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The Potential of Ozone Therapy in Dentistry

Ozone has a promising role in oral healthcare, but further research is needed to verify its efficacy and safety.

PURCHASE COURSE
This course was published in the June/July 2024 issue and expires July 2027. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.

AGD Subject Code: 010

EDUCATIONAL OBJECTIVES

After reading this course, the participant should be able to:

  1. Discuss the historical background and chemical properties of ozone.
  2. Identify the various forms of ozone therapy used in dental treatments, their mechanisms of action, and their applications in managing dental diseases.
  3. Recognize the potential benefits and risks associated with ozone therapy in dentistry.

For more than a century, ozone has been used in the medical realm, serving as a disinfectant and blood purifier. Ozone’s benefits are based on its ability to combat bacteria, viruses, and fungi, along with its immunomodulatory, anti-hypoxic, biosynthetic, and anti-inflammatory characteristics.1

While healthy cells are equipped with antioxidants, pathogenic bacteria possess minimal antioxidants within their membranes. This deficiency renders them vulnerable to ozone; ultimately, leading to the destruction of their cell membranes.2

Ozone is a widely embraced alternative treatment for a variety of conditions. Its current rise in popularity can be attributed to its straightforward application, favorable patient acceptance, lack of adverse effects, and cost-effectiveness.3 Ozone therapy is a flexible bio-oxidative treatment involving the administration of oxygen/ozone through gas or its dissolution in water or oil-based mediums.4

Composed of three oxygen atoms, ozone has a molecular weight of 47.98 g/mol.4 Ozone is an unstable gas that occurs naturally in the outer atmosphere through the action of ultraviolet rays on oxygen. 1 In the Earth’s stratosphere, it also absorbs ultraviolet rays, protecting living organisms from their damaging effects.5

Ozone works by oxidizing organic compounds and destroying bacterial cell walls by reacting with unsaturated fatty acids, phospholipids, and proteins. It also stimulates the proliferation of immunocompetent cells, supporting healing. The mechanisms of ozone production depend on the specific generator used, such as ozone ultraviolet systems, cold plasma systems, and corona discharge systems.6 Ozone has high efficacy in low concentrations by utilizing the principle of hormesis, which is the beneficial effect of low-level exposure to an agent that is harmful at high levels.

RudolfSimon, via Wikimedia Commons

Ozone can be used in three different states: gas, liquid, and oil. Gaseous ozone is commonly used in restorative dentistry and endodontics for the treatment of dental caries and as a disinfectant.3 Ozone generating equipment converts oxygen to ozone, which is then led through a silicone cup over the tooth for a minimum of 10 seconds.4 Concerns include the need to scavenge excess ozone gas and prevent it from escaping into the clinical area, as well as the potential for air embolism with intravenous injections of ozone.7 It requires specialized equipment with a sealed suction system and must be used rapidly as it is difficult to store.2

Ozonated oil, which occurs naturally in plant extracts, can penetrate deeply into gingival tissues.2,8 Ozonated oils are pure plant extracts that undergo a chemical reaction to form a thick, viscous oil or a petroleum jelly-like product, the final product containing ozonides. Gaseous ozone, when compared to ozonated oil, may not be as feasible to produce in large quantities for multiple patients.9

Ozonated water is considered the most efficient and safer method of ozone depletion. It has been linked to successful management of wound healing, dental caries, gingivitis, and periodontitis. Additionally, it is effective against both Gram-positive and Gram-negative oral microorganisms.3 Aqueous ozone can be used as a disinfectant, to cleanse wounds in bones and soft tissues, control bleeding, and improve healing by increasing the local supply of oxygen to the wound area. It can also increase metabolic processes related to wound healing and can be used in candidiasis, periodontitis, and as a disinfectant to rinse the oral cavity.10

