Oral Health Monitoring of Homebound Older Adults Using Teledentistry in Primary Health Care: A Pilot Pragmatic Randomized Trial

1. Introduction

Population ageing is a global phenomenon that has substantially increased the number of older adults living with chronic diseases, functional limitations, and complex healthcare needs. Oral health is recognized as an essential component of healthy ageing, as oral diseases and tooth loss may negatively affect chewing ability, nutritional status, communication, social interaction, and quality of life [1,2]. Despite improvements in oral health indicators over recent decades, inequalities in access to dental care remain pronounced among older adults, particularly among those experiencing mobility restrictions and functional dependence [1,3].

Homebound older adults constitute a particularly vulnerable subgroup within the ageing population. These individuals frequently experience multimorbidity, frailty, dependence on caregivers, and reduced access to healthcare services, including oral healthcare. In Brazil, data derived from the 2013 National Health Survey indicate that approximately 4.9% of community-dwelling older adults are classified as bedbound, a condition strongly associated with advanced age, lower educational attainment, chronic diseases, and functional impairment [3]. Oral healthcare for this population is especially challenging, as mobility limitations frequently restrict access to conventional dental services, while the need for continuous monitoring increases as oral health conditions become more complex and cumulative over time [3,4].

Within the Brazilian Unified Health System (SUS), Primary Health Care (PHC) is responsible for coordinating care and ensuring access to health services for vulnerable populations. Oral Health Teams (dental surgeon and dental assistant) incorporated into the Family Health Strategy are expected to provide domiciliary care when necessary; however, qualitative evidence from Brazilian dentists indicates that home-based oral healthcare is frequently limited by logistical difficulties, insufficient equipment, workforce constraints, and the absence of standardized protocols for domiciliary dental care [3]. These challenges may compromise continuity of care and hinder regular monitoring of oral health conditions among homebound older adults.

Teledentistry has been proposed as a strategy to support oral healthcare delivery using information and communication technologies, encompassing applications such as remote screening, oral health monitoring, referral support, patient education, and interprofessional communication [1,5]. A systematic review evaluating the role of teledentistry for the elderly found that its use may reduce costs and optimize referral pathways, highlighting its potential to facilitate access for individuals with mobility limitations [1]. A scoping review focused specifically on older adults further documented evidence supporting teledentistry across a variety of care settings and underscored its promise for overcoming geographic, mobility-related, and logistical barriers, while also identifying substantial evidence gaps regarding community-based and PHC implementation [5]. Experiences conducted in long-term care facilities have similarly demonstrated the feasibility of integrating asynchronous teledentistry into routine care pathways, expanding access to preventive and diagnostic services for older adults with limited access to conventional dental care [6].

Nevertheless, the current evidence base remains limited and contested. A scope review examining concordance between virtual and clinical oral examinations among community-dwelling older adults identified a striking scarcity of studies and concluded that evidence on the accuracy of teledentistry for this specific subgroup remains insufficient, with most existing research restricted to institutionalized populations [7]. A pilot study evaluating mobile photographic teledentistry for oral screening in aged-care home residents found only fair-to-moderate concordance with in-person clinical examinations for caries detection, with higher specificity than sensitivity, underscoring technical limitations that must be addressed before wider implementation [8]. Moreover, a rapid review specifically addressing teledentistry for homebound older adults in PHC found no formal interventions implemented at the primary care level internationally, highlighting critical gaps in implementation, feasibility, and integration into routine healthcare services [9].

Recent evidence from Brazil has further illuminated both the potential and the challenges of teledentistry for older adults receiving care at home. In a feasibility study conducted within PHC, homebound older adults reported positive experiences with remote oral health follow-up and perceived teleconsultations as comfortable, convenient, and trustworthy. However, participating dentists raised concerns about diagnostic limitations and reported infrequent use of available telehealth platforms, emphasizing the need for structured protocols and implementation strategies capable of supporting routine adoption within public health services [10]. Together, these findings suggest that the main challenge is no longer whether teledentistry can be used for older populations, but rather how it can be effectively and systematically incorporated into existing care models for individuals with substantial mobility restrictions.

