Ozone Therapy in Periodontics: A Review

Introduction

Ozone is a naturally occurring gas present in the stratosphere layer of the atmosphere, where its role is to protect living creatures from the harmful effects of UV radiations. It is a highly unstable triatomic compound derived from dioxygen molecule catalyzed by the action of UV rays and electrical discharges. Ozone was discovered in the year 1840 by a scientist named Christian Friedrich Schönbein. By the end of 19^th century, reliable methods for preparation and analysis were developed and commercial equipment for preparation of ozone became available. Healozone and Ozicure were the available devices. When used without sufficient suction, Ozicure would cause ozone levels to exceed those that were allowed; therefore its use was discontinued.¹ Ozone was identified for its great benefits by the 20th century.² It was first used as a disinfectant for operating rooms in the year 1856. In 1870, ozone was used as a blood purification means. It has been over 100 years that ozone has been in use in the specialty of dentistry. In the year 1930, for the first time, a dentist by the name Edward Fisch used ozone therapy for wound healing and disinfection and saw excellent results.³ At present, ozone seems to be a strong oxidant and thus has been projected as a disinfectant, deodorizer, cleaning and bleaching agent, food additive and air/water purifier. Due to its characteristics, it has been identified as a viable substitute to treat a number of dental disorders such as dental caries, oral lichen planus, gingivitis and periodontitis, halitosis, osteonecrosis of the jaw, post-surgical pain, plaque and biofilms, root canals, dentin hypersensitivity, temporomandibular joint disorders.

What is Ozone Therapy?

Ozone therapy is the use of medical grade ozone, a highly reactive form of pure oxygen to produce a healing response in the body. The body has mechanism to renew and regenerate by itself, but during the time of bacterial or foreign body invasion, there is an alteration in body’s self-healing ability. The oxidative properties of ozone trigger the body to remove these disease-causing micro-organisms and thus promotes the body to heal and recover by itself.

Some of the areas where ozone therapy has been proven to be a boon are listed below:

• In case of infectious diseases, it helps in the activation of immune system.
• Helps to improve ischemic cardiovascular conditions by improving the cellular utilization of oxygen.
• Helps in the regeneration of damaged joints and degrading disc conditions by promoting release of various growth factors. 
• It has a potential to act on pain receptors present in our body, thus relieving or sometimes even eliminating chronic pain conditions.
• It can also expedite wound healing, which benefits with the recovery of a number of infectious diseases like herpes, hepatitis, cystitis and metabolic disorders like diabetes.

Routes of Ozone Administration

Gaseous Ozone

Gaseous form of ozone can be used in an open arrangement or with the help of sealing suction setup in order to avoid inhalation and its adverse effects.⁴

Appliances used to produce gaseous ozone are as follows.

• Heal Ozone by KaVo

Gas application takes place in a closed circuit. Its excess is drained out and neutralized by manganese ions. The concentration of ozone in the cap adjacent to the tissue amounts to 2100 ppm. For the administration of ozone, the cap must be completely airtight. Hence, the use is only feasible on surfaces that can offer such airtightness.

• Ozony Tron by MYMED

Oxygen activation generator makes use of high voltage and frequency power. Through current strength, triggered concentration of oxygen can be regulated in five levels. A mixture of noble gases that transmits and produces electromagnetic energy is contained in the glass probe, which is constructed from two pieces of glass. As soon as the probe's tip makes contact with the tissues, it generates energy throughout the treated area and divides ambient diatomic oxygen into singular atomic oxygen and ozone. Since it uses an open circuit arrangement, it can be used in locations with limited accessibility, such as periodontal pockets or root canals.

• Product photo by W&H

Prozone is known for its comfortable application and safety during its usage. When gassing the periodontal pockets, it enables a secure and hygienic treatment regimen owing to its single use plastic attachments like Endo tips and Perio tips.

Ozonated Water

Aqueous form of ozone has proven to be effective against bacteria, fungi and viruses. Although gaseous ozone has shown to possess superior microbicide properties than the aqueous form,⁵ its use is limited due to its toxic effects when inhaled into the respiratory tract. Thus aqueous form is more frequently used to control oral infections and to limit the growth of various pathogens.⁶

Ozonized Oil

Sunflower and other plant-based extract ozonized oils are also seemingly effective and are convenient anti-microbial agents. Most common advantage of ozonized oil form (like sunflower oil) is its broad availability. Commercially available ozonized oil like Oleozone, Bioperoxoil have shown to be efficient against a variety of microorganisms, especially Mycobacteria along with Streptococci, E. coli, Staphylococci and has also been used as an anti-fungal agent.