Wound Healing

Ozone promotes wound healing and manages opportunistic infections. Evidence shows that the regular application of ozonized water enhances the natural healing process.8 Oxygen serves a vital function in the creation of collagen, development of fresh capillaries, and regulation of infections. The revival of injured tissue primarily hinges on the oxygen within the bloodstream, facilitating the stimulation of fibroblast migration and generation of granulation tissue.3,5

A Swiss study revealed that patients who employed ozonated water experienced greater wound healing compared to those who used conventional water.11 In a comparative study between an experimental group treated with ozonated oil and a control group undergoing antibiotic therapy for alveolitis treatment, patients treated with ozonated oil exhibited a faster healing rate.12

Ozone has been utilized for the sterilization of implants before their insertion. Due to ozone’s capacity to expedite wound healing, fewer occurrences of postoperative complications, such as pain, dry socket, and bone necrosis, have been noted.8 In a study on peri-implantitis in which the control group was treated solely with saline while the experimental group received ozonated water, pocket depth values were lower among those who received ozonated water than the control group at the 3-month follow-up.13

Ozone can help manage avascular osteonecrosis of the jaw, leading to the complete healing of lesions and the alleviation of associated symptoms.4 It is also useful as a post-surgical treatment for jaw osteonecrosis.2

Periodontal Diseases

Ozone stands out for its exceptional disinfection capabilities compared to other antiseptics, making it a valuable alternative or supplementary disinfectant for treating conditions such as periodontitis, gingivitis, peri-implantitis, and surgical incisions.3

Irrigating the pockets of patients with aggressive periodontitis with ozonated water after scaling and root planing proved to be effective in enhancing clinical outcomes.10 This treatment regimen involved weekly irrigation of periodontal pockets with 150 ml of ozonated water for 5 to 10 minutes over the course of 4 weeks. Significant reductions were observed in pocket depth, plaque, gingival indices, and bacterial count.

In cases of peri-implantitis, gaseous or aqueous ozone forms can be employed, with complete coverage of the abutment by using an appropriately sized polyvinyl chloride or silicone cap. A proper seal must be achieved around the implant’s gingival borders when utilizing ozone gas infiltration in this context.3 The bacteria Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythia are all associated with aggressive periodontal disease; ozone is highly effective against these pathogens.14

Dental Caries

Research has demonstrated ozone’s effectiveness in treating pit and fissure, root, and interproximal caries.15 One of the key advantages of ozone therapy lies in its effectiveness in treating deep pits and fissures, as it removes the smear layer and exposes the dentin, which can then be occluded by the application of remineralizing agents.4 This process not only eliminates bacteria but also promotes the remineralization of the affected area.15 Further research and clinical trials are warranted to explore the full potential of ozone therapy in this application.

Ozone therapy has been found to inhibit and kill cariogenic bacteria, thereby arresting or reversing the progression of early childhood caries .16 Ozone therapy can also prevent infection in the primary tooth from affecting the permanent tooth germ and developing roots. Ozone therapy can be used in conjunction with other techniques to treat incipient pit and fissure caries. The procedure involves using an air polishing device to clean biofilm and debris from occlusal surfaces, isolating and drying the tooth with cotton rolls, and applying ozone at a concentration of 2,100 ppm. After ozone application, sealants can be applied. Studies have shown that this approach can lead to remineralization of dental surfaces.17

Oral Lesions

Aphthous ulcers and herpes labialis have shown positive response to ozone therapy. In the case of oral lichen planus, ozone therapy has demonstrated potential to replace steroid treatment by increasing wound healing after high-dose radiotherapy and resolving symptoms effectively.5

In one study, success with treatment of herpes simplex virus was found with three applications of ozone therapy and treatment of recurrent aphthous ulcers using three 2-minute ozone applications.8 Ozone therapy has also shown effectiveness in treating oral candidiasis, as its antifungal properties make it a potential alternative or adjunct to antifungal medications.8

Traumatic dental ulcers, often caused by denture-related issues, are a frequent concern for denture wearers. One study proved that exposing denture-related ulcers to ozone using an appliance that produces ozone from oxygen for 60 seconds provided faster healing of the lesions and reduced pain.18 Further, direct application of the ozone did not provide harmful effects to oral tissues and both the duration and size of the ulcers diminished after ozone application.

