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Table of Contents
REVIEW ARTICLE
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 87-92

Ozone therapy in dentistry: A literature review


1 Department of Prosthodontics, Rungta College of Dental Sciences and Research, Bhilai, Chattisgarh, India
2 Department of Prosthodontics,Chattisgarh Dental College and Research Institute, Rajnandgaon, Chattisgarh, India

Date of Web Publication17-Sep-2011

Correspondence Address:
Bikash Pattanaik
Department of Prosthodontics, Rungta College of Dental Sciences and Research, Bhilai, Chattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.85024

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   Abstract 

This review of literature is an attempt to summarize different modalities of ozone application in dentistry. Ozone gas has a high oxidation potential and is effective against bacteria, viruses, fungi, and protozoa. It also has the capacity to stimulate blood circulation, platelets, and immune response. Ozone is used in dentistry in gaseous, ozonated water and as ozonated oils. Ozone was shown to be biocompatible and is used in all aspects of dentistry. It has been shown to stimulate remineralization of recent caries-affected teeth and is used as a preventive therapy in caries, root caries, and intracanal irrigants in endodontic treatment. It has been used in treatment of alveolitis, avascular osteonecrosis of the jaw, and herpes virus infection. It also inhibits plaque formation and can be used as an adjuvant in periodontal surgical and maintenance phase. Ozone has also been used in dental unit water line to disinfect water. Advantage of ozone therapy is it is an atraumatic, biologically based treatment. While laboratory studies suggest a promising potential of ozone in dentistry, less number of clinical studies were documented. More number of randomized, controlled trials need to be conducted to determine the precise indications and guidelines to treat various dental pathologies with this promising medical agent.

Keywords: Ozone in caries, ozone in dental clinics, ozone in dentistry, ozone in endodontics, ozone in oral surgery, ozone in periodontics, ozone in prosthodontics


How to cite this article:
Pattanaik B, Jetwa D, Pattanaik S, Manglekar S, Naitam DN, Dani A. Ozone therapy in dentistry: A literature review. J Interdiscip Dentistry 2011;1:87-92

How to cite this URL:
Pattanaik B, Jetwa D, Pattanaik S, Manglekar S, Naitam DN, Dani A. Ozone therapy in dentistry: A literature review. J Interdiscip Dentistry [serial online] 2011 [cited 2018 Jun 23];1:87-92. Available from: http://www.jidonline.com/text.asp?2011/1/2/87/85024


   Introduction Top


The word Ozone (O 3 ) is derived from the Greek word ozein (odorant). Ozone is one of the most powerful antimicrobial agents available for use in medicine and dentistry. In the 1920s Dr Edwin Parr, a Swiss dentist, started to use O 3 as part of his disinfection system. [1] Ozone therapy is a well-established alternative and complementary therapy in most of the European countries. A systematic review was performed on studies investigating the effects of ozone on oral tissues and microorganisms and unveil the uses of ozone in dentistry in all aspects.


   Method of Selection of Literature Top


Studies to be included were grouped into two categories: clinical studies and in vitro studies. Eligibility criteria were fixed for each category. Clinical studies were included if they reported (1) a clear outcome of the study, (2) had a control group, and (3) the study included at least a 6-month follow-up analysis. For in-vitro studies biological studies were included, interaction with oral cells and microorganisms were reviewed. The objectives of this review were to find out

  • Effect of ozone on oral tissues and microorganisms.
  • Mode of administration in dentistry.
  • Biocompatibility of ozone.
  • The different uses of ozone in dentistry till date.


We searched the literature using PubMed, electronic databases from 1990 to 2009. Key words such as ozone in dentistry, ozone in dental clinics, ozone in caries, ozone in periodontics, ozone in oral surgery, ozone in endodontics, and ozone in prosthodontics were used. The search was restricted to English language articles, published from 1990 to December 2009.

Maximum studies were in vitro studies, and less number of clinical studies were found. Few studies were human histological studies, animal studies. A total of 68 articles were selected after elimination. Clinical studies: 16, In-vitro Studies: 52.