Given the complexity of implementing technology-based interventions in real-world Primary Health Care settings, pragmatic trial designs are particularly appropriate for generating evidence relevant to healthcare decision-making. Pilot studies play a fundamental methodological role by allowing the prior assessment of feasibility, acceptability, intervention delivery, and operational viability before definitive effectiveness of trials are conducted [11]. Therefore, this pilot pragmatic, randomized trial aimed to evaluate the feasibility of implementing a structured teledentistry protocol for oral health monitoring among homebound older adults within Brazilian Primary Health Care, compared with conventional home-based dental care delivered by dentists on Oral Health Teams.

2. Materials and Methods

2.1. Study Design

This study was a pilot pragmatic, randomized feasibility trial conducted within Primary Health Care (PHC) in southern Brazil. The pilot was designed as a preliminary stage of a larger pragmatic randomized clinical trial aiming to evaluate a teledentistry protocol for oral health monitoring among homebound older adults.

The study followed the principles of pragmatic trials, seeking to evaluate the intervention under routine service conditions rather than under highly controlled experimental settings. The degree of pragmatism was assessed using the Pragmatic–Explanatory Continuum Indicator Summary 2 (PRECIS-2) framework [12]. The trial design and reporting were guided by the CONSORT extension for randomized pilot and feasibility trials [13].

The teledentistry protocol was developed from evidence identified in a rapid review of teledentistry interventions for homebound and institutionalized older adults [9] and refined using findings from a previous feasibility study conducted in Brazilian PHC settings [10].

2.2. Ethical Considerations

The study was approved by the Research Ethics Committee of the Federal University of Santa Catarina under protocol number 7.602.588. All procedures complied with the ethical principles established in the Declaration of Helsinki and Brazilian regulations governing research involving human participants.

Written informed consent was obtained from all participants or their legal representatives prior to enrolment. Confidentiality and data security were ensured through restricted access to electronic records and storage within the REDCap® platform.

The study was registered in the Brazilian Registry of Clinical Trials (ReBEC) under identifier RBR-2j9zqkz.

2.3. Setting

The study was conducted in municipalities located in the northern region of the state of Santa Catarina, Brazil, within the context of the Brazilian Unified Health System (SUS). Participants were recruited through Primary Health Care (Family Health Strategy) teams and their respective Oral Health Teams operating in PHC services.

These services routinely provide home-based care for individuals with mobility limitations and therefore constitute a suitable setting for evaluating innovative care models based on digital health technologies.

2.4. Participants

2.4.1. Older Adults and Caregivers

Eligible participants were community-dwelling adults aged 60 years or older who were classified as homebound or bedridden and were registered within participating PHC services.

Participants were required to have internet access either directly or through a caregiver and to be able to participate in remote consultations. Caregivers aged 18 years or older who were responsible for daily care activities were also eligible.

Exclusion criteria included institutionalization in long-term care facilities, inability to establish communication during the study period, refusal to participate, or absence of a caregiver when required for participation.

As a pilot feasibility trial, a formal sample size calculation was not required. The sample of six participants was defined based on the logistical capacity of the Oral Health Teams during the study period. The number was deemed sufficient to evaluate the acceptability of the intervention and the feasibility of the data collection instruments.

2.4.2. Dentists

Dentists working in Oral Health Teams were invited to participate. Eligible professionals were required to be actively employed in PHC and to complete training regarding the teledentistry workflow and digital platform before study initiation.

2.5. Randomization and Allocation Concealment

Participants were randomized in a 1:1 ratio to either the teledentistry intervention group or the conventional home-based care group.

The allocation sequence was generated electronically by an independent researcher not involved in recruitment or outcome assessment. Allocation of concealment was maintained until participant enrolment and baseline assessment had been completed.

2.6. Blinding

Due to the nature of the intervention, blinding of participants, caregivers, and treating dentists was not feasible.

However, baseline and follow-up assessments were conducted by an independent evaluator who was not involved in intervention delivery and remained unaware of group allocation whenever possible.

