Trial Outcomes & Findings for Oral Hygiene in Assisted Living (NCT NCT03892200)

Last Updated: 2026-04-16

Results Overview

The Plaque Index for Long-Term Care (PI-LTC) is a modification of the Simplified Oral Hygiene Index. It is derived by separately scoring the buccal and lingual surfaces of six sextants in the mouth (left, front, and right regions of the upper and lower jaw), resulting in 12 separate observations for residents with a full set of teeth; sextants not containing teeth do not receive a score. Within each sextant, the tooth surface with the worst plaque is scratched using an explorer and assigned a score (0=no plaque or stain present; 1=soft plaque covering not more than one third of the tooth surface or presence of extrinsic stains without other plaque regardless of surface area covered; 2=soft plaque covering between one third and two thirds of the tooth surface; or 3=soft plaque covering more than two thirds of the exposed tooth surface). PI-LTC scores range from 0-3 and are the average sextant score. Lower scores are better.

Recruitment status

COMPLETED

Study phase

Target enrollment

1405 participants

Primary outcome timeframe

Baseline Visit

Results posted on

2026-04-16

Participant Flow

For Aims 2 and 3, assisted living (AL) communities were recruited and randomized to treatment arms. Within communities, AL residents (primary participants) were recruited for observation at up to 3 timepoints (baseline, 4 months, 8 months). A total of 200+214=414 residents across 24+28=52 communities were enrolled. AL Staff (983=461+366+156) and public health dental hygienists (n=8) were also enrolled as secondary participants (not randomized and did not receive the intervention). Total = 1405.

AL residents (n=414, primary) and dental hygienists (n=8, secondary) were interviewed at baseline and 4-months. AL staff (n=983=461+366+156, secondary) completed cross-sectional surveys at up to 3 timepoints but were not followed individually. To represent these different groups, they are shown below as "periods". The study protocol also describes instrument development in Aim 1 but it does not meet the definition for a clinical trial and is not included here.

Unit of analysis: Assisted living communities

Participant milestones

Participant milestones
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
AL Residents (Primary Participants) STARTED	101 12	99 12	121 14	93 14
AL Residents (Primary Participants) Plaque Index Data Provided (Baseline)	84 12	80 12	98 14	78 14
AL Residents (Primary Participants) Gingival Index Data Provided (Baseline)	82 12	78 12	98 14	77 14
AL Residents (Primary Participants) Denture Index Data Provided (Baseline)	24 12	19 12	30 14	16 14
AL Residents (Primary Participants) Plaque Index Data Provided (Month 4)	64 12	59 11	83 13	69 14
AL Residents (Primary Participants) Gingival Index Data Provided (Month 4)	64 12	59 11	83 13	69 14
AL Residents (Primary Participants) Denture Index Data Provided (Month 4)	21 12	11 11	27 13	13 14
AL Residents (Primary Participants) Plaque Index Data Provided (Baseline and Month 4)	61 12	56 11	80 13	66 14
AL Residents (Primary Participants) Gingival Index Data Provided (Baseline and Month 4)	61 12	55 11	80 13	65 14
AL Residents (Primary Participants) Denture Index Data Provided (Baseline and Month 4)	18 12	10 11	24 13	13 14
AL Residents (Primary Participants) Plaque Index Data Provided (Month 8)	50 11	43 9	0 0	0 0
AL Residents (Primary Participants) Gingival Index Data Provided (Month 8)	50 11	43 9	0 0	0 0
AL Residents (Primary Participants) Denture Index Data Provided (Month 8)	15 11	9 9	0 0	0 0
AL Residents (Primary Participants) COMPLETED	82 12	65 11	104 13	81 14
AL Residents (Primary Participants) NOT COMPLETED	19 0	34 1	17 1	12 0
AL Staff at Baseline (Secondary) STARTED	116 12	117 12	117 14	111 14
AL Staff at Baseline (Secondary) COMPLETED	116 12	117 12	117 14	111 14
AL Staff at Baseline (Secondary) NOT COMPLETED	0 0	0 0	0 0	0 0
AL Staff at 4-months (Secondary) STARTED	97 12	82 11	103 13	84 14
AL Staff at 4-months (Secondary) COMPLETED	97 12	82 11	103 13	84 14
AL Staff at 4-months (Secondary) NOT COMPLETED	0 0	0 0	0 0	0 0
AL Staff at 8-months (Secondary) STARTED	82 11	74 9	0 0	0 0
AL Staff at 8-months (Secondary) COMPLETED	82 11	74 9	0 0	0 0
AL Staff at 8-months (Secondary) NOT COMPLETED	0 0	0 0	0 0	0 0
Dental Hygienists (Secondary) STARTED	0 0	0 0	0 0	8 14
Dental Hygienists (Secondary) COMPLETED	0 0	0 0	0 0	8 14
Dental Hygienists (Secondary) NOT COMPLETED	0 0	0 0	0 0	0 0

