Homebound is a challenging condition characterized by the need for assistance with activities of daily living, life‐space confinement, mobility, powerlessness, reduced endurance, and weakness [1]. Poor oral health among homebound older people can worsen existing health conditions, reduce quality of life, and increase the burden on caregivers and healthcare services. Adequate oral health care may be associated with better functional and nutritional status in this population and may reduce the risk of mortality and other adverse health-related outcomes in older adults [2].

Primary health care can expand access to health services [3] and improve health outcomes for homebound older people [4]. Integrating dental care into primary healthcare services can improve access to oral health services, particularly for vulnerable populations [5] such as homebound older adults. This integration can contribute to better health outcomes, more sustainable dental services, and more effective management of oral diseases [6].

However, the frequency of dental consultations decreases with age among older adults [7]. The reasons for the lack of regular dental consultations are multifactorial, including financial barriers, functional and cognitive impairment, and worsening general health [7]. Most studies exploring dentists’ experiences in providing oral health care to older adults are surveys focused on long-term care institutions [8]. This highlights a gap in evidence on the provision of dental care to homebound people within a primary healthcare model of care.

In this context, we sought to understand the relationships among social, health, and oral health conditions and home dental care provision for homebound older adults in primary healthcare, integrating quantitative and qualitative data through a convergence-divergence analytical matrix. The quantitative data aimed to estimate the associations between sociodemographic, health, and oral health conditions and home dental care, defined as home dental assistance and daily oral hygiene. The qualitative approach aimed to analyze the perceptions of homebound older adults, caregivers, and primary healthcare dentists regarding home oral health care. By integrating both datasets, this study provides a broader understanding of the factors involved in home dental care for homebound older adults in primary healthcare.

A total of 123 homebound older adults from Florianópolis participated in the quantitative component of the study. Their sociodemographic characteristics are presented in Table 1. Most participants were women (62.6%), aged between 70 and 79 years (34.9%) or 80 and 89 years (31.7%), had one to four years of schooling (61.0%), had a family income of one to three minimum wages per month (70.7%), had been homebound for one to four years (52.0%), and had a caregiver (87.0%).

Oral health status and home dental care characteristics are presented in Table 2. Visible biofilm was observed in 69.9% of participants, and 56.1% were edentulous. Among dentate participants, 57.4% had cavitated caries lesions, 51.9% had at least one residual root, 20.4% had tooth mobility, and 1.9% had fistula or exudate. Oral mucosal lesions were observed in 8.9% of the total sample.

Regarding oral healthcare, Table 2 shows that 75.6% of participants performed or received daily oral hygiene, while 24.4% did not. Almost half of the participants (45.5%) needed help with oral hygiene. Difficulty accessing dental services was reported by 32.5% of participants, and 17.9% had received home dental assistance provided by a dentist.

The bivariate analysis of sociodemographic characteristics, oral health status, and oral healthcare variables, stratified by home dental assistance and daily oral hygiene is presented in Table 3. No statistically significant associations were observed between home dental assistance and the analyzed variables. However, unresolved oral health problems showed borderline statistical significance in relation to home dental assistance (p = 0.053).

Performing or receiving daily oral hygiene was associated with sex (p = 0.003), age group (p < 0.001), family income (p = 0.007), unresolved oral health problems (p = 0.001), and need for help with oral hygiene (p < 0.001), as shown in Table 3. These findings should be interpreted as exploratory, considering the bivariate design of the analysis and the absence of multivariable adjustment.

The Kihon Checklist results are presented in Table 4 and indicate a high burden of functional and health-related limitations among homebound older adults. Most participants did not walk for more than 15 minutes (86.2%), did not leave the house more than once a week (76.4%), had gone out less often in the previous year (61.0%), had suffered at least one fall in the previous year (52.8%), and reported discomfort due to dry mouth (50.4%). The prevalence of frailty was 89.4%. The most frequently impaired KCL domains were physical strength (95.1%), mood (73.2%), socialization (69.9%), and memory (65.9%).

The qualitative analysis identified three main categories: the context of older adults at home, home care for older adults, and oral care for homebound older adults in primary healthcare. These qualitative findings were integrated with the quantitative results in Table 5. The first category, the context of older adults at home, included social, economic, emotional, and health-related aspects affecting this population. Functional dependence, mobility restrictions, financial limitations, fear of leaving home, emotional vulnerability, and caregiver dependence emerged as central aspects of daily life. These conditions affected autonomy, access to healthcare services, and the ability to maintain oral health routines.

The second category, home care for older adults, described the practices, perceptions, and challenges experienced by older adults and caregivers in the home environment. General care was strongly dependent on family members and caregivers. Oral care was often reported as part of daily routines, but it was not always prioritized or supervised by a professional. Caregivers frequently accumulated several responsibilities, including feeding, medication management, hygiene, mobility support, and household tasks, which contributed to oral health being neglected or treated as a secondary need.

