<p>Dental caries is the most common chronic condition in the oral cavity globally, and is now largely accepted to be a dysbiosis-mediated and biofilm-based disease rather than a traditional infectious disease. Modern studies have moved the caries management beyond a blind eradication of the microbes toward ecological and equilibrium-driven therapeutic interventions that do not aim to eradicate microorganisms but instead regulate biofilm activity, reinstate microbial homeostasis, and maintain tooth structure. This narrative review is a critical analysis of current developments in microbiome-based caries management, focusing on three themes that are interrelated. To begin with, natural and synthetic bioactive agents, which reduce cariogenic virulence have been proposed to regulate acidogenic metabolism, promote remineralization, but do not disrupt the commensal microbiota. Second, biomaterials and localized drug delivery systems, such as mucoadhesive formulations, hydrogels, dental films and stimuli-responsive carriers, are being considered in reference to their capacity to surmount salivary clearance and promote site-specific therapeutic effects. Third, novel precision-based methods, including pH-responsive materials and selective control of biofilm responses are discussed in the perspective of ecological plaque theory. Although these strategies show promising preclinical and early clinical results, there are still serious issues surrounding long-term microbiome safety, formulation stability, and regulatory translation. On the whole, this review shows the promise of the equilibrium-based methods to reformulate the caries management by putting ecological balance, minimal intervention, and long-term oral health on the forefront.</p>