Episode 95: Geriatric Dentistry: Keep Your Teeth for Life

[00:00:00 – 00:00:42] Eon Engelbrecht – eRadio SA: Welcome back to another episode of Save Your Money, Save Your Teeth. I’m Eon Engelbrecht from eRadio SA, and today, as always, we are joined by Dr Clifford Yudelman from OptiSmile in the beautiful Sea Point in Cape Town. Today we are tackling a topic that affects us all as the years go by: Geriatric Dentistry. Many people assume that losing your teeth is just a natural part of growing old, but Dr Yudelman is here to tell us why that is an outdated myth and how you can keep your natural smile for life. Dr Yudelman, welcome back.

[00:00:42 – 00:00:56] Dr Clifford Yudelman – OptiSmile: Thank you. Thank you. Thanks for having me back. Great to hear your voice, and looking forward to chatting with you today.

[00:00:56 – 00:01:12] Eon Engelbrecht – eRadio SA: Absolutely. I want to start off by asking you, Doctor: is losing teeth inevitable as we get older, or can we possibly keep them for life?

[00:01:12 – 00:02:37] Dr Clifford Yudelman – OptiSmile: So, speaking as an elder, I’m already 65. I haven’t lost any teeth other than my wisdom teeth. But I guess, as we say “getting older”, maybe we are talking about more like into your 80s, 90s, and beyond, because it seems like these days people are living a lot longer. So, I want to just say that losing teeth is not an inevitable part of ageing and that belief is outdated and, quite frankly, harmful.

Teeth are lost due to disease, mainly decay and gum disease, not because of age itself. But what changes with age is risk exposure. People accumulate fillings, medications, chronic conditions, and habits over the decades. Each of these increases vulnerability if not actively managed.

So, long-term studies actually show that people who maintain regular dental care, plaque control (which is your brushing), and use fluoride toothpaste can retain most or even all of their natural teeth well into their 80s and 90s. The key shift here is mindset. Dentistry in older adults should be preventative and anticipatory, not reactive.

Monitoring wear, gum attachment levels, saliva flow, and existing restorations allows us to intervene conservatively before more things break or failure occurs. From a financial point of view, preserving natural teeth is almost always cheaper than replacing them. And from a biological point of view, nothing functions as well as your own teeth. Ageing does not take teeth away; neglect and delayed care do.

[00:02:37 – 00:02:48] Eon Engelbrecht – eRadio SA: So, Doctor, why do our mouths get drier as we age? And also, how does that cause cavities?

[00:02:48 – 00:04:47] Dr Clifford Yudelman – OptiSmile: I mean, Eon, as you know, we have done quite a few different podcasts that touch on this subject, but I thought it was a good place for this question here. So, dry mouth, or xerostomia (spelt X-E-R-O-S-T-O-M-I-A; “xero” means dry and “stomia” means mouth), is one of the most significant drivers of dental disease in older adults. Importantly, ageing itself is not the primary cause; medications are.

Many prescribed drugs for blood pressure, depression, anxiety, allergies, prostate conditions, and chronic pain reduce your saliva flow. Saliva is critical for neutralising acids, washing away bacteria, and supplying minerals that repair early enamel damage. When saliva decreases, the mouth becomes acidic more often and for longer periods. This dramatically increases the risk of decay, especially around the gum line and your existing fillings.

Then cavities in dry mouth patients often grow very rapidly and also painlessly until there is a big hole and damage has occurred. We see that a lot at OptiSmile in older patients with dry mouth. Evidence consistently shows that xerostomia is strongly associated with increased caries incidence and reduced quality of life in older adults.

So, managing dry mouth proactively with drinking enough water (hydration), saliva substitutes (which we have spoken about), fluoride therapies, and medication reviews can dramatically reduce dental breakdown and cost.

[00:04:47 – 00:04:57] Eon Engelbrecht – eRadio SA: Okay. And then root decay? Why does it happen more frequently in seniors?

[00:04:57 – 00:06:58] Dr Clifford Yudelman – OptiSmile: So, yeah, root decay is decay that forms on the exposed root surfaces rather than on the enamel crown. It is particularly common in older adults because your gums naturally recede over time. That exposes the root or the root dentine.

Root dentine is much softer than enamel, and it demineralises at a higher pH, in other words, it takes less acid to cause damage. When you combine exposed roots with a dry mouth and plaque retention, you have a perfect storm for rapid decay. Studies have shown that root caries prevalence, how often it happens, increases significantly with age, especially in individuals with reduced saliva or dry mouth, and also a lot of people as they get older with arthritis or just limited dexterity (which means your ability to brush your teeth properly or to use your hands).

