Face Mask Usage among Dental Practitioners at the Workplace after the COVID-19 Pandemic and Its Adverse Effects: A Cross-Sectional Survey

INTRODUCTION

Ever since its emergence in December 2019, the COVID-19 pandemic has claimed millions of lives on a global scale. What made the pandemic more dreadful was the fact that there were many uncertainties surrounding it, and very little was known about the disease or the pathogen causing it.^[1] With time, it was understood that the disease is caused by severe acute respiratory syndrome coronavirus 2, which is primarily an airborne organism spread through the respiratory mode. Therefore, to limit disease transmission, various measures such as lockdowns, social distancing, and wearing personal protective equipment (PPE) were implemented.^[2]

Health professionals continued their essential duties during the pandemic and were, thus, at a high risk of contracting the disease. Dentists are at an even greater risk owing to direct exposure to the oral cavity. Consequently, the dental professionals donned PPE kits during work hours, which was quite physically taxing.^[3] Furthermore, they were compelled to wear N95 face masks, respirators, or face shields for the remainder of the day, which continued even after the virulence of the pandemic. Over time, the compulsion to wear the facemasks for the entirety of the day waned off.^[4] However, owing to many stigmas associated with the disease, a significant proportion of healthcare professionals still opted to wear facemasks in their workplaces. This behavior was fuelled by various sources of information cautioning about the need to wear facemasks at all times to prevent contracting COVID-19.^[5] Whether or not this practice was essential is still a matter of debate.

Contradicting evidence in favor and against wearing facemasks for prolonged durations has been reported in the past 3 years. While the majority of prominent sources, including the World Health Organization, recommended wearing them to reduce the risk of transmission, a faction of sources revealed that several adverse effects are associated with the prolonged wearing of face masks.^[6] The initial sources were in the form of sporadic case reports, which later transformed into cross-sectional studies. Symptoms such as difficulty in breathing, nasal dryness and itching, dermatitis, retroauricular pain, and headaches began to be frequently reported among healthcare providers, including dental professionals. While one may consider the symptoms as minor or unalarming, the possibility of deleterious systemic effects that can occur over the long term must not be overlooked.^[7]

Studies have revealed a 300-fold contamination of face masks beyond the acceptable limit for ventilation outlets with a predominance of Staphylococcus and Bacillus species.^[8,9] Fungal colonies were also identified to have a predominance of Cladosporium.^[10] A linear relation between the colony counts of microorganisms and the duration of mask usage has also been established.^[9] The contamination of masks was found to be particularly higher in healthcare workers, highlighting the risk faced by this strata of society of developing pathologies due to prolonged mask usage.^[11]

In this context, the present study aimed to gauge the face mask-wearing patterns of dental professionals post-COVID-19 pandemic and any adverse effects experienced because of their use. The objective of the study is to rationalize the use of masks and enhance dental professionals’ awareness of the potential adverse effects associated with their use. This would aid the healthcare workers as well as the general community in carefully weighing the pros and cons of their mask-wearing patterns should a similar situation arise in the future.

MATERIAL AND METHODS

The present cross-sectional questionnaire-based survey study was conducted over a period of 2 months, from October 2022 to December 2022, in a dental institute in Navi Mumbai. The study was conducted in accordance with the Declaration of Helsinki, and the study protocol was approved by the institutional Biomedical Ethics Committee [Reference Letter No.: IEC324032022 v0.001, dated March 31, 2022].

A 30-point questionnaire was prepared based on interviews among coworkers of the dental institute for prolonged usage of masks. The questions were prepared on the adverse effects of masks as discerned from the suggestions and valid points made by all the interviewees about their own opinions and experiences, along with a vigilant review of the literature. Each effect was graded on a Likert’s scale of never, rarely, sometimes, often, and very often.

An a priori sample size was estimated using the single-proportion formula:

Assuming a 95% confidence level (Z_1−α/2 = 1.96) and an expected prevalence of mask-related adverse reactions of 54.5% based on the prospective survey by Techasatian et al. (reported prevalence of adverse skin reactions under face masks = 54.5%), the margin of error was set at 9.1% (feasibility-based for a time-bound institutional survey).^[11] The minimum required sample size was:

Accordingly, the target sample size was 115, which was achieved for the final analysis. Given the observed response rate of 82.19%, approximately 140 individuals were required to obtain the target analyzable sample, and 146 co-workers were invited during the study period.