Reasons for withdrawal

Reasons for withdrawal
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
AL Residents (Primary Participants) Death	10	19	2	6
AL Residents (Primary Participants) Resident discharged from AL community	9	9	11	6
AL Residents (Primary Participants) Resident found to be ineligible after baseline	0	1	0	0
AL Residents (Primary Participants) Assisted Living (AL) community withdrew from study	0	5	4	0

Baseline Characteristics

Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	Standard Mouth Care-Aim2 n=12 AL Communities Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=12 AL Communities The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=14 AL Communities Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=14 AL Communities The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.	Total n=52 AL Communities Total of all reporting groups
Age, Continuous AL Residents at Baseline (Primary)	83.6 years STANDARD_DEVIATION 8.9 • n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	83.8 years STANDARD_DEVIATION 9.0 • n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	79.9 years STANDARD_DEVIATION 10.4 • n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	82.8 years STANDARD_DEVIATION 8.6 • n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	82.4 years STANDARD_DEVIATION 9.5 • n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Age, Continuous AL Staff at Baseline (Secondary)	41.0 years STANDARD_DEVIATION 13.3 • n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	37.5 years STANDARD_DEVIATION 13.6 • n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	38.5 years STANDARD_DEVIATION 13.8 • n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	37.6 years STANDARD_DEVIATION 14.1 • n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	39.2 years STANDARD_DEVIATION 13.5 • n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Age, Continuous AL Staff at 4-Months (Secondary)	42.9 years STANDARD_DEVIATION 13.5 • n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	39.0 years STANDARD_DEVIATION 13.2 • n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	38.5 years STANDARD_DEVIATION 14.6 • n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	40.2 years STANDARD_DEVIATION 14.7 • n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	40.2 years STANDARD_DEVIATION 14.2 • n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Age, Continuous AL Staff at 8-Months (Secondary)	41.6 years STANDARD_DEVIATION 13.8 • n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	38.3 years STANDARD_DEVIATION 13.0 • n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	40.0 years STANDARD_DEVIATION 13.5 • n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Age, Continuous Dental Hygienists at Baseline (Secondary)	—	—	—	44.3 years STANDARD_DEVIATION 9.4 • n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	44.3 years STANDARD_DEVIATION 9.4 • n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Residents (Primary) · Female	71 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	71 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	83 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	69 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	294 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Residents (Primary) · Male	28 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	24 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	36 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	22 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	110 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Residents (Primary) · Not Reported	2 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	10 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at Baseline (Secondary) · Female	105 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	105 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	98 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	95 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	403 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at Baseline (Secondary) · Male	8 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	5 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	23 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at Baseline (Secondary) · Not Reported	3 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	8 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	14 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	10 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	35 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at 4-Months (Secondary) · Female	83 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	74 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	86 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	74 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	317 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at 4-Months (Secondary) · Male	6 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	16 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at 4-Months (Secondary) · Not Reported	8 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	13 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	33 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at 8-Months (Secondary) · Female	72 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	69 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	141 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at 8-Months (Secondary) · Male	6 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	8 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized AL Staff at 8-Months (Secondary) · Not Reported	4 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	3 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	7 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized Period: Dental Hygienists (Secondary) · Female	—	—	—	8 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	8 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized Period: Dental Hygienists (Secondary) · Male	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Sex/Gender, Customized Period: Dental Hygienists (Secondary) · Not Reported	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Residents (Primary) · Hispanic or Latino	2 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	7 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Residents (Primary) · Not Hispanic or Latino	97 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	93 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	117 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	89 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	396 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Residents (Primary) · Unknown or Not Reported	2 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	3 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	11 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at Baseline (Secondary) · Hispanic or Latino	3 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	5 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	12 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	26 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at Baseline (Secondary) · Not Hispanic or Latino	82 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	81 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	80 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	76 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	319 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at Baseline (Secondary) · Unknown or Not Reported	31 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	31 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	25 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	29 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	116 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at 4-Months (Secondary) · Hispanic or Latino	5 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	14 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at 4-Months (Secondary) · Not Hispanic or Latino	66 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	62 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	77 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	60 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	265 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at 4-Months (Secondary) · Unknown or Not Reported	26 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	19 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	22 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	20 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	87 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at 8-Months (Secondary) · Hispanic or Latino	6 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	