Dental Face Masks Guide - Type, uses and best practices for patient and staff protection

Selecting the most suitable Personal Protection Equipment (PPE) for your practice has always been vital, and since 2020, it has become more important than ever. In order to help you stay informed, and to help you inform your patients and staff alike, we've answered the most common questions about the different kinds of protective face masks.

Currently there is an extremely heightened public awareness about facemasks. This is the natural and inevitable result of the worldwide concern over the pandemic, virus transmission and personal safety. Providing accurate information is the key. Considering the facts is important for choosing the right option for your environment, healthcare workers and your patients.

Are Face Masks Effective Against Covid 19?

They certainly help – in two important ways. The degree of effective protection will vary, of course, depending on the person, the type of mask, and the situation. The right types of masks will be most effective in specific situations. Not all masks are equal, and not all situations have the same health risks.

Masks should always be selected based on the design, fit, and filtration levels needed for each procedure or risk level.

1. As a general rule of thumb, the type of cloth masks worn by Joe Public are intended mainly to protect other people. This is what is usually called source control. The masks help those around you by mitigating the spread of the virus from the mouth and nose when you speak, cough or sneeze in public.

2. Specialized surgical masks and respirators are designed and manufactured to protect the Health Care Professional in situations where there is higher risk.

The FDA cautions: "It is important to recognize that the optimal way to prevent airborne transmission is to use a combination of interventions from across the hierarchy of controls, not just PPE alone."

What are the differences between face masks, surgical masks, and respirators?

Cloth Face Masks:

The Center for Disease Control (CDC) recommends that members of the public use these basic cloth face coverings in public. They are not officially tested or rated for Healthcare Professionals, and they are not considered to be medical devices. Their purpose is source control – i.e. to slow the spread of airborne infections, since this will help people who may have the virus and do not know it from transmitting it to others.

Earloop Face Masks

Earloop masks are general on/off ear loops with standard pleating and high breathability - the most commonly used mask in healthcare practice. The most commonly used mask used in an environment with minimal fluid exposure. Typically used in general patient care practices like home health care, long term care facilities and clinics. 

This product can be used in the operating room but some professionals choose not to wear it due to concerns of microbial shedding from skin and hair. Available in three ASTM levels from 1 to 3, the higher the level, the higher the fluid pressure resistance for better protection.

Surgical Masks

Surgical masks are sometimes mistakenly called face masks (or earloop masks), but there are important differences. In fact they are considered to be medical devices by the ASTM International, and are regulated under 21 CFR 878.4040. Such a mask meets certain fluid barrier protection standards, effective in blocking splashes and large-particle droplets. However, they do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the mask and the face.

Respirators (N95 Respirators)

Respirators are widely known as filtering facepiece respirators (FFRs). This classification includes the industrial N95 and surgical N95 groups. These medical devices are tested, and filter at least 95 percent of airborne particles. They reduce exposure to pathogenic airborne particles, and are designed for a health care environment. They provide a higher level of protection against viruses and bacteria when properly fit-tested.

What about Face Shields for Splash Protection?

Dental face shields can indeed provide clinicians with additional  protection from spray and splatter without interfering with the field of vision. However, they obviously don’t work to filter out aerosols, and so should always be used together with the appropriate mask.

Your plastic shield should be large enough to provide protection for the entire head and face, and should be comfortable to wear while performing normal clinical tasks. Face shields can be worn via a headband, or attached to your mask. 

One common issue with Face shields is fogging. In order to minimize this inconvenience you can try some of the following strategies:

• Insert a facial tissue between your face and the top of your mask—fitting snugly over the bridge of your nose— the moisture from your breath will be absorbed by the tissue instead of hitting your glasses.
• Choose a mask with a wire. Masks that have a flexible wire allow you to mold it around the bridge of your nose, blocking the warm exhaled air from your mouth.
• If you wear glasses, you can try washing your glasses with soapy water.
• Or use a de-fogging spray

How are Dental Masks and Respirators Rated?

