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Feline Orofacial Pain Syndrome

by jk176 - January 8, 2021

Sorry to ask this question here, but I received an error stating to update 0 cases when I tried to ask a case question.

Elliot is a 9 year old mn Maincoon cat. He weighs 17 lbs.

History:

He has been diagnosed with feline orofacial pain syndrome and has been managed on gabapentin. He had a tooth extracted on 10/29/20 due to a resorptive lesion. Since then his oral pain signs have been worse - follow up oral exams/dental rads have been normal.
He is still eating and maintaining his weight. Occasionally, he won't eat for a day. He rarely vomits. His BM is dry. His thirst is increased. He prefers warmth. He is a very friendly cat at home. He is outgoing and will be out in the middle of the room even when there is a party of people. He goes over and touches/puts his paw on workers when they come to the home. His owner describes him as a "Zen Master". He is eating Stella and Chewy dry dog food with taurine - he won't eat the cat food. He used to vomit more frequently before starting this diet.

Signs: grinding his teeth or chattering his jaw - he will stop eating and do this and also do this when he is not eating. His owner reports is looks like his jaw dislocates when he does this. She also reports it looks like his jaw is in spasm at times - he holds it open.

History: He is still eating and maintaining his weight. Occasionally, he won't eat for a day. He rarely vomits. His BM is dry. His thirst is increased. He prefers warmth. He is a very friendly cat at home. He is outgoing and will be out in the middle of the room even when there is a party of people. He goes over and touches/puts his paw on workers when they come to the home. His owner describes him as a "Zen Master". He is eating Stella and Chewy dry dog food with taurine - he won't eat the cat food. He used to vomit more frequently before starting this diet.

Exam/past test results - impossible to do a thorough exam at the clinic without injectable sedation, I was able to see his tongue and feel his pulse.
tongue - red, pulse - wiry/toned
1/6 murmur - echo 10/8/20 - borderline left ventricular hypertrophy, no cardiac enlargement, trace to mild av valve insufficiencies - likely reflecting chronic degenerative valve disease

abd u/s 9/6/20 - to work up his occasional vomiting - suspected small intestinal segmental enteropathy - some segments have a mildly thick muscularis layer, mildly enlarged ileocolic lymph node

Superchem/cbc/t4/u/a 8/27/20 - unremarkable other than usg 1.060, protein 2+

A: qi/blood stagnation - jaw area, spleen qi deficiency, possible yin deficiency - dry stool/high usg, possible rebellious qi - occasional vomiting, earth/fire personality

I started him on Kan Bupleurum and Kudzu clearing formula - 0.4 ml PO BID on 11/24/20 - he has not really improved on this formula.

I would love to know what your assessment is and what formula you recommend. I was considering Minor Bupleurum.

Thank you,
Jennifer

by naturevet

January 13, 2021

Hi Jennifer

I guess my first thought is that this is a chiropractic issue - that is, a jaw dislocation (or TMJ) arising from the extraction. These are commonplace and need a few chiropractic treatments to restore normal jaw function. Do you have a veterinary chiropractor you can refer to? If not, there may be a human chiropractor in the area advertising themselves as focusing on TMJ. If they use an Activator, they may be willing to come to your clinic and help you out with the cat (simply out of professional interest).

If that doesn't help then I think first of Bupleurum and Kudzu, which you have tried. If that doesn't help, XCHT is also less likely to help, since it is a component of the former. For humans, I've used the western herb Boneset to relieve unrelenting post-dental jaw pain. It's part of Hoxsey and Boneset Combination, which may work here, or you could try to source it separately. As well, homeopathic Arnica is advocated for post-dental pain and is easy to try here.

One of these options should work, if nothing else to get things back to where they were pre-dental

Steve

by jk176

January 13, 2021

Hi Steve,

Thank you so much for the input. I will look for a chiropractor. One day, I hope to learn this modality. Is it ok to use Hoxsey and Boneset Combo and Arnica? Do you have doses for each of these for a 17 lb cat?

Jennifer

by naturevet

January 13, 2021

It should be okay to use both together, Jennifer

For Arnica, probably get 30C and give 3 to 5 pellets two to three times a day, for a week or two anyway. If no benefits after the first week you can probably stop. Otherwise, if there are potential improvements, see if you can drop back to once or twice daily at that point and have them still persist

For the Hoxsey Combo, give 0.2 ml per 5 lbs (so about 0.6 or 0.7 ml) twice daily or even three times daily for the first couple of days, if it's not too cumbersome. To improve palatability, the Hoxsey can be diluted, for example in broth, to make it easier to give, or even put into a gel cap that is then used immediately.

Let us know how it goes!

Steve

by jk176

January 14, 2021

Thank you for getting back to me so quickly. I forgot to mention Elliot is a major caution when he comes in the clinic even on gabapentin. We have to sedate him with alfaxalone and butorphanol. Would chiropractic manipulation work and/or be dangerous if it is performed under deep sedation? We are having trouble finding a chiropractor. Would acupuncture be an option and/or work under deep sedation?

I really appreciate your help.

Jennifer

by naturevet

January 14, 2021

Acupuncture and chiropractic are both effective and safe under deep sedation. The jaw may be physically misaligned, though, so acupuncture alone won't be rapidly effective.

You can place an index finger over each TMJ with the mouth closed and push side to side until the lower jaw feels like it is moving freely, equally and easily laterally in each direction. That together with acupuncture may help but the procedure might need to be repeated a few times every 7 days or less to resolve the problem. You should know after the first treatment if it is helping though. Even a slight reduction in symptoms will tell you that you are on the right track.

Steve

by jk176

January 15, 2021

Thank you so much for your guidance. I will offer this option. I am very excited to try this to see if I can help Elliot.

Jennifer

by jk176

February 14, 2021

Hello Steve,

I have an update on Elliot.

I have performed 4 treatments of acupuncture and gentle pressure on the TMJ to try to mobilize the lower jaw approximately 1 week apart. Elliot tolerated these treatments surprisingly well with oral gabapentin and injectable butorphanol. I was able to mobilize the lower jaw more easily to the left than the right. Elliot's owner reports his episodes of opening his mouth and/or grinding his teeth have become more frequent but less intense and shorter in duration. At this point, I told her to give him 2 weeks off to see how he does. During the last treatment, when I moved his jaw he would spasm, but in a way that felt like some blockage was being released - not sure how else to explain this. It didn't happened during this treatment. Do you think muscle relaxants would help him?

I am eager to take a chiropractic course and plan to as soon as the pandemic eases up a bit.

Thank you again for your guidance and expertise,
Jennifer

by naturevet

February 16, 2021

Hi Jennifer

I don't think there is any harm in trying muscle relaxants. Or even Valerian. A lot of TMJ is perpetuated by cervical vertebral fixations. Relaxing the neck may relax the jaw, and Valerian is good for that.

If he doesn't improve with the rest, try a firm abrupt nudge or two laterally of the mandible in the direction it doesn't want to go, which sounds like is to the right. Try to get it where it is somewhat free floating and mobile in both directions. After a week or two of muscle relaxants, whichever one you use, it might be easier to do.

Sounds like based on the shifts you're seeing that this is the problem, though, so at least the mystery appears to be solved

Steve

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