The third category, oral care for homebound older adults in primary healthcare, reflected the organization and limitations of home-based oral healthcare. Participants and dentists reported barriers related to mobility, access to dental services, limited resources, inadequate planning, and limited incorporation of oral health into domiciliary primary healthcare. Dependence on caregivers, limited caregiver knowledge, and socioeconomic constraints contributed to inadequate or insufficient oral care.

The integration of quantitative and qualitative findings is presented in Table 5. The integrated analysis showed convergence between the high prevalence of frailty, functional limitations, caregiver dependence, and the qualitative reports of dependence in daily activities. Qualitative findings expanded the quantitative results by showing how caregiver burden, fear of leaving home, and limited access to services influenced oral care routines.

As shown in Table 5, the integration also revealed a divergence between reported oral hygiene practices and clinical oral health conditions. Although many participants reported performing or receiving daily oral hygiene, clinical examination showed a high prevalence of visible biofilm, edentulism, and cavitated caries lesions among dentate participants, and a need for oral health support. This suggests that having an oral hygiene routine did not necessarily indicate adequate oral care or sufficient professional guidance.

Overall, the integration presented in Table 5 indicated that home dental care for homebound older adults is influenced by functional dependence, caregiver availability, socioeconomic vulnerability, oral health needs, and limitations in the organization of domiciliary dental care within primary healthcare.

Our findings corroborate previous studies highlighting the vulnerability of homebound older people. This group faces several challenges, including frailty, risk of depression, low cognitive function, limited socialization, compromised oral health, and restricted access to dental services through primary healthcare [16,17].

Most homebound older adults in this study were women aged 70 - 79 years, with low levels of schooling and income of up to 3 minimum wages. Previous studies also showed a predominance of women with low income and schooling among homebound older adults [18]. However, a more recent study found a higher prevalence of this condition among men, suggesting regional or methodological variations [11].

Oral health problems were frequent among homebound older adults, including edentulism, untreated caries, residual roots, visible biofilm, dry mouth, and oral mucosal lesions. These conditions may contribute to functional limitations and indicate the need for dental care. Previous studies reported similar findings, with high prevalence of tooth loss and dental caries among older adults [19,20]. This scenario reflects an oral healthcare model still centered on curative practices, aggravated by social determinants such as low income, low schooling, and limited access to health services [21].

In the bivariate analysis, performing or receiving daily oral hygiene was associated with sex, age, family income, unresolved oral health problems, and need for help with oral hygiene. These findings suggest that demographic, socioeconomic, and care-related factors are involved in maintaining oral hygiene among homebound older adults [22,23]. Income may influence access to dental services and oral hygiene supplies, and the ability to maintain daily oral care.

The findings highlight the interaction between social determinants and oral health practices. The association between income and daily oral hygiene is consistent with evidence showing that socioeconomic disparities influence access to dental services and adherence to basic oral care, such as toothbrushing [23]. Among homebound older adults, low income may restrict access to oral hygiene supplies and reduce autonomy in seeking care, reinforcing cycles of oral neglect [21,24]. Dependence on caregivers may intensify this situation, especially when oral hygiene competes with other daily care demands. The qualitative findings showed that oral health was often not prioritized in home care and that caregivers frequently lacked specific guidance on oral hygiene. This indicates gaps in integrating oral health education into home care and primary healthcare services [6,8].

Unresolved oral health problems may be related to physical limitations, dependence on caregivers, difficulty accessing dental services, low priority given to oral health, lack of knowledge about oral hygiene, and socioeconomic barriers [24]. They may also reflect limited coverage and accountability on the part of dental teams providing care to homebound patients. This reinforces the need to strengthen dentistry’s role within primary healthcare and to apply equity principles for populations with greater barriers to accessing services.

A substantial proportion of homebound older adults needed help with oral hygiene, reported difficulty accessing dental services, and had not received dental assistance at home from a dentist. These findings suggest that oral health needs remain insufficiently addressed in this population. Older adults with oral health problems may face additional barriers to seeking treatment outside the home, especially when frailty, mobility limitations, transportation difficulties, and caregiver dependence are present.

Fear of leaving home was common among the older adults in this study, especially among the frailest, increasing dependence on caregivers and restricting access to healthcare services. Fear of going out has been associated with risk of depression, fear of falling, reduced frequency of going out, need for help, and strong dependence on care [25]. These factors may reduce confidence in daily activities, limit socialization, and increase frailty [16,26].

The integration of qualitative and quantitative findings showed that risk of depression, mood changes, and impairment in daily activities were related to social isolation, dependence, and reduced autonomy. These findings reinforce the importance of adequate diagnosis, social support networks, and comprehensive care strategies to improve the quality of life of homebound older adults [17,27].

The mixed-methods integration also revealed relationships among oral care, general health, frailty, and dependence. Quantitative data showed a high prevalence of frailty, functional limitations, poor oral health indicators, and limited home dental assistance. Qualitative data helped explain these results by showing how dependence on caregivers, caregiver burden, fear of leaving home, lack of guidance, and limited service organization affect oral care. Thus, oral health problems in this population should not be interpreted only as individual conditions, but as the result of social, functional, caregiving, and service-related barriers.