Unlike enamel decay, root decay is scarier; it can spread very quickly and often, as a dentist, if you find one, you are going to find more than one. It undermines the integrity of the tooth, especially next to or underneath the gum on old crowns. That is where it is the worst, and it is more difficult to find because it doesn’t show on X-ray because old crowns normally won’t show up on X-ray.

So, often it is the hygienist that finds it. She is cleaning along a tooth and then the instrument sort of sinks into the tooth. And that is why it is very important to see the hygienist.

Early detection and prevention are critical, especially using fluoride toothpaste. There are professional fluoride applications and also other things you can buy at your dentist that you can use to prevent cavities. Then really working on your oral hygiene as if you were a teenager or a kiddy. And yeah, that can avoid extensive restorative work or even extractions.

[00:06:58 – 00:07:22] Eon Engelbrecht – eRadio SA: And when you are older, you get things like arthritis, and that is in your hands, and it affects your brushing ultimately. So, how does it affect your brushing, and also what tools can help seniors maintain hygiene even if they can’t hold that brush as they are used to?

[00:07:22 – 00:09:08] Dr Clifford Yudelman – OptiSmile: Yeah, so arthritis affects your hand strength, your grip, your fine motor control, making effective brushing and flossing more difficult. And it is not really a motivational issue; it is a mechanical one. And you know, when brushing becomes physically challenging, plaque control gets worse and worse, even in people who care a lot about their oral health. And over time, it leads to increased gum inflammation, decay, and tooth loss.

So adaptive tools make a big difference. Electric toothbrushes require less grip force and do most of the work automatically. I think these days that would be the way to go. You can get thicker handles, or you can get stuff to put, like plastic, that you can add onto a normal brush. Water flossers can help a bit; I am not a big fan of water flossers, I think you still need to brush.

And, you know, all the evidence points towards these electric toothbrushes, especially for people who can’t use their hands properly, elderly people with arthritis, etc. And the goal is not perfection, but consistency. Choosing the right tools preserves your independence, dignity, and your oral health well into later life.

[00:09:08 – 00:09:20] Eon Engelbrecht – eRadio SA: Okay. And let’s talk about dental implants. Is this actually a safe option for people over 70 or even 80, Doctor?

[00:09:20 – 00:11:27] Dr Clifford Yudelman – OptiSmile: My favourite expression is “100%!” 100%. Age alone is not a contraindication for implants. Meaning, many healthy individuals in their 70s and 80s are excellent implant candidates. My late dad had implants when he was 87, and he lived another eight years and he was very happy to have his teeth and not to have a denture.

And in fact, in his case, he even had, because of cancer, radiation on his jaw, and you are supposed to not get any kind of implants or extractions when this has happened. And some wonderful specialists in Joburg were able to place implants, and they worked fine. He had some special oxygen therapy when he was healing, and it healed well. And yeah, he kept those teeth up until when he passed away at 95.

So, someone who is thinking that they are 70, “Oh, I’m 70, I’m going to die soon” or “I’m 70, I’m too old for implants”, that is just a nice personal story there. Someone who thinks, “Oh no, I’m 70, I’m too old”, age itself is not a factor. What happens more is your overall health, the quality of the bone in the area (not in general), your oral hygiene, smoking status, and ability to attend follow-up care.

Research shows that implant survival rates in older adults are comparable to those in younger patients when all of those factors are in your favour. Implants are not maintenance-free; they require very good oral hygiene and ongoing monitoring.

And sometimes simpler solutions, like sometimes doing nothing, or a plate that can be taken out and cared for with the help of a carer (in that case, if someone’s got limited dexterity or cognition, which means if someone is getting dementia or Alzheimer’s, you know, you are not going to go and put in an implant that they are not going to be able to look after, or that someone can’t help them to look after).

And also complex medical conditions, uncontrolled diabetes, etc. Diabetes is a big one; if it is controlled, then diabetes is not really a factor. And the decision should always be individualised. Implants can dramatically improve quality of life, but they should be chosen for the right reasons and a realistic understanding of the long-term care requirements.

I think one of the best services that a 70 or 80-year-old can get is for someone who has had a denture for a long time, especially a lower denture, people seem to suffer with that. If the lower denture is sliding around because they don’t have any bone left, and if they don’t have the funds (because it is very expensive to get, say, four or five implants on the lower and then get a permanent bridge screwed onto that), even getting one or two implants on the lower with a little clip that the denture can clip onto makes that denture work way better. The person can then eat meat and have a better diet, and they have shown that you then live longer because you can chew your food and you don’t just eat junk.

