J Bagh College Dentistry

Vol. 23(4), 2011

Salivary streptococcus

Salivary streptococcus mutans and lactobacilli in relation

to rampant caries pattern among children
Yasameen A.A. Al-Bayati, B.D.S., M.Sc. (1)

ABSTRACT
Background: Several interrelated factors which are the tooth and saliva (host), microorganisms, substrate and time
are involved in the process of dental caries. Rampant caries is a severe form of tooth decay that can affect primary
or permanent teeth. It is characterized by its speed of onset and progression. Nursing caries is a type of rampant
caries affecting the primary teeth of young children and has been associated with prolonged unrestricted bottle or
breast feeding. This study was conducted in order to estimate the salivary level of streptococcus mutans and
lactobacilli among the rampant, nursing caries and control (caries free) children.
Materials and methods: Seventy five children aged 3 to 10 years old were included in the study. Forty six children
were selected for colony counting (19 children with nursing caries, 13 children with rampant and 14 children with
caries free).Dental caries was measured using dmfs, DMFS for primary and permanent teeth respectively using the
criteria of WHO. One ml of unstimulated (resting) whole saliva was collected from the children using spitting method
then diluted and applied on the surface of agar media specific for streptococcus mutans and lactobacilli growth.
Colony forming units with morphology characteristic of s. mutans and lactobacilli were counted and expressed as
numbers of CFU per ml of saliva.
Results: The results of present study showed no significant difference in the number of colonies of Streptococcus
mutans and lactobacilli among nursing, rampant and caries free groups (p>0.05) however there was a highly
significant difference in caries experience in the primary teeth among the three groups (p<0. 01) and a significant
difference in caries experience in the permanent teeth among the three groups (p<0.05).
Conclusion: The etiology of dental caries is multifactorial in that simultaneous participation of multiple factors is
required for caries to occur. Streptococcus mutans and Lactobaculli are microorganisms with cariogenic capacity,
however, their presence only do not determine the presence of dental caries.
Key words: streptococcus mutans, lactobacilli, nursing caries, rampant caries, saliva. (J Bagh Coll Dentistry
2011;23(4):153-157).

INTRODUCTION
Dental caries is a microbial disease of the
calcified tissues of the teeth characterized by
demineralization of the inorganic portion and
destruction of the organic substance of the tooth
( )
. Several interrelated factors such as: the tooth
and saliva (host), microorganisms, substrate and
time are involved in the process of dental caries
(2)
. Streptococcus mutans and lactobacilli are the
active microorganisms contributing dental caries.
The essential role of s.mutans is in the initial
process of caries while lactobacillus is correlated
with the active caries episode (3, 4).
Different types of streptococci were identified
in saliva these are s. mitis, s. oralis, s.salivarius, s.
anginosus, s. sanguis, s. vestibularis, s.mutans,
and s. gordonii (5). Different studies have shown a
correlation between counts of s.mutans in the oral
cavity and both the prevalence and incidence of
caries (6, 7, 8).However, in other studies, no
correlation has been found between the quantity
of s. mutans and the incidence of caries (9, 10). On
the other hand, some researchers have suggested
the importance of streptococci other than s.
mutans in the generation of dental caries (11).

(1)Assistant lecturer. Department of Pediatric and Prevention

Dentistry. College of Dentistry. University of Baghdad.

Orthodontics, Pedodontics, and Preventive Dentistry153

Rampant caries has been defined as "a

suddenly appearing rapidly burrowing type of
caries resulting in early pulp involvement. It is
one of the most frustrating and difficult condition
to treat. It results in pain, infection, nutritional and
esthetic impairment. There are different types of
rampant caries:
1. Nursing bottle rampant caries 2- Adolescent
rampant caries.3. Xerostomia induced rampant
caries (radiation rampant caries) (12).
Nursing caries is a type of rampant caries
affecting the primary teeth of young children, and
has been associated with prolonged unrestricted
bottle or breast feeding (13).
The characteristic feature which differentiates
nursing caries from rampant caries is that the
pattern of decay in nursing bottle caries is
distinctive. The four upper anterior teeth are
mostly affected while the four lower anterior teeth
exhibit no involvement at all because they are
protected by the tongue, lower lips and pooled
sublingual saliva, also the canines and molars may
exhibit some involvement but not as severely
affected as the maxillary incisors (14) .The
distinguishing characteristics of rampant caries
are the involvement of proximal surfaces of the
lower anterior teeth which are usually spared in
nursing caries (1).