Effect on bacteria, virus, fungus, protozoa

Bacteria

Ozone acts on bacterial cell membranes, by oxidation of their lipid and lipoprotein components. There is evidence for interaction with proteins as well. [2],[3] Ozone seems to render the spores defective in germination, perhaps because of damage to the spore's inner membrane. [4]

Virus

All viruses are susceptible to ozone; yet differ widely in their susceptibility. [5] Lipid-enveloped viruses are especially sensitive to ozone. [6],[7] Analysis of viral components showed damage to polypeptide chains and envelope proteins impairing viral attachment capability, and breakage of viral RNA. [5]

Fungal and protozoa

Ozone inhibits cell growth at certain stages. [1]

Effect on blood cells

Ozone reduces or eliminates clumping of red blood cells and its flexibility is restored, along with oxygen carrying ability. [8] There is a stimulation of the production of glutathione peroxidase, catalase, and superoxide dismutase which act as free radical scavengers. [9]

Effect on leukocytes

Ozone behaves as a weak cytokine such as tumor necrosis factor-α (TNF-α), interleukin-2, interleukin-6, interleukin-8, transforming growth factor-β [TGF-β]) inducer. [10],[11],[12],[13] Ozone reacts with the unsaturated fatty acids of the lipid layer in cellular membranes, forming hydrogen peroxides (H 2 O 2 ), one of the most significant cytokine inducers. [14]

Platelets

H 2 O 2 generated by blood ozonation activate phospholipase C, phospholipase A2, cyclo-oxygenases and lipo-oxygenases, and thromboxane synthetase, allowing a step increase of intracellular Ca 2 , release of prostaglandin E2, prostaglandin F2a, and thromboxane A2 with irreversible platelet aggregation. [15],[16],[17]

Modes of ozone administration

The European Cooperation of Medical Ozone Societies warns from direct intravenous injections of ozone/oxygen gas that should not be practiced due to the possible risk of air embolism. [18]

Ozone gas application

Ozone generating equipment converts oxygen to ozone. The ozone is thereafter led to a hand piece fitted with a silicone cup. Differently shaped silicone cups are available that correspond to the form of various teeth and their surfaces. This ensures close contact between the silicone cup and the carious area of the tooth so that the ozone does not escape. The ozone is led through the silicone cup over the tooth for a minimum of 10 s. The ozone in the silicone cup is collected again and reconverted to oxygen by the apparatus.

Ozone aqueous solution

The following properties of ozone are used in this case:

  • Disinfectant and sterilizing effect;
  • Hemostatic effect, especially in cases of hemorrhages;
  • Accelerated wound healing, improved oxygen supply and support of metabolic processes


Ozone oil

Ozonated oils are pure plant extracts, through which pure oxygen and ozone are passed. The plant extracts undergo a chemical reaction to form a thick, viscous oil, or in some cases, a petroleum jelly-like product. The final products contain ozonides. This method of external application is harmless.

Advantages of topical ozone therapy

There is always a chance of development of resistance against antibiotic. Pathogens on the other hand, cannot overcome oxidative challenges of ozone. [19] In addition, there is evidence that ozone directly inactivates bacterial toxins, while antibiotics do not. Indeed, toxins are major contributors to bacterial tissue destruction. [19]

Biocompatibility of ozone

A study investigated cytotoxic effects of gaseous ozone and aqueous ozone on human oral epithelial (BHY) cells and gingival fibroblast (HGF-1) cells compared with established antiseptics chlorhexidine digluconate (CHX) 0.2%; sodium hypochlorite (NaOCl) 5.25%, 2.25%; hydrogen peroxide H 2 O 2 3%. Aqueous ozone revealed the highest level of biocompatibility of the tested antiseptics. [20] The metabolic activity of L-929 mouse fibroblasts was high when the cells were treated with ozonated water, whereas that of significantly decreased when the cells were treated with 2.5% NaOCl. [21] Irrigation of the root surface of avulsed teeth did not reveal a negative effect on periodontal ligament cell proliferation. [22] Another study demonstrated that odontoblastic cells exhibited inflammatory responses against bacterial lipopolysaccharides (LPS). Ozonated water improved LPS-induced inflammatory responses. [23]

Uses in oral medicine

Herpes lesions have been studied with topical ozone administration. [24],[25] Ozonated oil applied on herpes labialis and mandibular osteomyelitis demonstrated faster healing times than conventional protocols. [18] Ozone, in these cases, neutralizes herpes virions by direct action, thus inhibiting bactericidal suprainfections, and stimulating the healing of tissues through circulatory prompting. Ozone has been proven to be one of the most powerful oxidants we can use in dentistry. [26]

