Despite progress in dentistry, tooth loss in old age is still a reality, even more so in long-term-care residents. However, recent trends indicate that natural teeth are lost later in life. Functional decline and age-related pathologies have to be considered in oral health care for this vulnerable population. Retaining and restoring teeth and oral function in elders is important. Tooth loss significantly impairs masticatory performance, which cannot be fully restored by prosthodontic means. Hence an unconscious change in food intake occurs, often involving malnutrition and withdrawal from common meals. Poor oral appearance and bad breath may further impede social activities. Although a chewing activity may be beneficial for cognitive function, natural teeth can present a considerable risk for fragile elders, in whom aspiration of biofilm can lead to pneumonia and death. The presence of natural teeth is also correlated with higher life expectancy, but socio-economic confounding factors have to be considered. When evaluating oral health in the elderly population, standards and priorities for reporting oral health outcome measures have to be defined. Anatomical indicators such as the number of natural teeth or the presence of prostheses might be one option for reporting. However, functional indicators such as masticatory performance and patient-centred outcome measures may be more relevant. In conclusion, there is an overwhelming body of evidence that maintaining a healthy natural dentition in old age is beneficial from a structural, functional and psycho-social point of view.