Dentinal Hypersensitivity

Studies show that ozone treatment can lead to an average decrease of 55% in dentinal hypersensitivity pain levels.8,10 For hypersensitivity in general, applying ozone spray for 60 seconds, followed by a mineral wash on exposed dentin, can provide rapid relief. Ozone has the ability to penetrate dentinal tubules, and, in the case of cervical hypersensitivity, it can eliminate bacteria entering the tubules by penetrating the separation of calcium and phosphate ions.8

Risks Posed by Ozone Use

There are four main ways to produce ozone gas: corona discharge system, electromagnetic system, ultraviolet system, and cold plasma system. In dentistry, the corona discharge system, in which oxygen generates electrical sparks is the most commonly used. This phenomenon is frequently utilized by indoor air purifiers.19

When used imprecisely or in larger than recommended proportions, ozone can turn toxic, giving rise to pulmonary complications.8 Oral health professionals must adhere to the recommended dose of ozone, with a maximum concentration of 5% ozone and minimum oxygen content of 95%.3 Therefore, the accurate measurement of ozone concentrations within the mixture necessitates generators equipped with precise photometers and the capability to perform accurate calculations.8

Ozone poses potential risks and contraindications that must be considered. It is difficult to store due to its instability and should be used immediately upon formation.2 Interference of oxygen during ozone formation can result in the production of toxic nitrogen dioxide.18

Contraindications for ozone therapy include pregnancy, asthma, epilepsy, myocardial infarction, anemia, myasthenia gravis, pacemaker implantation, ozone allergy, immunocompromised conditions, hyperthyroidism, hemorrhage, alcohol intoxication, and glucose-6-phosphate dehydrogenase deficiency.7,18 Ozone toxicity occurs when exposed to high levels of atmospheric ozone, leading to injury and inflammation.

Medical-grade ozone typically consists of 0.1% to 5% ozone and 95% to 99.6% pure oxygen.1 During ozone therapy, a maximum ozone concentration of 0.01 ppm can be safely used in the oral cavity.3 However, inhalation of ozone can be toxic due to its highly oxidative nature.15

Symptoms of ozone intoxication include nausea, vomiting, headache, coughing, and upper respiratory tract irritation. In such cases, patients should be placed in a supine position and provided with humid oxygen for inhalation. Additionally, the administration of ascorbic acid, vitamin E, and N-acetylcysteine can be beneficial for chronic ambient ozone exposure.20

To prevent adverse reactions, materials that come into contact with ozone must be ozone-resistant, such as glass, silicon, and Teflon. While ozone therapy may offer certain benefits, remaining mindful of its potential risks, contraindications, and proper administration is critical to patient safety.

Role of the Dental Hygienist

Dental hygienists can recommend ozone for use as a complementary approach or in combination with treatment.8 Ozonated water may serve as a preparatory mouthrinse for patients prior to dental procedures, as well as a home remedy for oral malodor.10,15 Due to its potent capability to eliminate both Gram-positive and Gram-negative microorganisms, using ozone-infused water to irrigate regions that are impacted prior to and after procedures, such as scaling and root planing, and nonsurgical pocket curettage serves to reduce the initial burden of harmful microorganisms locally and systemically.3,15

Incorporating ozonated water into the dental water supply offers protection against aerosol-borne contaminants. Ozone’s sterilization action ensures the generation of solely oxygen and water as residual byproducts.7 At the end of treatment, each pocket and sulcus may be infused with ozone gas, directly sanitizing the tissues. Additionally, patients can be provided with ozonated oil for topical application on soft and delicate oral tissues.15 Dental hygienists might suggest that patients with periodontal diseases administer ozonated oil at home into periodontal pockets on a weekly basis with a blunt 25‑gauge needle or any other appropriate tip.3,21

Conclusion

Ozone therapy is nontoxic and does not damage cells, making it a safe option for patients.7,10 It has potential to become a valuable treatment modality in dental care. However, more research is needed to further explore the use of ozone in dental practice.

