Facial masks for COVID-19 pandemic an approach toward awareness among health practitioners

Shivani Sachdeva; Harish Saluja1; Amit Mani; Shubhangi Mani; Kirti Chawla; Syeda Nikhat Mohammadi

doi:10.4103/jhnps.jhnps_19_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 9 | Issue : 2 | Page : 136-141

Facial masks for COVID-19 pandemic an approach toward awareness among health practitioners

Shivani Sachdeva¹, Harish Saluja1², Amit Mani³, Shubhangi Mani⁴, Kirti Chawla⁵, Syeda Nikhat Mohammadi⁶
¹ Department of Periodontology, Rural Dental College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
² Department of OMFS, Rural Dental College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
³ Department of Periodontics, Rural Dental College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
⁴ Department of Orthodontics, Rural Dental College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
⁵ Department of Periodontology, Jamia Milia Islamia, New Delhi, India
⁶ Department of PHD, Rural Dental College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India

Date of Submission	08-Apr-2021
Date of Decision	19-Apr-2021
Date of Acceptance	22-Apr-2021
Date of Web Publication	17-Dec-2021

Correspondence Address:
Dr. Kirti Chawla
Jamia Milia Islamia; New Delhi
India
Shivani Sachdeva
Department of Periodontology, Rural Dental College, Pravara Institute of Medical Sciences, Loni, Maharashtra
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jhnps.jhnps_19_21

Abstract

Objective: Coronavirus pandemic is a human respiratory disease caused by the severe acute respiratory syndrome (SARS-CoV-2). The objective of the present study was to evaluate the type of mask, frequency of change, difficulties in breathing, dryness of mouth, hazards, and treatment taken for skin allergies if any due to use of facial masks in the present Coronavirus pandemic. Materials and Methods: The present survey was carried on dental practitioners for evaluating knowledge and attitude among 1640 participants. The anonymous survey was carried among different groups of age, gender, and qualifications among dentists all around the globe. SPSS 23.0 statistical software was used for statistical analysis. GraphPad Prism 6 was used for statistical analysis and visualization using Chi-square test, one-way ANOVA and post hoc test. The validity of the questionnaire was pilot tested and measured. The Chron bach's alpha value was 0.71. Results: Among the participants 46.3% used respirators such as N95, filtering facepiece respirators 2, or the equivalent. Surgical masks were used by 43.9% and the remaining used cloth masks. When inter group comparison was done for different age groups, it was found that there was a statistically significant for the type of mask used. Sixty-six percent participants reported oral malodor after using the facial masks while dryness of the mouth was reported in 41.5 and 9.1% reported acne. Conclusion: The use of face masks has become mandatory ornament along with social distancing to avoid transmission. Hypercapnia and breathing difficulties reported were less. For treating the face after long use of facial mask many of the participants reported that no treatment was taken while, others hydrated the face frequently with water, moisturizer and very few used antifungal agent.

Keywords: Breathing difficulties, contact dermatitis, COVID 19, dental aerosols, facial masks, SARS-CoV-2

How to cite this article:
Sachdeva S, Saluja1 H, Mani A, Mani S, Chawla K, Mohammadi SN. Facial masks for COVID-19 pandemic an approach toward awareness among health practitioners. J Head Neck Physicians Surg 2021;9:136-41

How to cite this URL:
Sachdeva S, Saluja1 H, Mani A, Mani S, Chawla K, Mohammadi SN. Facial masks for COVID-19 pandemic an approach toward awareness among health practitioners. J Head Neck Physicians Surg [serial online] 2021 [cited 2023 Jun 4];9:136-41. Available from: https://www.jhnps.org/text.asp?2021/9/2/136/332714

Introduction

The COVID 2019 wave has affected people all over the globe. Doctors from all fields are on the front warriors to combat this deadly pandemic. Managing dental emergency situations in such chaos is truly a challenge for the dental professionals. The virus has shown to be persistent in aerosols for hours and thus can be hazardous in the dental setup. The dental practice involves the professional using various aerosol-forming instruments such as handpieces, ultrasonic scalers, and air-water syringes. These instruments create a spray which can have particles of water, blood, saliva, microorganisms, or debris of the infected patient. The pandemic has made it essential for one and all to wear facial masks to avoid droplet transfer. Thus, the survey aims at knowing the effects of wearing facial masks for prolonged hours in the dental office and hygiene and maintenance of masks.