J Bagh College Dentistry

Vol. 23(4), 2011

This study was conducted in order to estimate

the salivary level of streptococcus mutans and
lactobacilli among the rampant, nursing caries and
control (caries free) children.

MATERIALS AND METHODS

Salivary streptococcus

to rinse out their mouths with water. The first

mouthful of saliva was discarded, and then one ml
unstimulated (resting) whole saliva was collected
into small labeled plastic polyethylene tubes using
spitting method for collection. The following
points were followed for collection whole saliva
according to Fejerskov and Thylstrup (19).
v The patient should not eat or drink (except
water) one hour before saliva collection.
v A pre sampling period of one minute is
recommended.
v A fixed collection time (10-15 min. for
unstimulated saliva) should be used.
v The patient should sit in a relaxed position in
an ordinary chair.
v Samples containing blood should be
discarded if chemical analyses of saliva are
planned.
After collection of saliva from both the study
and control groups, the saliva was diluted with
normal saline in the bacteriology laboratory of
Baghdad College of Dentistry and then by using
micropipette the saliva was applied on the surface
of Mitis salivaris agar and Rogosa agar medium
which were used for streptococcus mutans and
lactobacilli growth. The plates were incubated in
an anaerobic atmosphere for 48 hours at 37C.
Colony forming units with morphology
characteristic of s.mutans and lactobacilli were
counted and expressed as numbers of CFU per
milliliter of saliva (20).
Statistical analysis was performed using SPSS
version 13. The data were submitted to the
analysis of variance (ANOVA) one way test for
comparison of significance among the groups.
When significance was found, least significant
difference (LSD) test was used to find where the
significance occurs.

Children Selection and grouping

Seventy five children in the age group of 3 to
10 years who came for treatment to the
Department of Pediatric and Preventive Dentistry,
University of Baghdad, College of Dentistry and
from nearby kindergarten and primary schools
were included in the study. All children had no
history of any systemic disease. Permission was
obtained from parents for including their children
in the study. Forty six children were selected for
colony counting:
1. Study group includes:
A. nursing caries group (19 children)
.They had the following specific criteria
of nursing caries according to Tinanoff
(15)
.
-Maxillary incisors are involved by
carious lesion, the child should have one
surface at least lingual, facial or proximal
is involved in all four incisors.
-Mandibular incisors are not carious.
B. rampant caries group (13 children).
They had the following specific criteria
of rampant caries according to lmez et
al. (16) and Winter et al. 1966 (17).
- Many teeth are involved.
- Lesions development is rapid.
- Carious lesions occur on the surfaces
generally considered to be at low risk to
decay, such proximal surfaces of
mandibular anterior teeth, facial surfaces
of maxillary anterior teeth, and lingual
surfaces of posterior teeth.
RESULTS
2. Control group (caries free) 14 chidren.
The results of the present study showed no
Children matching in age and gender for
significant
difference in the number of colonies of
both study groups chosen from the same
streptococcus
mutans and lactobacilli between
environmental condition.
nursing
and
rampant
caries groups and that of the
Methods
control
group
p>
0.05
(table 1); however there
Dental Examination
was
a
highly
significant
difference in caries
Examination of teeth was carried out using
experience
in
the
primary
teeth
among the three
mouth mirror and dental explorer. The teeth were
groups
p<
0.01
and
it
was
highest
in the rampant
dried using cotton rolls. Dental caries was
caries group followed by the nursing caries group
measured using dmfs, DMFS for primary and
(table 2). Further investigation using least
permanent teeth respectively using the criteria of
significant difference (LSD test) showed a highly
WHO (18).
significant difference between each two groups of
Saliva Analysis
the three selected groups (table 3).The results also
Collection of Salivary Samples
showed that there was a significant difference in
Salivary samples were collected in the
caries experience in the permanent teeth among
morning between (10-11) a.m. at least one hour
the three groups p< 0.05 and it was highest in the
after breakfast, and then the children were asked
Orthodontics, Pedodontics, and Preventive Dentistry154

J Bagh College Dentistry

Vol. 23(4), 2011

rampant caries group followed by the nursing

caries group (table 4).Further investigation using
LSD test showed a significant difference between
rampant group and control group p< 0.05(table 5).