6 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at 8-Months (Secondary) · Not Hispanic or Latino	50 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	59 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	109 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) AL Staff at 8-Months (Secondary) · Unknown or Not Reported	26 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	15 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	41 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) Dental Hygienists (Secondary) · Hispanic or Latino	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) Dental Hygienists (Secondary) · Not Hispanic or Latino	—	—	—	8 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	8 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Ethnicity (NIH/OMB) Dental Hygienists (Secondary) · Unknown or Not Reported	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Residents (Primary) · American Indian or Alaska Native	0 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Residents (Primary) · Asian	0 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Residents (Primary) · Native Hawaiian or Other Pacific Islander	0 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Residents (Primary) · Black or African American	11 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	7 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	19 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	11 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	48 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Residents (Primary) · White	87 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	87 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	99 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	79 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	352 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Residents (Primary) · More than one race	0 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Residents (Primary) · Unknown or Not Reported	3 Participants n=101 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	3 Participants n=99 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=121 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=93 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	10 Participants n=414 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at Baseline (Secondary) · American Indian or Alaska Native	5 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	11 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at Baseline (Secondary) · Asian	1 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at Baseline (Secondary) · Native Hawaiian or Other Pacific Islander	0 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at Baseline (Secondary) · Black or African American	66 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	51 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	39 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	49 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	205 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at Baseline (Secondary) · White	40 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	54 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	57 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	40 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	191 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at Baseline (Secondary) · More than one race	1 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	3 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	14 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at Baseline (Secondary) · Unknown or Not Reported	3 Participants n=116 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	11 Participants n=117 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	10 Participants n=111 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	28 Participants n=461 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 4-Months (Secondary) · American Indian or Alaska Native	2 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	3 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	3 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	8 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 4-Months (Secondary) · Asian	0 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	3 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 4-Months (Secondary) · Native Hawaiian or Other Pacific Islander	1 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	11 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	13 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 4-Months (Secondary) · Black or African American	55 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	41 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	39 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	36 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	171 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 4-Months (Secondary) · White	29 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	33 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	44 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	26 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	132 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 4-Months (Secondary) · More than one race	3 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	5 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	4 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	12 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 4-Months (Secondary) · Unknown or Not Reported	7 Participants n=97 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	5 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	9 Participants n=103 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	6 Participants n=84 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	27 Participants n=366 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 8-Months (Secondary) · American Indian or Alaska Native	1 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	1 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 8-Months (Secondary) · Asian	0 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	1 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 8-Months (Secondary) · Native Hawaiian or Other Pacific Islander	1 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	1 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 8-Months (Secondary) · Black or African American	36 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	36 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	72 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 8-Months (Secondary) · White	34 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	35 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	69 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 8-Months (Secondary) · More than one race	4 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	4 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) AL Staff at 8-Months (Secondary) · Unknown or Not Reported	6 Participants n=82 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	2 Participants n=74 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	—	—	8 Participants n=156 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) Dental Hygienists (Secondary) · American Indian or Alaska Native	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) Dental Hygienists (Secondary) · Asian	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) Dental Hygienists (Secondary) · Native Hawaiian or Other Pacific Islander	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) Dental Hygienists (Secondary) · Black or African American	—	—	—	1 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	1 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) Dental Hygienists (Secondary) · White	—	—	—	7 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	7 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) Dental Hygienists (Secondary) · More than one race	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Race (NIH/OMB) Dental Hygienists (Secondary) · Unknown or Not Reported	—	—	—	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.	0 Participants n=8 Participants • Rows show different study populations (not one population followed over time). AL staff (secondary) completed cross-sectional interviews at up to 3 timepoints and were not followed individually. Baseline characteristics are summarized by the number of participants surveyed at each timepoint.
Region of Enrollment United States	396 Participants n=396 Participants	372 Participants n=372 Participants	341 Participants n=341 Participants	296 Participants n=296 Participants	1405 Participants n=1405 Participants