2.7. Intervention Protocol

2.7.1. Teledentistry Group

Participants allocated to the intervention group received oral health monitoring through synchronous video consultations conducted using the Telemedicine and Telehealth System (STT) of the Federal University of Santa Catarina.

The protocol was structured around 27 clinical recommendations distributed across five domains:

• Social and health-related determinants;
• Oral cavity assessment;
• Oral function and prosthesis-related conditions;
• Oral hygiene assessment;
• Care planning, guidance, and referral needs.

Consultations were conducted by PHC dentists with support from caregivers when necessary. The protocol emphasized monitoring, early identification of oral health problems, self-care guidance, and referral of cases requiring face-to-face assessment.

2.7.2. Conventional Care Group

Participants allocated to the control group received the usual home-based dental care routinely provided by Oral Health Teams within PHC services with an equivalent set of recommendations.

Care followed local protocols and professional clinical judgment, including home visits whenever deemed necessary.

2.8. Data Collection

Participant recruitment and follow-up assessments were conducted between January and March of 2026.

Data were collected at baseline and follow-up using standardized electronic forms developed in REDCap® [14].

Sociodemographic variables included age, sex, educational attainment, living arrangements, and caregiver characteristics.

Clinical and patient-reported outcomes were assessed using validated instruments:

6.

Frailty Assessment

Frailty was assessed using the Brazilian version of the Kihon Checklist (KCL), a multidimensional instrument composed of 25 dichotomous items covering physical, nutritional, cognitive, psychological, and social domains [15,16].

7.

Oral Frailty Assessment

Oral frailty was assessed using the Portuguese version of the Oral Frailty Index-8 (OFI-8), which evaluates self-reported indicators of declining oral function, including chewing, swallowing, salivation, and tongue function [19,20].

8.

Oral Health-Related Quality of Life

Oral health-related quality of life was assessed using the Brazilian version of the Oral Health Impact Profile (OHIP-14) [20,21]. Higher scores indicate greater negative impact of oral conditions on quality of life.

2.9. Feasibility Outcomes

The primary purpose of this pilot trial was to assess feasibility rather than clinical effectiveness.

Feasibility indicators included:

• recruitment capacity;
• participant retention;
• completeness of outcome data collection;
• technological functionality of the telehealth platform;
• adherence of dentists and caregivers to study procedures;
• integration of the intervention into routine PHC workflows;
• operational barriers and facilitators.

Additionally, implementation outcomes were measured using the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) [22].

These instruments consist of four items each scored on a five-point Likert scale (1-5), with higher scores indicating more favorable perceptions regarding implementation.

To determine the progression to a future definitive randomized controlled trial, predefined criteria were established. Progression was considered feasible if the overall mean scores on the implementation measures (AIM, IAM, and FIM) achieved 3.0 or higher, and if no major operational barriers or adverse events related to the teledentistry intervention were identified.

2.10. Adverse Events

Potential risks were considered minimal and included temporary discomfort associated with questionnaire completion, difficulties using digital technologies, or concerns regarding privacy during remote consultations.

All unexpected events reported by participants, caregivers, or professionals were documented and reviewed by the research team.

2.11. Statistical Analysis

As recommended for pilot and feasibility studies, analyses focused on descriptive estimation rather than formal hypothesis testing [13].

Categorical variables were summarized using absolute and relative frequencies, whereas continuous variables were described using means, standard deviations, medians, and ranges when appropriate.

Feasibility outcomes were reported descriptively, emphasizing recruitment, retention, intervention delivery, data completeness, and implementation of indicators. Statistical analyses were performed using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA).

3. Results

As this is a pilot trial with a small sample size (n=6), the presented results are descriptive and exploratory. The findings regarding clinical and functional outcomes are suggestive and serve the purpose of evaluating trends and the feasibility of the data collection instruments, not allowing for significant statistical inferences.

