Keeping your teeth in good condition into your late sixties and beyond

Why this matters more than it used to

Maintaining quality of life is an integral part of ageing. From a dental perspective that means controlling oral disease, and restoring or replacing lost or damaged teeth. What is restorative dentistry? and what does restorative dentistry involve? set out what the second half covers.

The consequences of not doing so are concrete, not abstract:

• Discomfort and pain — see what are the causes of toothache and what are their symptoms? and what to do if you suffer from sensitive teeth
• Inability to eat, chew and enjoy certain foods — see what are the replacement options for missing teeth?
• Difficulty speaking
• Reluctance to smile — see teeth and aging: how can I keep my smile looking younger?

All of these directly affect quality of life, and there are consequences for self-esteem and social interaction as well. Someone who has stopped eating in company because chewing is difficult or embarrassing has lost something that does not show up on a dental chart.

The link to general health

Sub-par oral health can lead to conditions of the mouth that directly influence general health. Health problems linked to poor oral hygiene, the importance of dental hygiene — a window onto your overall health and how good oral hygiene can increase your lifespan go through the evidence.

Conditions that have been linked to oral disease include:

• Coronary heart disease
• Cardiovascular disease
• Stroke
• Uncontrolled diabetes — see diabetes and oral health and diabetes and dental health: the two-way street
• Aspiration pneumonia
• Alzheimer's disease (a more recent area of research)

“Linked” is the operative word. These are associations identified in research rather than established one-way causes, and they should be read that way. Aspiration pneumonia is the most direct of them mechanically — oral bacteria inhaled into the lungs, a recognised risk in older adults and particularly in those with swallowing difficulties.

It is also the one most often described as settled when it is not, so it is worth the detail. The current Cochrane review — Oral care measures for preventing nursing home-acquired pneumonia, 2022, Issue 11, CD012416 — pooled six randomised trials in 6,244 nursing home residents and found “insufficient evidence of a difference” in the incidence of pneumonia between professional oral care and ordinary self-administered care, rated low-certainty evidence. The only positive result was on deaths rather than infections: risk ratio 0.43 (95% CI 0.25 to 0.76) for pneumonia-associated mortality at 24 months, from two trials totalling 454 residents, also low certainty. All six trials were at high risk of bias, none was Australian, and none compared mouth care with no mouth care. The reviewers' conclusion is that “the effect of professional oral care on preventing NHAP remains largely unclear”. So assisted mouth care for someone who can no longer manage their own is well worth having — for pain, infection, tooth loss and the ability to eat — and it is not established pneumonia prevention.

The diabetes strand is the one with the firmest numbers, and they are worth knowing at this age because type 2 diabetes becomes more common with it. A review published in Diabetologia reports that “the risk of periodontitis is increased by approximately threefold in diabetic individuals compared with non-diabetic individuals”, with glycaemic control the driver — in NHANES III, adults with an HbA1c above 9% had a significantly higher prevalence of severe periodontitis than those without diabetes (OR 2.90; 95% CI 1.40, 6.03) after adjustment for age, ethnicity, education, sex and smoking.

The same review contains a finding that bears directly on tooth loss in later life. Following people with type 2 diabetes for a median of 9.4 to 14.9 years, the incidence of severe kidney disease was “2.3, 3.5 and 4.9 times as high for those with moderate or severe periodontitis or who were edentulous, respectively”, compared with those with no or mild periodontitis — a dose-response running all the way to having no teeth at all. That is an association in a specific population, not a general prediction, but it is a reason to treat gum disease as a medical matter rather than a cosmetic one. Periodontists are the specialists in that work.

The practical implication stands regardless of how the causal question resolves: oral health is part of general health, not separate from it. Dental health and general wellbeing and the Three Layers of Dental Wellness & Longevity are the site's fuller statements of that; wellness and longevity is the service page.

What has changed for this generation

Here is the fact that reframes the whole subject.

Twenty years ago, the majority of Australia's 65-year-olds no longer had their own teeth — they were edentulous.

The prevalence of edentulism has been gradually reducing across all age groups over the past half-century, which means more and more older Australians are now retaining their own teeth.

Combined with increasing life expectancy, the need to keep teeth healthy and retain them for longer has never been more important.

That is worth sitting with. Older Australians are now being asked to maintain natural teeth for two or three decades longer than the previous generation had to. The care model built around dentures for the over-65s does not apply to a population that still has its own teeth — and those teeth have had a lifetime of wear, fillings and root surface exposure to accumulate. On the denture side, 5 things you should know about your new dentures, what are the different types of dentures? and dentures cover the options where teeth have already been lost.

Why the risks change shape rather than simply increasing

Two things happen to a mouth that has kept its teeth into its sixties, and neither is a matter of trying harder.