PRIMARY outcome

Timeframe: Baseline Visit

Population: This measure only applies to Aim2. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=84 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=80 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Plaque Index Score for Long-Term Care (PI-LTC) - Baseline-Aim2	1.6 score on a scale Standard Deviation 0.7	1.6 score on a scale Standard Deviation 0.7	—	—

PRIMARY outcome

Timeframe: 4 Months Follow-up Visit

Population: This measure only applies to Aim2. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=64 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=59 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Plaque Index Score for Long-Term Care (PI-LTC) - 4 Months-Aim2	1.6 score on a scale Standard Deviation 0.7	1.3 score on a scale Standard Deviation 0.7	—	—

PRIMARY outcome

Timeframe: Change from Baseline to 4 months

Population: This measure only applies to Aim2. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=61 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=56 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Change in Plaque Index Score for Long-Term Care (PI-LTC) - 4 Months-Aim2	0.1 score on a scale Standard Deviation 0.6	-0.3 score on a scale Standard Deviation 0.6	—	—

PRIMARY outcome

Timeframe: Baseline Visit

Population: This measure only applies to Aim2. All data are reported.

The Gingival Index for Long-Term Care (GI-LTC) is a modification of the Gingival Index. Within each sextant, the most inflamed gingival surface is identified, swept using an explorer, and assigned a score (0=no inflammation; 1=mild inflammation, slight change in color, little change in texture; 2=moderate inflammation, glazing, redness, edema, and/or hypertrophy; or 3=severe inflammation, marked redness, edema and/or hypertrophy of the marginal or papillary gingival unit, spontaneous bleeding, congestion, or ulceration). Overall GI-LTC scores range from 0-3 and are the average sextant score. Lower scores are better.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=82 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=78 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Gingival Index Score for Long-Term Care (GI-LTC) - Baseline-Aim2	1.8 score on a scale Standard Deviation 0.9	1.7 score on a scale Standard Deviation 0.9	—	—

PRIMARY outcome

Timeframe: 4 Months Follow-up Visit

Population: This measure only applies to Aim2. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=64 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=59 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Gingival Index Score for Long-Term Care (GI-LTC) - 4 Months-Aim2	1.7 score on a scale Standard Deviation 0.9	1.3 score on a scale Standard Deviation 0.8	—	—

PRIMARY outcome

Timeframe: Change from Baseline to 4 Months

Population: This measure only applies to Aim2. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=61 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=55 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Change in Gingival Index Score for Long-Term Care (GI-LTC) - 4 Months-Aim2	0.0 score on a scale Standard Deviation 0.7	-0.3 score on a scale Standard Deviation 0.6	—	—

PRIMARY outcome

Timeframe: Baseline Visit

Population: This measure only applies to Aim2. All data are reported.

