FACE CLAWING, TONGUE TEARING – FELINE OROFACIAL PAIN SYNDROME IN CATS

These cats start clawing at their mouths and cheeks, sometimes severely harming themselves. “It looked like she was gagging or something was stuck in her teeth,” said one owner. “Then I came home later to find blood everywhere.” It is incredibly distressing both for cats and for their owners. Vets researching this behaviour call this Feline Orofacial Pain Syndrome or FOPS (Rusbridge et al., 2010).

I studied this syndrome for my BSc. Dissertation in 2010.  My owner survey showed that FOPS occurred in Burmese and cats of Burmese ancestry (Tonkinese, Burmillas, crossbreds). The cats in my survey did not suffer from an unusual number of stressors. The behaviours shown by the cats included head shaking as well as face clawing, and owners did not find any treatment very efficacious other than cutting nails and pain relief.

There are four vets who specialise in FOPS  -Clare Rusbridge of the Stone Lion Veterinary Centre, ( www.veterinary-neurologist.co.uk): Sarah Heath of Behavioural Referrals, (https://behaviouralreferrals.co.uk ): and Professor Danielle Gunn-Moore of the Royal Dick School of Veterinary Studies, Edinburh University, (https://www.ed.ac.uk/vet) and dental expert Norman Johnston of Dentalvets in Scotland (www.dentalvets.co.uk). I recommend asking your vet to refer the cat to these specialists as soon as possible. There is a information sheet here from Clare Rusbridge which would be useful for your vet.

FOPS may be similar to human orofacial pain and the cat’s behaviour is not unlike that of rats and mice with orofacial pain (Luccarinia , 2006). Headshaking in horses (which can’t paw their muzzles) may also have some similarities (Madigan & Bell, 2001, Mills et al., 2002). Humans also suffer from orofacial pain, including trigeminal neuralgia (Pawl 1997) and burning mouth syndrome (Muzyka & De Rossi, 1999), disorders which are still not fully understood and for which there is little agreed treatment (Turp et al., 2007). Among humans there may be a hereditary component (Fleetwood, 2001) and even humans will sometimes self harm because of the intense pain (Mailis, 1996)..

IF YOUR CAT IS CLAWING ITS FACE

A diagnosis of “self mutilation”  does not explain the cause: it merely describes the symptoms. Feline Orofacial Pain Syndrome is the term that links the behaviour to its probable cause. Read this carefully if you have a cat with this troubling problem.  Some cats lick in an exaggerated way or claw at their mouths or inside their mouths till they bleed. Some will pull the skin and fur off the whole of the side of the face or rip their tongues.

When a cat starts clawing at its mouth, the most obvious explanation is either there is something stuck in the mouth of the cat is experiencing oral or dental pain. Therefore these are the first possibilities, which must be considered. However, in some cases repeated dental examinations and removal of some or many teeth may not stop the behaviour and bad dental work may provoke it. So a specialist dental vet is a must if dental work is to be done.

The syndrome was first mentioned in 1994 (Roche, 1994) and I wrote about it in my then Daily Telegraph column a few years later. It seems there are episodes of this behaviour, separated in time sometimes by years; or for some cats the behaviour is continuous. It may start in kittenhood at teething or vaccination time. Adult sufferers are more common than kittens.

The mysterious face clawing behaviour seems to occur mostly in Burmese, crossbred Burmese, and breeds with Burmese ancestry such as Burmillas and Tonkineses. It is probably an inherited susceptiblity.

IF YOUR CAT HAS THIS PROBLEM

You will need to make sure the vet investigates thoroughly, particularly the question of facial pain. Read Clare Rusbridge’s information sheet at  www.icatcare.org which you can find from the search button. The case of Pepper (below) shows that vets, unfamiliar with the problem, may fail to give a proper dental and mouth examination under anaesthesia. This is essential. A specialist dental vet should be involved (see no 5) if dental work is required.

The following possibilities may trigger FOPS and need careful consideration.
1. Dental problems.
2. Mouth ulceration (common during cat flu or after cat flu vaccination) or gingivitis.
3. Teething in kittens.
4. Facial pain of some other kind. (In humans facial pain can be caused by muscle spasm sometimes set off by unconscious tooth clenching due to stress. Trigeminal neuralgia is agonising stabs of pain often caused by a trigger spot on the facial skin being touched and usually self limiting. Possibly these apply to cats.) Even a facial infection or wound might start the clawing.
5. Dental work. Sometimes very minor dental work such as a scale and polish may set off the syndrome. But too much or poorly done dental work is more likely to start if off – this is why a specialist dental vet should be involved from the start.
6. Stress. This has been proposed as a trigger for onset.

TREATMENT

Pain relief is essential while undergoing treatment. Indeed pain relief may be the treatment. See lower down for vet’s opinions on treatment. Your vet may give you painkillers to use in an emergency.

