Rethinking Dental Caries: From a Disease Label to Dynamic Biofilm Ecology and Mineral Homeostasis

Dental caries is highly prevalent worldwide and represents a major oral-health challenge. Although commonly labelled as a disease, this terminology may not fully capture its biological, chemical, and clinical nature. The aim of this review is to examine whether dental caries is best conceptualized as a discrete disease entity or as a dynamic, site-specific pathological process characterized by biofilm dysbiosis and disturbed mineral homeostasis at the tooth surface. Unlike many classical disease entities, caries does not represent a clearly defined binary state, but develops gradually from subclinical mineral imbalance to non-cavitated lesions, cavitation, and pulpal complications. It results from a dynamic imbalance between demineralization and remineralization at the tooth surface rather than from a single causative pathogen. Moreover, clinical relevance and treatment need depend on lesion activity, lesion severity, and individual risk context, not merely on the presence of a lesion. Early caries lesions are biologically active and can be arrested or reversed by restoring ecological and physicochemical balance at the tooth surface. Caries progression is strongly influenced by diet, oral hygiene, saliva, oral microbiome dysbiosis, and biofilm ecology, and can often be controlled through preventive and non-invasive measures. Therefore, dental caries is best understood not as a classical disease entity, but as a pathological process affecting the dental hard tissues—one that is fundamentally preventable, controllable, and, in its early stages, reversible.