Not all N95 masks are the same. Many of these respirators are manufactured for the construction industry, to protect workers from dust and small airborne contaminants, hence the popular 3M N95.

Medical and Dental Respirators are slightly different. They are single-use, disposable respiratory protective devices used and worn by health care personnel. Surgical N95 respirators are Class II devices , and are regulated by the FDA, under 21 CFR 878.4040, and CDC NIOSH under 42 CFR Part 84.

In the United States, the FDA recognizes the ASTM mask standards. Masks are graded based on their performance in five criteria:

• Bacterial Filtration Efficiency (BFE)
• Particulate Filtration Efficiency (PFE)
• Fluid Resistance
• Differential Pressure (Delta P)
• Flame Spread

How do N95 Respirators Compare with Surgical Face Masks?

There are some similarities. Both kinds are tested and rated for fluid resistance and filtration efficiency, and neither the surgical masks nor the respirators may be shared or reused. However, there are important differences between them:

• A Surgical mask is loose fitting, and the edges of the mask do not form a tight seal around the nose and mouth. 

• N95 Respirators are shaped to provide a much closer fit, and therefore provide far more efficient filtration of airborne particles. This means your N95 respirator has a user seal check requirement – in other words, the seal must be checked each time you put it on.

The CDC has a useful infographic about the similarities and differences. 

What are the Three ASTM Levels of Mask Protection?

Surgical masks are rated suitable for various risk levels. These masks are tested by the American Society for Testing Material (ASTM).

• ASTM Level 1 – This is the lowest level of protection for surgical masks. A Level 1 mask has a low fluid resistance (80 mmHg and a BFE and PFE of 95%.2 ). This mask is designed for procedures with low amounts of fluid and aerosols, such as exams, radiographs, and cleaning.

• ASTM Level 2 – This level provides a medium level of protection. Masks on level 2 have a fluid resistance of 120 mmHG  and provide a BFE and PFE of 98%. This level of protection may be suitable, for example, during restorative procedures where a high-speed handpiece is not required.

•  ASTM Level 3 – This is the highest level of protection and fluid resistance available. The fluid resistance level is 160 mmHG with the BFE and PFE at 98%. This kind of mask is preferred for high risk procedures, for example - procedures with a high-speed handpiece.

Are Surgical Masks or N95 Respirators Reusable?

No. Based on manufacturer recommendations, surgical masks and N95 masks are designed for one-time use. 

The CDC and NIOSH do not formally recommend decontamination and re-use of N95 masks. However, the supply of N95 respirators can become depleted during a health emergency such as Covid 19. In such cases, there are emergency strategies for conserving and extending the use of masks.

The CDC has Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings.

What Kinds of Masks Can be Washed?

 Standard cloth face masks for the general public (not the N95 or Surgical kind) can be washed and reused. The WHO recommends washing such a mask every day, provided the mask is undamaged.

Wash fabric masks in soap or detergent and preferably with hot water (at least 60 degrees Centigrade/140 degrees Fahrenheit) at least once a day.

If it is not possible to wash the mask in hot water, then wash it in soap/detergent and room temperature water, followed by boiling the mask for 1 minute.

When Should Health Care Personnel Wear Masks or Respirators?

The short answer: As long as the COVID-19 public health emergency continues, wear a cloth mask at least.

On this point, the CDC recommends that health care personnel wear face masks at all times. That includes the total time spent working in the health care facility, including break times and when in common areas, where contact with co-workers or visitors may occur.

The directive is clear that simple cloth face coverings should NOT be worn instead of a respirator or surgical mask if more than simple source control is needed.

Since surgical masks are in limited supply, and a top priority, the rule is slightly flexible. However, the guidelines are clear: When available, surgical masks are preferred over cloth face coverings for health care personnel. This is simply because surgical masks offer source control, as well as protection against exposure to splashes and sprays of infectious material in the workplace.

You should always wear a N95 or equivalent or higher-level respirator, instead of a face mask, for aerosol generating procedures, as well as surgical procedures that might pose a higher risk for transmission.