Healthcare workers working in the hospital were included in the study based on convenience sampling. Only dental professionals working in the institute who were systematically healthy were considered eligible for inclusion. Those with physical/mental disability or respiratory disorders were excluded. Informed consent was obtained from all the participants, following which they were directly interviewed by the investigators, who recorded the responses on the questionnaire. The questionnaire (Supplementary Material) was developed through structured discussions with dental professionals to identify commonly perceived adverse effects of prolonged mask use, followed by content mapping to the available literature. Face and content validity were assessed by expert review (n = 10), yielding a content validity ratio of 0.70. Item clarity and relevance were reviewed by five subject experts, and items were refined for wording, sequence, and relevance. Test–retest reliability was evaluated in 20 participants at 2 time points, and agreement was quantified using Cohen’s kappa (κ = 0.80), indicating substantial agreement. Internal consistency reliability was evaluated for the Likert-scale items (5-point scale: never – rarely – sometimes – often – very often), and the questionnaire demonstrated a Cronbach’s α = 0.877, confirming good internal consistency across items.

All the data from the questionnaire were entered in Microsoft Excel v2019 (Redmond, Washington, USA). Then, it was retrieved in the Statistical Package for the Social Sciences (IBM, v25) software for statistical analysis. The independent variables and prevalence of adverse effects were obtained as frequency of responses in terms of number and percentage. Incomplete responses were excluded from the data analysis. In addition to descriptive statistics, inferential analyses were performed. Chi-square goodness-of-fit tests (with an equal expected distribution across response categories) were used to assess whether responses for perceived discomfort and functional difficulty items were evenly distributed. Associations between categorical variables (duration of mask use and mask type) and musculoskeletal/temporomandibular joint (TMJ) symptoms were evaluated using the Chi-square test of independence. Relationships between mask-use duration at the workplace and outdoors and self-reported symptom frequency were assessed using Spearman’s rank correlation. Differences in symptom ratings across mask types were assessed using the Kruskal–Wallis test with Bonferroni-adjusted post hoc comparisons. A two-tailed P ≤ 0.05 was considered statistically significant.

RESULTS

Descriptive statistics

A total of n = 120 participants out of 146 co-workers responded to the questionnaire, thereby giving the survey a response rate of 82.19%. Out of these, n = 115 were discerned as eligible for final data analysis [Figure 1]. The age of the study participants ranged from 19 to 50 years, with a mean of 26.16 + 8.02 years. Among these, n = 91 were females (79.1%) and n = 24 were males (20.9%). Of the total study participants, n = 92 (80%) were graduates (Bachelor of Dental Surgery) and n = 23 (20%) had completed their postgraduate degree program (Master of Dental Surgery).

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Figure 1:

STROBE flow diagram depicting the flow of the study process from selection to data analysis.

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It was observed that the participants wore face masks for variable durations at their workplace and outdoors, with an almost equal number for each category of the durations listed in Table 1. Only 14% participants wore masks for more than 6 h outdoors when not at their workplace.

Table 1: Daily duration of wearing face masks as reported by the participants.

Duration of wearing face masks	Workplace		Duration of wearing face masks	Outdoors
	n	%		n	%
2–3 h	16	13.9	1–2 h	29	25.2
3–4 h	19	16.5	3–4 h	26	22.6
4–5 h	21	18.3	4–5 h	27	23.5
5–6 h	22	19.1	5–6 h	14	12.2
6–7 h	15	13	6–7 h	8	7
>7 h	18	15.7	>7 h	8	7
Missing data	4	3.5	Missing data	3	2.6

Table 2 presents the distribution of self-reported symptoms experienced by participants following the regular use of face masks. Irritation of the face emerged as the most prevalent complaint, with over half of the respondents (approximately 82.6%) reporting it at least “sometimes” and nearly 28% experiencing it “very often.” Sweating near the mouth was another frequently reported symptom, with 73.1% of the participants acknowledging it as “often” or “very often”. Prolonged pain due to mask wear was also notable, as 58.3% reported experiencing it “often” or “very often.”

Table 2: Symptoms experienced by the participants after the use of face masks.

Symptom	Never (%)	Rarely (%)	Sometimes (%)	Often (%)	Very often (%)
Pain with headgear	8 (7.0)	16 (13.9)	47 (40.9)	31 (27.0)	12 (10.4)
Pain prolonged period	5 (4.3)	13 (11.3)	30 (26.1)	40 (34.8)	27 (23.5)
Irritate face	3 (2.6)	17 (14.8)	36 (31.3)	27 (23.5)	32 (27.8)
Discomfort	9 (7.8)	16 (13.9)	29 (25.2)	40 (34.8)	21 (18.3)
Difficulty in breathing	11 (9.6)	20 (17.4)	38 (33.0)	28 (24.3)	18 (15.7)
Difficulty to communicate	8 (7.0)	13 (11.3)	37 (32.2)	37 (32.2)	20 (17.4)
Sweating near the mouth	4 (3.5)	5 (4.3)	22 (19.1)	41 (35.7)	43 (37.4)

In contrast, fewer participants reported pain from the headgear as a consistent issue; 40.9% experienced it “sometimes,” while 27.0% and 10.4% noted it “often” and “very often,” respectively. Discomfort and difficulty in communication were also relatively common, with more than half of the participants (53.1% and 49.6%, respectively) experiencing them “often” or “very often.” Difficulty in breathing was reported frequently by nearly two-fifths of the respondents (40%), highlighting the physical strain associated with prolonged mask use.

