Table of Contents 

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What is Streptococcus mutans?

Classification of Streptococcus mutans

Habitat of Streptococcus mutans

Morphology of Streptococcus mutans

Cultural characteristics of Streptococcus mutans

1. Nutrient Agar

2. Sucrose Agar

3. Blood Agar

Biochemical Characteristics of Streptococcus mutans

Fermentation

Enzymatic Reactions

Virulence factors of Streptococcus mutans

1. Biofilm

2. Acid tolerance

3. Carbohydrate metabolism

Pathogenesis of Streptococcus mutans

1. Transmission

2. Colonization

4. Invasion

Clinical Manifestations of Streptococcus mutans

1. Dental caries

2. Infective endocarditis

Lab diagnosis of Streptococcus mutans

1. Morphological and biochemical characteristics

2. Rapid identification kits and automated systems

3. Molecular diagnosis

Treatment of Streptococcus mutans infections

Prevention of Streptococcus mutans infections

References

Last Updated on January 13, 2021 by Sagar Aryal

What is Streptococcus mutans?
Streptococcus mutans is a Gram-positive coccus that is a major inhabitant
of the oral cavity and is considered a significant contributor of tooth decay
and cavities.
 Streptococci are spherical or ovoid cells, arranged in chains or pairs
where many species are members of the commensal microflora on
mucosal membranes of humans or animals, and some are highly
pathogenic.
 S. mutans is a commensal present as a part of the human normal
flora, mostly in the oral cavity. It is rarely pathogenic but might act
as an opportunistic pathogen in some cases.
 It is also called a cariogenic bacterium as it is present in the oral
cavity and in the multispecies biofilms on the surfaces of teeth and
causes dental plaque and cavities.
 It is a dominant species with higher biomass in dental biofilms than
other Streptococcus species, including S. sanguinis,  S. mitis, and S.
salivarius, due to its acid tolerance and thus the capability to live in
low pH environment of oral cavities.
 S. mutans is one of the eight species belonging to the mutans group
of Streptococci which are differentiated based on their heterogenicity
in their genomic structure.
 It was first discovered and named by J Kilian Clarke in 1924 which
were isolated and identified from carious lesions.
 Streptococcus mutans are major cariogenic organisms as a result of
their ability to produce large quantities of glucans as well as acid,
exceeding the buffering capacity of the oral environment.
Created with BioRender.com

Classification of Streptococcus mutans

 The genera Streptococcus belong to the lactic acid bacteria, which is a
taxonomically diverse group of gram-positive, non-spore-forming
cocci and rods defined by the formation of lactic acid as a sole or
major endproduct of carbohydrate metabolism.
 Based on 16S rRNA gene sequence analysis the
genus Streptococcus belongs within the low (< 50 mol%) G+C
branch of the Gram-positive eubacteria, and is a member (type
genus) of the family Streptococcaceae.
 The genus currently consists of over 50 recognized species which, for
the most part, fall within “species groups” which are identified on the
basis of different characteristics.
 S. mutans belongs to the mutans group because of its heterogeneous
genomic structure.
The following is the taxonomical classification of S. mutans:
Domain: Bacteria

Phylum: Firmicutes

Class: Bacilli
Order: Bacillales

Family: Streptoococcaceae

Genus: Streptococcus

Species: S. mutans

Habitat of Streptococcus mutans

 All the Streptococcus species are obligate parasites of mucosal
membranes and, for some species, tooth surfaces of humans and
several animals. 
 Many of the species are life-long and dominant members of the
commensal microflora on mucosal membranes of the upper
respiratory tract, and some colonize the intestinal and genital tracts
of humans and various animals.
 S. mutans however, exclusively colonize tooth surfaces and are
present only after tooth eruption.
 Members of S. mutans may cause infection when introduced into
normally sterile compartments of the body or in immunocompromised
patients.
  The natural habitat of S. mutans is the human mouth, more
specifically dental plaque, where the bacterium resides in multispecies
biofilms that form on the surfaces of teeth.
 The oral cavity is a dynamic environment that undergoes large and
rapid fluctuations in pH, nutrient availability and source, oxygen
tension, temperature, and osmolality. 
 The ability of S. mutans to survive under such an environment is
attributed to its ability to produce acid as well as glucans from
carbohydrates which enables the organism to maintain a favorable
condition.
 The optimum temperature for the organism is the average body
temperature of the host, but it is known to survive in a temperature
range of 18-40°C.
Morphology of Streptococcus mutans