Materials and Methods

An anonymous survey for voluntary participation was carried out in Ahmednagar district. The total of 164 participants included the students, graduates, postgraduates, and staff working at dental colleges situated in Ahmednagar district. The subjects were grouped on demographic variables by age, gender, and qualification. There were 108 females and 60 males the subjects were scrutinized in 3 different age groups. In 18–25 years of age group, 70% subjects were there; in the age group 26–35 years, 12% and in 36–55 years only 18% subjects were there. No identifiable details were collected from the subjects. There qualification was evaluated and interpretated as bacheolar's in dental surgery and postgraduation in dental surgery.

With utmost honesty and sincerity all the participants were requested to answer the questionnaire through Google forms which was mailed to them. Their responses were recorded and plotted. The participants were enquired about the type of mask they used and how frequently they changed their masks and did they use the same mask within the dental operatory and outside the operatory. The next set of questionnaires was related to problems faced after wearing masks which revolved around the linear scale for breathing difficulties, oral malodor, dryness of mouth, rashes, or itching within the area covered with masks. Moreover, the third set of questions was about the treatment they used for itching and rashes. SPSS 23.0 (IBM Corporation, Armonk, NY) statistical software was used for statistical analysis. GraphPad Prism 6 (GraphPad Software, USA) was used for statistical analysis and visualization using Chi-square test, one-way ANOVA and post hoc test.

Results

The 164 dental professionals participated in survey undergraduate dental students who constituted 68.9% of the total sample, 11% were post graduate students and 19.5% were M. D. S staffs while staff having done bachelors in dentistry were just 0.6%. Among these 46.3% used respirators such as N95, filtering facepiece respirators 2 or the equivalent. Surgical masks were used by 43.9% and the remaining used cloth masks, the [Graph 1] depicts the type of masks used for dental professionals [Graph 1]. The results were highly significant using Chi-square tests and are depicted in [Table 1]. When intergroup comparison was done using one-way ANOVA, and post hoc test was applied for different age groups, it was found that there was a statistically significant difference between the age group of 18–25 and 26–35 years (P = 0.051) when asked about the type of mask used.

Table 1: Questionnare for different groups of age, gender, qualification

Click here to view

The frequency of change of masks among the total participants was 64.6% who changed their masks in 1–2 days, 23.2% changed in 4–5 days and the rest changed within a week's time. The [Graph 2] depicts the frequency of change in masks [Graph 2].

Table 1 shows that Chi-square test was highly statistically significant (P < 0.05) for age, gender, and qualification for all the dependent variables except for the frequency of changing the mask for age (γ 2 = 8.035; P = 0.430) which was nonsignificant. Hence, it can be interpreted that results were statistically nonsignificant for frequency of change of masks amongst different groups of age, gender, and qualification.

Although depending on the type of mask the frequency of change should be established. The cloth mask should be changed daily if used on regular basis and twice if used in operatory.

One important aspect was to survey about the use of mask inside the operatory or outside the operatory. 73.8% used a different set of masks for dental operatory and outside the operatory, while 13.4% used the same mask sometimes and 12.8% used the same mask both in the operatory and outside it. When intergroup comparison was done the results were found to be highly statistically significant in the response related to the use of the same mask in dental operatory and outside the operatory between the age groups of 18–25 and 26–35 years (P = 0.001).

Breathing difficulties were reported on the scale of 1–10. With the maximum number of participants reported the level of difficulty as 3 (14.7%). Lesser level of difficulty was experienced on higher linear scale depicted in [Graph 3]. [Graph 3]. The results were found to be highly statistically significant in terms of independent variables age, gender, and qualifications for breathing difficulties.

