of caries. On the contrary there are several protective factors (dark green): the host defense (immune system) and the oral hygiene limit the number of microorganisms. By oral hygiene the biofilm can be completely removed at least locally, and thus acid formation can be avoided. In addition, the components of saliva as well as locally applied fluorides and calcium enhance the remineralization of dental hard tissues, which may alleviate the signs and symptoms of caries. Besides these (local) direct factors there are several indirect (distant) factors, which only indirectly influence the caries process but may be strongly associated with caries. For simplicity, not all associations are marked.
With the exception of the consumption of fermentable carbohydrates that is shown in Fig. 4.1 as a pathogenic factor (dark red), all of the other factors that locally influence the caries process are shown as protective factors (dark green). However, the minimization or elimination of protective factors can have a significant influence on the caries process. For example, the elimination of saliva's protective function in patients with hyposalivation frequently causes caries to progress extremely fast, even though other factors are scarcely modified.25 The risk factors for caries are accordingly increasing the pathogenic factor of fermentable carbohydrates as well as eliminating or reducing protective factors.
According to our present understanding, caries is a multifactorial disease. If and how fast caries develops depends on the complex interrelationships between the various pathogenic and protective factors. If the protective factors predominate, caries does not develop, or existing caries is arrested or healed. However, if the pathogenic factors predominate, the disease progresses.20 This dynamic character of the caries process enables the disease to be influenced in every stage. Approaches for preventing caries therefore seek to minimize the pathogenic factors and support the protective factors.
SUMMARY
Scientific paradigms guide our understanding of diseases and therefore also influence our preventive/therapeutic approaches. The paradigm of the specific plaque hypothesis leads to preventive approaches for avoiding infection with cariogenic microorganisms and forms of therapy to eliminate all cariogenic microorganisms. Contrastingly, the ecological plaque hypothesis is based on environmental and behavioral influences and consequently leads to interventions for reducing pathogenic factors and/or promoting protective factors.
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