Figure: Gram-stained, thioglycollate broth culture specimen, revealed

numerous, Gram-positive, Streptococcus mutans bacteria. Image
Source: CDC/ Dr. Richard Facklam.
 The cells of S. mutans are coccoid, approximately 0.5–0.75 µm in
diameter, but rod-shaped morphology may be evident on primary
isolation from oral specimens.
 The arrangement of cells in S. mutans is characteristic of all
Streptococci as the cells are arranged in pairs or as short- to
medium-length chains. This arrangement is due to the presence
of successive division planes that are parallel to one another as in
rod-shaped bacteria.
 The cell wall consists of the shape-forming peptidoglycan (murein),
various carbohydrate structures including teichoic acids, and a
number of proteins, which form an interwoven complex.
 As in other gram-positive cell walls, the peptidoglycan consists of
multiple glycan chains that are cross-linked through short peptides,
and the glycan moiety is composed of alternating b-1,4-linked units
of N-acetylglucosamine and N-acetylmuramic acid.
 Rhamnose is the primary carbohydrate of the cell wall, and Glycine is
the major amino acid.
 The cell membrane is a typical lipid-protein bilayer, composed mainly
of phospholipids and proteins.
  S. mutans also produce an array of proteins associated with the cell
wall and are generally exposed on the outer surface of the cell wall.
 Members of this species also have different adhesins on their surface
that mediate binding to salivary glycoproteins and bacteria-derived
salivary components.
 These adhesins recognize extracellular matrix and serum
components, particularly fibronectin and plasminogen, as well as host
and other microbial cells.

Cultural characteristics of Streptococcus
mutans
 The growth of S. mutans on ordinary nutrient media is generally low
in contrast to that of other Gram-positive species.
 Growth is more profuse on media enriched with blood, serum, or a
fermentable carbohydrate. 
 To avoid competition and to inhibit other Gram-positive
organisms, Selective Strep Agar is used as a selective media.
 S. mutans is facultatively anaerobic; while most strains grow in air
growth is optimum at 37°C under the anaerobic condition with some
strains CO2-dependent. 
 A few strains have been reported to grow at 45°C, but no growth
occurs at 10°C.
1. Nutrient Agar
 White to grey colored colonies of an average size of 1 mm in
diameter. The colonies were round with raised elevation and an entire
margin.
 Growth is mostly poor and requires air with supplied carbon dioxide.
2. Sucrose Agar
 Growth on sucrose-containing agar typically produces rough, heaped
colonies, about 1 mm in diameter. Some strains may form smooth or
mucoid colonies.
 The soluble extracellular polysaccharide is formed that is visible as
beads, droplets, or puddles of liquid on or surrounding the colonies.
 The polysaccharide will, in some of the strains, result in coherent and
adherent colonies that may be difficult to sub-cultivate on to agar
plates or into fluid media.
3. Blood Agar
 Growth on blood agar after incubation anaerobically for 2 d produces
colonies that are white or grey, circular or irregular, 0.5–1.0 mm in
diameter.
 Sometimes, however, hard colonies tending to adhere to the surface
of the agar and slightly pitting into the agar surface might be
observed.
 Hemolytic reaction on blood agar is usually α-hemolytic or non-
hemolytic with very occasionally strains to give β-hemolysis.
Biochemical Characteristics of Streptococcus
mutans
The biochemical characteristics of Streptococcus mutans can be tabulated
as follows:
Biochemical
S. Streptococc
Characteristic
N us mutans
s 

1. Capsule  No capsule

2. Shape  Cocci

3. Catalase Negative (-)

4. Oxidase  Positive (+)

5. Citrate  Negative (-)

Methyl Red
6. Negative (-)
(MR)

Voges
7. Positive (+)
Proskauer (VR)

OF (Oxidative- Facultative
8. 
Fermentative) anaerobes

9. Coagulase Negative (-)

10. DNase Negative (-)

11. Clumping factor Negative (-)

12. Gas Negative (-)

11. H2O2 Negative (-)

12. Hemolysis α, β-hemolytic

13. Motility  Non-motile

 Nitrate
14. Negative (-)
Reduction 

Gelatin
15. Negative (-)
Hydrolysis

Pigment
16. Variable
Production 

17. Bile esculin test Positive (+)

The
majority of
18. Bacitracin 
strains are
resistant.

