In late 2019, a novel coronavirus was identified in China and rapidly spread throughout the world. The new virus was named SARS-CoV-2 and the disease it caused was named COVID-19. It quickly became apparent that wearing face masks could help prevent the spread of the novel coronavirus and other respiratory infections. Throughout 2020, people around the world were encouraged to wear a cloth face mask to prevent infection. Those at higher risk, such as healthcare workers, have been advised to wear surgical masks or N95 respirator masks.
Masks act as a physical barrier and stop respiratory droplets from being expelled into the air and onto other people when a person coughs, sneezes, sings or speaks loudly. While masks are an effective barrier in public settings and help slow the spread of infections like the novel coronavirus, using a mask for extended periods has led to some unwanted side effects. One of these adverse effects is mask mouth.
The adverse effects of wearing face masks on oral health can have serious consequences. However, avoiding this protective measure is not advisable because of its critical role in slowing the spread of the virus. The good news is that mask mouth is a treatable and preventable condition.
Keep reading to learn more about this new phenomenon called mask mouth, its symptoms, the risks it poses to oral health, and last but not least, what you can do to prevent it.
What is mask mouth?
Ever since people began wearing masks for extended times, dentists have been noting an increased incidence of oral health problems like bad breath, dry mouth, tooth decay, gum disease, and mouth ulcers. These symptoms have been attributed to the side effects of wearing a mask for long periods. Dental professionals have coined a new term for these adverse effects and called them “mask mouth.”
Therefore, mask mouth refers to a collection of oral symptoms that occur as a result of wearing face coverings for an extended time. Given the continuing spread of COVID-19 and the emergence of new strains of the coronavirus, it looks like face masks will be necessary at least for the foreseeable future. So, what’s the solution?
While continued use of face masks is recommended to prevent transmission of the virus and to protect both yourself and others, dental professionals also recommend taking specific measures to prevent and treat mask mouth and boost oral health. In the following paragraphs, we’ll explore some of the symptoms of mask mouth and what you can do to reduce your risk of developing it.
What causes mask mouth?
It appears that the adverse oral effects of wearing a face mask (mask mouth) occur due to several different factors, some of which are explained below.
Disruption of breathing
You have likely worn a face mask within the past year, so you know how difficult it can be to breathe properly when your nose and mouth are covered with a cloth or other material.
Studies have shown that wearing a mask can lead to rapid, shallow breathing through the mouth instead of the nose. A face covering also causes you to involve your neck and chest muscles rather than your diaphragm in how you breathe.
When you breathe through your mouth, it causes the saliva in your mouth to dry up. Saliva provides an important defense against the buildup of plaque in the oral cavity. Therefore, disrupted breathing patterns such as mouth breathing increase the risk of tooth decay, gum disease, and halitosis (longstanding bad breath). 1
Disruption of thermoregulation
Not only does wearing a protective face mask alter breathing patterns, but it also has an impact on thermoregulation (the process by which the body maintains a core internal temperature). This is because a face mask impairs the dissipation of heat through evaporation, radiation, and convection processes. Therefore, wearing a protective face covering can lead to a small but significant increase in the core body temperature as well as oral and facial temperature. This, in turn, can have significant psycho-physiological effects due to changes in brain temperature. 2
Dehydration
Staying well hydrated is important to maintain healthy teeth and gums. When you’re wearing a face mask, you tend to drink less water. The resultant dehydration can harm your oral health. Dehydration is bad for your teeth and gums because it causes dry mouth.
Dry mouth is associated with a significantly increased risk of dental problems like tooth decay and gum disease. This is because saliva plays a crucial role in clearing away food and bacteria from the mouth. When you’re dehydrated, your mouth doesn’t contain enough saliva, making it a breeding ground for bacteria, which can lead to cavities, gum disease, and halitosis (bad breath).
Dehydration is a particularly concerning problem in healthcare workers who wear PPE (personal protective equipment) in high-risk environments. The PPE can impose physiological burdens (prevent the body from functioning normally) and cause significant sweating from heat exposure. The dehydration can be further exacerbated by long working hours without adequate breaks for nutrition and hydration. Therefore, healthcare workers are at increased risk of the oral side effects of mask mouth due to dehydration. 3
Recycled air
Studies have shown that wearing a face mask causes you to breathe recycled air with a higher concentration of carbon dioxide (CO2). Although this increase in CO2 concentration in the breathing zone of the mask does not have a toxic effect on the body as a whole, it can lead to undesirable symptoms such as headache, fatigue, and poor concentration.
Also, the less-than-ideal exchange of oxygen and carbon dioxide can lead to an increase in acidity in the oral micro-environment with symptoms like bad breath and gum disease.
What are the symptoms of mask mouth?
Mask mouth symptoms can vary from person to person depending on the type and duration of mask use as well as their underlying oral health status. The most common symptoms of mask mouth are listed below.