DISCUSSION
The mean number of salivary streptococcus
mutans and lactobacilli represented by the colony
forming units in nursing and rampant caries group
are higher than in control group, but no significant
difference among the three groups was found p >
0.05. This finding is agreed with (9, 10, 20, 21) while
disagree with (22, 23) although the caries experience
was high in both primary and permanent teeth.
This could be attributed to that the etiology of
dental caries is multifactorial in that simultaneous
participation of multiple factors is required for
caries to occur. Streptococcus mutans are
considered to be the main etiological
microorganisms in caries disease, with lactobacilli
and other microorganisms participating in the
disease progression. Occasionally, some other
microorganisms have been traced as initiator
microorganisms (24).Children with nursing caries
harbored more types of mutans streptococci than
caries-free children (25, 26). It was found that
streptococcus mutans and Lactobacullus are
microorganisms with cariogenic capacity,
however, their presence only do not determine the
presence of dental caries (27).The multifactoriality
of the disease, including the potential action of
several species of acidogenic and aciduric
microorganisms, should be seriously considered.
A unique specificity of mutans group streptococci
has never been proved in observational studies (28).
High level of saliva mutans streptococci, bad
oral hygiene, frequent intake of sweet food, and
sugar contents in nursing bottle were the
important risk factors for dental caries on primary
teeth (29).
Nursing and rampant caries are more
commonly found in children who live in poverty
or in poor economic conditions, which belong to
ethnic and racial minorities, are born to single
mothers, and parents with low educational level,
especially illiterate mothers. In these populations
the oral hygiene of the children is usually poor,
exposure to fluoride is probably insufficient, and
there is a greater preference for sugary foods (30).

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Orthodontics, Pedodontics, and Preventive Dentistry155

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20. Krishnakumar R, Singh S, Subba Reddy VV,

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Table 1: ANOVA one way to compare the mean colonies number of S.Mutans and lactobacilli
among the three groups

SM
Sal.
LB
Sal.

Groups

Mean

SD.

SE.

nursing
rampant
control
nursing
rampant
control

19
13
14
19
13
14

.322
.355
.297
.316
.212
.110

.355
.444
.456
.479
.388
.175

.081
.123
.122
.110
.108
.047

df

0.067

1.169

Sig.
0.935

0.320

Table 2: ANOVA one way to compare caries experience for the primary teeth among the three
groups

dmf

ds

Groups
nursing

N
28

Mean
23.607

SD.
11.328

SE.
2.141

df

Sig.

rampant
control
nursing
rampant
control

21
26
28
21
26

42.476
0
20.571
36.762
0

19.717
0
9.555
18.692
0

4.303
0
1.806
4.079
0

68.335

.000

60.940

.000

Table 3: Least significant difference test among the three groups regarding caries experience in
the primary teeth
Dependent
variable
dmf

ds

Group

Group

nursing
nursing
rampant
nursing
nursing
rampant

rampant
control
control
rampant
control
control

Orthodontics, Pedodontics, and Preventive Dentistry156

Mean
difference
-18.869
23.607
42.476
-16.195
20.571
36.762

SE.

Sig.

3.607
3.403
3.666
3.308
3.211
3.362

0.000
0.000
0.000
0.000
0.000
0.000

J Bagh College Dentistry

Vol. 23(4), 2011

Salivary streptococcus

Table 4: ANOVA one way to compare caries experience for permanent teeth among the three
groups

DMF

DS

Groups
nursing
rampant
control
nursing
rampant
control

N
13
9
7
13
9
7

Mean
0.846
1.667
0
0.846
1.667
0

SD.
1.214
1.658
0
1.214
1.658
0

SE.
0.337
0.553
0
0.337
0.553
0

df

Sig.

3.602

0.04

3.602

0.04

Table 5: LSD test among the three groups regarding caries experience in permanent teeth
Dependent
variable
DMF

DS

Group

Group

nursing
nursing
rampant
nursing
nursing
rampant

rampant
control
control
rampant
control
control

Orthodontics, Pedodontics, and Preventive Dentistry157

Mean
difference
-0.820
0.846
1.667
-0.821
0.846
1.667

SE.

Sig.

0.536
0.579
0.623
0.536
0.579
0.623

0.138
0.156
0.013
0.138
0.156
0.013