References

  1. Srinivasan SR, Amaechi BT. Ozone: a paradigm shift in dental therapy. Journal of Global Oral Health. 2019;2(68):68-77.
  2. Suh Y, Patel S, Kaitlyn R, et al. Clinical utility of ozone therapy in dental and oral medicine. Med Gas Res. 2019;9:163-167. d
  3. Gulafsha M, Anuroopa P. Miracle of ozone in dentistry: an overview. World Journal of Pharmaceutical Research. 2019;8(3):665-677.
  4. Sandhu RK. Ozone in dentistry-a review. Journal of Advanced Medical and Dental Sciences Research. 2021;(9):115-119.
  5. Gallo S, Scribante A. Ozone therapy in dentistry: from traditional applications towards innovative ones. A review of the literature. IOP Conf Ser Earth Environ Sci. 2021;707:012001.
  6. Viebahn-Haensler R, León Fernández OS. Ozone in medicine. The low-dose ozone concept and its basic biochemical mechanisms of action in chronic inflammatory diseases. Int J Mol Sci. 2021;22:7890.
  7. Sen S, Sen S. Ozone therapy a new vista in dentistry: integrated review. Med Gas Res. 2020;10:189-192.
  8. Barczyk I, Masłyk D, Walczuk N, et al. Potential clinical applications of ozone therapy in dental specialties-A literature review, supported by own observations. Int J Environ Res Public Health. 2023;20:3.
  9. Malik T, Kaura S, Kakria P. Dental ozone: a boon for dentistry. Indian Journal of Dental Sciences. 2020;12(1):49-52.
  10. Karimi A. Applications of ozone in dentistry and oral health: A systemic review. Science Progress and Research. 2021;1(3):243-249.
  11. Filippi A. The influence of ozonised water on the epithelial wound healing process in the oral cavity. Dtsch Zahnarztl. 2001:56.
  12. Das S. Application of ozone therapy in dentistry. Indian J Dent Adv. 2011;3:538-542.
  13. Isler SC, Unsal B, Soysal F, Ozcan G, Peker E, Karaca IR. The effects of ozone therapy as an adjunct to the surgical treatment of peri-implantitis. J Periodontal Implant Sci. 2018;48:136.
  14. Çalışır M, Talmac AC, Ege B, Poyraz Ö, Dumlupınar E. The effect of ozone gas on IL-1β and IL-10 levels of gingival crevicular fluid in aggressive periodontitis patients. Ozone: Sci Eng. 2019;41:571-578.
  15. Vats D, Dhall S, Sachdeva S. Ozone therapy in dentistry: a literature review. Journal of Oral Research and Review. 2022;14(1):84-88.
  16. D’Amario M, Di Carlo M, Natale SM, et al. Application of ozone therapy in paediatric dentistry. Appl Sci (Basel). 2022;12:11100.
  17. Unal M, Oztas N. Remineralization capacity of three fissure sealants with and without gaseous ozone on non-cavitated incipient pit and fissure caries. J Clin Pediatr Dent. 2015;39:364-370.
  18. AlZarea BK. Management of denture-related traumatic ulcers using ozone. J Prosthet Dent. 2019;121:76-82.
  19. Yadav RK, Tiwari R. Relevance of ozone therapy in the field of conservative dentistry and endodontics. Journal of Oral Research and Review. 2023;15(1):87-91.
  20. Srinivasan K, Chitra S. The application of ozone in dentistry: a systematic review of literature. Scholar Journal of Dental Sciences. 2015;2(6):373-377.
  21. Deepa D, Gupta S. Applications of ozone therapy in dentistry. J Oral Res Rev. 2016;8:86.

From Dimensions of Dental Hygiene. June/July 2024; 22(4):32-35

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