Sixty six percent participants reported oral malodor after using the facial masks while dryness of mouth was reported in 41.5% as depicted in [Graph 4]. On the linear scale, 26.2% were scaled as 1 while very few were scaled above 5. This inferred that dryness of mouth was present but was less severe [Graph 4].

68.3% reported with no incidence of itching, rashes, or acne on the face. While 9.1% reported acne on the face and itching around the ear lobes. For treating the face after long use of facial mask many of the participants reported that no treatment was taken while, others hydrate the face frequently with water, moisturizer, and very few used antifungal agent also.

When intergroup comparison was done using one-way ANOVA, and post hoc test was applied for different age groups, it was found that there was a statistically significant difference between the age group of 18–25 and 26–35 years (P = 0.051) when asked about the type of mask used. The results were highly statistically significant in the response of related to the use of the same mask in dental operatory and outside the operatory between the age groups of 18–25 and 26–35 years (P = 0.001).

Discussion

The present survey was carried out in Dental college of Ahmednagar district in Central India. The total participants who enrolled in the study were 164. The questionnaire was prepared and the responses were assimilated.

Protection for mask and changing time for masks

Among all the participants surgical masks were used by 43.9%, 46.3% used respirators, N 95 or equivalents to those. Cotton masks were used by very few and more in the youngest group for female. The results were statistically significant. Cotton cloth is not designed to fully filter virus particles in the nanometer range. However, it could be very helpful for asymptomatic individuals who would normally be wearing nothing, said Rodney Rohde, associate dean for research at the College of Health Professions at Texas State University though 97% of the air's virus particles can easily penetrate cloth masks.^[1]

The question how frequently the mask was changed? Among the total participants, 64.6% changed their masks in 1–2 days which showed that there was awareness in dental practitioners and results were clinically significant. The frequency of change of masks was more common for males than females and also for those having postgraduation degrees than those pursing bacheolar's degree. The results were significant both for gender and qualification.

Ever since the global pandemic hit us, researchers have been studying how long it can live on various surfaces. A new report published in The Lancet 2020… “says the infectious virus could still be present on the outer layer of a mask for up to 7 days… “Strikingly, a detectable level of the infectious virus could still be present on the outer layer of a surgical mask on day 7,” the researchers wrote.^[2] They also concluded that various disinfectants can be used to kill the novel coronavirus to clean the mask properly.

73.8% used a different set of masks for dental operatory and outside the operatory, while 12.8% used the same masks. The masks should be different for both the within the operatory and outside operatory. Depending on the type of surgery which involves high aerosol the masks within the operatory should be changed within 4 h without touching the outer surface and it should be disposed off with proper hand hygiene measures which should be taken after disposal. Cloth masks can be use outside the dental operatory but since the inner surface can harbor bacteria and fungi they should be washed regularly.

How often should we wash our masks?

The Centers for Disease Control and Prevention (CDC) recommends washing your mask at least once a day. It should be washed typically when you are done with it. CDC suggested washing your fabric mask after every use. Also touching face, nose, mouth should be avoided, and wash your hands before and after touching.^[3],[4]

Emily de Golian, a board-certified dermatologist at Dermatology Consultants in Georgia, told us that, ideally, masks should not be worn for more than 30 min because the dampness from our breath makes it less effective as a barrier against coronavirus transmission.

If you're a frontline worker or spend your time in public where social distancing measures are difficult to maintain, consider washing your fabric mask every 2 h, if possible, Marinov advised.^[5]

Whats the best way to wash masks?

World Health Organization's specifies that the temperature should be at least 60°C (140° Fahrenheit). We do not have studies on SARS-CoV-2, but the similar SARS-CoV-1 dies quickly at temperatures above 60°. You can also disinfect masks by ironing or putting them in an oven for 20 min at about 160° Fahrenheit.”^[5]

If hand washing is your only option, de Golian and Almer (2020) suggested “lathering the masks with soap and scrubbing them for at least 20 s with warm to hot water. Washing should be followed by hot air drying.” Dry your mask and ironing can be done on the highest possible heat the fabric will allow. Again, this will depend on what material was used to construct your mask.