[00:11:27 – 00:11:42] Eon Engelbrecht – eRadio SA: And then in older patients also, how do we manage oral health if there is dementia or for caregivers?

[00:11:42 – 00:13:58] Dr Clifford Yudelman – OptiSmile: Yeah, shame. Actually, I have seen that a lot, especially when I was practising in America in the 80s, from ’86 to 2002. I spent 16 years in America, and my patients were already, in those days, if you were 70 or 75, you were getting on there. But by the time they got to 80, there was quite a lot of dementia. I think it is before we even knew much about Alzheimer’s.

And you can see patients who have had really good teeth their whole life, and then all of a sudden they come in and they are not really looking after their teeth properly, and the care becomes inconsistent or distressing. And the focus shifts from ideal dentistry to practical prevention: simplified routines.

There is special mouthwash with chlorhexidine; that can work well. You can even put it in a spray. Working with carers and caregivers is very important, and using consistent timing, making sure that especially before bed their teeth get properly cleaned.

Research links poor oral hygiene in these patients to increased pain, infection, malnutrition, and other systemic complications. And caregivers often underestimate dental pain because patients sometimes can’t speak properly or tell them.

So early planning is crucial: addressing any failing fillings or crowns, smoothing off any rough edges, and removing hopeless teeth before the dementia progresses. And obviously, you are not going to do an implant if someone already has bad dementia.

[00:13:58 – 00:14:14] Eon Engelbrecht – eRadio SA: Doctor, I also want to ask you: why do teeth seem to darken or even yellow significantly with age? Is it just wear and tear?

[00:14:14 – 00:15:44] Dr Clifford Yudelman – OptiSmile: No, not wear and tear. Generally, they darken with age for several reasons. Your enamel gradually does thin out due to, I wouldn’t say wear and tear, it is more due to erosion. We have spoken about acid erosion, especially, and allowing more of the darker underlying dentine to show through. The dentine is the middle part of the tooth that is quite dark. And also, the dentine continues to thicken and darken over time.

Decades of exposure to staining substances such as tea, coffee, wine, and tobacco accumulates within the tooth structure. And some medications can also discolour your teeth.

The change is natural; it doesn’t indicate disease. But whitening, polishing, and bonding can rejuvenate the appearance of aged teeth safely. It is never too late to whiten your teeth. I have done whitening on 70 and 80-year-olds. I can’t remember if I have ever done a 90-year-old. In fact I have! My late dad would use his whitening trays and touch up his whitening into his early 90s. He wore his trays with his peroxide gel. We have done a whole podcast about that. So, age is not a limiting factor.

Cosmetic treatment in older adults does help people feel better when they look better. Just because you are 80 doesn’t mean you don’t look in the mirror anymore. And the goal is enhancement, not aggressive treatment. We would never go and do a whole bunch of veneers, although we have done injection moulding for 80-year-olds where we have replaced missing enamel, and a lot of the time it is functional as well as cosmetic.

[00:15:44 – 00:15:58] Eon Engelbrecht – eRadio SA: Okay. And what is the link between aspiration pneumonia and poor oral hygiene in the elderly?

[00:15:58 – 00:17:39] Dr Clifford Yudelman – OptiSmile: Yeah, so I mean in the 90s I developed a tongue scraper which I sold all over America, and I got a patent on that, and I was obsessed with this whole thing about oral hygiene, especially the tongue and aspiration pneumonia. And it is one of the most important yet least understood connections between oral health and general health.

Aspiration pneumonia occurs when the bacteria from the mouth are inhaled into the lungs in frail or hospitalised elderly patients, especially if they have swallowing difficulties. It is called dysphagia, where you can’t swallow properly. This risk increases significantly, and many studies have shown that improved oral hygiene reduces the incidence of aspiration pneumonia in elderly populations, particularly in care facilities.

The mouth acts as a reservoir, like a dumping ground, for bacteria, especially on the tongue. When plaque in the mouth is not controlled, you get more plaque on your tongue, and then it is easier to sort of choke on that plaque. It can go down the wrong way.

So good oral care is therefore not just about teeth; it is about life-saving intervention in vulnerable older adults.

And what I was fascinated about and did so much research on, and this is before ChatGPT and, you know, Google was still very early, and I used to go to the medical library, is that when you inhale some of this you get like a toxic shock. And a lot of strokes, I believe, are caused by this because people come into hospital with a fever, they have a stroke, but they also happen to have a fever. And then one or two days later they are in hospital with a stroke, and the next thing they get what is sometimes called “hospital-acquired pneumonia”, but they actually get the pneumonia before they have the stroke because they are breathing in this junk that is on their tongue and that builds up because their teeth were not clean. So it is a bit of a downward spiral.