3.1. Sample Characterization

The sample consisted of six homebound older adults, evenly distributed between the home care group (n=3) and the teledentistry group (n=3). There was an equal distribution between females and males. The average age of the participants was 71.3 years, with a mean education of 6.5 years, and all had a caregiver. The average time restricted to home (homebound duration) was 11 years. Regarding household income, there was a predominance of participants with an income between one and five minimum wages (50.0%) (Table 1)

From a clinical and functional perspective, the participants’ mean Body Mass Index (BMI) was 26.5 kg/m². Normal weight participants, overweight participants, and one case of obesity were observed. All participants reported the need for dental treatment and daily oral hygiene performance. There was a prevalence of dental prosthesis use (66.7%), dry mouth (50%), difficulty chewing (66.7%), and choking on liquids (33.3%). Regarding mobility and functionality, all participants showed dependence for instrumental activities of daily living, such as using transportation, shopping, and managing finances, as well as mobility limitations, such as climbing stairs and walking for long periods (Table 2).

3.2. Clinical and Functional Outcomes and Quality of Life

Comparing the pre- and post-intervention moments, a reduction in the mean scores of the Kihon Checklist instrument was observed, indicating an improvement in general frailty in both groups. In the home care group, the mean was reduced from 9.0 to 7.7, while in the teledentistry group it went from 8.0 to 6.7. As for oral frailty, the OFI-8 instrument registered a slight increase in the mean scores in both groups. In home care, the mean went from 3.7 to 4.7, while in teledentistry it varied from 4.0 to 4.3.

Regarding the self-perception of oral health-related quality of life, evaluated by the OHIP-14 instrument, distinct behavior was observed between the two care modalities over the three-week follow-up. In home care, there was a reduction in the mean impact scores, which went from 14.3 in the pre-intervention moment to 12.7 in the post-intervention moment. On the other hand, in the teledentistry group, the mean scores increased, going from 12.0 to 15.3 in the same period (Table 3).

Considering the total sample, a reduction in the mean Kihon Checklist scores was observed between the pre- and post-intervention moments, while the mean OFI-8 and OHIP-14 scores showed an increase in the same period. The descriptive statistics of the instruments, including mean, standard deviation, median, and minimum and maximum values, are presented in Table 4.

3.3. Feasibility and Implementation Evaluation

The feasibility evaluation of the study highlighted the dynamic between the caregiver and the older adult, both as a limiting and facilitating factor in the data collection process. Although a caregiver was present, a disparity was found between the caregiver’s report and the real oral health condition. Furthermore, during the application of the OHIP-14 and OFI-8 instruments, caregivers showed confusion or lack of knowledge regarding specific details of the older adult’s oral function.

Regarding the technological infrastructure, the STT platform proved to be a good tool for conducting teleconsultations, but somewhat inaccessible due to the target audience’s low digital literacy. The use of the platform requires registration and navigation steps that were not part of the older adults’ daily lives, configuring an obstacle to autonomy. However, it was noted that the presence of caregivers with higher digital health literacy acted as a facilitator.

The logistical difficulties extended to the recruitment and sensitive data collection process. The capture of the sample via Community Health Workers (CHWs) showed a weakness in the initial screening, with the erroneous inclusion of functionally independent older adults, which generated operational harm to the research team. In addition, participants’ resistance to providing personal data, such as the Brazilian Individual Taxpayer Registry (CPF) and family income, remotely to unknown collectors, in some cases required an in-person visit by the dentist to the home.

No missing data or inconsistencies were observed in completing the instruments registered in REDCap®, both in the home care group and the teledentistry group. The quantitative analysis of implementation corroborated the study’s operational descriptive findings. The application of pragmatic measures to participants followed by teledentistry resulted in intermediate scores on the scale from 1 to 5. This group obtained a mean score of 3.0 for Acceptability of Intervention Measure (AIM), 3.5 for Intervention Appropriateness Measure (IAM), and 3.3 for Feasibility of Intervention Measure (FIM), considering a response scale of 1 to 5. Among the three evaluated measures, IAM had the highest mean, followed by FIM and AIM.

Table 5. Scores of teledentistry implementation measures (n=3).

Measure	Participant 1	Participant 2	Participant 3	Mean
AIM	3.2	2.7	3.2	3.0
IAM	3.5	4.2	2.7	3.5
FIM	4.5	2.7	2.7	3.3

Table 5. Scores of teledentistry implementation measures (n=3).

