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Interview: “Bioactive endodontics is the future”

Dr. James Bahcall and colleagues are exploring the possibilities of cryotherapy in endodontic dentistry. (Photograph: Dr. James Bahcall)
Monique Mehler, Dental Tribune International

Monique Mehler, Dental Tribune International

Mon. 8. July 2019


In the medical field, cryotherapy is used in an effort to relieve pain and swelling after soft-tissue management or surgery. Currently, researchers in the U.S. are exploring the possibilities and limitations of vital pulp cryotherapy in clinical trials. Dr. James Bahcall, who plays an important role in these investigations, is a clinical professor at the University of Illinois at Chicago. He spoke to Dental Tribune International about the studies.

Dr. Bahcall, in collaboration with other researchers, you have published an article titled “Introduction to vital pulp cryotherapy” in which the use of cold therapy in endodontics is explored. What is the history behind the use of  cryotherapy in vital pulp therapy?
There has been a paradigm shift in vital pulp therapy over the last three to five years. We have gained a better understanding of pulp biology from caries involvement, and there have been new developments in bioceramic materials. We have also come to view vital pulp therapy as a permanent rather than temporary dental treatment. All of this allowed us to develop vital pulp cryotherapy. Although we did not invent cryotherapy, we were the first to bring it into endodontics for vital pulp treatment. Medicine has demonstrated since the early 1960s that cryotherapy can reduce nerve pain response, inflammation and hemorrhaging, and can help reduce a patient’s need for postoperative pain medications.

Vital pulp cryotherapy is performed when a carious lesion is removed from a tooth and there is direct or indirect exposure of the dental pulp. The cryotherapy portion of treatment involves placing sterile ice on the exposed pulp. The application of ice lowers the temperature of the tooth’s blood and nerve supply, and this has been shown clinically to reduce inflammation and post-treatment tooth pain. It is important to note that, after performing the cryotherapy procedure, 17% EDTA irrigation is applied, a bioceramic material is then placed over the directly or indirectly exposed pulp, and the tooth is restored with a permanent restorative material, such as composite or amalgam.

How is this different from classic root canal therapy?
Vital pulp cryotherapy involves treating a carious tooth while maintaining the tooth’s pulpal tissue as opposed to root canal therapy that involves removal of the entire dental pulp and replacing it with gutta-percha and sealer.

What are the benefits of vital pulp cryotherapy, and what are its limitations?
The benefits of vital pulp cryotherapy are its ability to eliminate pulpal inflammation and a patient’s tooth pain without the complete removal of the dental pulp. By maintaining the dental pulp, we are able to maintain the tooth’s strength by not having to remove root dentin, the pulp–dentin complex and the pulp’s immune defense mechanisms. Another benefit of vital pulp cryotherapy is the treatment time for the patient. Once the patient is properly anesthetized and the caries is removed, the actual time to complete the vital pulp cryotherapy portion is 10–15 minutes. In comparison, root canal therapy can take 1–2 hours. Vital pulp therapy procedures are completed in one patient treatment visit.

The limitation of vital pulp cryotherapy is that this procedure can only be performed on vital teeth that can be permanently restored with composite or amalgam immediately after the procedure. It cannot be performed with necrotic or partially necrotic pulps. A clinician cannot prepare a vital pulp cryotherapy treated tooth for a crown. The reason for this is that, once the vital pulp cryotherapy is completed, you do not want to do any further dental treatment to this tooth because you risk the possibility of restimulating the pulpal inflammation.

In your article, you conclude that further clinical studies are needed in order to establish the long-term prognosis of a pulp after vital pulp cryotherapy. What are your expectations?
As with any new dental procedure, clinical cases and studies need to be published in peer-reviewed dental literature. Vital pulp cryotherapy is no different. We have published case reports and have been conducting clinical research on vital pulp cryotherapy. Our study has found that patients have less postoperative pain immediately after treatment and maintain normal pulp vitality at six months and at one year after treatment. This is as far as our clinical study has patient recalls at this point. Our expectations are, firstly, to demonstrate that this is a valid procedure for vital pulp treatment beyond one year. Secondly, we hope to encourage our dental colleagues to publish vital pulp cryotherapy case reports and clinical research in the dental literature.

How do you think vital pulp cryotherapy will advance endodontics?
We feel that vital pulp cryotherapy will help to broaden the type of pulpal treatment that we can provide to our patients. It also will be an important treatment component in bioactive endodontic therapy. Bioactive endodontics is the future. By definition, “bioactive” means having a biological effect. Bioactive endodontics in conventional endodontic treatment includes vital pulp cryotherapy and regenerative endodontics. It involves the use of bioactive materials and the patient’s own blood to help heal, as in the case of vital pulp cryotherapy, and to replace the gutta-percha and sealer in classic root canal therapy.

