Masks, Bad Breath, Facial Pain, and Anxiety

THE ‘NEW NORMAL’ FROM THE DENTAL CHAIR

Imagine in February of 2020, if I had asked you about your ‘mask. How would you have responded? However, in November 2020, the majority of people are familiar with this portmanteau of mask plus acne that has been added to our coronavirus lexicon to describe acne breakouts, dry skin, and irritation caused by chronic mask use. The ubiquitous fashion accessory of 2020, has come with some unexpected side effects. In the dental office, we are seeing an explosion of complications arising from mask usage, and while the most common complaint is bad breath the more serious concerns are increased dental decay, gum disease, temporomandibular joint (TMJ) dysfunction, facial pain, and bruxism (tooth grinding).

‘Mask Mouth’ is the new term being given to the associated dental diseases arising from chronic mask-wearing. The Center for Disease Control (CDC) acknowledges the efficacy of face masks in blocking the release of small respiratory droplets that may contain the COVID-19 virus and therefore the use of face coverings is essential to help curb the spread of this virus. The three most common types of masks are cloth masks, surgical masks, and respirators like the n95 or kn95’s, more commonly worn by healthcare providers. While the importance of mask use is indisputable, acknowledging the side effects and planning accordingly will help limit potential damage.

HALITOSIS (Bad Breath)

Bad breath has been the most common complaint from wearing a mask. The bacteria in our mouth produce a sulfurous compound called methyl mercaptan. This is often described as smelling like cabbage or rotting eggs and is believed to be responsible for halitosis. When you are wearing a mask many people breathe through their mouth instead of through their nose. This leads to a decrease in saliva and dry mouth (xerostomia). Saliva is responsible for washing away the build-up of bacteria that forms a biofilm on the teeth. Saliva also contains antimicrobial agents that help reduce the bacterial population and contains an abundance of minerals necessary for remineralizing enamel. A dry mouth increases your bad breath by allowing far more bacteria to populate. In addition to mouth breathing and dry mouth, people are drinking far less water because it is often cumbersome to remove the mask; this is especially true for those of us working in the healthcare field where donning and doffing (applying and removal) of personal protective equipment can be quite a chore. This increased difficulty decreases water intake throughout the day leading to further dehydration. Lastly, during the pandemic, we have seen an increase in coffee and alcohol consumption, both of which worsen dehydration and lead to increased dry mouth.

There are several steps you can take to help prevent dry mouth and improve your bad breath. First drink more water throughout the day and try to decrease your coffee and alcohol intake. Set a schedule for water consumption throughout the day if necessary. Try a humidifier while sleeping to increase the ambient moisture. Use an alcohol-free mouth rinse and a tongue scraper to help decrease the bacterial load and increase the frequency of your professional dental cleanings. Lastly, there are excellent over-the-counter oral health care products, such as Biotene, that have been specifically designed to help with xerostomia.

TOOTH DECAY AND GUM DISEASE

While bad breath may be the number one concern for the patients, tooth decay and gum disease are far more concerning to your dentist. The decrease in salivary flow from dehydration and dry mouth allows for a build-up of bacteria, particularly around the gum line of your teeth. Since the root surface of your tooth lacks the hard-protective enamel coating it is much more prone to decay and that decay spreads much faster. Your saliva is a natural buffer, neutralizing acid from food and bacteria, as well as being supersaturated with minerals like calcium that help to mitigate the damage from the acidic challenge produced by these bacteria. Dry mouth will also allow food particles normally swept away to stay stuck around and between the teeth serving as a food source to the adherent bacteria, increasing the likelihood of decay.

Additionally, without saliva to help lubricate and wash away the bacteria, it will begin to harden on the tooth surface converting from plaque to tartar or calculus. This hardened build-up of bacteria on the tooth will cause irritation and inflammation of the tissue and underlying bone. If this build-up is left untreated it can lead to an irreversible loss of the supporting structures known as periodontal disease or loss of the protective keratinized tissue around the tooth, known as gingival recession. In addition, the inflammation caused by periodontal disease has been associated with multiple systemic conditions including heart disease and diabetes. While gum disease is painless in the early stage, bleeding gums when you brush and floss is a good indication that the inflammation is progressing.

Chronic mask usage may also be responsible for making the bacteria in your mouth more aggressive. There has been some misinformation regarding the use of cloth or even surgical masks, implying their use can cause a decrease in blood oxygen (hypoxia) or a build-up of carbon dioxide in the blood (hypercapnia). While this is false, there remains some debate as to whether the extended use of masks, particularly a respirator-style like an n95, may result in a slight carbon dioxide increase over time. Now, while this build-up is thought to be so low that it doesn’t affect the wearer's general health, any increase in carbon dioxide in the mouth would favor the proliferation of more virulent and aggressive anaerobic bacteria. This could worsen the potential for decay and gum disease over an extended period of time.

TMJ DYSFUNCTION, FACIAL PAIN, AND HEADACHES

TMJ dysfunction, facial pain, and headaches are an unexpected side effects of chronic mask use and have proven to be a real problem for many people. Dentists have seen a significant increase in the number of patients presenting with joint and jaw pain, headaches, and facial pain.