Overall, only a small proportion of respondents, ranging from 2.6% to 9.6%, reported never experiencing any of these symptoms, while 4.3–17.4% experienced them rarely. These findings collectively indicate that extended or repetitive mask usage is commonly associated with multiple forms of physical discomfort, particularly facial irritation, sweating, and breathing difficulty.

On the contrary, dermatological and oral concerns were observed across a relatively lower proportion of the participants [Table 3]. Xerostomia was one of the most frequently reported oral concerns, with 63.5% of participants experiencing it at least occasionally (“sometimes” to “very often”), while only 36.5% never reported dryness of the mouth. Halitosis showed a similar trend, with 61.7% experiencing it to some degree and 38.3% never affected. Gingivitis and angular cheilitis were relatively uncommon, with 70.4% and 68.7% of participants, respectively, reporting they had never experienced these problems. In contrast, dermatological issues such as dermatitis and acne were more prevalent; dermatitis was reported “sometimes” to “very often” by 45.2% of participants, while acne was noted in 71.4% of respondents within the same frequency range. Headaches were also observed in 51.3% of participants at least occasionally. Overall, while inflammatory oral lesions were less frequent, conditions such as xerostomia, halitosis, acne, and dermatitis were notably common among individuals wearing masks for prolonged durations.

Table 3: Dermatological and oral concerns in the participants after wearing face masks.

Experience	Never (%)	Rarely (%)	Sometimes (%)	Often (%)	Very often (%)
Xerostomia	42 (36.5)	22 (19.1)	23 (20.0)	18 (15.7)	10 (8.7)
Halitosis	44 (38.3)	27 (23.5)	17 (14.8)	17 (14.8)	10 (8.7)
Gingivitis	81 (70.4)	13 (11.3)	12 (10.4)	6 (5.2)	3 (2.6)
Angular cheilitis	79 (68.7)	17 (14.8)	9 (7.8)	8 (7.0)	2 (1.7)
Dermatitis	44 (38.3)	19 (16.5)	22 (19.1)	17 (14.8)	13 (11.3)
Acne	27 (23.5)	6 (5.2)	24 (20.9)	27 (23.5)	31 (27.0)
Headaches	36 (31.3)	20 (17.4)	28 (24.3)	24 (20.9)	7 (6.1)

Besides these signs and symptoms, certain problems were faced by the participants in their clinical practice. Fogging of eyeglasses while working with a facemask on was reported by n = 82 (71.3%) of participants. It was reported by n = 61 (53%) participants that the patients are unable to interpret their expressions and communication when the doctors wear face masks during counseling. Furthermore, n = 113 (98%) participants acknowledged that they were forced to speak louder when wearing masks.

DISCUSSION

The objective of the present study was to describe patterns of face mask usage among dental professionals and to document self-reported adverse experiences associated with their use in the post-pandemic workplace context. Although participants were distributed across multiple workplace mask-wear duration categories (2 h to >7 h), most respondents reported wearing masks for <6 h when outdoors. This pattern suggests that while workplace duration was largely shaped by clinical requirements and individual workflow, participants tended to limit mask use outside the workplace when not mandated.^[12] This preference may reflect perceived discomfort and practical barriers associated with mask use, as reported by respondents; however, causal inferences cannot be drawn from the present cross-sectional design.

A large proportion of respondents reported pain and discomfort with prolonged mask use, which aligns with prior observations among healthcare workers. Yau et al. (2022) similarly reported a high frequency of orofacial pain associated with prolonged N95 usage and noted relatively rapid symptom relief after mask removal.^[13] The literature proposes that continuous mechanical pressure and friction from mask straps and tight facial seal may plausibly contribute to irritation and discomfort through localized skin compression and barrier disruption.^[14] Concomitant use of other headgear (e.g., spectacles and headcaps) may further increase perceived pressure points, which was commonly reported by participants in the present study.^[15] Nonetheless, mask fit, strap tension, and individual susceptibility were not objectively measured; therefore, mechanistic explanations should be interpreted as plausible hypotheses rather than confirmed causal pathways.^[16]

Participants also commonly reported breathing difficulty while wearing masks for extended periods. Prior experimental and clinical studies have discussed perceived dyspnea in relation to factors such as airflow resistance and heat/ humidity accumulation within the mask micro-environment, although physiological effects may vary by mask type, intensity of activity, and individual factors.^[17,18] Importantly, the present study captured subjective perception rather than objective physiological parameters. Headaches were also frequently reported and may be multifactorial, potentially reflecting prolonged PPE use, strap-related discomfort, hydration status, workplace stress, and ergonomic strain rather than a single mechanism.^[16,19] Accordingly, the present findings should be interpreted as symptom burden reported by dental professionals rather than evidence of direct physiological harm.