Uses in oral surgery

Ozone is known to encourage wound healing as well as control opportunistic infection. [27] It was shown that daily treatment with ozonized water accelerates the physiological healing rate. [18] In a study which compared the use of ozonated oil in an experimental group to a control group in which antibiotic therapy was used in the treatment of alveolitis, it was found that patients treated with ozonated oil healed more quickly. [18] Ozone was used in the treatment of avascular osteonecrosis of the jaw (ONJ). There was complete healing of the lesions with the disappearance of symptoms. [28],[29],[30],[31]

Uses in periodontia

Ozonated water inhibited the accumulation of experimental dental plaque in vitro.[32] Ozonated water had strong bactericidal activity against bacteria in plaque biofilm. It was found that ozonated water (0.5-4 mg/L) was highly effective in killing of both gram-positive and gram-negative microorganisms. Gram-negative bacteria, such as Porphyromonas gingivalis,  Porphyromonas endodontalis Scientific Name Search re more sensitive to ozonated water than gram-positive oral streptococci and Candida albicans in pure culture. [32] One study concluded that the addition of ozone to a ultrasonic cleaning system containing different experimental solutions resulted in antibacterial activity against Staphylococcus aureus.[33] Ozonated water has an excellent anti- inflammatory capacity. [20],[34],[35] Researchers choose the NF-kappaB system, a paradigm for inflammation-associated signaling/transcription. Their results showed that that NF-kappaB activity in oral cells in periodontal ligament tissue from root surfaces of periodontally damaged teeth was inhibited following incubation with ozonized medium. The use of ozone around implants is supported by published research showing that ozone not only effectively sterilizes the surfaces of both the implant and bone, but also initiates the reparative mechanisms allowing tissue regeneration around implant surface. [36],[37]

Uses in prosthodontics

The effect of ozonated water on oral microorganisms and dental plaque was assessed. [32],[38] Few oral microorganisms and no viable C. albicans were detected after exposure to flowing ozonated water (2 or 4 mg/L) for 1 min, suggesting the application of ozonated water might be useful in reducing the number of C. albicans on denture bases. One study compared the microbicidal effect between gaseous ozone and ozonated water on dentures and found that direct exposure to gaseous ozone was more effective. [39]

Uses in endodontics

The oxidative power of ozone characterizes it as an efficient antimicrobial. Its antimicrobial action has been demonstrated against bacterial strains, such as Micobacteria,[34] Streptococcus,[21] Pseudomonas aeruginosa,[34],[40]  Escherichia More Details coli,[34] Staphylococcus aureus, [34],[41] Peptostreptococcus,[40] Enterococcus faecalis, [21],[40],[42],[43] and Candida albicans.[38],[40],[43] Notably, when the specimen was irrigated with sonication, ozonated water had nearly the same antimicrobial activity as 2.5% NaOCl. [21],[38],[40] A study evaluated the effects of intracanal medication using ozonated oil compared to a calcium hydroxide paste associated with camphorated paramonochlorophenol and glycerin (HPG) for the endodontic treatment of teeth with periapical lesions. The radiographic, histopathological, and histobacteriological analysis showed no significant differences between periradicular tissue responses to both medications. [44] In vitro studies [21],[41] showed that ozone was effective over most of the bacteria found in cases of pulp necrosis. Ozone works best when there is less organic debris remaining. Therefore, the recommendation is to use either ozonated water or ozone gas at the end of the cleaning and shaping process. Ozone is effective when it is used in sufficient concentration, for an adequate time. Ozone will not be effective if too little dose of ozone is delivered or it is not delivered appropriately. [40]

Ozone therapy and dental caries

Ozone therapy is used as an atraumatic treatment modality in dental practice. Some of the in vitro studies with short-term follow-up assessed the effect of ozone on pit and fissure caries [45] and primary root caries [46],[47],[48],[49] with results showing significant reductions in the number of microorganisms in the carious lesions. In small, noncavitated lesions showed a greater reduction in number of microorganisms after the application of ozone than did larger lesions, and lesions closer to the gingival margin also showed less reduction in the number of microorganisms. [45] This suggests that the reversal of carious lesions depend on the size and localization. [46] Noncavitated lesions were more likely to reverse than cavitated lesions. The hardness values improved significantly in the ozone-treated test lesions after 4, 6, and 8 months (P < 0.05) compared with baseline while the control lesions had no significant change in hardness at any recall interval. [50],[51] It has been shown that the infusion of ozone into noncarious dentine prevented biofilm formation in vitro from S. mutans and L. acidophilus over a 4-week period. [52]