Bad breath: Breathing recycled air and the dehydration caused by face masks can lead to halitosis (chronic bad breath). In people who already have this condition, prolonged mask wearing can worsen it. Wearing a mask can also trap strong food smells in the mouth, such as garlic and onions, increasing the chances of developing stinky breath.
Dry mouth: Prolonged mask wearing causes xerostomia (dry mouth) due to a lack of sufficient saliva in the mouth. Saliva is necessary to keep the inside of the mouth moist and to protect the oral cavity against bacteria. Another function of saliva is to maintain the pH in a neutral range in the oral cavity. If the pH in the mouth becomes acidic, it can lead to demineralization of the teeth.
Bleeding gums: Gingivitis is a dental condition characterized by swollen and bleeding gums. Prolonged use of face masks can lead to a proliferation of bacteria in the mouth, leading to a buildup of plaque, which can advance to inflammation and infection of the gum tissues.
Cavities: Dentists are reporting an increased incidence of dental caries since the pandemic began and suspect it could be due to the use of face masks. The culprit is mouth breathing and drying of the saliva. Saliva usually protects the teeth from getting cavities.
Mouth sores: Face masks trap the warm, moist air that is exhaled from the lungs. This creates a perfect environment for bacteria and yeast to flourish. Prolonged or incorrect use of face masks can lead to a variety of problems ranging from acne flares to angular cheilitis (cracked and ulcerated skin at the corners of the mouth). In particular, a yeast called Candida loves the humid climate created by wearing a mask. The trapped moisture becomes a breeding ground for Candida, leading to redness and inflammation. If you do not moisturize your lips or are constantly licking them dry, this can further exacerbate your symptoms of mask mouth.
What are the risks of mask mouth?
Let’s examine some of the consequences of prolonged mask use in more detail.
Hyperventilation
Wearing a cloth face mask increases the resistance to airflow. In response to this increased resistance, the mask wearer takes shorter, more rapid breaths, inhaling and exhaling at a faster rate than normal. This shallow, rapid breathing is called hyperventilation, and it can have both short- and long-term adverse effects throughout the body.
Mouth breathing
During normal breathing, the diaphragm, a muscle that separates the chest from the abdomen, contracts and flattens, pulling air into the lungs. The inhalation and exhalation of air through the nose is effortless, silent, and regular. Wearing a mask encourages abnormal mouth breathing, which is faster, irregular, and involves the neck and chest muscles. Breathing through the mouth dries the inside of the mouth, leading to a change in the type of bacteria present there. This change in the microbiome of the oral cavity promotes tooth decay and gum disease.
Increased oral temperature
Studies have found that wearing a surgical or N95 mask for as little as 30 minutes can lead to a significant rise in oral temperature and body temperature. 4Studies have also shown a link between normal body temperature and healthy teeth. 5In other words, normal body temperature is necessary to prevent tooth decay. Mask wearing may indirectly promote tooth decay by increasing the temperature in the oral cavity and the core. However, further research is needed to establish this connection with more authority.
How to prevent mask mouth?
Even if you’re experiencing some of the symptoms of mask mouth, you still have to keep wearing your mask to protect yourself and others from COVID-19. However, you can undertake the following preventive measures to reduce the impact of mask wearing on your oral health.
Practice deep breathing
Make it a habit to take 5 deep breaths before putting on your mask, immediately after putting it on, and again after removing it. A deep breath consists of inhaling for 4 seconds through the nose, exhaling for 6 seconds, pausing for 2 seconds, and repeating the process. Taking deep breaths before and immediately after wearing your mask will help set a healthy breathing pattern. It will prevent you from automatically going into an unhealthy pattern of rapid, shallow breathing. While you have your mask on, remind yourself to take longer, slower breaths.
Train your respiratory muscles
Respiratory muscle training is known to improve the strength of the respiratory muscles, enhance exercise capacity, and reduce breathlessness. People with weak respiratory muscles are at increased risk of poorer outcomes from respiratory infections like the coronavirus. Regular respiratory muscle training for 5 minutes in the mornings and evenings will allow you to take deeper, fuller breaths while wearing a mask. You can do this by practicing slow, deep, diaphragmatic breathing. You can also use a hand-held inspiratory/expiratory muscle training device.
Take regular breaks
If you need to wear a mask for prolonged periods, make it a habit to take regular breaks. Find an area, preferably outdoors in the fresh air, where you are not near any other people. When it is safe and you can maintain social distancing, take a breathing break by taking your mask off.
Limit mask time
There are many ways to protect yourself and your friends and family against the novel coronavirus. Wearing a mask is one of them, but it comes with the risk of developing mask mouth. You can reduce the amount of time you spend wearing a mask by practicing behaviors like going out less, avoiding crowded public places, and limiting contact with people who aren’t members of your household. When you remain in environments that don’t require you to wear a mask, you automatically drastically reduce your risk of getting mask mouth.
Stay hydrated
Staying well hydrated is always important, but more so when you are wearing a face mask or have started experiencing symptoms of mask mouth. In addition to drinking at least 8 glasses of water every day, it can also be helpful if you limit dehydrating beverages like caffeine and alcohol.