The temporomandibular joint is a sliding hinge joint that connects the jawbone (mandible) to your skull. It is positioned anteriorly or in front of your ears and you can feel the joint move as you open and close your jaw by lightly positioning your fingers just in front of the tragus of your ear. Temporomandibular joint disorders (TMD) are characterized by pain in the jaw joint and the muscles associated with jaw movement. Oftentimes, TMD is believed to arise in patients who are prone to clenching, grinding, and nocturnal bruxism. These habits are often associated with anxiety, stress, and emotional disturbances. The coronavirus pandemic has certainly made the anxiety, stress, and emotional disturbances a common problem for many, many Americans, leading to significant increases in TMD. These problems are being mistakenly identified as sinus issues, toothaches, neck pain, facial neuralgia’s and headaches leaving those suffering without any relief.

Why are masks hurting our jaw joints and causing so many complications? Many people are uncomfortable wearing a mask. Often, the wearer will tense the jaw and jaw muscles to help hold the mask in place. It results in increased small jaw movements as people attempt to move the mask away from their face and mouth or attempt to reposition the mask to keep it in place or release the tension on the bridge of the nose or the face. It is this constant muscle tension and movement that fatigue and overwork the muscles of mastication leading to pain.

Many people protrude the lower jaw to ‘tent’ the mask away from their face. This is especially common in children or those suffering from conditions that make them especially sensitive to touch or texture, such as Autism. Others subconsciously protrude the lower jaw to open their airway and increase breathing efficacy. This is especially common with geriatric patients and those patients with breathing issues. Protruding the lower jaw will help increase airflow while mouth breathing to help overcome the resistance to airflow caused by the mask. This is especially true in the healthcare environment and those wearing respirators and high-level surgical masks.

An additional cause of headaches from masks can be from the ear loops, which apply pressure to the auriculotemporal nerve (a branch of the trigeminal nerve) which runs just in front and above the ear into the scalp. Compression in this area from tight ear straps can cause facial pain and headaches. Using ‘ear savers’ or mask extenders allows you to eliminate the pulling or compression caused by the ear loops on most masks.

If you believe you’re suffering from TMD, headaches, or facial pain associated with mask usage there are several steps you can take to help. Try to keep your jaw relaxed while wearing the mask, your teeth should not be touching, lips slightly apart and tongue resting lightly on the floor of your mouth. Try not to clench your jaws or protrude/push your lower jaw forward while wearing your mask. My other recommendation is something I call ‘M & M’ therapy. Unfortunately, it doesn’t mean you get to indulge in delicious candy-coated chocolates. It stands for, Moist heat, Massage, Motion, Motrin (or any anti-inflammatory, such as ibuprofen), Mush diet, Mouthguard, and Muscle relaxer. You want to treat early TMD symptoms with simple physical therapy; moist heat, massage, and motion to help relieve muscle tension, use an anti-inflammatory to reduce swelling and pain in the joint, limit hard and tough foods (especially gum chewing), use a night guard to reduce further pressure on the joint and a muscle relaxer to help spasm. If you’re not getting relief, you may need to consult your dentist.

ANXIETY, DEPRESSION, ISOLATION, AND FACIAL PAIN

This time has been one of the most unique, scary, isolating, and depressing times anyone can remember. It has tested many people's emotional constitutions, and many of us have been forced to find different methods to cope with isolation and stress. Physicians and pharmacies are reporting significant increases in the number of prescriptions written and dispensed for antidepressant and anxiety medications during 2020.

Many of the medications prescribed for the treatment of depression, anxiety, and emotional distress are in a class of medications known as SSRIs or selective serotonin reuptake inhibitors. SSRI’s block the reabsorption (reuptake) of serotonin into the neurons in the brain. Serotonin is a key hormone that stabilizes our mood and promotes a feeling of well-being and happiness. Serotonin generally makes humans happier and less stressed. Unfortunately, SSRIs have a common side effect, they increase clenching and grinding.

Reports have chronicled patients suffering from symptoms of bruxism, including jaw clenching, headaches, tooth grinding, and broken teeth after they began treatment for relief of depression and anxiety with common SSRIs. These medications include fluoxetine (Prozac), Sertraline (Zoloft), Venlafaxine (Effexor), Escitalopram (Lexapro), Paroxetine (Paxil), and many others.

It seems counterintuitive that medications designed to make you feel better, less depressed, and less stressed will paradoxically increase your clenching, grinding, and nocturnal bruxism, leading to facial pain and even broken teeth. It’s important as dentists that we recognize this problem and identify our patients that might be suffering so that we may take steps to mitigate this side effect and help our patients to a better quality of life.

This year has been proven to be difficult in so many different and unexpected ways. We must take the necessary steps to protect ourselves and each other so that we may all get through this together. As medical and dental professionals, it is also necessary that we, as medical and dental professionals, recognize the new challenges that face us during this time. Mask wearing is important but it comes with consequences. It is important to talk with your physician or dentist if you believe you are experiencing any of these symptoms. Stronger together.