Failure to eat is a real danger. Make sure this is addressed from the start. Ask about syringe or tube feeding -see the case of Pepper. Liquidise soft food so that the cat does not have to chew. Feed kitten food (high in protein) or a prescription diet if the cat has been anorexic.

Helpful short term measures may include bandaging the paws so that the cat cannot harm itself or use of a buster or Elizabethan collar. Cats need to groom themselves and cannot in a collar, so you must groom the cat at least twice a day while it is wearing this. These should be short-term not long term measures and pain relief should always accompany this.

Euthanasia should be considered if you think your cat is in unrelenting and continual pain.

TREATMENT FOR STRESS

After examination and proper treatment of any medical or dental causes, it is worth looking at stress.  If nothing else, reducing stress will help your cat in recovery. Look at this FAQ also on this website, Reasons Why Your Cat is Stressed.  While you are pursuing treatment get a Feliway Diffuser (which lasts a month) that promotes calm in the household. Reducing stress can do no harm. To diagnose stress factors properly you need a cat behaviour expert. Remember that indoor cats need an enriched environment and that multi-cat households, especially with unrelated cats, may be very stressful for some of the inmates.

VETS’ RESEARCH

Sarah Heath, Clare Rusbridge, Professor Danielle Gunn-Moore and dental expert Norman Johnston, vets have published “Feline orofacial pain syndrome (FOPS): a restrospective study of 113 cases’ in Journal of Feline Medicine and Surgery, see reference list.  Examination for oral or facial pain is essential and proper pain relief is important. They report that NSAIDs are useful for mild attacks (these must be prescribed by a vet; used wrongly they poison cats), and gabapentin or carbamazepine for severe cases. This can be injected for immediate relief. A few severe cases may need lifelong drug treatment with regular liver function tests.

Norman Johnston of Dentalvets in Scotland (www.dentalvets.co.uk) likened this behaviour to trigeminal neuralgia in humans (agonising unexplained facial pain). “I saw cases where there was undoubted pathology, particularly those involving the lower jaw, which I could do something about. Causalgia is a condition whereby injury to a sensory nerve, most commonly during a difficult tooth extraction, appears to be the reason. Trigeminal neuralgia in adult humans has similar features but the reasons for these attacks in humans have also been a mystery for several centuries.”

Sometimes cats show anxiety before an attack. This may give owners time to give them drugs to reduce the onset of pain or bandage paws to stop claw damage. Never used human painkillers; alway use medicines prescribed by a vet who is familiar with your cat.

