HOW TO PERFORM ENDOSCOPY IN EQUINE PRACTICE

How to Make Dental Endoscopy Part of Your

Routine Oral Examination

Travis J. Henry, DVM, DAVDC (NSS), DAVDC (EQ)

Author’s address: Midwest Veterinary Dental Services, PO Box 466, Elkhorn WI, 53121;
e-mail: [email protected]. © 2017 AAEP.

1. Introduction pictures pertaining to many aspects of the pa-

The equine oral exam is the cornerstone of equine tient’s medical record in their practice database.
dentistry. In the past decade, the veterinary pro- This bolsters the medical record for purposes of
fession has fostered an increased interest in monitoring and communicating with other practi-
equine dentistry. This has led to the publication tioners and owners. The equine oral cavity has
of scientific papers that have focused on the challenges of examining structures in a dark tun-
benefit of a thorough oral examination. Peer- nel that often does not lend itself to easily being
reviewed papers have been published specifically photographed. A camera of a cell phone or a good
on equine oral anatomy, oral pathology, and meth- digital camera has often been used in conjunction
ods to perform the oral examination.1,2 The basic with a mouth mirror to capture images of perti-
instruments needed for the oral examination, in a nent pathology. Recently, boroscopes and small
digital capture devices have become available for
sedated patient, are a full-mouth speculum, a
other industries that make capturing images in
mouth mirror, and a bright light source. Docu-
a wet, poorly lit environment possible. Peer-
menting the oral exam findings has historically reviewed papers and textbook chapters have been
been through written text in a medical record or published describing many uses of oral endoscopy
better yet recorded on an equine dental chart. systems.3– 6
Intra-oral images in the mouth have been ob- In this article, we will discuss the common de-
tained by taking a picture of the mouth mirror vices that are commercially available and the com-
reflecting the pathology. This can be a difficult ponents that can be individually sourced to build
task in the standing sedated patient and image your own system. Pros and cons of each system
quality is less than desirable. Oral endoscopy will be discussed to aid the practitioner in pur-
can allow excellent visualization of the dentition chasing the correct system for their practice.
with a convenient method of capturing images. This is not a complete list of all endoscopic sys-
Technology has now become part of our every- tems available for use in the oral cavity but rather
day life as a practitioner. Modern equine prac- a representation of systems that are being used
tices now have the ability to capture and store routinely in the horse.

NOTES

AAEP PROCEEDINGS Ⲑ Vol. 63 Ⲑ 2017 39

 HOW TO PERFORM ENDOSCOPY IN EQUINE PRACTICE
2. Materials and Methods
The practitioner must identify their goal for use of
oral endoscopy equipment. Questions that need to
be answered:

