Frequency and Difficulty in the Usage of Face Shields Among Oral and Maxillofacial Surgeons During the COVID-19 Era: An Online Survey

Abstract

Aim

During the COVID-19 era, personal protective equipment (PPE) has become a necessary part of surgeons' routines, and face shields are considered an additional barrier to prevent disease transmission via aerosols. This study aimed to evaluate how often oral and maxillofacial surgeons (OMFS) use face shields and the challenges they face while using them.

Methods

An online survey consisting of fourteen questions was distributed to OMFS, and the responses were collected and analyzed using the chi-square test to determine any associations between categorical variables. A P-value of ≤ 0.05 was considered statistically significant.

Results

Out of the 310 OMFS who responded to the survey (181 males, 129 females, 235 residents, 10 fellows, and 65 practitioners), 42.9% (133/310) and 39.4% (122/310) reported using face shields for minor and major surgical procedures, respectively. The majority of the respondents (74.1%, 230/310) reported decreased efficiency while using a face shield. Reasons for non-compliance included vision-related issues, headache, difficulties with disinfection, and ergonomic factors.

Conclusion

Based on the survey results, the regular use of face shields by OMFS was less frequent, and almost three-fourths of the surgeons found it challenging to use due to various reasons. The reduced compliance with face shield usage highlights the need for more ergonomic face shields to improve compliance.

Introduction

The Corona virus disease-19 (COVID-19) pandemic has changed the panorama and pattern of surgical practice by oral and maxillofacial surgeons (OMFS) [1]. Since the emergence of the COVID-19 pandemic, healthcare personnel are required to use personal protective equipment (PPE) to prevent the aerosol transmission of disease. Various guidelines and protocols have been put forth by the World Health Organisation (WHO) and other authorities on the importance of PPE to prevent the transmission of COVID-19 [2]. The face shield has been one of the equipments commonly used by healthcare workers (HCWs) that help in hindering the splashes, sprays, and spatters from directly contacting the face. They are seldom used alone and hence referred to as adjunctive PPE [3]. From out-patient (OP) reviews to performing major and emergency procedures, the use of adjunctive PPE such as goggles and face shields plays a crucial role in preventing droplet infection [3].

Predominantly spread by contact or droplet transmission, the approximate distance the large aerosol infective particles can travel is said to be one meter [4]. This airborne transmission of virus particles may occur during oral and maxillofacial surgical procedures which need to be effectively thwarted. The use of surgical or N95 masks is preferred to reduce the chances of contracting the infection. Howbeit, the infective particles can still enter other exposed areas of the face. Hence, the face shield acts as a barrier and an adjunct, thus synergizing the prevention of transmission to a HCW [5]. Various studies in the literature suggest the daily usage of PPE to prevent the spread of airborne diseases and protect surgeons from ocular injuries they may encounter [6].

There are various types of face shields available in the market, disposable or non-disposable, half-piece face shield that extends to cover only the upper half of the face, or neck-length face shield that extends to completely cover the face [3]. Various guidelines have been put forth for the use of this equipment, and many innovations have emerged in the due course to face the scarcity of face shields in the wake of the COVID-19 pandemic. Although many in-house designs and production of face shields were encouraged [7], some of the OMFS who operate on a day-to-day basis did not seem to opt for regular usage of the face shield. This might be due to cumbersome maintenance of the face shield or difficulty to work with the current design of the face shield. Hence, we carried out this study to analyze the frequency, efficiency, and difficulty in the use of face shields. This will help in further improvement in ergonomics design; encourage the effective use and maintenance of face shields.

Materials and Methods

A fourteen-question online survey was developed on SurveyMonkey (San Mateo, CA) to assess the ease, preference, frequency, perception of safety, impact on efficiency on the usage of face shields. The survey comprised both open and closed-ended questions with a free text response section at the end of the survey. An invitation letter stating the study aims, description of the survey with an option to opt-out was sent to OMFS and they were requested to forward it to their colleagues for further distribution relying on snowball recruitment. The study period was from December 2021 to March 2022. The responses were retrieved from the online electronic survey portal, compiled and transferred to statistical product and service solution (IBM SPSS® Statistics version 25.0). Responses to each question were optional, and hence, the variation in response rates was observed. Descriptive statistics were computed to provide an overview of the study sample. As the variables were categorical, data were presented in percentages. Chi-square test was done to find out the association between categorical variables and a p-value of ≤ 0.05 was considered statistically significant.

Results

A total of 310 OMFS from India participated in the survey. 235 were residents, 10 were fellows and 65 were practitioners.181 were males and 129 were females. Most surgeons commonly used face shields for minor oral surgical procedures (42.9%, 133/310) compared to procedures under general anesthesia (GA) (39.4%, 122/310). Most of the surgeons (61.6%, 191/310) perceived that the usage of the face shield is pivotal in preventing the transmission of airborne infections. 74.1% (230/310) of the study population believed that the face shields reduced the efficiency of the surgery. 12.9% (40/310) of the participants reported discarding their face shield after usage in suspected or confirmed COVID-19 cases while 21.6% (67/310) discarded it daily or after every week and 3.6% (11/310) of the participants never changed them. 11.9% (37/310) of the participants reported changing face shields based on the supply of resources. Concerns or suggestions elicited through free-response question included reuse and availability of face shield and their sterilization/cleaning method. The survey question with response rate is enumerated in Table 1. The reasons cited for non-compliance with the usage of face shield are represented in Fig. 1.