The Denture Plaque Index (DPI) is scored by removing the denture, placing it in a bath of disclosing solution for 30 seconds, rinsing it under lukewarm water for 15 seconds, and assigning a score to each of four quadrants (upper and lower, and lingual and buccal) as follows: 0=no plaque, 1=light plaque (1-25% of area covered), 2=moderate plaque (26-50% of area covered), 3=heavy plaque (51-75% of area covered), or 4=very heavy plaque (76 100% of area covered). DPI is reported as the mean score of all quadrants and lower scores are better.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=24 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=19 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Denture Plaque Index Score (DPI) - Baseline-Aim2	2.7 score on a scale Standard Deviation 1.1	2.3 score on a scale Standard Deviation 1.2	—	—

PRIMARY outcome

Timeframe: 4 Months Follow-up Visit

Population: This measure only applies to Aim2. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=21 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=11 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Denture Plaque Index Score (DPI) - 4 Months-Aim2	2.4 score on a scale Standard Deviation 1.1	1.8 score on a scale Standard Deviation 1.3	—	—

PRIMARY outcome

Timeframe: Change from Baseline to 4 months

Population: This measure only applies to Aim2. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=18 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=10 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Change in Denture Plaque Index Score (DPI) - 4 Months-Aim2	-0.2 score on a scale Standard Deviation 1.2	-0.7 score on a scale Standard Deviation 1.2	—	—

PRIMARY outcome

Timeframe: Baseline Visit

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=98 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=78 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Plaque Index Score for Long-Term Care (PI-LTC) - Baseline-Aim3	—	—	1.5 score on a scale Standard Deviation 0.8	1.7 score on a scale Standard Deviation 0.8

PRIMARY outcome

Timeframe: 4 Months Follow-up Visit

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=83 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=69 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Plaque Index Score for Long-Term Care (PI-LTC) - 4 Months-Aim3	—	—	1.5 score on a scale Standard Deviation 0.7	1.5 score on a scale Standard Deviation 0.7

PRIMARY outcome

Timeframe: Change from Baseline to 4 months

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=80 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=66 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Change in Plaque Index Score for Long-Term Care (PI-LTC) - 4 Months-Aim3	—	—	0.0 score on a scale Standard Deviation 0.6	-0.2 score on a scale Standard Deviation 0.8

PRIMARY outcome

Timeframe: Baseline Visit

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=98 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=77 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Gingival Index Score for Long-Term Care (GI-LTC) - Baseline-Aim3	—	—	1.2 score on a scale Standard Deviation 0.9	1.5 score on a scale Standard Deviation 0.8

PRIMARY outcome

Timeframe: 4 Months Follow-up Visit

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=83 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=69 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Gingival Index Score for Long-Term Care (GI-LTC) - 4 Months-Aim3	—	—	1.2 score on a scale Standard Deviation 0.7	1.2 score on a scale Standard Deviation 0.8

PRIMARY outcome

Timeframe: Change from Baseline to 4 months

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=80 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=65 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Change in Gingival Index Score for Long-Term Care (GI-LTC) - 4 Months-Aim3	—	—	-0.0 score on a scale Standard Deviation 0.7	-0.3 score on a scale Standard Deviation 0.8

PRIMARY outcome

Timeframe: Baseline Visit

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=30 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=16 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Denture Plaque Index Score (DPI) - Baseline-Aim3	—	—	2.7 score on a scale Standard Deviation 1.0	2.4 score on a scale Standard Deviation 0.9