1. Will the system be utilized in the field?

2. Will the system be utilized primarily to show
the client their horse’s oral examination?
3. Will the primary use of the system be to cap-
ture images for the medical record and/or for
publication in medical journals?
4. Do you currently utilize endoscopy in your
practice?
Fig. 1. Eezy-view camera with an image captured of a maxillary
If the goal is high-resolution images for publication, cheek tooth in a horse.
this needs to be decided early in the progression of
setting up your system so that a camera can be
chosen that will produce high-resolution images.
If the goal is to produce images for medical records bility that allows the image viewing and capturing
and to demonstrate findings to the client, all the to be performed on a tablet device. Clients and the
described systems in this paper will perform nicely. practitioner can use the larger screen of the tablet to
All equine patients receiving an oral exam can be view the oral cavity and even record voice descrip-
examined with an oral scope. tions of the exam. Below is an example of compo-
The systems that are commonly utilized for oral nents to build your DIY systems.
endoscopy can be broken down into two categories:
1. Rigid endoscope with 30° to 120° field of view
1. Systems that are commercially available. with a minimum length of 30 cm. The Storz
2. The do-it-yourself (DIY) systems where Endocameleon™ is a specialized scope that
the practitioner compiles the components has a variable viewing angle from 0° to 120°f.
themselves. 2. USB high-definition camera with capturing
software or camera mount to digital camera or
Commercially Available Systems smart phone.
These systems have a vast range in price, image 3. Endoscopic light source preferably battery-
quality, and function. The practitioner must de- operated light-emitting diode (LED).
cide for themselves what fits their budget and how 4. Storage device such as laptop, secure digital
this instrumentation will benefit their practice. (SD) card, USB drive, or cloud storage.
Below is a list of commercially available systems
from least expensive to most expensive. It is by no 3. Results
means a complete list but is a list of commonly used Commercially available systems will often have a
devices by practitioners. warranty and will often provide some form of train-
ing to best use the system for your practice. These
1. Eezy-view cameraa systems will range in price from inexpensive to sev-
2. Portascope Dental stickb eral thousands of dollars. The image quality will
3. Stoll Oral endoscope packagec have a direct correlation to cost.
4. Dr Fritz Dental Stickd
5. MDS Scope source flexible endoscopee Eezy-View Camera
This system has a 90° viewing angle, a rotatable
DIY-Assembled Systems joint at the viewing head so that the handle and
These systems are compiled from different sources viewing screen can remain in an upright position,
such as Ebay™ or endoscopy instrument suppliers. LED light source, and wireless capability to multiple
Many imaging towers can be outfitted with a rigid LCD monitors. The diameter is 10 mm with a shaft
endoscope to capture images in the oral cavity. length of 43 cm. The image file size is low but is
There are a few important features of the system suitable for medical records and documentation.
that need to be present in order to obtain images in The price of the system is under $700.00 US. Extra
the oral cavity. The field of view angle, a bright wireless LCD monitors are $325.00 US. Storage of
light source, and the quality of the camera one uses the images is to a removable SD card (Fig. 1).
to obtain the image. Cameras are either a USB
camera designed to clip onto the ridged scope or a Portascope Dental Stick
camera adapter fitted to a standard digital camera This system has a scope that is 6 mm in diameter
that allows it to attach to the scope. Many of the and 23 cm long. There is a cord between the scope
digital cameras have wireless communication capa- and the LCD screen. The price is advertised at
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 HOW TO PERFORM ENDOSCOPY IN EQUINE PRACTICE

Fig. 2. Portascope Dental stick.

$999.00 US. Image quality is good and adequate

for demonstrating findings to owners. The ability Fig. 4. Dr. Fritz wireless dental stick.
to store images with this system is not known.
Wifi capability can be added to this system (Fig. 2).
Stoll Oral Endoscope are interchangeable. Storage of the images is via
This system is an excellent system for examination, the tablet’s storage capabilities. This system pro-
demonstrating oral findings to clients, and visualiz- duces a nice image and is extremely portable. The
ing oral surgical procedures, and produces high- cost of the system is $6000.00 to $8000.00 US, de-
quality images for recordkeeping and publishing. pending on options that one wants to purchase with
The system utilizes a light source that is powered by the system (Fig. 4).
a USB port from the laptop computer. The basic
components are a Storz ridged endoscope, Storz MDS Scope Source Flexible Video Endoscope
USB light source, Storz USB camera, and laptop This is a system that utilizes a four-way directional
computer. Various Storz rigid endoscopes can be flexible endoscope with irrigation and biopsy chan-
utilized with the system. Price for the system is nel. The diameter is 8 mm and the length is 140
approximately $6000.00 US without the laptop. cm. The digital image produced is excellent for dem-
There is an option for this system to have irrigation onstrating findings to clients and for publishable-
to rinse debris from the viewing head (Fig. 3). quality images. The small diameter of the scope
allows the end to be bent in a close radius allowing
Dr. Fritz Dental Stick visualization from 0° to 120°. A protective sheath
This wireless system has several different configu- of nylon is custom made and slid over the scope end
rations. The endoscope viewing angle is 90° with to protect it from abrasive areas of the teeth. The
LEDs as the light source. The focal distance tends sheath also serves as a handle and provides rigidity
to be close to the structure being imaged making it to the end of the scope while in the mouth. Porta-
slightly difficult to orientate yourself in the mouth. bility is hampered; however, there are options for
The image is sent wirelessly to a tablet device. cases to contain the components. The system has
The endoscope has rechargeable battery packs that the added advantage of being able to perform upper
airway exams as well with the protective nylon
sheath removed. Cost of the entire system is
⬃$13,000 US (Fig. 5).
DIY-assembled systems may come with a war-
ranty on certain components but overall the system
will not be warranteed. The system will also not
come with training specific to the horse’s mouth.
The operator will have to be willing to trouble-shoot
problems that arise with the system. All of the
following systems described demonstrate different
camera options that can be attached to a ridged
endoscope. The practitioner must first purchase a
rigid endoscope (Fig. 6) with specifications listed
above and couple that with a camera. The Storz
endocameleon has a variable viewing angle from 0°
Fig. 3. Stoll Oral endoscope shown here with USB LED light to 120° degrees (Fig. 7). Rigid scopes can range in
source, Storz USB camera, and Storz boroscope. price from used of $1000.00 US to new prices up to
AAEP PROCEEDINGS Ⲑ Vol. 63 Ⲑ 2017 41