Table 1.

Questions with response rate

	Question	Response	Percentage (%)
1	I am an Oral and Maxillofacial Surgery resident, fellow, or practitioner in India	Yes	100
		No	0
2	Gender	Male	58.4
		Female	41.6
		Decline to report	0
3	Type of respondent	Resident	75.8
		Fellow	3.2
		Practitioner	21
4	Age	< 45 years	81.9
		45–60 years	15.8
		> 60 years	2.3
		Decline to report	0
5	Do you use face shield during the Pandemic for OP reviews?	Yes, regularly	32.9
		Yes, occasionally	49.7
		No, not at all	17.4
6	Do you use face shield for minor oral surgical procedures?	Yes, for all the minor oral procedures	42.9
		Yes, only for the aerosol-generating procedures	35.8
		Yes, occasionally	12.3
		No, not at all	9.0
7	Do you use face shield for surgical procedures under general anesthesia?	Yes, for all the GA procedures	39.4
		Yes, only for aerosol-generating procedures	13.2
		Yes, occasionally	11.0
		No, we do prior COVID 19 testing	32.3
		No, not at all	4.1
8	Do you feel face shields prevent transmission of airborne diseases?	Yes	61.6
		Maybe	28.7
		No	9.7
9	Do you feel face shield reduces the efficiency of your surgery?	Yes	74.1
		Maybe	11.1
		No	14.8
10	How often do you change your face shield?	After every case	12.9
		Daily	21.6
		Weekly	21.6
		Reusable – Hence do not change often	18.4
		Monthly	10.0
		Never	3.6
		Others	11.9
11	How long did you take to get adjusted/adapted to the use of face shield?	Not a problem at all	25.5
		Within minutes-hours	15.8
		Within few days	6.1
		Very difficult to adjust/Not adjusted	52.6
12	Ease of cleaning or disinfecting	Easy	59
		Cumbersome	41
13	Do you feel face shield affects the efficiency of performing surgical procedures? (Increase or decrease, with reasons)		Figure 1
14	Any other comments or suggestions?

Fig. 1.

Reasons cited in the present study for non-compliance with face shield

On comparison of the usage of face shields with respect to age, there was no statistically significant difference between them. Female surgeons changed their face shield more often than male surgeons which was found to be statistically significant (p = 0.025). Association between the frequency of usage of face shields for OP reviews and the perception that face shields prevent transmission of airborne diseases was statistically significant in our study (p < 0.01) (Fig. 2). Those who got adapted to the usage of face shield early, used it regularly, (70.9%) compared to those who got adapted within hours (40.8%), days (36.8%), and difficult to adapt (11.7%). This was found to be statistically significant (p < 0.01).

Fig. 2.

Comparison of frequency of usage of versus the perception of safety provided by face shields

Discussion

COVID-19 is a considerably contagious disease that was declared a pandemic due to its rapid spread across the globe. Aerosols were considered a potential route of transmission. The high prevalence rate among HCWS demanded adequate use of PPE [8]. The usage of PPE by OMFS was considered vital due to the high viral load in the oral cavity and aerosol-generating procedures (AGPs) like bone drilling posed high risks of acquiring the virus [8]. Health organizations have recommended the use of standard PPE, including masks, face shields, goggles, gowns, caps, and gloves, and full PPE, including respirators, in addition to standard PPE to prevent cross-transmission of the virus [8]. The use of adjunctive PPE like face shields was neglected or least preferred for routine use during the pandemic. Hence, this study was carried out to assess the frequency, preference, and difficulties encountered in the usage of face shields by OMFS.

There is a scarcity of studies in literature determining the efficacy of face shields in the prevention of disease transmission when a person coughs or exhales except for a few simulation studies. Face shield prevents the inhalation of the virus by 92% when a physical distancing of six feet is present [9]. Simulation studies by Lindsley et al. showed that face shields can substantially reduce short-term exposure to large infectious aerosol particles. However, smaller particles can remain airborne longer and flow around the face shield more easily to be inhaled. Therefore, face shields provide a useful adjunct to respiratory protection for workers caring for patients with respiratory infections [9].

The risk of influenza transmission increases threefold when face shields are not used during aerosol-generating procedures (AGPs) [10]. However, some studies dispute the effectiveness of using face shields alone [11]. Therefore, the Occupational Safety and Health Administration (OSHA) recommends using face shields as an adjunct to masks rather than a substitute [12]. Face shields are equally effective as surgical masks in protecting against droplets larger than 3 µm and more effective in protecting against droplets less than 3 µm [13]. Due to the limited coverage and soakage of surgical masks during AGPs, face shields are necessary. However, face shields do not replace the need for surgical masks since they do not provide close coverage [13]. Silva et al. have promoted the use of both surgical masks and face shields during surgical procedures [14]. There is a lack of literature on the attitude of OMFS toward using face shields and the difficulties associated with them.