Limitations of Non-Surgical Periodontal Therapy

Periodontitis is a disease affecting the tissues surrounding tooth structure, mainly caused by interaction between microorganisms harboring in the dental biofilm and the host.⁷ This in turn synergistically aggravates the infection and inflammation-induced tissue destruction.

Conventional periodontal treatment procedures comprise of mechanical debridement which generally targets at the removal of bacterial deposits. Scaling and root planing although considered as highly efficient procedures, irrespective of the type of instrumentation used, they require time, exceptional skill, patient compliance with periodontal maintenance and are frequently ineffective in the elimination of subgingival microbial biofilms. In general, these limitations are encountered when disease has led to the formation of pockets more than 5 mm in depth.^8,9

Many researchers have suggested that the effective removal of sub-gingival deposits decrease with increasing probing depth. According to one of the studies done by Caffesse et al., when the pocket depth is more than 5 mm, health care practitioners generally overlook to sufficiently debride root surfaces.¹⁰

Other drawback of conventional therapy is its inability to supress Aggregatibacter actinomycetem comitans, due to bacterium tissue-invasiveness.

Therefore, sites with persistent periodontal pockets and inflammatory signs following a conventional therapy should be considered to be treated with surgical or other adjunctive procedures.

Ozone Therapy in Periodontics

Ozone is mostly used in dentistry due to its antibacterial qualities. Its antagonistic effect against Gram-positive and Gram-negative bacteria, fungi, and viruses has been demonstrated in numerous studies.¹¹ Ozone in the form of oil, water and gas has been proven to be efficacious in reducing bacterial load, inhibiting biofilm formation and thus accumulation of plaque. It can be applied into the sulci or even directly used into abscess or into areas of chronic infection to arrest and eradicate the bacterial population. The deep, infected crevices can be irrigated with ozone gas using fine cannula, followed by application of ozonated oils for long term disinfection^.12

Aqueous ozone therapy has been shown to be effective not only in mechanical cleansing of root surfaces, but also aids in its decontamination without causing any negative impact on periodontal cells post irrigation.¹³

Ozone therapy inhibits the growth of bacteria, promotes its cell membrane destruction and can cause cell lysis reaction confirming its bactericidal and bacteriostatic action against gram-negative and gram-positive bacteria.¹⁴

When the experimental dental plaque was exposed to ozonated water in vitro, it has shown to strongly inhibit the accumulation of dental plaque. After the dental plaque samples from human subjects were exposed to ozonated water, number of viable S. mutans decreased remarkably and almost no viable bacterial cells were detected. It was concluded that after ozonated water therapy, almost no microorganisms were detected at the dosage of 4mg/L for 10s.

It is likely that ozonated water has anti-inflammatory effects because it inhibits the NF-kB (Nuclear factor kappa-light-chain enhancer of activated B cells) mechanism, which is known to be linked to inflammation induced transcription and signalling.¹⁵

Ozone treatment improved the health of individuals with persistent gingivitis, periodontitis, periodontal abscesses, herpes labialis, and purulent periodontitis. Application of ozone post tooth extraction was also found to be beneficial.¹⁶

Application of ozonated water accelerated the physiologic healing rate of an epithelial wound within the first 48 hours, resulting in earlier mucosal wound closure after seven days.¹⁷

According to a recent study conducted comparing the treatment of peri-implantitis with conventional, surgical and ozone treatments, the most successful cleaning of the implant surface, the surrounding tissues and prevention of pathogenic microbial recolonization, bacterial inhibition was observed in the group of patients who had ozone therapy.¹⁸

In a randomized, double-blind, crossover split-mouth research, ozone irrigation was found to be more effective than chlorhexidine in reducing plaque index, gingival index, and bleeding index. Ozone use also significantly reduced A.a. (25%) and was noticeable as compared to irrigation with chlorhexidine showing no change in A.a. Ozone's antifungal qualities were also recognized during the study period, in contrast to chlorhexidine, which had no antifungal effects.¹⁹

Ozone has an antimicrobial effect equivalent to that of the Er:YAG laser.²⁰ Also ozone therapy demonstrated its beneficial effect as a preprocedural agent.²¹

Application Modalities for Periodontal Treatment

In accordance with the clinical case, ozone gas, ozonated water, ozonized oil (in-offices, as well as home use) are all acceptable forms of ozone applications.