Root surfaces become exposed, and root surface is not enamel. Diabetes Australia describes the sequence precisely: periodontitis “can cause the bone and gum around the tooth to recede,” which “uncovers and exposes the root surface, which is not as strong as the white enamel covering the tooth crown.” Decay of that surface “can occur more often in people with diabetes,” driven by the recession itself and by reduced saliva. This is why a routine that served you for forty years may stop being enough without anything having got worse in your habits.

Saliva reduces, and saliva is a defence. Diabetes Australia notes that “saliva helps to protect the teeth against decay, therefore, a decrease in saliva can cause a person to become more prone to decay,” and lists dry mouth (xerostomia) alongside oral thrush, delayed wound healing and altered taste among the oral complications that become more common. Medication is the other common cause of dry mouth in this age group, and it is worth raising a current medication list with your dentist rather than assuming it is irrelevant: my mouth is always dry and my mouth always feels dry! What can I do?.

And the disease that does the most damage is the quietest. The Diabetologia review is blunt about it: “In the early stages, the condition is typically asymptomatic; it is not usually painful, and many patients are unaware until the condition has progressed enough to result in tooth mobility.” It also explains why the hygienist measures rather than just cleans: “‘Pocketing' is not evident on simple visual inspection, and assessment using a periodontal probe is essential.” Waiting to feel something is not a strategy that works with this condition.

The examination that is not about your teeth

Part of a check-up at this age is a look at the soft tissue, and it is worth understanding why rather than sitting through it.

The RACGP reports that “oral cancer is linked with risk factors such as age >45 years (especially men), tobacco use, alcohol consumption, areca (betel) nut chewing and limited access to dental care,” and recommends that “risk-associated screening should be done on a case-by-case basis for patients aged 45 years or over and for those who are current or past substance users.”

The age profile puts this squarely in view for this page’s readers. Cancer Council Victoria records that in 2023, 1226 Victorians were diagnosed with oral and oropharyngeal cancer — 883 males and 343 females — at a rate of 23 per 100,000 males and 8 per 100,000 females, and that “the median age at diagnosis of oral and oropharyngeal cancer is 64 years in males and 67 in females.” It was the 6th most commonly diagnosed cancer in Victoria that year, accounting for 3.1% of all cancers diagnosed. Dental Health Services Victoria puts the national picture at “more than 4000 new cases of head, neck and lip cancers diagnosed every year,” the majority of them oral cancers, with “an estimated 2642 cases of lip and oral cancers” in 2022.

The detail that matters most for what you do at home is this, from the RACGP: “initial lesions of oral cancer are generally painless.” Nothing will hurt to tell you. Its threshold for action is specific — anyone with “unexplained and/or non-healing changes or symptoms in the mouth for more than two to three weeks (eg a persistent ulcer, red patches, lumps, a sore throat, or erythematous or speckled lesions) should have an oral cancer screen,” and it identifies “the lateral margins of the tongue and the floor of the mouth” as the highest-risk sites.

Two further points from the same paper are worth stating plainly rather than glossing. There is “limited evidence to implement a formalised population oral cancer screening program,” so there is no invitation letter of the kind that arrives for bowel or breast screening — the examination happens because you turn up. And “an Australian study showed there was an average diagnostic delay of approximately four months between symptom onset and initial histological diagnosis.” Dental Health Services Victoria attributes oral cancer’s low survival rates “largely… to delayed presentation or diagnosis.” Those four months are the reason for the three-week rule above.

A dentist screens and refers; diagnosis is made elsewhere, on a biopsy. See oral cancer: how your dentist can help with early detection and oral and maxillofacial surgeons.

How to do it

Regular check-ups and cleans

These allow your dentist to identify problems early and treat them as necessary. How often should I go to the dentist?, what does a dental hygienist do? and dental cleans and hygienists describe what happens at those appointments.

Early identification matters more with age, not less. Root surfaces exposed by recession decay faster than enamel, and existing restorations reach the end of their service life. Periodontal (gum) disease, when do you need deeper cleaning? and how long do dental fillings last? cover both of those.

Restoring what has been lost

Restoring damaged or lost tissue is just as crucial as having the tools to maintain oral health at home. Function and maintenance are two halves of the same job. Bridges, implants, or dentures for replacing missing teeth?, implant versus bridge for a single tooth replacement, what do I need to know about dental implants? and what types of dental crowns are available? set out the options; prosthodontists are the specialists in this work and complex dentistry covers the larger cases.

A home-care routine built for you

Each individual's oral health regime is unique to them, and it will change over time. Discuss with your dentist what is appropriate for you now — not what worked twenty years ago. What is the ideal daily routine for oral hygiene? is the starting template.

