‘Mask Mouth’- a novel threat to oral health in the COVID era – Dr Pooja Muley
Today the use of face masks has become necessary and ubiquitous due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Even though a face mask protects the user from SARS-CoV-2 infection, it has certain adverse effects. One of the new and recently noticed side effect is on the oral health of the wearer known as ‘Mask Mouth’. This includes symptoms like caries, gingivitis, halitosis, candidiasis and angular cheilitis. But a positive aspect of the mask-mouth is that it can be easily prevented and treated. In this article, we will see this new phenomenon, its aetiology, symptoms and prevention.
Presently the humanity is threatened by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Hence the wearing of face masks has become necessary and ubiquitous, not only in hospitals but also in the community. Even though the use of a face mask protects the user from SARS-CoV-2 infection, it has certain adverse effects. Headaches, difficulty in communication, eye discomfort, breathlessness, impaired cognition and acne were all recognized as common adverse effects. One of the new and recently noticed side effect is on the oral health of the wearer. A new term has been coined for this phenomenon – ‘Mask Mouth’.
Dentists all over the world have started to notice an increase in patients with complaints of halitosis, gingivitis, ulcers and caries. All these symptoms are being linked to the excessive and improper use of a mask.
Etiology Mask mouth is triggered by covering mouth for longer periods of time which increases the dryness of the mouth. Also, there is an increased incidence of mouth breathing when using a mask. Mouth breathing causes surface dehydration and reduced salivary flow rate (SFR). When the salivary function is diminished, there is more risk of patient’s developing caries, gingivitis, halitosis and having diseases such as candidiasis than there is in patients who have normal SFRs .
Pathophysiology of Mask Mouth:
Implications of ‘Mask Mouth’:
Dental Caries- Predisposition to caries has been placed in correlation with the entry of air through the mouth due to mouth breathing and the regular intake of fermentable carbohydrates, resulting in the formation of plaque mostly composed of acid-forming and acid-tolerable species, such as Streptococcus mutans (S. mutans) and Lactobacilli . Thus we can say prolonged use of face mask can be a predisposing factor for dental caries.
Plaque Index and Gingivitis- Mouth breathing causes reduction of buffering capacity of saliva and its flow rate. In a study conducted by Mummolo, et al (2018) it was observed that the mouth breathing subjects seem to be predisposed to develop a higher plaque index compared with healthy subjects . Studies demonstrated that mouth breathing may cause an increase in susceptibility of gingival inflammation .
Halitosis- Most of the patients having mask mouth complain about halitosis, also known as ‘mask breath’. An important factor for halitosis is the layer of debris on the tongue and tongue coating. It plays an important role in increasing volatile sulphur compounds concentration in mouth . Decrease in salivary flow rate and decreased water intake increases its severity.
Candidal Infection- Oral and decreased salivary rate dehydration due to the use of mask, may alter the oral microbiota and increase the risk for opportunistic infections, such as candidiasis.
Angular Cheilitis and Ulcers- Prolonged use of a mask creates a warm moist environment on surrounding skin of mouth which is a perfect condition for bacteria to flourish and grow. This overgrowth of bacteria can produce angular cheilitis, cracking and ulcers at the corner of the mouth.
Prevention of ‘Mask Mouth’
In today’s times, the benefits of wearing masks outweigh the adverse effects. Likewise, the adverse effects can be easily prevented by following certain principles like -
a. Mask etiquette Use proper technique to wear a mask, wearing a clean mask, avoiding mouth breathing while wearing a mask should be followed. Frequent work breaks to be incorporated into work shifts to allow for a shorter duration of mask use and reduction of PPE exposure. 
b. Preventative measures such as drinking more water throughout the day. Frequent consumption of water helps to stimulate saliva production, reduce chances of dry mouth and help in caries prevention. Likewise applying moisturizers, emollients, and barrier creams to prevent skin breakdown .
c. Oral hygiene practices- brushing teeth, tongues and the sides of our cheeks carefully 2 or 3 times a day with fluoridated toothpaste. Flossing once a day is recommended.
d. Use of mouthwashes at least once a day is advised. Using chlorhexidine mouthwash highly effective for the prevention of caries and plaque formation.
e. Dental procedures- Preventive fluoride application, prescribing 10% chlorhexidine varnish , scaling, pit and fissure sealants can help in preventing mouth mask.
f. Making the patients aware of the ‘Mask Mouth’ is very essential to prevent its implications. At present, there is insufficient data to quantify all of the adverse effects that might reduce the acceptability, adherence, and effectiveness of face masks. Urgent research is also needed on various other symptoms and implication of a mask-mouth. Also use of mouth masks cannot be avoided in current times. But a positive aspect of the mask-mouth is that it can be easily prevented and treated. So it is the need of the hour to act fast and save the population from the long term effects of ‘Mask Mouth’!
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2. P. D. Marsh, “Microbiology of dental plaque bioflms and their role in oral health and caries,” Dental Clinics of North America, vol. 54, no. 3, pp. 441–454, 2010. 3. Mummolo, S., Nota, A., Caruso, S., Quinzi, V., Marchetti, E., & Marzo, G. (2018). Salivary markers and microbial flora in mouth breathing late adolescents. BioMed research international, 2018.
4. E. Nascimento Filho, M. Mayer, P. Pontes, A. Pignatari, L. Weckx, Caries Research 2004 (38) (2004) 572–575.
5. Kanehira, T., Takehara, J., Takahashi, D., Honda, O., & Morita, M. (2004). Prevalence of oral malodor and the relationship with habitual mouth breathing in children. Journal of Clinical Pediatric Dentistry, 28(4), 285-288. 6. Johnson AT (2016) Respirator masks protect health but impact performance: A review. J Biol Eng 10: 4. 7. Darlenski R, Tsankov N (2020) Covid-19 pandemic and the skin- What should dermatologists know? Clin Dermatol. 8. Banting, D. W., Papas, A., Clark, D. C., Proskin, H. M., Schultz, M., & Perry, R. (2000). The effectiveness of 10% chlorhexidine varnish treatment on dental caries incidence in adults with dry mouth. Gerodontology, 17(2), 67-76
Dr Pooja Muley an alumna of Govt. Dental College Aurangabad has been passionately working in the field of oral medicine, diagnosis and oral radiology. She has received various national and international awards for her work in dentistry one of them is Pierre Fauchard Academy’s International Senior Student Award. She was awarded by IAOMR (Indian Academy of Oral Medicine & Radiology) for her research paper in Oral Imaging. She has presented numerous research papers in national & International conferences and received the best paper and poster prizes. She has also published research articles in various Journals & newspapers like Times of India. She was in the Editorial Board of the quarterly ‘The Dental Experts’. She has recently published her book-‘Concepts of Immunity in Oral and Maxillofacial diseases’. Dr Pooja Muley has a keen interest in creating awareness about oral health and she has given several lectures, interviews and talks in that regard. Her area of expertise is CBCT, implant planning, oral diagnosis, oral cancers, TMJ disorders, orofacial pain, sleep apnea and tobacco cessation counselling. Currently, she is working as a consultant oral radiologist and oral physician.