Measure	Participant 1	Participant 2	Participant 3	Mean
AIM	3.2	2.7	3.2	3.0
IAM	3.5	4.2	2.7	3.5
FIM	4.5	2.7	2.7	3.3

4. Discussion

In this study, the results demonstrated that the teledentistry strategy was feasible to implement, allowing for remote follow-up and the application of the proposed evaluation instruments. Furthermore, barriers and facilitators related to the implementation process were identified, as well as trends in changes in clinical and functional outcomes, which should be investigated in studies with larger sample sizes.

The sample characterization evidenced a profile of homebound older adults with a long time restricted to the home, averaging 11 years. Population-based studies conducted in Brazil identified a prevalence of bedridden older adults of 4.9% in 2013 and 4.3% in 2019, among older adult participants of the National Health Survey (PNS) [4,22]. Although representing a relatively small portion of the older adult population, this group has important care demands, especially related to frailty.

The mean scores on the Kihon Checklist (9.0 in the home care group and 8.0 in the teledentistry group) characterized both groups of the sample as frail, since scores equal to or higher than 8, out of a total of 25 points, are indicative of this condition [16,17]. Frailty is characterized by a reduction in homeostatic reserve and adaptability to stressors, resulting in greater vulnerability to adverse health outcomes [23], reinforcing the need for strategies for the early identification of functional changes and longitudinal monitoring of this population.

In addition to the general frailty observed, participants presented changes related to oral function, evidenced by the high frequency of perception of the need for dental treatment (100.0%), use of dental prostheses (66.7%), difficulty chewing (66.7%), and episodes of choking on liquids (33.3%). These findings dialogue with the concept of oral frailty, understood as a state of vulnerability characterized by the progressive impairment of multiple oral functions. Oral frailty constitutes a dynamic process that can contribute to the development of physical frailty, sarcopenia, and loss of functional capacity [24,25].

Besides the high general and oral frailty of the sample, it is worth noting that participants presented important functional limitations, with dependence for transportation use (100.0%), financial administration (100.0%), as well as limitations for continuous walking in most of the sample (83.3%). These conditions make access to traditional in-person dental services difficult and reinforce the importance of alternatives, such as home-based dental care and teledentistry.

Globally, community programs aimed at the oral health of the older population are scarce, as are initiatives for continuous surveillance and monitoring. Moreover, in low- and middle-income countries, budgetary constraints and primary care workforce limitations hinder the implementation of preventive actions and longitudinal follow-up [26].

Home Care constitutes a relevant assistance modality for monitoring homebound older adults. In Brazil, it is part of the Health Care Network, which aims to ensure the continuity of care for people with limited access to health services, through actions of health promotion, prevention, treatment, and rehabilitation at home [27,28].

Although foreseen as an attribution of Primary Health Care (PHC), its incorporation by oral health teams still represents a challenge. Studies point to difficulties related to work organization, integration with the multiprofessional team, and the predominance of an attention model centered on clinical procedures [29,30].

In addition to organizational challenges, socioeconomic factors can influence access to and knowledge of this modality by older adults and their caregivers [30]. In the sample of this study, the household income bracket between one and five minimum wages predominated, although the research was conducted in a Brazilian state with socioeconomic indicators higher than the national average, such as the Human Development Index [31].

Given the limitations of access to in-person services, teledentistry emerges as a complementary strategy for home care. This modality uses digital technologies and devices for the remote provision of oral healthcare, enabling interaction between patients and healthcare professionals, or between professionals [32]. In the present study, the results obtained by the Kihon Checklist, OFI-8, and OHIP-14 instruments demonstrated that longitudinal monitoring of participants was possible in both home care and teledentistry. Although the findings should be interpreted with caution, they reinforce the feasibility of applying this protocol in future studies with larger sample sizes.

When comparing pre- and post-intervention moments, a reduction in the mean scores of the Kihon Checklist was observed in both groups, dropping from 9.0 to 7.7 in home care and from 8.0 to 6.7 in teledentistry, suggesting a tendency towards improvement in the frailty condition throughout the follow-up, regardless of the modality used. Conversely, an increase was observed in the OFI-8 scores in both follow-up modalities. This inverse trend reinforces its potential for remote monitoring of oral frailty, as the OFI-8 proved sensitive in capturing functional decline even without a face-to-face clinical examination, which qualifies it as a promising tool for telehealth.