A tailored routine may combine:

• Electric and manual toothbrushes — which toothbrushes do dentists recommend?
• Floss — is flossing really that important?
• Interdental brushes
• Mouthwashes — the truth and myths about mouthwashes
• Creams and pastes — with so many toothpastes on the market, how can I make a wise choice?

Your dentist can also teach you the most appropriate and effective techniques. How much pressure should I apply when brushing my teeth? and over brushing: what can it do to my teeth? matter more once recession has exposed softer root surface.

That list is not generic. Interdental brushes become more relevant with age as the spaces between teeth open up with recession — and they clean those wider spaces far better than floss does. Electric brushes help where dexterity, grip strength or arthritis makes manual brushing harder. High-fluoride pastes are commonly recommended where root surfaces are exposed — see the benefits of fluoride and selecting a toothpaste: fluoride or non-fluoride?. The routine should change as the mouth changes.

What good care is actually for

Of supreme importance for older adults is being able to:

• Eat and talk comfortably
• Feel happy with their appearance
• Stay pain free
• Preserve self-esteem
• Maintain the standards of hygiene and care they have established throughout their lives

That last point is easily missed and it matters. People who have looked after their teeth for sixty years want to keep doing so — and where illness, medication, reduced dexterity or reduced mobility make that harder, the answer is adapting the routine, not abandoning it. If anxiety or a long gap since the last visit is the obstacle, how can I ease my anxiety about visiting the dentist? and dental anxiety are the places to start.

Common questions

Am I too old for an implant?

Age on its own is not the deciding variable, and it is rarely the reason an implant is or is not recommended.

The largest recent dataset in this corpus is a registry study of 158,824 implants placed in 53,874 patients through an Israeli health fund between 2014 and 2022. It reports an overall survival rate of 97.79 per cent and a total failure rate of 2.21 per cent. Of all the implants placed, 1.59 per cent failed within the first year, and the early failure rate during osseointegration — before any crown or bridge was fitted — was 1.56 per cent. Longer-horizon figures from an ITI consensus workshop put cumulative survival of implants supporting fixed bridgework at 95.4 per cent at five years and 92.8 per cent at ten.

What the same literature identifies as risk factors is more useful than the headline numbers, because they are the things worth discussing at a consultation: smoking, implants shorter than 10 mm, and implants placed in the upper jaw were associated with early failure. Late failures — those after the implant has integrated — were “frequently associated with factors such as the quality of cancellous bone in older adults.” So bone quality, not birthday, is the age-related variable, and it is something that can be assessed before anything is decided.

Two cautions on reading survival figures at all. Survival means the implant is still in place, not that it has been trouble-free; and the gum around an implant can become diseased much as it does around a natural tooth, which is why implants are maintained on a hygiene recall rather than fitted and forgotten. What do I need to know about dental implants? covers the staging.

It needs root canal treatment. At my age, should I just have it out?

This is a real decision rather than a formality, and the numbers are better than most people assume.

A long-term practice-based study followed endodontically treated teeth and reported overall success of 87.8 per cent at tooth level (95% CI 84 to 90 per cent) and 80.8 per cent at patient level (95% CI 75 to 86 per cent). Its cumulative figures are the ones that bear on this question: success at 10, 20, 30 and 37 years was 93, 85, 81 and 81 per cent respectively. Success was not meaningfully affected by which tooth it was — molars 85.8 per cent, premolars 86.3, cuspids 88.6, incisors 94.6.

The authors are candid that their results sit above some of the literature — systematic reviews have reported around 82.8 per cent at five years, and one earlier study 61 per cent at eight — and they attribute part of the gap to differences in how success was judged and where the treatment was done. Take the range rather than the best number.

Set against that, an extraction is permanent, and what follows it is either a gap, a denture, a bridge or an implant, each with its own cost and its own maintenance. A treated natural tooth keeps the bone that an implant would otherwise need. None of which decides the case — a tooth that is split, or that has too little sound structure left to restore, is a different conversation — but “I am 68” is not by itself a reason to remove a restorable tooth.

I take several medications. Does that change my dental treatment?

Yes, and two categories matter enough to raise before anything is planned rather than on the day.

Anything affecting bone. Healthdirect Australia warns that you should tell your dentist if you are taking, or have ever taken, cancer medication or bone medication such as bisphosphonates, because these increase the risk of osteonecrosis of the jaw — a rare condition in which bone tissue in the jaw begins to die and a socket fails to heal after an extraction. Have ever taken is the phrase to notice: a course finished years ago still belongs on the history. This does not mean treatment cannot go ahead; it means the plan, and the order of things, may be different.

Anything that dries the mouth. Reduced saliva is one of the commonest medication effects in this age group and, as set out above, saliva is a defence rather than a comfort. Less of it means faster decay, particularly on exposed root surfaces, and more difficulty wearing a denture.