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Guided Biofilm Therapy is an absolute patient favourite

Modern dental cleaning uses AIR-FLOWING. This effective and particularly gentle method is suitable for biofilm management on all oral tissue as well as on restorations, implant components and fixed orthodontic appliances. (Image: EMS)

Wed. 6. December 2023


NYON, Switzerland: Those who prioritise their overall health also understand the importance of oral health and consistently seek professional prophylaxis. Over 278,000 patients worldwide have been surveyed after undergoing preventive care with Guided Biofilm Therapy (GBT), and 94% of them prefer GBT to conventional methods and therefore recommend it to family and friends. In the survey, they were also asked about their perception of pain during GBT, the time the treatment required and the usefulness of disclosing biofilm.

Owing to the high burden of disease, the World Health Organization has identified oral disease—including caries and periodontitis—as a key health problem.1, 2 As dentists know, to address these, the microbial biofilm must be removed regularly and completely, and patients must be encouraged to follow a healthy lifestyle. However, daily personal oral hygiene removes a maximum of 50% of the biofilm from supragingival tooth surfaces, particularly in the interdental area.3

Regular and effective professional prophylaxis too is therefore of crucial importance.4, 5 For this to be successful, it must be patient-friendly and reflect current knowledge and technical progress.6–11 In response to these requirements, EMS developed GBT in collaboration with leading experts.12 In order to determine the acceptance of GBT compared with conventional methods, patients of GBT-certified practices are surveyed using standardised questionnaires.

Method and results

Fig. 1: Patients love Guided Biofilm Therapy. The vast majority clearly prefer the systematic and risk-adapted protocol, 99.3% of them giving it a 3-, 4- or 5-star rating. (Image: EMS)

The GBT certification protocol includes training of the practice team by the Swiss Dental Academy and the collection of patient feedback. The anonymised responses are provided to EMS by GBT-certified practices and clinics for evaluation (278,258 responses from 13,082 practices and clinics as at 31 October 2023).

The questionnaire used for the feedback consisted of seven questions, in response to which the respondents gave a rating on a scale of 0 to 5. All of them scored around 4.7 of 5.0 possible points, showing a very high level of approval of GBT. Among the questions are the appropriate amount of time required and the absence of pain. The results were unequivocal: 93.93% of the patients preferred GBT to the conventional method (Fig. 1), and disclosing was considered to be useful by 93.17% of the respondents. This step in the GBT protocol ensures that the biofilm has been completely removed—providing assurance for the patient and practitioner. The University of Zurich in Switzerland was involved in the further development of the questionnaire for this newest survey.


The use of invasive sonic, ultrasonic and manual instruments in conventional professional tooth cleaning13 to remove calculus and subsequent polishing result in the loss of valuable tooth substance without achieving a smoother surface.14 In addition, staining is often omitted.15 In GBT, however, the biofilm is first removed from all oral surfaces. This is done—after mandatory disclosing—in a minimally invasive and gentle manner with AIR-FLOWING.16 This involves the use of the AIRFLOW Prophylaxis Master device with the AIRFLOW MAX handpiece, PERIOFLOW handpiece and PLUS powder for highly effective and efficient professional prophylaxis, thanks to EMS’s patented laminar technology, which ensures that the PLUS powder leaves the nozzle at a constant and regulated flow rate (Fig. 2).17 Only in the second step is the piezoceramic ultrasonic system (PIEZON PS NO PAIN) used to remove the remaining visible calculus.

Fig. 2: Only with AIR-FLOWING (left) does the PLUS powder leave the nozzle at a constant and regulated flow rate (patented laminar AIRFLOW technology).17 AIR-FLOWING is the combination of the AIRFLOW Prophylaxis Master, AIRFLOW MAX or PERIOFLOW and PLUS powder, making biofilm management more predictable, safer, more efficient and more convenient. (Image: EMS)

Today’s informed patients want effective and modern prophylaxis management that aligns with the latest advances in science and technology, and they wish to collaborate on their care with the dental team. The positive experience of this gentle and pain-free preventive treatment is of great importance for patient loyalty and recall—and therefore also for the financial success of a practice. GBT has been shown to be superior in these aspects, both in primary prophylaxis and in secondary and tertiary prophylaxis.6, 7, 9–11

The most recent assessment of patients treated with GBT—over 278,000 surveyed—clearly confirms the high patient acceptance of the GBT protocol. This supports the findings of an earlier evaluation from April 2022.18 The enthusiasm of the prophylaxis team for GBT may affect the evaluation by patients (Hawthorne effect).19 However, the results of the patient survey are in very good agreement with published studies from practice and academia.20 Owing to the differentiated research question and high number of participants, a clear preference for GBT compared with conventional procedures can therefore be established.

Become a GBT-certified practice

If you want to offer prophylaxis at the highest level, you can have your practice certified in accordance with GBT. Further information can be found at www.ems-dental.com/en/gbt-certified.

Editorial note:

A list of references can be found here.

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