And you know, simple measures like regular cleanings, denture hygiene (keeping the dentures clean), and professional care can significantly reduce serious medical complications. And if someone is in an aged care facility, they often have a dentist that will come round and check people’s teeth or do home care and teach the carers.

[00:17:39 – 00:17:51] Eon Engelbrecht – eRadio SA: Okay. And just getting back to dentures again, how often should denture wearers see a dentist, even if they have no teeth?

[00:17:51 – 00:18:59] Dr Clifford Yudelman – OptiSmile: I mean, the recommendation is once a year. Dentures change over time as your bone resorbs and the tissues, the soft tissues, remodel. Ill-fitting dentures can cause sores and infections and accelerated bone loss. Oral cancer can develop in a denture wearer and may go unnoticed without regular exams.

And that is what I was going to say: a lot of the time when older people get oral cancer, it is because they haven’t actually been to a dentist for two or three years. So the cancer goes unnoticed, whereas if you have even a few teeth left and you are going to the dentist to look after those teeth and you get a small area that is a bit suspicious, the dentist might send you for a biopsy and catch it very early (by “catch it”, I don’t mean like an infection, I mean find it early and treat it while it is still tiny).

And you know, dentures themselves will harbour plaque and fungus organisms if not cleaned properly. There is something called “denture stomatitis”, which is often painless; it is common, especially if people sleep with a denture, and it compromises comfort and health.

Routine dental visits allow us to check the fit, do oral cancer screening, reinforce hygiene, and do timely replacement or adjustment. And you know, having no natural teeth doesn’t mean you no longer need dental care.

[00:18:59 – 00:19:15] Eon Engelbrecht – eRadio SA: Okay. And then just one more question for today: can we still do cosmetic procedures like bonding on aged teeth?

[00:19:15 – 00:20:31] Dr Clifford Yudelman – OptiSmile: Yes, and often very successfully, but conservatively. I had a patient in earlier today that we are going to be doing some onlays to open up her bite, her back teeth are very worn down, and we are going to do injection moulded composite bonding to give her a lovely smile. She has always wanted that. And a lot of the time it is when the grandkids say, “Granny, why are your teeth so brown?” or “Why are your teeth broken?” That is a very big motivator.

And so we do a lot of cosmetic dentistry on older, especially older females. Composite bonding is minimal removal of tooth structure, and we can fix the appearance of worn or chipped or discoloured teeth. For discolouration, we usually whiten teeth first and then use composite bonding to change the size or the shape or the length, and preserve everything that is left of the natural teeth. We don’t drill the tooth down. I am very much against veneers or crowns, no matter what the age of the patient; we always try and avoid veneers or crowns.

And the key is careful case selection. Older teeth may have reduced bonding surfaces, cracks, or big fillings that mean we have to tailor our approach. Cosmetic treatment should enhance function and comfort and not overload a compromised tooth. And if it is done thoughtfully, cosmetic dentistry in older adults can significantly improve confidence, chewing ability, and quality of life without any aggressive treatment.

[00:20:31 – 00:21:05] Eon Engelbrecht – eRadio SA: Dr Yudelman, thank you so much for your wonderful insights once again. It is clear that the right tools and the preventative mindset, a healthy smile truly has no expiry date with those. If you would like to learn more or book a consultation at OptiSmile, remember you can visit OptiSmile.co.za. Thank you so much, Dr Yudelman.

[00:21:05 – 00:21:38] Dr Clifford Yudelman – OptiSmile: Thank you. And looking forward to Podcast number 96 next week, where we have now done with the teenagers and the ugly duckling and the toddlers and the males. We did all the way from baby teeth to now to geriatric dentistry. And next week we are going to be talking about mimicking nature: biomimetic dentistry. So tune in next week.

[00:21:38 – 00:21:55] Eon Engelbrecht – eRadio SA: That sounds very, very interesting. Looking forward to it, Doctor. Thank you so much. And also don’t forget to tune in next time for more tips on how to save your money and your teeth. We will see you in the next episode.

[00:22:04 – 00:22:31] Announcer: Discover the world of dental excellence with OptiSmile. Join us for a weekly podcast featuring Dr Clifford Yudelman, a seasoned expert with 40 years of dental experience across four continents. Gain unique insights and expert dental advice by visiting OptiSmile.co.za for articles that illuminate the path to optimal oral health. If you are seeking unparalleled dental care in Cape Town, get in touch with OptiSmile or book directly online on OptiSmile.co.za. OptiSmile: where global expertise meets local care.