Lancefield Non-
19.
group  groupable

Fermentation
S. Substrat Streptococcus
N e  mutans

1. Glucose  Positive (+) 

2. Fructose  Positive (+)

3. Galactose  Positive (+)

4. Lactose  Positive (+)

5. Maltose  Positive (+)

6. Mannitol  Positive (+)

7.  Mannose  Positive (+)

8. Raffinose  Positive (+)

9. Ribose  Negative (-)

Positive (+)
Extracellular
10. Sucrose  polysaccharide (dext
ran) is produced
from sucrose.

11. Starch  Positive (+)

12. Trehalose  Positive (+)

13. Xylose  Negative (-)

14. Salicin  Positive (-)

15. Glycerol  Positive (+)

16. Dulcitol Negative (-)

Cellobios
17. Positive (+)
e 

Rhamnos
18. Negative (-)
e 

Arabinos
19. Negative (-)
e 

20. Inulin  Positive (+)

21. Sorbitol  Positive (+)

22. Pyruvate  Negative (-)

23. Glycogen Negative (-)

Enzymatic Reactions
Streptococcu
S.N Enzymes
s mutans
1. Acetoin  Positive (+)

Acid
2. Positive (+)
Phosphatase

Alkaline
3. Negative (-)
Phosphatase 

Ornithine Not
4.
Decarboxylase  determined

5. Hyaluronidase  Negative (-)

β-D-
6. Negative (-)
galactosidase

Arginine
7. Negative (-)
Dehydrolase

8. Neuraminidase  Negative (-)

 S. mutans can hydrolyze arginine but cannot hydrolyze esculin and

gelatin.
 They can tolerate 6.5% NaCl but cannot tolerate higher
concentrations than that. 

