The microbial etiology of dental caries is discussed in terms of the dynamic relationship among the dental plaque microbiota, dietary carbohydrate, saliva, and the pH-lowering and cariogenic potential of dental plaque. The evidence supports a concept of caries as a dietary carbohydrate-modified bacterial infectious disease. Its key feature is a dietary carbohydrate-induced enrichment of the plaque microbiota with organisms such as the mutans streptococci and lactobacilli which causes an increase of plaque's pH-lowering and cariogenic potential. The shift in the plaque proportions of these organisms appears to be related to their relatively high acid tolerance.

A large body of evidence also supports a major effect of saliva on caries development. Integration of salivary effects with the concept of caries as a dietary carbohydrate-modified bacterial infectious disease suggests a broader concept whichincludes a major role of saliva in the regulation of the exposure of tooth surfaces to carbohydrate and of plaque acidity and, hence, the microbial composition and the pH-lowering and cariogenic potential of dental plaque. It is proposed that caries occurs preferentially in dentition sites characterized by a relatively high exposure to carbohydrate and diminished salivary effects. Some implications of this concept are discussed.