Aetiological concepts of dental caries have evolved over the years from being considered as a disease initiated by nonspecific microorganisms, to being regarded as an 'infectious' disease caused by specific bacteria, to the current paradigms that emphasise a 'mixed bacterial-ecological approach' as being responsible for lesion initiation and pathogenesis. These aetiological paradigms are not just intellectual concepts but have important implications on how clinicians manage this age-old disease in the twenty-first century. Despite evidence-backed recommendations for adopting more biological measures to counter the disease, a significant proportion of dentists continue following traditional caries management guidelines in their daily clinical practice. This paper will review the evolving dental caries aetiological concepts and highlight the current evidence for adopting a more ecological approach to caries prevention, risk assessment, and treatment.