The contact time can be defined as the length of time the tissues are exposed to ozone before ozone disintegrates. The longer the contact time, the better the microbiological kill rate. It was showed that by increasing the contact time from 10 to 20 s, the bacterial kill rate changed from ozone being a disinfectant to acquiring sterilizing effect. [53] A 40 s application of ozone was found to reduce significantly the numbers of Streptococcus mutans.[49] One recent study [54] reported that following 60 s of ozone treatment, the cariogenic species S. mutans, L. casei, and A. naeslundii were almost eliminated. This killing was reduced in the presence of saliva although increasing the ozone application time to 60 s overcame these reductants in saliva. Detection of altered salivary proteins indicates that saliva components constitute additional targets for ozone. [54] In one study on primary root caries lesion (PRCL) found that ozone application for either for 10 or 20 s dramatically reduced most of the microorganisms in PRCLs without any side effects recorded at recall intervals between 3 and 5.5 months. [55] Another study [56] observed after 18 months 100% of ozone-treated PRCLs had improved.

Ozone had no influence on the physical properties of the enamel to enhance or hinder the sealing ability. Thus, ozone can be applied over intact and prepared enamel during the restoration process. [57],[58] A study concluded that the application of gasiform ozone does not affect the modulus of elasticity and the Vicker's hardness of dentin. Thus, the application of ozone on dentin could be performed by the dental clinician without impairing the micromechanical properties of the substrate. [59]

Ozone and dental unit water lines

Dental unit water line (DUWL) contamination has become a concern. [60],[61] Water becomes stagnant when the units are not in use. Detachment of microorganisms, splatter, and aerosols from dental procedures may possibly infect health care personnel. [61] Szymanska [62] identified moulds, bacteria, and yeasts in biofilms which are hazardous to the health care worker and other patients during treatment. Opportunistic pathogens were cultured from the mains water. [63] Another study suggested that DUWL biocides may adversely affect adhesion of resin to enamel. [64] Ozone has been used for purification of water due to its efficiency and lack of side effects. Kohno et al [65] published their results that indicated acidic electrolyzed water could be applied as an appropriate measure against bacterial contamination of the DUWL. Montebugnoli et al [66] concluded that dental manufacturers should be invited to design dental units that incorporate automated devices to disinfect DUWLs. In model dental unit water lines, ozone achieved a 57% reduction in biofilm and a 65% reduction in viable bacteria in spite of being used in a very low dose and with a short time of application. [67]

Ozone toxicity

Overwhelming evidence shows that the bronchial-pulmonary system is very sensitive to ozone and this gas should never be inhaled. [68] The respiratory tract lining fluid is constituted by a very thin, watery film containing a minimal amount of antioxidants that makes mucosal cells extremely vulnerable to oxidation. Pulmonary embolism, which occurred during direct intravenous administration of O 2 /O 3 , an application prohibited by the European Society of Ozonetherapy since 1983. [69] Known side effects are epiphora and upper respiratory irritation, rhinitis, cough, headache, occasional nausea, and vomiting.


   Conclusion Top


Ozone is used in almost all aspects of dentistry. There are good evidence of ozone biocompatibility, and effectiveness in removing the microorganisms from dental unit water lines, the oral cavity, and dentures. Advantage of ozone therapy is it is an atraumatic, biologically based treatment. It is toxic when inhaled, and in intravenous administration. It used in dentistry in 3 forms, gas, oil, and with water. Used as a preventive agent in pit and fissure caries and as a therapeutic agent in primary root caries. Used as an irrigating agent in endodontic, an adjuvant in periodontal surgical and maintenance phase. It must be clear that if we want to use ozone, we must avoid its toxicity by using a precise ozone generator, by collecting a precise gas volume with a defined ozone concentration. Limitation of this study is that most of the conclusions were assessed from in vitro studies due to paucity of clinical studies. Laboratory studies suggest a promising potential of ozone in dentistry. Future of ozone therapy must focus on the establishment of safe and well-defined parameters in accordance with randomized controlled trials to determine the precise indications and guidelines in order to treat various dental pathologies with this promising medical agent.

 
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