CASES

• • Derbyshire, an outdoor Burmese, had this disorder at the age of 2, 7, 11 and 12 -so there were long OK intervals. The clawing would only last for 48 hours, then it would stop. Her owner would wrap gauze around her front paws, followed by stocking plaster without lint –a difficult process. ‘But by this time some damage had always been done’.
• • Sophie was an indoor brown Burmese. Had three or four episodes. Vet diagnosed allergy and gave antihistamine which seemed to help (sedative effect?). Had eaten spider plant. “Since Sophie has been allowed to go out and has a pot of grass to eat when confined to the house, she has not had an episode. I do not think stress was the problem -she has a laid back attitude to life.”
• • Some cats which have a perfectly good outdoor life also have the disorder. So indoor life is unlikely to be a causal factor (see my research).  Abby, a Burmese, was treated unsuccessfully with steroids, had her paws bandaged (only she tore them off), had an Elizabethan collar which was dangerous when unsupervised (she caught her paw), and unsuccessful homeopathic treatment. BUT she has done less damage to her face since her owner has kept her claws very short. Abby is not an indoor cat and lives with a Siamese. Two other cats in the same house have separate entrances/exits and lead separate lives!
• • Nicky, a male Burmese, who started clawing at his face and throat was operated on for a blockage in his throat -only to discover there wasn’t one. He stopped doing this when the stress (travel and a new home) was removed.
• • Joey a Burmilla, a breed arising from a Burmese cross, would scratch his face and try to put his paw in his mouth -often after a meal. Vets visits and dental work did not relieve the situation until a retired vet decided he might have ‘neck erosion’ of the tooth. His owner insisted on having all his back teeth taken out leaving only one front one and after that ‘he was much happier”.
• • Archie, a rescue chocolate Burmese with cat flu in youth, had two episodes and giving a sedative (second time) seemed to stop it. But since having builders in the house he has been over-grooming and manic nail biting. Feliway Diffuser did not help.
• • Angel, his sister, a lilac female and flu survivor, had one episode of face clawing which seemed directly connected to a rotten tooth and she was back to normal as soon as the tooth was taken out.
• • Pepper, was found clawing at her mouth, her paws and mouth covered with blood. She was taken to the local Vets hospital where she was diagnosed as “self harming.” She was put in a buster collar, given pain relief, anti-inflammatories and antibiotics. A day later she was sent home with amitriptyline as a sedative. She was eager to eat, but stopped after a few mouthfuls apparently in pain. She was taken back to the hospital for 3 days and kept in a buster collar. By now she was apathetic and refused food and water. The owner removed the collar and Pepper would claw if she tried to eat or drink. Two more days later she was seen again at the hospital by a vet who proposed an exam under anaesthesia. This found a depressed lesion in the mouth, possibly a tumour. But poor Pepper never came round from the anaesthetic. The biopsy results showed a “necrotic ulcerated glossitis’ at the base of her tongue. The veterinary hospital interpreted this to mean that the glossitis was caused by, rather than the cause of, the mouth clawing.
• • Burbage, a male Burmese with the same disorder had dental work and was prescribed medication. Several teeth were removed. The tooth removal seemed to make no difference. “Now at the warning signs –dilated eyes starting up to two days before –I zap him with valium which seems to stop it happening. The behaviour seems triggered by stress,” reported his owner in l999. But by the following year, she had moved to Hong Kong and Burbage seemed worse. A local vet diagnosed an allergy -showed how Burbage’s gums, muzzle and nostrils were swollen, itchy and his airways were narrowed. The air pollution made this common in Hong Kong. Burbage was given a low allergy diet. The owner got rid of scented products, litter with deodorants, got rid of furniture polish, turpentine, cleaning fluids etc. The clawing stopped. “Work out through careful observation what is triggering the reaction. Buy fragrance free litter. Change the diet to low allergy food. Stop using perfume. There is a strong chance that the cat will not suffer further attacks,” says Burbage’s’ owner. Also kept an eye out for an allergic reaction to dry cleaned clothes.
• •Muffin, the 16 year old lilac Burmese companion, started clawing at her mouth about 2 weeks after Pepper’s death. The diagnosis was gingivitis, gum disease, with bleeding. The gum disease was treated with dental cleaning and antibiotics. An opiate painkiller was administered and the clawing stopped. A cat with oral pain.
• Liam, aged 18, of unknown breed, had a bad reaction to gabapentin and Metacam did nothing for him – drugs that can be successful in treating orofacial pain. “I’ve found a way to stop him clawing at his face during episodes,” says his owner. “For the last 4 years he has a couple of episodes each year. We’ve tried everything including heavy sedation which he hated. Have had him thoroughly checked for underlying causes. Anyway when he starts I find distraction and gentle massage of the jaw, underneath stops him clawing, mouthing, grinding teeth. I can tell when he’s through the “moment” as he relaxes, often looks up at my face, can start purring and his eyes seem to clear. “

 

REFERENCES

Fleetwood, I. G., Innes, A., Hansen, S. R., & Steinnberg, G., K., (2001), ‘Familial trigeminal neuralgia’, Journal of Neurosurgery, 95, 5131-517.

Luccarinia P., Childerick. A., Gaydier, A-M., Voisin, D., & Dallel, R., (2006), ‘The Orofacal Formalin Test in the Mouse: A Model for Studying Physiology and Modulation of Trigeminal Nociception,’ The Journal of Pain, 7, 908-914.

Madigan, J. E., & Bell, S. A., (2001), ‘Owner survey of headshaking in horses’, Journal of the American Veterinary Medical Association, 219, 334-337.

Mailis, A., (1996), ‘Compulsive targeted self-injurious behaviour in humans with neuropathic pain: a counterpart of animal autonomy. Four case reports and literature review,’ Pain, 64, 569-578

Mills, D. S., Cook, S., Taylor, K., & Jones, B., (2002), ‘Analysis of the variations in clinical signs shown by 245 cases of equine headshaking’, Veterinary Record, 150, 236-240.

Muzyka, B. C., & De Rossi, S. S., (1999) ‘A review of Burning Mouth Syndrome’, Cutis, Cutaneous Medicine for the Practitioner, 64, 29-35.

Pawl, R., P., (1997), ‘Trigeminal Neuralgia and Atypical Facial Pain,’ Current Pain and Headache Reports, 1, 1751-181.

Roche, G. M., (1994), ‘Irritation from erupting teeth,’ The Veterinary Record, 13,360.

Rusbridge, C., (2009) ‘Feline orofacial pain syndrome face and tongue mutilation in Burmese’ Feline Information Bureau. Available at: http://www.fabcats.org/breeders/infosheets/orofacial/orofacial.html Accessed 27 February 2009.

Rusbridge, C., Heath, S., Gunn-Moore, D. A., Knowler, P. S., Jonston, N., & McFadyen, A., (2010),’Feline orofacial pain syndrome (FOPS): a retrospective study of 113 cases,’ Journal of Feline Medicine and Surgery, 12, 498-508.

Turp, Sommer, C., & J. C., Hugger, A., (2007), The Puzzle of Orofacial Pain. Integrating research into Clinical Management, Basel, Switzerland, Karger.