A total of 310 OMFS participated in the online survey. The utilization rate of face shields was relatively higher for minor surgical procedures (42.9%) compared to procedures under general anesthesia (39.4%). This might be attributed to reasons like higher pre-testing for COVID for major elective and emergent surgical procedures [15] than for minor oral surgical procedures. In addition, chances of coughing by awake patients leading to splattering of bio-aerosols also supports the increased usage of face shields during minor surgical procedures.

In the study participants, 21.9% discarded the face shield after every case especially when positive or symptomatic patients were operated on, 21.6% used a new face shield every day and 21.6% discarded it after a week of its usage. This indicates that the majority of OMFS used stock polyethylene terephthalate glycol (PETG) and disposable variety. However, 11.9% of the surgeons had a problem with the scarce supply to meet the demands.

In our study, as low as only 18.4% of the participants mentioned the usage of reusable face shields. It may be assumed that the rest of the surgeons used either disposable face shields or designed their face shields to meet the sudden rise in demand during the pandemic. Although a majority of the surgeons used disposable face shields, almost half of them felt it was cumbersome to sterilize or disinfect them. This might be due to the discrepancy in the size of the face shield and modalities used for sterilization. Despite many guidelines being proposed for proper disinfection of face shield [3, 16], the awareness and implementation of the same were questionable. Safety guidelines for use of face shields recommend proper sterilization of reusable face shields, utmost care during usage of disposable face shields and at least five reusable face shields to be kept in hand readily to alternate them for sterilization [16].

Various reasons expressed for non-compliance while performing surgical procedures with face shield can be broadly divided into vision-related and general factors. Vision-related factors include reduced visibility due to fogging, glare/scratches hindering a clear view, fear of worsening/incidence of vision problems, optical imperfection, and dry eyes. These issues can be overcome by the use of anti-fogging, anti-scratch, and anti-glare solutions available in the market [17]. Detergents, soap solutions, hand sanitizers, and antiseptic liquids have been suggested as anti-fogging agents. Manufacturing face shields using scratch-resistant materials should be considered [17, 18]. Direct hot airflow within the face shield environment can cause dry eyes, burning, and other ocular issues. The use of topical ophthalmic medications and preparations may help to prevent such complications [19]. 74% of the study participants expressed the reduction in efficiency of surgery while wearing face shields. This non-compliance in usage might be due to the material used for manufacturing face shields. Materials commonly used for face shields like plastic sheets, tempered glass, and hard-coated polycarbonate are optically imperfect [6] and cause inconvenience in focused vision during precision surgeries. The extra strain required to get adjusted to the operating field in participants with prescription glasses inculcated fear of an increase in existing vision problems (9.4%).

General factors like headache on prolonged usage, clashing with assistants due to bulk, disinfection issues and ergonomic non-compliance can be overcome by customized 3D printed and fitted face shields [7]. Female surgeons changed their face shields more often than male surgeons (p = 0.025). This might be due to inadequate housing for long hairs, especially in females, and cumbersome headbands. Several modifications have been made to face shield designs such as elastic straps instead of tight plastic wraps and the incorporation of foamed or soft sponge straps [5] to reduce strain over the temporal and forehead region. These modifications improve the comfort due to snug fit. Therefore, it is recommended to consider newer face shield designs that incorporate these modifications. From our study, participants who got adapted to usage early used them regularly. Hence, earlier the adaptation, the higher the frequency of usage. Therefore, compliance in usage is expected to increase with more comfortable and durable face shields.

Limitations of the Study and Suggestions for Future Research

The sample size of the study was limited to OMFS in India. Hence, the findings of the study may not be generalizable to OMFS in other countries. The study did not use any objective measurements to assess the efficiency of face shields or the difficulties faced by OMFS while using them. The study used a cross-sectional design, which limits the ability to establish causality or assess changes in PPE use over time.

Based on the results of this study, some future suggestions for research may include: (i) investigating the impact of different face shield designs on compliance and efficiency. This could involve comparing different types of face shields, such as disposable versus non-disposable, or half-piece versus neck-length. Variables such as type of facemask used with the face shield, average operating time, type of suction apparatus used, and airflow of the operatory may be analyzed; (ii) conducting a larger, multicenter study to determine if the findings of this study are generalizable to a broader population of OMFS; and (iii) exploring the impact of face shield usage on patient outcomes, such as postoperative infections, to determine if there is a measurable benefit to their use.

Conclusion

Based on the survey, it was found that the regular use of face shields by OMFS was less common. Nearly 75% of the surgeons found them difficult to use, due to various reasons. The reduced compliance with using face shields indicated by the current survey underscores the need for ergonomic face shields to enhance compliance.

Funding

None.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not applicable.

Informed Consent

Informed consent was obtained for participation in the study.