Hypercapnia and breathing difficulties

In the present survey, breathing difficulties reported was less. On the scale of 10 maximum of participants (50%) had breathing difficulties in milder range from 0 to 3. Readings on linear scale 4–7 were considered moderate (40%) while 8–10 reported as severe breathing difficulties (10%). While very few had major difficulties and these participants who had major difficulties reported to have asthma (4%) and few were having habits of smoking (6%). According to the National Institute of Health, in rare cases, it can be really dangerous. Inhaling high levels of carbon dioxide may be life-threatening. Hypercapnia, the carbon dioxide toxicity can cause headache, double vision, vertigo, difficulty in concentrate, seizures, and suffocation due to the displacement of air. The concentration level of carbon dioxide has to be very high to really cause any harm. Around 0.4% of carbon dioxide is present in the atmosphere. To become dangerous the concentration has been around 10%.

An expert say, wearing N95 mask for a prolonged period may have alterations in their blood chemistry that can change the level of consciousness, if severe. This is most likely to happen in those who already have breathing difficulties due to smoking, obesity, chronic obstructive pulmonary disease, or asthma. Any mask including the N95 has not shown to cause carbon dioxide toxicity in healthy people. Breathing becomes harder with a mask, thus people with existing breathing problems must be careful while wearing a face mask.

Dehydration and oral malodor

Sixty-six percent participants reported oral malodor after using the facial masks while dryness of mouth was reported in 41.5%. Though few myths have been there of drinking a lot of warm water which kills the coronavirus but keeping good hydration is helpful to maintain homeostasis.

Mask contact dermatitis

In the present survey, 68.3% reported with no incidence of itching, rashes, or acne on the face. While 9.1% reported acne on the face and itching around the ear lobes.

In addition to practicing good mask hygiene, it is necessary to avoid wearing makeup beneath a face mask to prevent further occlusion of the pores. Do, however, apply sunscreen, as UVA and UVB rays and blue light all can penetrate a mask. Below, dermatologists offer solutions for common skin irritations caused by face masks, from minor to severe.

Although the CDC has not addressed how long we will be expected to wear face masks in public, some health experts say we should continue wearing them for the next 18 months, at least. Because face masks foster a micro-environment of increased humidity, friction, and heat, they can cause irritation, especially in people with underlying skin conditions. Still, “the benefit of viral protection and helping to stop the spread far outweighs the temporary risks to your skin, Blair Murphy-Rose, a board-certified dermatologist. The good news is that tweaks to your existing skincare regimen can do wonders to prevent and treat mask-induced issues.

The epidemiology of occupational skin diseases due to masks used in the healthcare settings is not well documented and epidemiological studies addressing this topic are rare. Most publications are case reports among healthcare workers during the SARS pandemic between 2002 and 2004, and most of them report adverse skin reactions to N95 masks. A study by Foo et al. in Singapore showed that 35.5% of healthcare practitioners in their cohort who used N95 mask regularly during the SARS pandemic developed adverse skin reactions. Of these patients, 59.6% developed acne, 51.4% developed facial itch and 35.8% developed a facial rash.^[6]

The participants had used moisturizers and kept the face hydrated and only few used antifungal powder on the inner surface of masks. Also, in many of the studies like one done by Donovan et al., conducted on healthcare workers used N95 face masks during the SARS pandemic in Toronto, reported contact urticaria and allergic contact dermatitis. It showed that two patients tested positive for ethylene urea melamine-formaldehyde and quaternium-15. One of these two patients also tested positive for free formaldehyde in N95 mask. They improved after acne treatment with systemic antimicrobials and topical retinoid.^[7]

Proposed approach for reusing surgical masks in COVID-19 pandemic

Furthermore, the existence of an asymptomatic carrier phase decreases the effectiveness of prevention strategies that rely on symptoms. There is a strong rationale for a universal mask policy. Wearing a face mask will not only prevent airborne viral transmission but also reduce the likelihood of one's hands touching the mouth and nose. It is particularly needed to prevent the transmission from asymptomatic medical professionals to patients and colleagues. Owing to the current shortage of masks, it is prudent to conserve masks whenever possible.^[8]