The practical step is unglamorous: bring the actual list, including over-the-counter items and supplements, and bring it again when it changes. A medication history that is two years out of date is a medication history that will not catch either of the problems above.

Do I still need x-rays at my age?

The two conditions that do the most damage in later life — decay on root surfaces and bone loss around teeth — are precisely the two a visual examination cannot measure. That is the case for imaging, and it does not weaken with age.

On the dose question, the International Atomic Energy Agency gives the effective dose of an intraoral dental x-ray as 1 to 8 microsieverts, and notes that doses from intraoral dental procedures are “usually less than one day of natural background radiation.” A panoramic film is higher — the IAEA range is 4 to 30 microsieverts — and a cone-beam CT higher again. How safe are dental x-rays? sets the comparison out properly.

The principle that governs it is justification: a radiograph is taken because it will change a decision, not on a schedule. Two reasonable questions at any age are what this particular image is for, and what will be done differently depending on what it shows.

Dentistry is expensive and Medicare does not cover it. How do people manage?

It is worth saying plainly that cost is a real barrier rather than a discreet one. A submission to a Senate inquiry into out-of-pocket medical costs cited an Australian Institute of Health and Welfare survey in which nearly a third of people aged 5 or older — 32 per cent — avoided or delayed visiting a dentist because of cost, and argued that the absence of any national dental fee schedule in Australia contributes to it. That is an advocacy submission rather than a government finding, and it should be read as one, but the underlying pattern of delayed care on cost grounds is well recognised.

What that means in practice for someone weighing up work in later life:

• Ask for the plan in writing, itemised, before anything begins. Published fees are in the price guide and understanding your treatment describes how a plan is set out.
• Ask what can be staged. Much restorative work can be sequenced over months, with the urgent and the disease-controlling parts done first.
• Ask what happens if nothing is done, and over what timeframe. That answer is part of informed consent and it is often the most decision-useful thing in the conversation.
• Ask about the maintenance cost of each option, not only the fitting cost. A denture, a bridge and an implant have different long-run costs.

And the cheapest dentistry at this age remains the appointment where nothing is found — which is an argument for keeping the recall interval you have agreed, not for stretching it.

Sources for the figures on this page

• Preshaw et al., Periodontitis and diabetes: a two-way relationship, Diabetologia (PubMed Central) — the threefold risk, the NHANES III odds ratio, the kidney disease dose-response including edentulousness, and the descriptions of asymptomatic progression and periodontal probing.
• Cao et al., Oral care measures for preventing nursing home-acquired pneumonia, Cochrane Database of Systematic Reviews 2022, Issue 11, CD012416 — the trial and participant counts, the finding of insufficient evidence of a difference in pneumonia incidence, the pneumonia-mortality risk ratio, and the low-certainty ratings.
• Diabetes Australia, Dental health — root surface exposure and decay, saliva, and the other oral complications.
• Royal Australian College of General Practitioners — oral cancer risk factors, the two-to-three-week threshold, painless initial lesions, high-risk sites, the absence of a population screening program, and the four-month average diagnostic delay.
• Cancer Council Victoria — the 2023 Victorian incidence, sex split, rates and median age at diagnosis.
• Dental Health Services Victoria / Oral Health Victoria — the national case numbers and the attribution of low survival to delayed presentation.
• Dental Implant Survival Rates: Comprehensive Insights from a Large-Scale Electronic Dental Registry (PubMed Central) and the ITI consensus workshop on implant-supported fixed partial dentures — the implant survival and failure figures.
• A long-term practice-based study of endodontically treated teeth (PubMed Central) — the 87.8 per cent tooth-level success rate and the cumulative figures to 37 years.
• Healthdirect Australia — the bisphosphonate and cancer-medication caution on osteonecrosis of the jaw.
• International Atomic Energy Agency — the effective dose ranges for intraoral and panoramic dental radiography.
• Submission 265 to the Senate inquiry into the value and affordability of private health insurance and out-of-pocket medical costs, citing an Australian Institute of Health and Welfare survey — the 32 per cent figure and the fee-schedule argument.

The edentulism statement in “What has changed for this generation” is the practice’s own summary of the trend, published in 2014; the independent sources above do not supply that figure.

Related reading

• Why do teeth shift?
• How do I prevent dental decay?
• Top tips on how to avoid dental problems
• My denture is broken. What should I do?
• Understanding your treatment
• General dentistry

Practical details

Written by Dr Silvia Ciach.

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000 — getting here. Phone 13 13 96, contact us, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment. The clinical team is listed by name.

Published 16 July 2014. Prevalence figures are as at that date, except where a later source is named above. General information only; it does not replace advice from your treating practitioner.

Smile Solutions trades under ABN 28 193 514 103.