Numerous lines of evidence have conclusively established the role of sugars in caries etiology and the importance of sugars as the principal dietary substrate that drives the caries process has not been scientifically challenged. While sugars appear to differ little in acidogenic potential, sucrose has been given special importance, as the sole substrate for synthesis of extracellular glucans. Water-insoluble glucans might enhance accumulation of mutans streptococci on smooth tooth surfaces and appear to enhance virulence by increasing plaque porosity, resulting in greater acid production immediately adjacent to the tooth surface. Data indicating that the sugar consumption/caries relationship is now weaker have led to suggestions that recommendations to restrict sugar consumption are no longer necessary. Clearly, fluoride has raised the threshold of sugar intake at which caries will progress to cavitation, but fluoride has its limits, and caries remains a serious problem for disadvantaged individuals in many industrialized countries and is a rising problem in many developing countries. A weakening of the sugar/caries relationship may also be explained by many technical, biological, behavioral and genetic factors. Future research should aim to determine the biologic and behavioral factors that influence caries risk. Measures to educate the public on the dangers of frequent sugar consumption, combined with recommendations for proper oral hygiene and fluoride use, are still warranted. Individual dietary counseling is highly recommended for patients at high caries risk. As dental caries is a preventable disease, each country must decide: what level of disease is society willing and able to tolerate?