Regarding the OHIP-14, distinct behavior was observed between groups throughout the follow-up. While the home care group showed a reduction in scores, indicating improved oral health-related quality of life, the group followed by teledentistry presented an increase in these values. Considering the exploratory nature of this pilot trial, this finding must be interpreted with caution. A possible explanation is that remote monitoring may have favored a greater perception of the participants’ own oral health condition, without immediate clinical interventions capable of modifying these conditions.

During the application of the OHIP-14 and OFI-8 instruments, it was observed that some caregivers had difficulty answering questions related to oral function and the perception of older adults’ oral health. This finding is consistent with the literature, which demonstrates that subjective aspects, such as symptoms, quality of life, and health perception, tend to be better represented by self-report, whereas evaluations carried out by substitute informants present greater agreement in physical and functional domains. Although discrepancies between patient and proxy assessments can occur, they do not invalidate the use of substitute informants, especially when the older adult has communication or cognitive limitations. Thus, whenever the older adult’s communication capacity is preserved, their report should be prioritized, leaving the caregiver to play a complementary role in the evaluation [33].

The results of this study demonstrated the feasibility of using teledentistry for remote monitoring of homebound older adults. It was possible to carry out remote consultations, apply instruments, and longitudinally monitor participants during the study period. These findings are consistent with the literature, which demonstrates that teledentistry shows satisfactory performance in different care contexts, with remote evaluations comparable to in-person ones for diagnostic planning, definition of conduct, and referrals [34].

In addition to synchronous approaches, the literature also demonstrates the potential of asynchronous teledentistry, based on the capture and submission of intraoral photographs obtained by smartphones. In a pilot study conducted with older adults living in long-term care facilities, this strategy showed high specificity and good accuracy for caries screening and for classifying the need for dental care, when compared to the clinical face-to-face exam. Authors highlight that this model can optimize triage and referral processes, besides expanding access to care by requiring less technological infrastructure and offering greater operational flexibility for professionals [8].

In line with this evidence, the results of this study demonstrated the feasibility of using teledentistry for remote monitoring of homebound older adults. Through the Intervention Appropriateness Measure (IAM), the Feasibility of Intervention Measure (FIM), and the Acceptability of Intervention Measure (AIM), a favorable perception regarding the implementation of the intervention was observed. The IAM suggests that the teledentistry proposal made sense in the reality of the homebound older person, and the FIM points to a technical feasibility of the STT platform. These findings reinforce the potential of teledentistry as a remote care strategy, favored by the advancement of information and communication technologies in health [35].

However, the mean AIM score was the lowest among the three instruments, suggesting that factors related to participants’ interaction with the utilized web platform may have influenced this perception. A possible explanation for this result is digital health literacy, defined as the ability to seek, understand, evaluate, and use health information from electronic environments [36]. Although this competence was not directly evaluated in this study, low levels of digital health literacy can hinder the use of digital services, compromise informed decision-making, and represent a challenge for the implementation of digital health strategies [37].

5. Conclusions

The study evidenced that homebound older adults could present general and oral frailty, associated with functional limitations and barriers to accessing traditional dental services. This reinforces the need for strategies such as home care and teledentistry, which expand access and ensure the longitudinal follow-up of this population.

The results demonstrated that teledentistry has good potential for remote monitoring of homebound older adults, allowing the application of instruments for evaluating general frailty, oral frailty, and oral health-related quality of life. The pilot study allowed the identification of barriers and facilitators related to the implementation of teledentistry.

Although remote monitoring was technically viable, barriers related to digital health literacy suggest that its use should occur complementarily to face-to-face care, integrating teledentistry and home visits according to the users’ needs.

Finally, despite the limitations inherent to the pilot design and the small sample size, this study provides subsidies for improving the proposed protocol and for the development of future research on the implementation and effectiveness of teledentistry in Primary Health Care.