Communication challenges emerged as an important workplace concern. Masks can attenuate higher-frequency components of speech and remove non-verbal cues such as lip movements and facial expressions that support speech comprehension, especially in clinical counseling contexts.^[20,21] In the present study, participants frequently reported difficulty in communication and misinterpretation of expressions during patient counseling, consistent with literature indicating that face coverings can adversely affect perceived interaction quality and participation.^[22] Nearly all respondents reported speaking louder while masked, which may increase vocal strain and can alter perceived tone during clinical encounters.^[23] These findings represent perceived communication barriers and underscore the need for practical mitigation strategies (e.g., structured counseling, visual aids, optimized operatory acoustics) rather than implying deterministic effects.

With respect to oral symptoms, a substantial proportion of participants reported xerostomia and halitosis, whereas gingival changes were less frequently reported. The cluster of self-perceived dry mouth and malodor during mask use has been discussed under the term “mouth mask syndrome,” and prior studies have reported higher self-perceived dry mouth and halitosis among mask users, sometimes in association with longer wear duration.^[24,25] At the same time, conflicting evidence exists, with some reports suggesting minimal measurable impact on oral health indicators.^[26,27] In the present analysis, mask-use duration at the workplace did not demonstrate statistically significant correlations with most self-reported oral–facial symptoms. However, greater outdoor mask-use duration showed a small but statistically significant positive correlation with angular cheilitis and gingival changes, suggesting an association that merits confirmation in longitudinal designs. Symptom ratings were broadly comparable across mask types; halitosis was the only symptom that differed significantly by mask type, with higher ratings reported among users of 3-ply surgical masks compared with N95 users. One plausible explanation for self-perceived halitosis is heightened awareness of one’s own breath due to the physical barrier of the mask, although this remains speculative without objective malodor assessment.^[28]

Dermatological complaints were also commonly reported, particularly acne and dermatitis, which are broadly consistent with earlier reports of mask-associated skin reactions in healthcare settings.^[11] Variability across studies is expected due to differences in population characteristics, mask materials, climate, skincare practices, and reporting methods, and some studies have reported no significant increase in certain dermatologic outcomes following mask use.^[29] In the present study, dermatological findings should be interpreted cautiously because they may be influenced by unmeasured confounders such as baseline acne/dermatitis history, cosmetic use, skincare routines, hormonal factors, stress, and environmental conditions, none of which were captured in the questionnaire. Repeated friction and pressure at mask contact points have been proposed as contributors to local barrier disruption and irritation, potentially predisposing susceptible individuals to lesions in contact zones.^[30,31] However, given the study design, these explanations cannot be established as causal.

The methodological strength of the present study lies in its validated questionnaire administered in person to dental professionals in a real-world clinical setting soon after the pandemic period. Nevertheless, several limitations require emphasis. The cross-sectional design precludes establishing temporality; therefore, the findings should be interpreted as self-reported associations and symptom burden, not evidence that mask use caused the reported outcomes. Furthermore, the sample had a marked female predominance (79.1%), and potential confounders, such as pre-existing dermatological conditions (acne/dermatitis), baseline oral health status, smoking/tobacco use, hydration and medication history, occupational stress, mask reuse practices, and mask fit, were not measured or controlled, which may have influenced symptom reporting. In addition, the outcomes were self-reported and may be subject to recall and reporting bias, and clinical confirmation of oral or dermatological diagnoses was not performed. Despite a priori sample size estimation, the use of convenience sampling from a single institution may limit generalizability. Even so, the study highlights a substantial prevalence of perceived discomfort and functional challenges among dental professionals, supporting the need for pragmatic workplace measures such as scheduled mask breaks in safe areas, hygiene education regarding mask handling and replacement, and improvement in ergonomic mask design for prolonged clinical use.

CONCLUSION

Within the limitations of this cross-sectional study, mask use among dental professionals was associated with a notable self-reported symptom burden affecting comfort, breathing perception, and communication during patient care. Inferential testing indicated that these difficulties were not uniformly distributed and were consistently reported by a meaningful proportion of participants. Overall, symptom patterns showed limited dependence on workplace mask-wear duration and were broadly similar across commonly used mask types, with only selective outcomes differing. These observations support strengthening awareness regarding appropriate mask use and hygiene, and encourage adoption of feasible workplace measures and ergonomic mask designs to reduce discomfort during prolonged use.