Please note that some N95 models have exhalation valves. This feature can make breathing out easier and help reduce heat build-up – but these should not be used when sterile conditions are needed.

What Level of Mask Should Dental Hygienists Use?

Both the Occupational Safety and Health Administration (OSHA) and the CDC have guidelines to protect oral health professionals from disease transmission. The type and rating of the mask that needs to be worn will depend on the procedure being carried out.

• Level 1 masks (low protection at ≥ 95% BFE and PFE) are usually good for brief examinations, exposing radiographs, and cleaning tasks.

• Level 2 masks (moderate protection at ≥ 98% BFE and PFE) are preferable for procedures that involve a slightly higher risk of aerosols.

• Level 3 masks have a high level of protection (at ≥ 98% BFE and PFE) and are the best choice for procedures involving high levels of aerosols such as ultrasonic scaling, surgical procedures, and crown preparation.

How Can I Conserve My Supply of Masks?

CDC guidelines recommend a combination of strategies to conserve supplies while minimizing the health risks to workers :

• Minimize the number of individuals who need to use respiratory protection.

• Use alternatives to N95 respirators where feasible.

• Allow for extended use and/or limited reuse of N95 respirators, when acceptable; and

• Prioritize the use of N95 respirators for the highest risk areas.

What is the Correct Way to Wear a Surgical Face Mask?

• Always wash your hands or use hand sanitizer before putting on your mask. Dirty hands will contaminate a fresh mask.

• Inspect the mask for tears, holes and signs of wear. Never reuse unsafe masks.

• Fit the mask comfortably over your nose and mouth, tucking it securely under your chin. If your mask has a metal strip, it can be bent to fit better over the bridge of your nose. Make sure you can breathe comfortably.

• Make sure the metal strip is at the top, and the colored side is facing outwards, with the plain white side facing inwards.

• Ensure that the mask fits snugly against the sides of your face. Slip the loops over your ears or tie the strings securely behind your head.

• Ensure the right fit and minimal contact with hands. If you find that you have to continually adjust your mask, that means it doesn’t fit properly. Each time you touch the mask, your risk of infection increases. You may need to find a different mask type or brand. 

What is the Correct Way to Wear a Respirator?

• The same precautions apply as for surgical masks, listed above, and the below:

• Your respirator should be the correct size for your face, so no gaps or leaks are detectable around the edge of the respirator. If there are gaps, try fitting a different size of respirator.

• Make sure there is no facial hair at the points of contact with your skin. Facial hair will cause gaps, and reduce the filter effectiveness.

• Check your mask seal

• Place your hands over the respirator to block the majority of the airflow, and take a breath to ensure it seals tightly to your face.

• Conversilty, place your hands over the respirator and then exhale quickly, if there is easy air leakage, it is not correctly fitted.

• If air leakage continues anywhere (even after adjustments to straps and nose wire) ask for assistance or better, try a different size.

• To remove the respirator

• Do not touch the front of it as it may be contaminated. 

• Remove by pulling the bottom strap followed by the top strap over the back of your head.

• Discard in a waste container, and immediately wash your hands.

Can Anyone Wear the N95 Respirator?

No. There are a few important limitations:

Since the N95 respirator can make it more difficult for the wearer to breathe, people with chronic respiratory, cardiac, or other medical conditions that make breathing difficult should not wear them.

The N95 respirator is designed for a snug fit – and unfortunately that creates other limitations. It is therefore not suitable for people with facial hair, or for children.

General Tips for Standard Face Masks in Public:

• Make sure to clean your hands before touching your mask.

• Make sure you have your own mask and do not share it with others.

• Resist the temptation to pull down your mask to your chin or take it off when speaking to other people.

• Do not store your mask around your arm or wrist or pull it down to rest around your chin or neck. Instead, store it in a clean plastic bag.

Useful Respiratory Protection Info: 

3M Respiratory FAQ PDF