Virulence factors of Streptococcus mutans

Even though S. mutans hasn’t yet evolved to cause diseases, it is known
to cause infections of the teeth and gums in immune-compromised
patients. As one of the many etiological factors of dental caries, S.
mutans is able to acquire new characteristics, allowing for the increased
pathogenicity in specific environmental conditions. Beginning with the
attachment to a solid surface, S. mutans is then capable of colonizing the
oral cavity and also forming a bacterial biofilm. Other properties
assisting S. mutans in colonizing the oral cavity include specific
interaction with other microorganisms colonizing the oral ecosystem and
the ability to survive in an acidic environment.
The following are some virulence factors of S. mutans in detail:
1. Biofilm
 Biofilms play a significant causative role in most oral cavity infections
like dental caries.
 Biofilms present in the oral cavity are mostly proteinaceous
structures, embedded in an exopolysaccharide matrix, consisting of
bacterial cells anchored to solid surfaces, mostly the tooth enamel,
tooth roots, or dental implants.
  The exact structure and composition of the exopolysaccharide matrix
present on the outside of the biofilm is determined by the conditions
of the oral cavity and changes over time.
 The process of biofilm formation in S. mutans occurs by one of two
mechanisms, where one is sucrose-dependent and the other is
sucrose-independent.
 In the sucrose-dependent mechanism, glucosyltransferases produced
by S. mutans play an important role.
 Glucosyltransferases are a group of enzymes that play vital roles in
dental plaque formation and are responsible for glucans formation
from sucrose. 
 The glycan synthesized from the sucrose provides the possibility of
both bacterial adhesion to the tooth enamel and microorganisms to
each other. 
 In the sucrose-independent mechanism, adhesion of the bacteria
occurs as a result of an interaction between the adhesive proteins
of S. mutans and the agglutinins present in the saliva.
 Agglutinins found in saliva are also involved in the process of
adhesion and aggregation of S. mutans. It occurs as a result of the
interaction with the I/II antigen, which is a multifunctional PI adhesin
situated in the bacterial cell wall.
 The formation of a biofilm provides an advantage to the organism
where it can better adapt to environmental factors and has increases
resistance to hostile conditions.
2. Acid tolerance
 The ability of S. mutans to produce large quantities of glucans as well
as acid also aids in the virulence factor of the organism.
 The bacteria produce large quantities of glucans as well as acid from
the carbohydrate present in the mouth beyond the salivary buffering
capacities, which gives the bacteria an advantage to outcompete
noncariogenic commensal species at low pH environments.
 The ability to survive in an acid environment by modifying the sugar
metabolic pathways along with the irreversible binding to teeth is a
crucial component to S. mutans pathogenesis.
 The acid tolerance of S. mutans is primarily mediated by an F1F0-
ATPase proton pump and also involves adaptation with a resulting
change in gene and protein expression. Together they constitute the
acid-tolerance response (ATR).
 It has been assumed that the acid-tolerance may be aided by the
synthesis of water-insoluble glucan and the formation of a biofilm.
3. Carbohydrate metabolism
 In addition to the proteins and enzymes that contribute to the
adhesion of the bacteria, other proteins are also involved in the
metabolism of sucrose, glucans, or other carbohydrates that are
considered potential virulence factors. 
 Some of these proteins include a fructosyltransferase (Ftf), a
fructanase (FruA), an extracellular dextranase (DexA), and other
proteins responsible for intracellular polysaccharide accumulation.
Pathogenesis of Streptococcus mutans
S. mutans are cariogenic organisms, residing in the human mouth and
occasionally causing dental caries. Because it is commensal, it has a
different mechanism that allows it to adhere to and colonize the musical
membrane of the oral cavity.
1. Transmission
 Streptococcus mutans is a part of the human normal flora of the
mouth, but it can also be passed from one person to another via
horizontal and vertical transmission.
 S. mutans is most frequently transmitted to infant children from their
mothers.
 It favors hard, non-shedding surfaces to establish permanent colonies
which is why the levels of S. mutans in infants are significantly lower
but increases once the primary teeth extravasate.
 The vertical transmission of S. mutans can be detected if the
organism is found in the furrows of the tongues.
2. Colonization
 The metabolic activities of the organism change the environment of
the oral cavity, which enables it to colonize and form dental plaques.
 Large quantities of glucans and acids are produced from the sucrose
in the mouth, which exceeds the buffering capacity of saliva and
changes the pH in the oral cavity.
 This change gives the bacteria an advantage to outcompete
noncariogenic commensal species at low pH environments.
 The adhesion of S. mutans to dental plaque is mediated via sucrose-
independent and sucrose-dependent means. 
 Even though sucrose-independent adhesion to the acquired enamel
pellicle might initiate the attachment process, but sucrose-dependent
adhesion is primarily responsible for establishing colonization to the
tooth surface.
 Adhesion to pre-formed glucan on the tooth surface is also possible
and might facilitate colonization.
Sucrose-dependent adhesion

 The major mechanism behind sucrose-dependent adhesion is the

action of glucosyltransferases in the synthesis of glucans.
 By the action of glucosyltransferases causes the splitting of sucrose,
into glucose and fructose. The glucose is then added to a growing
chain of glucan.
 The ability of glucan molecules to facilitate adhesion of S. mutans to
the pellicle is probably due to hydrogen bonding of the glucan
polymers to both the salivary pellicle as well as the bacteria.
3. Biofilm Formation
 The glucans, also called exocellular polysaccharides (EPS) produced
by S. mutans, are essential in the formation of biofilm and caries
development because they promote co-aggregation between the
organisms.
  These glycans are produced as adhesins that promote both the
attachment of bacteria to the teeth surface and with each other.
 Besides, agglutinins present in saliva are involved in the process of
aggregation of S. mutans as a result of the interaction with the I/II
antigen, which is a multifunctional PI adhesin present on the bacterial
cell wall.
 As a result of the aggregation, macroscopic agglomerates are formed
on the teeth surface. To this, the extracellular matrix produced by the
bacteria and derived from the environment is added, increasing the
strength of the biofilm.
 This is followed by proliferation and spread into other sites in the oral
mucosa modulated by the concerted action of genes and signaling
molecules. 
4. Invasion
  In the final stage of infection, the biofilm establishes a steady-state
which modifies the equilibrium of the oral ecology.
 Due to this, bacteria gain access into the deeper tissues and reach
into the gingival areas, ultimately causing dissolution of
hydroxyapatite crystals of enamel and dentin, resulting in cavities
within the tooth.
  If left untreated for long, this cavitation provides a suitable area
where microorganisms form a protected biofilm, enabling caries to
progress gradually to the adjacent tooth.

