The Sensory Deficits of Wearing Masks

Since the onset of the COVID-19 epidemic, life has been peculiar. The social, political, financial, and emotional tolls have been overwhelming. Despite being back out in society and at work, I have yet to resume seeing people’s faces. The world, as I know it, has become a moving body of masks and bandanas.

Part of my profession is consequently scrutinizing people’s faces, searching for clues of impending difficulty. I look at their mouths, how wide they open, the range of motion of the jaw. I look at their tongue, the protrusion of their teeth, and the arch of their palate measuring their thyro-mental distances. This exam is focused, and of course, the patients drop their masks for it; however, there are parts of the exam that are a matter of observation. Watching how their faces move when they speak to me is part of the assessment, and it can now be lost in translation. This phenomenon likely exists for everyone in different ways, but I wonder if it does so to an equal degree?

Working in an operating room setting where hats and masks are worn regularly, I am accustomed to this. Not seeing faces is routine to me. Now I confuse my pre-op nurses unless they are particularly tall or short. My facial assessment, a critical exam for an oral surgeon, is hampered. Gazing at my patient’s faces, I could tell how anxious they are in any given situation. Wearing masks all the time has removed that, heightening anxiety. Social cues for comic timing and rapport building are almost impossible to read with masks on. Though the eyes remain exposed, even these windows to the soul are rendered a bit more obscure without the context of the surrounding face.

Discovered by French anatomist Duchenne de Boulogne in 1862, I suggest using the Duchenne smile to convey warmth to others when our facial expressions are obscured. All smiling involves contraction of the zygomatic major (muscle of facial expression), which lifts the corners of the mouth. But a Duchenne smile is characterized by the additional contraction of the orbicularis oculi (muscle in the eyelids), crumpling the skin around the eyes into crows’ feet. It’s the smile that signals true joy, a signal to indicate that we wish to collaborate or bond with someone.

A neurologic condition called prosopagnosia, or face blindness is typically congenital, although it can be the result of a stroke or injury in a part of the brain called the fusiform gyrus. Affected individuals can’t recognize faces and in written accounts, describe being unable to identify even close friends and family: children, spouses, or even themselves. Often, these patients identify others by alternative features such as height, voice, prominent eyewear, or a distinctive nose.

The drawback of wearing masks for me is not being able to see each other’s smiles. The other likely downside is the potential risk of self-contamination due to manipulation of masks and subsequently touching eyes with contaminated hands. Some people struggle to breathe or have proper conservation because of the muffled sound. The other issue is mask acne, or ‘maskne’, which comes from the hot, germ-filled air emanating from your nose and mouth that gets trapped under the mask. The people that benefitted from masks are those with no teeth. People with huffing halitosis are doubly blessed.

We need distinct masking rules for people with disabilities. Masks affect people with sensory processing disorders like your tactile, olfactory, visual, auditory, and proprioceptive systems. There should be a legitimate reason not to mask people with physical or mental impairment. To put this into context, if you providing assistance to someone who relies on lip-reading, clear sound, or facial expressions to communicate, they should be exempt from the rule. For patients with special needs and respiratory conditions, visors may be a viable option. This list is not exhaustive. Facial masks may appear to be small, but they are capable of making an impact on people’s physical, mental, and emotional well-being. Please be kind, as not all disabilities are visible.

Yet the idea of wearing a mask for some ‘normal’ people stirs up a strong, visceral reaction in many who feel their personal freedoms are being curtailed. If that is the case, I have a simple offer: please come to work with me and see things from my perspective. Wearing a mask will seem a pretty small inconvenience after you do. We don’t have the option of refusing to treat patients the way you have the option of refusing to wear a mask. To put it another way, we don’t have the ‘freedom’ to keep ourselves safe, even though you have the ‘freedom’ to endanger us.

Because masks have been so politicized, I think the battle will be ongoing. Now is the time to soberly assess risk and respond to facts, not frustrations. Between airborne pathogens and pollution, the pros outweigh the cons. The pandemic has unequivocally proven the public health value of masks. Now is not the time to relax protective measures, while we are still in the midst of the deadliest pandemic.

The loss of life during this pandemic has been a hard enough cross to bear. Gloves and masks discarded aimlessly in public places only serve to undermine our triumphs over this scourge. I was at my gym last night. Though vaccinated, I was wearing a mask. My mask was only for the optics of those mostly mask less around me. Sometimes I can’t help but fixate on the lone, inside-out, blue mask or glove that someone forgot on countertops. Seeing this symbolic, likely germ-ridden mask so close, I feel my mask of sanity slipping away. Trash receptacles are ubiquitous in our society, yet appear to be underused.

Solving the mask garbage crisis an institutional change within consumer disposal and municipal collection systems. There must be a more widespread understanding of possible contagion. While most of us can avoid handling discarded masks and gloves, it’s part of the job for others. If used masks aren’t being thrown away in secure separate bags, the exposed items pose a health risk to sanitation workers. The waste from homes with suspected or confirmed COVID-19 cases should be treated as an infectious waste category. We must urge cities to explore alternative solutions by examining material reusability. Are there other options after collection besides burning or burying it?

National messaging about how and when to wear masks is abundant, but they are just isn’t enough public information on how to properly dispose of used ones in the mainstream media. Equally problematic is that most people don’t know this – just like they are unaware that plastic grocery bags shouldn’t go in the household recycling bin. Combatting COVID-19 via protection device utilization and treatment development is why we are prevailing against it. Now, we must address the threat created by those same tools of protection – pandemic waste. Our waste has become a virus, and we need to develop a viable vaccine – a problem to be taken seriously.

One of my patients complained to me that the masks have upset his dating life – “You never know what surprises are lurking underneath: crooked teeth! halitosis! facial hair! weird moles!” I suggested this may be a better way to find a partner. After all, there are plenty of ugly things on a person’s insides, and those take much longer to discover than unfortunate birthmarks. He dismissed the idea. Perhaps he has a point. The fact remains that while they ought not to be the standard of true beauty, oral and facial features are important. In this new world of expressionless faces, there is an entire dialogue within our interactions to which we are now blind.