schedule with hepatitis B antigen encapsu-
lated into alginate-coated chitosan nanoparticles. Eur J Pharm Sci 32:
278-290.
Jia R, Guo JH, Fan MW, Bian Z, Chen Z, Peng B, et al. (2004). Mucosal
immunization against dental caries with plasmid DNA encoding pac
gene of Streptococcus mutans in rats. Vaccine 22:2511-2516.
Kanasi E, Dewhirst FE, Chalmers NI, Kent R, Moore A, Hughes CV, et al.
(2010). Clonal analysis of the microbiota of severe early childhood car-
ies. Caries Res 44:485-497.
Kruger C, Hultberg A, van Dollenweerd C, Marcotte H, Hammarström
L (2005). Passive immunization by lactobacilli expressing single-
chain antibodies against Streptococcus mutans. Mol Biotechnol 31:
221-231.
Lewis DJ, Huo Z, Barnett S, Kromann I, Giemza R, Galiza E, et al. (2009).
Transient facial nerve paralysis (Bell’s palsy) following intranasal
delivery of a genetically detoxified mutant of Escherichia coli heat
labile toxin. PLoS ONE 4:e6999.
Liang S, Hosur KB, Nawar HF, Russell MW, Connell TD, Hajishengallis G
(2009). In vivo and in vitro adjuvant activities of the B subunit of Type
IIb heat-labile enterotoxin (LT-IIb-B5) from Escherichia coli. Vaccine
27:4302-4308.
Ma JK, Hikmat BY, Wycoff K, Vine ND, Chargelegue D, Yu L, et al. (1998).
Characterization of a recombinant plant monoclonal secretory antibody
and preventive immunotherapy in humans. Nat Med 4:601-606.
Nogueira RD, Alves AC, Napimoga MH, Smith DJ, Mattos-Graner RO
(2005). Characterization of salivary IgA responses in children heavily
exposed to the oral bacteria Streptococcus mutans: influence of specific
antigen recognition in infection. Infect Immun 73:5675-5684.
Shi W, Liu F, Yang J, Zhou D, Chen Y, Zhang Y, et al. (2012). Flagellin
enhances saliva IgA response and protection of anti-caries DNA vac-
cine. J Dent Res 91:249-254.
Smith DJ, Mattos-Graner RO (2008). Secretory immunity following mutans
streptococcal infection or immunization. Curr Top Microbiol Immunol
319:131-156.
Xu QA, Yu F, Fan MW, Bian Z, Chen Z, Fan B, et al. (2006). Immunogenicity
and persistence of a targeted anti-caries DNA vaccine. J Dent Res
85:915-918.
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