Although the United States Food and Drug Administration had approved mask decontamination by H2O2 vapor, which requires special equipment that limits its widespread application. Decontamination of masks is challenging because the filtration capacity of polypropylene is vulnerable to most commonly used sterilization methods, including autoclaving, bleach, and alcohol. The filtration layer of masks is made of melt-blown polypropylene that determines the pore size of a face mask. An analysis of 5 different decontamination methods identified dry heat as a preferred method. Although the dry heat approach did not significantly change the filtration efficiency of melt-blown polypropylene, it forms crystals at higher temperatures.^[9] The accumulation of the crystals will ultimately compromise the filtration efficiency. On the basis of the low crystallinity of poly-propylene at 708°C 3 and data demonstrating that coronavirus can be effectively inactivated at 658°C for 30 min, 4 dry heat at 658°C–708°C for 30 min should be an effective condition to decontaminate the used masks. It has been demonstrated that the filtration efficiency of a face mask is not significantly changed after up to 20 cycles of decontamination with hot air (758C) for 30 min in each cycle. Heating at 658°C–708°C can be achieved by baking in an oven, incubator, or even a blanket warmer. Although the efficiency of a mask treated under these conditions remains to be determined, this method provides a simple, straight forward and effective strategy for decontamination of used masks.^[9]

The general guideline for reuse of face masks includes:

Masks contaminated with fluids should not be reused, due to the compromise of filtration efficiency
When sanitizing with heat, place the mask in a brown paper bag, with your name on it, to avoid direct contact with the metal surface or other masks
The 0.3–10 um pore size of standard surgical face masks is much larger than the coronavirus (0.1 um) and incompletely form-fits the face.^[9]

Therefore, surgical masks should not be used when in contact with patients that are potentially positive for COVID-19.

Limitations

The drawback of the study was that it included only participants from a dental institution, the majority of whom were students as the proportion of students is more than staff. The article does not reflect the opinions from the general public and patients. The health care workers are most exposed in this pandemic so the survey was done at institutional level. Future perspective is to conduct more studies on general public and patients.

Conclusion

Future perspectives would be to carry out systematic and meta-analysis on wearing masks for a longer time interval. It's important to change masks frequently, wash them at 60° F depending on the material and its tolerance to high temperature and keep a different set of masks both in dental operatory and outside the operatory. We should keep the face and body hydrated. Washing of masks at apt. temperature is very important.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical statement

The ethical clearance was taken for the research study by institutional ethical commitee. The subjects understand that his/her/their name (s) and initials will not be published and due efforts will be made to conceal his/her/their identity, but anonymity cannot be guaranteed.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

1.	Roy K, Crawford B, Rohde R. Event information: Diagnostics, treatments, and vaccines for SARS CoV2 & COVID 19. 2020.
2.	The Lancet. Emerging understandings of 2019-nCoV. Lancet 2020;395:311.
3.	Berman E, Fowler L, Roberts JL. COVID-19 Surveillance. [Last accessed on 2020 Aug 03].
4.	Ahmad T, Haroon , Baig M, Hui J. Coronavirus disease 2019 (COVID-19) pandemic and economic impact. Pak J Med Sci 2020;36:S73-8.
5.	Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. Rational use of face masks in the COVID-19 pandemic. Lancet Respir Med 2020;8:434-6.
6.	Foo CC, Goon AT, Leow YH, Goh CL. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome – A descriptive study in Singapore. Contact Dermatitis 2006;55:291-4.
7.	Donovan J, Kudla I, Holness LD, Skotnicki-Grant S, Nethercott JR. Skin reactions following use of N95 facial masks. Dermatitis 2007;18:104.
8.	Liu Y, Leachman SA, Bar A. Proposed approach for reusing surgical masks in COVID-19 pandemic. J Am Acad Dermatol 2020;83:e53-4.
9.	van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564-7.