PRIMARY outcome

Timeframe: 4 Months Follow-up visit

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=27 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=13 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Denture Plaque Index Score (DPI) - 4 Months-Aim3	—	—	2.3 score on a scale Standard Deviation 1.3	1.7 score on a scale Standard Deviation 1.2

PRIMARY outcome

Timeframe: Change from Baseline to 4 months

Population: This measure only applies to Aim3. All data are reported.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=24 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=13 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Change in Denture Plaque Index Score (DPI) - 4 Months-Aim3	—	—	-0.5 score on a scale Standard Deviation 1.0	-0.8 score on a scale Standard Deviation 1.0

SECONDARY outcome

Timeframe: Cumulative from Baseline to Completion (up to 8 months)

Population: This measure only applies to Aim2. All data are reported.

The total number of AL residents diagnosed with pneumonia.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=101 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=99 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Number of Participants Diagnosed With Pneumonia-Aim2	5 Participants	4 Participants	—	—

SECONDARY outcome

Timeframe: Cumulative from Baseline to Completion (up to 8 months)

Population: This measure only applies to Aim2. All data are reported.

The total number AL residents with hospitalizations.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 n=101 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 n=99 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Number of Participants With Hospitalizations-Aim2	12 Participants	18 Participants	—	—

SECONDARY outcome

Timeframe: Cumulative from Baseline to Completion (up to 4 months)

Population: This measure only applies to Aim3. All data are reported.

The total number of AL residents diagnosed with pneumonia.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=121 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=93 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Number of Participants Diagnosed With Pneumonia-Aim3	—	—	3 Participants	0 Participants

SECONDARY outcome

Timeframe: Cumulative from Baseline to Completion (up to 4 months)

Population: This measure only applies to Aim3. All data are reported.

The total number of AL residents with hospitalizations.

Outcome measures

Outcome measures
Measure	Standard Mouth Care-Aim2 Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim2 The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim2 the intervention training is delivered by a research dental hygienist. Aim2 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim2 the intervention training is delivered by a research dental hygienist.	Standard Mouth Care-Aim3 n=121 Participants Assisted living communities will continue to provide standard mouth care to all residents. Assisted living staff will not receive training or supplies in the control condition.	Daily Mouth Care-Aim3 n=93 Participants The intervention being tested is a standardized educational and skill-building program for use in assisted living communities, which highlights that mouth care is infection control (e.g., can reduce pneumonia); includes techniques and products to clean and protect the teeth, tongue, gums, and dentures (e.g., the jiggle-sweep approach to remove plaque, use of an interdental brush instead of floss); provides strategies for care provision in special situations (e.g., broken teeth); and includes a toolkit of dementia-sensitive approaches for people who are resistant (e.g., refuse to open the mouth). It also includes information about potential dental emergencies and issues that merit assessment. For Aim3 the intervention training is delivered by state public health dental hygienists. Aim3 - Daily Mouth Care: Nursing assistants will be trained to provide daily mouth care to all residents in nursing homes. Mouth care supplies will also be provided to intervention assisted living communities. For Aim3 the intervention training is delivered by state public health dental hygienists.
Number of Participants With Hospitalizations-Aim3	—	—	12 Participants	9 Participants

Adverse Events

Standard Mouth Care-Aim2

Serious events: 20 serious events

Other events: 24 other events

Deaths: 10 deaths

Daily Mouth Care-Aim2

Serious events: 23 serious events

Other events: 35 other events

Deaths: 19 deaths

Standard Mouth Care-Aim3

Serious events: 14 serious events

Other events: 21 other events

Deaths: 2 deaths

Daily Mouth Care-Aim3

Serious events: 9 serious events

Other events: 3 other events

Deaths: 6 deaths

Serious adverse events

Other adverse events

Additional Information

Lynne Sampson, PhD, MPH

University of North Carolina at Chapel Hill

Phone: 919-843-7811

Email: [email protected]

Results disclosure agreements

Principal investigator is a sponsor employee
Publication restrictions are in place