One important finding was the divergence between reported oral hygiene and clinical oral health conditions. Although many participants reported performing or receiving daily oral hygiene, clinical examination showed a high prevalence of visible biofilm, edentulism, and cavitated caries lesions among dentate participants, and a need for oral health support. This suggests that having an oral hygiene routine does not necessarily mean oral care is adequate, technically effective, or supported by professional guidance.

Based on our findings, primary healthcare services should implement structured domiciliary oral health protocols. These protocols should include periodic oral health risk screening, assessment of oral hygiene and denture hygiene, identification of urgent needs, and referral pathways for pain, infection, residual roots, oral mucosal lesions, poorly adapted dentures, and feeding difficulties related to oral conditions. Caregiver and family training should also be incorporated into home care routines, including guidance on toothbrushing in dependent older adults, denture hygiene, recognition of warning signs, management of dry mouth, and when to seek dental care [17].

Many older adults who depend on home care services do not use oral healthcare services, indicating failures in the current care system [28]. Integrating oral care with general health management is a key strategy to address this gap. This model recognizes the interdependence between oral and general health while increasing the visibility of oral healthcare needs among older adults, caregivers, and health professionals [29]. Care solutions should be adapted to the changing needs of older adults, prioritizing quality of life and autonomy [30].

Recent studies emphasize that frailty, functional dependence, and socioeconomic determinants, such as low income and low education, are important barriers to adequate oral hygiene and access to specialized services [31,32]. Our integrated findings reinforce the notion that reliance on untrained or overburdened caregivers may contribute to oral neglect, oral morbidity, and reduced quality of life, a pattern also observed in international home care models [33,34]. Interdisciplinary guidelines should include caregiver training, comprehensive geriatric assessment, and the integration of dental professionals into home healthcare teams [32,33].

Intersectoral actions to reduce inequalities in access to basic oral hygiene supplies, combined with health education adapted to cognitive and functional limitations, are essential to reduce structural barriers.

This study has limitations. First, the use of convenience sampling and sample attrition may have introduced selection bias. Second, the initially estimated sample size was not reached because home visits were interrupted by the COVID-19 pandemic. This may have reduced statistical power, increased the possibility of type II error, and limited the generalisability of the findings. Therefore, the bivariate associations should be interpreted as exploratory. Third, the cross-sectional design does not allow causal inference. Fourth, oral examinations were performed under domiciliary conditions using simplified resources, including a wooden spatula and a mobile phone flashlight. Although data collection teams received standardized training and a pilot study was conducted, formal interexaminer agreement was not assessed. Some oral conditions may therefore have been underestimated or misclassified. Fifth, caregiver involvement was central to oral hygiene, but the study did not include a structured assessment of caregiver burden, oral health literacy, or caregiving skills. This limited a more detailed understanding of how caregiver-related factors influence daily oral care and access to dental services.

Future studies should explore strategies to improve oral healthcare for homebound older adults, including teledentistry and digital health. In public health services, teledentistry has been described as a tool for professional education and training, oral health surveillance, remote patient care, and interprofessional communication [35]. In the context of this study, teledentistry should not replace face-to-face domiciliary dental care when clinical intervention is required. It may be useful as a complementary strategy for remote triage, caregiver guidance, follow-up, prioritization of home visits, and communication among dental teams, other primary healthcare professionals, caregivers, and older adults. In primary healthcare, teledentistry can contribute to oral health literacy, reduce waiting times, support care coordination, and promote oral health equity [35].

The research agenda should prioritize multidisciplinary, longitudinal studies of oral healthcare practices for homebound older adults. Future research should evaluate the long-term effects of homeboundness on oral health, the effectiveness of domiciliary oral health protocols, the impact of caregiver training, and the contribution of teledentistry-supported follow-up. Such evidence may inform clinical guidelines, strengthen primary healthcare systems, and improve quality-of-life indicators in public health services.

Homebound older adults in this study were characterized by socioeconomic vulnerability, frailty, low physical strength, limited socialization, risk of depression, low cognitive function, and poor oral health conditions requiring professional attention. Despite these needs, access to home dental assistance through primary healthcare was limited, and daily oral care often depended on caregivers who may be overburdened and insufficiently supported. The findings indicate that home dental care for homebound older adults should be fully integrated into primary healthcare. This integration should include structured domiciliary oral health protocols, periodic oral health assessment, caregiver guidance, health promotion, disease prevention, and clear referral pathways for clinical intervention. Strengthening oral healthcare throughout the life course is also necessary to reduce the accumulation of untreated dental needs in older age.

Comprehensive care for homebound older adults requires recognizing oral health as part of general health, functional capacity, autonomy, and quality of life. Public health services should therefore ensure that dental teams are actively involved in home care, particularly for populations facing greater social, functional, and access barriers.