Ozonated gaseous administration via custom-made thermoformed dental appliance

Application of gas using a hard or medium-soft thermoformed dental device specially made to allow gas circulation is done extending 2-3 mm beyond the compromised gingival area. At the distal and mesial ends of the treatment region, two ports should be installed for the gas inlet and outlet, respectively. With a light or medium body silicone, the appliance's edges are reclined.

As an additional measure of protection, light-cured dam can be used to completely seal the borders. The suction pump and generator ports should then be connected. The procedure is aimed to manage both soft and hard tissues of the concerned area.

Irrigation with ozonated water

Scaling, root surface planing, and non-surgical pocket curettage can all be performed while using ozonated water to irrigate the afflicted area.

Ozonized oil use in-office and at home

With a blunt 25G needle or any other suitable tip, pockets can be filled with ozonized oil following in-office treatment with ozone gas or ozonated water. Some of the oils can be given to the patient for personal use. Once every week, ozonized oil application can be done in-office.

Surgical procedures

Ozonated water can be used to flush the site of the final surgery or as an irrigant during the surgical treatment. Following surgery, sutures treated with ozonized oil can be utilized for suturing.

Ozone Therapy in Peri-Implantitis

Peri-implantitis is a condition associated with the tissues surrounding dental implants. It is a plaque-induced pathologic condition characterized by inflammatory reaction in the mucosa surrounding the implant area and concomitant loss of alveolar bone.^22,23 According to the recent studies, peri-implantitis in general occurs within the initial years of implant placement,²⁵ and with the lack of treatment, it can progress in an accelerating pattern^.24,25

Efficacy of ozonated oil on the dental implants’ osseointegration process under the influence of immunosuppressive agent has shown positive impact on bone density and the quality of dental implant osseointegration.²⁶

Ozone therapy has shown great potential for treatment of peri-implant mucositis among all other treatment protocols available, like hydrogen peroxide therapy.²⁷

Ozone nanobubble water may be helpful and can be predicted as an adjuvant therapy for periimplantitis, according to a recent study conducted to investigate the effectiveness of ozone nanobubble water on peri-implantitis lesions with non-surgical treatment.²⁸

Application Modalities

If the prognosis of the peri-implantitis case comes out to be fair after its thorough assessment, then various modes of treatment modalities are available and can be utilized to prevent total loss of the implant.

With varied degrees of success, traditional techniques like manual debridement or lasers, as well as topical treatment with anti-microbial medications are frequently used. Ozone therapy in the form of gaseous or an aqueous form can be used and has proven to be useful in salvaging the implant. During the debridement and curettage procedure, ozonated gas and aqueous ozone can be utilized for infiltration or as an irrigant, respectively. Ozonized oil can also be prescribed to the patient during post-operative maintenance phase with an instruction to apply it on the concerned area for 3-4 times/day.

Advantages of ozone therapy

• Possibility of usage as a disinfectant.
• Has anti-inflammatory action.
• Helps in activation of intracellular metabolism of oral mucosa and dental wounds; thus helps in the improvement of regional circulation.
• Helps in the stimulation of regenerative processes.
• Assists in achieving hemostasis in capillary bleeding
• It is a non-invasive and a painless treatment protocol. 
• Disadvantages of ozone therapy
• The major drawback is ozone toxicity if the amount rises by 0.0007% during each application.
• Highly unstable.
• Not readily available.
• Contraindicated in pregnancy to avoid mutagenic risk, hyperthyroidism, severe anemia, thrombocytopenia, cardiovascular instability, patients on ACE inhibitors.

Conclusion

Ozone therapy has the potential to be used in periodontal practice as a therapeutic complement or as an alternative to conventional treatment, as shown by the findings of various research. Ozone therapy has proved to be a paradigm shift in the dental practice. It is not only a non-invasive, cost and time effective treatment protocol, but also eliminates microorganisms more precisely. It is painless resulting in increased compliance and acceptability by the patients.

To determine the key indicators and procedures for the use of ozone therapy in dental practice, more research must be done with a focus on the development of safe and well-defined criteria in compliance with randomized controlled trials.

Conflict of Interest

None