Wear a clean face mask
The whole idea of wearing a face mask is to prevent infection. It is, therefore, imperative that you regularly replace or wash your mask to prevent bacterial growth and virus transmission. The CDC recommendation is to wash a cloth face mask every day and to throw out a disposable mask after each use.
Use your mask properly
It’s important to use the correct type of mask based on your lifestyle and to use the proper technique when wearing the mask. This can help reduce the chances of your developing mask mouth. For instance, wearing a mask that is too tight can restrict the flow of air, causing mouth breathing and dry mouth.
Protect your skin
Apply moisturizers or emollient creams to prevent skin breakdown and ulceration on the corners of your mouth.
Avoid unhealthy stress eating
From banana bread binges to quarantinis, the pandemic has led to a surge in eating unhealthy, sugar-rich foods that are bad for your teeth. The consumption of excessive sugar disrupts the delicate balance of the oral microbiome, leading to a proliferation of microbes that metabolize simple carbohydrates. The microbes do this by releasing acids which can damage the enamel of your teeth and cause cavities. That’s why it’s important to stick to a healthy diet. Besides promoting overall health, it will reduce the risk of mask mouth.
Quick fixes don’t work
If you have developed bad breath as a result of mask mouth, you may think using a breath mint is a quick and effective solution. However, while this will take care of your mask mouth symptom of stinky breath temporarily, it will not address the root cause of the problem. What’s more, it might even do more harm than good because it may prevent you from seeking timely dental care.
Focus on oral health
Face masks will be a part of our lives for the near future at least. So, mask mouth will continue to be a potential problem in the coming months, if not years. With daily routines upended by the pandemic, many people have become lax about dental hygiene. However, to prevent symptoms of mask mouth, you need to take extra care in terms of your oral health. This means making sure you’re brushing your teeth twice a day, rinsing your mouth after meals, and flossing or using other interdental devices once a day. If you speed through the routine of brushing your teeth in the morning rush, start spending an extra minute or two making sure you’re brushing in every nook and cranny of your mouth.
Use mouthwash between brushings
Ask your dentist to recommend a mouthwash that doesn’t cause dry mouth. Use the mouthwash between teeth brushings to freshen your breath and fight mouth bacteria. Another option is chewing sugar-free gum which can promote saliva production, reduce symptoms of dry mouth, treat bad breath, and remove food debris from between teeth.
Get regular dental checks
With shelter-in-place orders and self-quarantines, many people have put off getting their regular dental checkups. However if you are developing problems related to mask mouth, the sooner they are caught, the less harm they are likely to cause. That’s why, now more than ever, it is important to stay on top of your preventive dental check-ups.
Contact a dental professional
If you notice any symptoms like bleeding gums, bad breath, discolored teeth, pain and tenderness, do not delay seeing your dentist and getting appropriate treatment. Mask mouth increases your chances of getting an oral infection and you should seek professional care as soon as possible if you have any worrisome symptoms. Your dentist may recommend fluoride application, varnishing, scaling, or other preventive procedures to help reduce the risk of mask mouth.
The bottom line
Dental professionals are still trying to understand the short- and long-term implications of mask mouth. But one thing is certain, mask mouth is more than just an inconvenience. Dentists say they are seeing inflammation in gums that were previously healthy and cavities in people who never had them before. Therefore, mask mouth can have serious consequences on oral health and should not be ignored.
There is insufficient data at present to justify reduced adherence to face masks because of mask mouth. However, only time will tell whether mask mouth has permanent consequences and what its long-term implications on oral health are. In the meantime, you can be proactive by taking steps to reduce your risk of mask mouth while still adhering to mask wearing protocols to protect yourself and your loved ones from the COVID-19 virus and other respiratory infections.
Express Dentist is a nationwide toll-free hotline in the United States that can help you find emergency dental care any time of the day or night. We are a national network of top-rated dental professionals that can help you deal with the symptoms of mask mouth or other dental problems like cracked or chipped teeth, toothache, and tooth abscess. Call us on 1-844-593-0591 to find high-quality dental care near you. Choose from our exhaustive list of emergency dentists.
About the author
Dr. Greg Grillo
Dr. Greg Grillo DDS studied at the University of Washington where he received a bachelors degree with Honors and later attended dental school on the same campus. Following school Dr. Greg served in the United States Navy as a dental officer. During this time he received advanced training in specialty areas of dentistry while also treating families of members of the military.
As well as sharing valuable information on dentistry and oral health, Dr. Greg remains a practicing dentist to this day. He works with families in the Okanogan Valley where he lives with his wife and three children.
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- CDC. The Physiological Burden of Prolonged PPE Use on Healthcare Workers during Long Shifts. Available online. Accessed on January 9, 2021.
- Hong Kong Journal of Emergency Medicine. The effect of wearing a face mask on body temperature. Available online. Accessed on January 9, 2021.
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