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 HOW TO PERFORM ENDOSCOPY IN EQUINE PRACTICE

Fig. 7. Examples of two rigid scopes of different lengths (Top)

30° viewing angle. Bottom, Unique scope that has the capability
of changing the viewing angle from 0° to 120° called the Endo-
cameleon. (Courtesy of Dr. Jack Easley.)

Fig. 5. MDS Scope source 8-mm flexible endoscope shown with

the protective nylon sheath. This system can also be used as an
upper airway system. (Fig. 10). Light sources are still needed to provide
light through the fiber optics of the scope. USB
cameras can range from a few hundred dollars to
several thousand dollars depending on image
$5000.00 US. Below will be combinations of DIY quality.
systems that are being used.
Medical Case Selection
Smartphone DIY System
The cases that are especially pertinent to utilize an
This system has a smartphone adapter that enables endoscope are patients that have small oral cavities
a smartphone to be attached directly to the rigid that are difficult to inspect with a dental mirror.
endoscope. A light source is also needed. The Patients that have progressive pathology such as
smartphone adapters are priced around $600 to periodontal disease or endodontic decay lend well
$800 US (Fig. 8). to having images captured for the medical record
DIY USB Camera and Standard Digital Camera Systems to document progression and response to treat-
ments. Patients with trauma or that have an
Several endoscope cameras are available that mount
extremely painful condition in the oral cavity are
to the endoscope with a USB connection to a laptop
often best examined with an oral scope to mini-
(Fig. 9). Mounts can be purchased that allow digi-
mize the amount of stimulation in the oral cavity
tal cameras to be attached directly to the endoscope
with bulky instrumentation.
In the author’s practice the horse is sedated, a
full-mouth speculum is placed and the mouth is
rinsed free of organic debris. The horse needs to be
sedated to the point of minimal tongue movement.
The author prefers to still utilize a mouth mirror to
quickly inspect the oral cavity and then perform a
detailed inspection with the oral scope. The max-
illary quadrants of the teeth are inspected first vi-
sualizing each tooth in entirety looking at the
surface of each pulp horn and each infundibulum
(Fig. 11). The scope is rocked slightly sideways
looking at the buccal and lingual surfaces for evi-
dence of periodontal disease and cemental decay
(Fig. 12). If the particular scope that is being used
is 0° to 45°, the soft palate and caudal oral cavity can
also be inspected for soft-tissue lesions. The man-
dibular quadrants are inspected in a similar man-
ner. The tongue will often have to be gently moved
toward the opposite quadrant to visualize the lin-
Fig. 6. Example of rigid endoscopes (Top, 6 mm ⫻ 30 cm and gual surface and the areas under the tongue. If the
bottom, 10 mm ⫻ 42 cm) both with 70° viewing angles. (Author horse is resistant or is having increased tongue
photos.) movement lidocaine jelly or lidocaine solution can be
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 HOW TO PERFORM ENDOSCOPY IN EQUINE PRACTICE

Fig. 8. Cell phone adapter caseg coupled with a 6 mm ⫻ 42 cm scope with a 70° viewing angle and battery-operated LED light source.
(Author photo.)

coated on the tongue and adjacent soft tissues. owner last name, and then patient name. This al-
Lidocaine can be sprayed in the mouth with a Luer lows access from any computer that is online and the
lock syringe attached to a 20-gauge needle with the images are labeled by tooth inspected. Videos as
needle broken off at the hub. The lidocaine jelly well as still images are stored for use in medical
can be placed on a gauze sponge and smeared on the records and discharge papers.
tissues using a long alligator forceps so that your
hand does not need to be placed in the mouth. 4. Discussion
The author encourages the user to purchase a scope The practitioner that is providing dental services is
that can focus well at several focal distances. This encouraged to consider adding oral endoscopy to
allows visualization of a whole tooth and part of the their practice. The main reasons would include the
adjacent tooth so that you do not lose your place in ability to provide a more thorough examination, al-
the mouth. This is particularly important when low the clients to visualize the exam with the prac-
examining the teeth in the center of the quadrant as titioner, and the ability to allow documentation of
the teeth all look similar and it is easy to lose your the examination for following pathologic conditions.
place and describe the wrong tooth. The practitioner must choose a system that fits the
The author utilizes Dropbox™, an online storage needs of the practice. The considerations can be
program that host the images locally on your com- distilled down to price, portability, ease of use, and
puter. The file tree is created by year, month, image quality.

