Episode 38 - Cat.exe Has Stopped Working; FOPS and the Furious Face (Clare Rusbridge)

(00:00:00) John introduces a new episode on Feline Orofacial Pain Syndrome (FOPS) — a baffling condition where cats can flip from calm to frantic self-injury around the mouth and face in seconds.

Chapter 1: Not Toothache — Neuropathic Pain With Teeth

(00:03:21) Clare Rusbridge introduces herself as a veterinary neurologist focused on neuropathic pain. She first recognised FOPS working alongside dentist Norman Johnston, then developed a rare multi-disciplinary collaboration with internist Danièle Gunn‑Moore and behaviourist Sarah Heath — a clue to how complex FOPS can be.

(00:05:05) What it looks like: the defining feature is mutilation — cats injuring themselves trying to get at the tongue/oral mucosa (and sometimes face). Clare’s headline: don’t call simple dental pain “FOPS”. Dental disease hurts, but in “normal” pain, self-trauma should stop once it becomes painful. In FOPS, the cat may keep going, causing extreme damage.

(00:07:51) Clare uses a neuropathic itch analogy: ordinary itch tends to stop once it hurts; neuropathic syndromes can drive continued self-trauma despite escalating injury.

(00:09:03) What it isn’t: Clare cautions against over-attributing dramatic grooming/rubbing to neurology — many cats shared online as “neurological” actually have facial pruritus/dermatitis. FOPS often looks unilateral (one-sided facial targeting), though that’s harder to see if the cat is focused on its tongue.

(00:10:07) Classic signalment: a Burmese (or related) kitten around five months, often during teething (commonly canine eruption). Owners may find a “bloodbath” with frantic tongue trauma. Some Burmese breeders bandage paws during teething to reduce injury.

(00:11:29) The life-course pattern: kitten episodes may resolve once teething ends, then recur later with periodontal disease. Adult episodes are often triggered rather than continuous.

(00:14:57) Why it behaves like this: Clare points to trigeminal nerve pain as the leading candidate (teeth/buccal mucosa), with glossopharyngeal also plausible given tongue focus. Adult signs may be triggered within minutes after eating, drinking or grooming, echoing trigeminal neuralgia in humans where mouth movement can trigger paroxysms of pain.

Chapter 2: Diagnosis With a Fine Tooth Comb

(00:17:39) Breed/genetics: a five-month Burmese kitten is highly suspicious; Clare says she hasn’t seen the teething presentation outside Burmese/very closely related breeds (for example Siamese crosses). Genetic work suggested a likely inherited component and a strong candidate region/gene involved in neural processing, but no funded clinical test exists.

(00:20:10) In older cats it’s harder: Clare insists on two anchors — there must be mutilation, and it should be disproportionate to the visible dental disease (often “just a bit of gingivitis” by everyday feline standards). Dental disease remains the most common trigger.

Dentistry is central: proper evaluation usually needs sedation/GA and ideally dental radiographs to identify lesions that are easily missed on casual inspection (Clare describes cats sent to neurology as “no dental lesions” who later prove to have pathology).

(00:22:40) A caution for clinicians: FOPS can be worsened by suboptimal dentistry or iatrogenic irritation near trigeminal nerve roots. Clare often advises referral to a colleague with strong dentistry skills/equipment, both for patient welfare and to reduce the risk of treatment-triggered deterioration.

(00:24:30) When dentistry is required, she recommends appropriate nerve blocks and careful peri-dental analgesia to reduce pain wind-up.

(00:25:15) Neurological exam (keep it simple): focus on trigeminal sensation and compare left vs right. Clare suggests gently stimulating inside each nostril, tickling whiskers to see facial twitch, and checking medial/lateral canthal reflexes. Remember the blink/whisker/ear movement includes a motor component via the facial nerve, which is worth assessing too.

(00:26:40) Don’t miss other head pain: Clare highlights ocular/retrobulbar disease as an important differential and recalls a rare, very painful post-lens-trauma tumour that once presented like FOPS (she can’t remember its name).

Chapter 3: Stop the Mutilation, Then Treat the Triggers

(00:28:40) Clare splits management into three parts: acute control, chronic management, and behaviour/environment.

(00:29:52) Acute priorities: prevent further injury (often a buster collar) — but “collar for life” is framed as unacceptable welfare. Then move quickly to neuropathic pain control; NSAIDs/opioids may help a little but are rarely enough alone.

(00:31:04) Common options in practice: pregabalin (noting availability of a licensed cat product for anxiety) and gabapentin. Clare notes trigeminal pain can respond differently, and some cases need alternatives.

(00:32:10) Anti-epileptic drugs in FOPS: Clare describes historical acute response to a benzodiazepine during a “seizure vs pain” debate, and subsequent benefit from phenobarbital. She frames this as pain modulation rather than “treating seizures”, notes modern caution around diazepam in cats, and points out injectable phenobarbital (where available) can be very effective.

(00:36:00) Duration/weaning: in teething kittens, medicate through the teething window (around four weeks) then wean, especially with phenobarbital (not stopped abruptly). Warn owners about later recurrence with periodontal disease.

(00:37:11) Dental-triggered episodes: treat dental disease properly and continue analgesia longer than “routine”. Clare notes dental pain in normal cats can persist about a week post-procedure; FOPS-prone cats may need longer coverage plus neuropathic pain medication.

(00:39:32) Behaviour and environment: around 1 in 5 cases had a stress-related trigger. Common themes include multi-cat households, new cats, catteries/cat shows, builders, and environmental disruption. Clare highlights the “five pillars” approach and even unusual triggers such as strong smells (perfume/air fresheners).

(00:43:52) Prognosis: generally good if triggers are identified and owners accept dental investigation/management. Poorer prognosis includes refusal/inability to investigate dental triggers under sedation, or inability to medicate.

(00:46:05) Hard-to-treat cases: Clare mentions off-licence use of Solensia (frunevetmab) in a difficult-to-medicate cat, stressing careful risk–benefit discussion and informed consent.

(00:50:23) John thanks Clare for clear, primary-care-friendly guidance and points listeners to the follow-up resources she’s provided for the show notes.

the show notes.

Links:

https://neurovet.co.uk/neuropathic-pain-syndrome/

https://journals.sagepub.com/doi/10.1177/1098612X241246518 Case 3

https://www.youtube.com/playlist?list=PLsBrqYVMr5vOBgQSAVDNKJaKfvP7gxnPd