Clinical Manifestations of Streptococcus
mutans
Dental caries is the primary infection or disease associated with S.
mutans, resulting in cavities and gingivitis. Although the primary disease
associated with is dental caries, some cases of infective endocarditis have
also been associated with this species.
1. Dental caries
 The signs and symptoms associated with dental caries differ
according to the location and the extent of infection.
 However, the common signs include spontaneous toothache that
occurs without any apparent cause.
 It also increases the sensitivity of the teeth with visible holes in the
teeth.
 Brown, black, yellow, or white staining is seen on the surface of the
teeth.
 If not treated, the biofilms slowly move into deeper tissues and cause
gingivitis. Septicemia is also possible if the infection is persistent.
2. Infective endocarditis
  About 20% of the endocarditis cases attributed to viridans
streptococci are caused due to S. mutans.
 The organism moves through the blood and can bind to a pre-existing
injury to the endothelium that might expose extracellular matrix
components such as fibronectin, laminin, and collagen.
  Patients with endocarditis experience flu-like symptoms, including
chills and fever.
 Chest pain and changed heart murmur are also typical.

Lab diagnosis of Streptococcus mutans

Lab diagnosis of Streptococcus mutans is based on the identification of
the organism by its microscopic, cultural, and biochemical
characteristics. Dental plaque and swabs from the cavities and taken as
samples for laboratory identification.
The following is the method of diagnosis and identification of the organism
from the clinical samples:
1. Morphological and biochemical characteristics
 Oral streptococci can often be isolated on selective media where
colony morphology provides the first basis for the identification of the
organism.
 Small, rough, heaped colonies with a soluble extracellular
polysaccharide, in the form of beads, droplets, or puddles of liquid on
or surrounding the colonies on sucrose agar indicates S. mutans.
 Following isolation is the observation of morphological characteristics
under the microscope. The appearance of Gram-positive, non-motile,
non-spore-forming cocci in a chain further confirms the presence
of S. mutans.
 Biochemical tests, especially bacitracin sensitivity tests and
hemolysis, are essential for the species identification of genus
streptococcus.
  Lancefield antigen grouping is also an important way to identify
different species of Streptococcus and S. mutans belongs to the non-
groupable.
2. Rapid identification kits and automated systems
 Besides the traditional methods of species identification, commercial
rapid identification kits for species identification of Streptococcus is
also available now.
 Commercial kits such as Rapid Strep 32 can be used for the
identification of Streptococcus species.
 In the case of S. mutans, the identification is based on the analysis of
their microbial cellular fatty acid compositions.
3. Molecular diagnosis
 Identification of streptococci may be achieved by comparing partial
DNA sequences of 16S rRNA genes or selected housekeeping genes
with those of appropriate type strains.
 To some extent, identification may also be achieved with DNA probes
that hybridize exclusively with the respective species.
 Thus, PCR amplification and sequencing of the 16S rRNA gene have
become an option for molecular identification of pathogenic bacteria
in diagnosis.
 Ribotyping, the analysis of rRNA by restriction fragment length
polymorphism, is an alternative method for molecular differentiation
of Streptococcus species.
Treatment of Streptococcus mutans  infections
 Chlorhexidine is considered the “gold standard” for oral antimicrobial
therapy. However, the use of high dose has adverse side effects such
as tooth staining and calculus formation. It is also not recommended
for long term daily therapeutic use.
 Based on the antibiotic susceptibility test performed to determine the
useful drugs against S. mutans, Nine drugs namely, ofloxacin,
doxycycline, tetracycline, chlortetracycline, erythromycin,
vancomycin, clindamycin, methicillin, and gentamycin were found to
be moderately effective.
 However, some infections like endocarditis and bloodstream infections
might require removal of the medical implants and immediate
treatments.
 Besides, other forms of treatments involving the hyperimmune serum
from human donors or humanized monoclonal antibodies directed
towards the surface components are also being studied.

Prevention of Streptococcus mutans  infections

 Prevention of S. mutans related dental caries can be achieved mainly
by maintaining proper dental and oral hygiene.
 The application of 1% chlorhexidine collagen gel, daily mouth rinsing
with 0.05% sodium fluoride solution has been found to decrease the
chances of dental caries significantly.
 To avoid severe cases of infective endocarditis, it is recommended to
treat dental caries as soon as possible to avoid the spread of the
bacteria into the bloodstream