Fig. 10. Digital camera with wifi capability coupled to a rigid

endoscope with a battery-operated LED light source. Pictured
Fig. 9. USB camera mounted on a 6 mm ⫻ 42 cm 70° viewing here is a Panasonic Lumixh GF6 camera with a micro four-thirds
angle scope with a battery-powered LED light source. (Author to C-mount adapter and a C-mount coupling lens. (Courtesy of
photos.) Jack Easley.)

AAEP PROCEEDINGS Ⲑ Vol. 63 Ⲑ 2017 43

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 HOW TO PERFORM ENDOSCOPY IN EQUINE PRACTICE

Fig. 11. Left, Axially rotated 109 with diastema at 108 and 109 tooth. Right, Complicated crown fracture tooth 109 with all pulp
horns exposed.

The practitioner must first decide their budget as careful to not spend more money piecing a system
it is hard to effectively increase one’s profit with an together, than if you had bought a commercially
oral scope over proper use of a dental mirror. It available system that would have training and a
however does increase one’s marketing of the oral warranty.
exam to the client with images and the ability to add There are several things to beware of when
them into the medical record. The author utilizes a shopping for a system. Wireless systems are
flexible endoscope for in clinic procedures that stores great and extremely portable. The disadvantage
the images automatically into a patient file that is of some of the wireless systems can be connectiv-
on Dropbox™. This allows easy sharing of the im- ity. One should always demo a system before
ages between practitioners and the safety of cloud purchase and compare several systems. There
backup. The flexible endoscope has the benefit of can be a wide variety of focal distances and area of
being able to change the angle of viewing and in
viewing that can make them hard to operate.
patients with sinus disease, this system can be uti-
For instance, a scope that has trouble getting a
lized to perform upper airway exams or sinoscopy.
The one drawback to this system is the lack of easy full tooth in view at a time can make it hard to
transportation. keep track of which tooth you are viewing during
The commercially available systems that are in- the exam. It is better to have a scope that can
expensive are good for the practitioner that wants to focus at different lengths to be able to get an
show clients the examination and to document pa- overall view of the quadrant and then move in to
thology in the medical record. The image quality examine the pathologic lesion closely.
will not be of publishable quality nor do they have
the ability to have irrigation. Irrigation is a must if
the practitioner wants to perform endoscopic-guided 5. Conclusion
intraoral surgery. In the present time, the flexible
endoscope and the Stoll systems with a Storz scope The are many options for systems to examine and
and USB camera are the only ones with true irriga- document the oral examination findings. The prac-
tion capabilities. titioner should spend ample time and demo several
The DIY systems are for the practitioner that has systems to find the system that is right for their
some technology in their background. One must be practice situation.

Fig. 12. Left, Senile diastema of the 208 and 209 teeth. Right, Open diastema of teeth 210 and 211.

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 HOW TO PERFORM ENDOSCOPY IN EQUINE PRACTICE
Acknowledgments 4. Ramzan PH. Oral endoscopy as an aid to diagnosis of equine
cheek tooth infections in the absence of gross oral pathological
Declaration of Ethics changes: 17 cases. Equine Vet J 2009;41(2):101–106.
5. Tremaine WH. Dental endoscopy in the horse. Clin Tech
The Author has adhered to the Principles of Vet- Equine Pract 2005;4(2):181–187.
erinary Medical Ethics of the AVMA. 6. Simhofer H, Griss R, Zetner K. The use of oral endoscopy for
detection of cheek teeth abnormalities in 300 horses. Vet J
Conflict of Interest 2008;178(3):396 – 404.

The Author has no conflicts of interest. a

MAI Animal Health, 605 Pro-Ject Drive Elmwood, WI 54740.
b
Portascope.com Inc., 6220 Manatee Ave., West #302, Braden-
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