Ozone Therapy in the Dentistry
The materials presented in this section are kindly provided by our Lebanese partner Dr. Fadi Sabbah, DDS.
The use of ozone in dentistry is gaining its place in every day's dental practice and is used in almost all dental applications. The undisputed disinfection power of ozone over other antiseptics makes the use of ozone in dentistry a very good alternative and/or an additional disinfectant to standard antiseptics. Minimally Invasive Dentistry is now the new Standard of Care in all disciplines of dentistry, most importantly in preventive and operative dentistry. So far, arresting and reversing the process of tooth caries without invasive treatment are unpredictable and rely very much on patient's compliance. Recent research and clinical studies on the use of ozone in treating early tooth caries without cavitations are very promising and are showing that it is now possible to arrest and reverse these lesions in a predictable and repeatable way without invasive intervention. These findings are establishing a paradigm shift, a revolution in dentistry.
Due to safety concerns, O3 gas was not recommended for intra-oral use. Only dissolved ozone in water and ozonated oils were and are still commonly used in different fields of dentistry. With the development of a footpedal-activated dental handpiece with a suction feature, O3 gas can now be used safely in situations where diffusion is an important factor, i.e.: dental hard tissues
1. Operative Dentistry
After a comprehensive diagnosis and caries risks assessment, depending on your preferred approach and management, you should be able to classify the caries lesions according to a severity index upon which you would be able to make a clinical judgment on how to proceed with treatment.
1.1. Primary Pits & Fissures Caries Lesions
The following table is an aid on how to perform ozone therapy depending on clinical cases. Remember that the availability of minimally invasive diagnostic and operative equipment is of great value in conjunction with the use of ozone.
Ozone concentration: 3.5 - 5 µg/ml
It is advisable to apply a remineralizing agent after the ozone application. Always emphasize on home oral hygiene and balanced diet.
1.2. Proximal Caries Lesions
As a general rule, in non-cavitated low speed onset lesions confined in enamel or at the EDJ, a non-invasive protocol should be used first. If the lesion extends in dentin, the final judgment should be based on the caries risks assessment of the patient. In cavitated lesions, restoration is a must.
Follow the same guidelines as described in the pits and fissures protocol.
1.3. Cervical Root(s) Caries Lesions
1.4. Hyper-Sensitive Teeth
Apply ozone for 40-60 sec on sensitive areas then a remineralizing agent. Repeat if necessary.
1.5. Cracked Tooth Syndrome
2. Root Canal Therapy - Peri-Apical Lesions
Ozone is highly indicated in root canal therapy due to its strong disinfection property and absence of cytotoxicity as well as other negative side effects at the recommended used concentration and form (gas or dissolved in water). Ozonized oils can also be used as a temporary canal(s) dressing in infected necrotic cases. In peri-apical lesions, ozone gas infiltration contributes in the non-surgical management of these lesions.
2.1. Vital Root Canal Therapy
After final shaping and cleaning of the canal(s), adapt a 25-27 G needle on the delivering central tip of the handpiece, making sure not to obliterate the free gas circulation inside the round tapered housing. Cut a piece of PVC or silicone tube according to the clinical situation in order to seal the access cavity with the needle inside the canal. The needle should not block the intra-canal gas circulation towards the canal orifice.
Fill the canal with saline or distilled water and apply ozone for 2-3 minutes per canal at 5µg/ml, 0.5 - 1 L/min flow rate.
During the canal shaping and irrigation, ozonated water can be used as a disinfectant and irrigant. Use Acquazone ozonated water column to easily prepare ozonated water for the entire root canal procedure. Irrigate at demand with large volumes.
2.2. Necrotic Root Canal Therapy
In some situations, there is a need to disinfect the root canal system with a temporary dressing until the symptoms are relieved and the canal(s) ready to be filled. Follow the same protocol as above and use ozonized olive oils as a temporary disinfection dressing. Fill a 1cc disposable syringe with the oil and adapt a 25G needle. Insert the needle as deep as possible inside the canal and inject slowly while retrieving the needle slowly out of the canal. You can also use a Lentulo to fill the canal with the ozonized oil.
2.3. Peri-Apical Lesions
Local anesthesia is recommended in this procedure.
In maxillary peri-apical lesions, ozone infiltration is performed the same way you give a local anesthetic injection on the buccal side. Depending on the size and severity of the lesion, the concentration varies between 5 and 10 µg/ml at a volume of 1-3 cc. Inject the gas very slowly as close as possible to the site of the lesion. Repeat the infiltration once a week until resolution of the symptoms.
In mandibular peri-apical lesions, the use of an intra-osseous needle to deliver the ozone gas right into the bone is indicated. Use your preferred technique to perforate the cortical bone, making sure to stay away of the alveolar inferior canal and mental nerve. The access point is usually 2-3 mm under the free gingival level where the cortical bone is easily perforated. Inject very slowly as described above.
3. Periodontal Therapy
Gingival and Periodontal diseases represent a major concern both in dentistry and medicine. The majority of the contributing factors and causes in the etiology of these diseases are reduced or treated with ozone in all its application forms (gas, water, oil).
The beneficial biological effects of ozone, its anti-microbial activity, oxidation of bio-molecules precursors and microbial toxins implicated in periodontal diseases and its healing and tissue regeneration properties, make the use of ozone well indicated in all stages of gingival and periodontal diseases.
According to the clinical case, different applications modalities are available using ozone gas, irrigation with ozonated water and in-office use of ozonized oil as well as home use.
3.1. Gas application via a customized thermoformed dental appliance
Prepare a suckdown thermoformed hard or medium-soft dental appliance extending 2-3 mm beyond the affected gingival area, leaving a free space for gas circulation. Attach 2 ports for the gas inlet and outlet respectively at the distal and mesial of the treatment area. Reline the edges of the appliance with light or medium body silicone. Light-cured dam can also be applied as an extra safety precaution to completely seal the borders. Attach the ports to the generator and the suction pump. This procedure will treat both hard and soft tissues of the affected area. You can always use the PVC or silicone cap and treat individually all the indicated areas in difficult situations where such an appliance is hard to use or uncomfortable to the patient.
3.2. Irrigation with Ozonated Water
Prepare the ozonated water using Acquazone and generously irrigate the affected area during and after scaling, root surface planning, and non-surgical pocket curettage.
3.3. In-office and Home Use of Ozonized Olive Oil
After in-office treatment with ozone gas or ozonated water, fill the pockets with ozonized olive oil using a blunt 25G needle or any other appropriate tip. Give the patient for home use some of the oils and instruct him/her on proper application. Repeat the in-office ozonized oil application once a week.
4. Post-Extractions - Surgery
In dental/oral surgery, the use of ozone is indicated during the surgical intervention as well as post-surgery as a topical disinfectant and healing agent. In these procedures, the use of ozone gas is not convenient due to the inability to properly seal the treated area. Ozonated water and oils are therefore the forms of application.
4.2. Post-Extraction Alveolitis
4.3. Surgical Procedures
5. Crowns & Bridges - Veneers - Removable Dentures
5.1. Crowns & Bridges - Veneers
A common occurrence we sometimes see during the temporization phase in crowns, inlays/onlays and veneers procedures is hypersensitivity. Many factors might contribute in this event, one of which is the presence of bacteria left inside the opened dentinal tubules during preparation. It is paramount to remove the smear layer and disinfect the prepared teeth before temporization and before seating of the final restoration.
The black stain that we see under the temporaries, mainly in the shrink-wrap veneers temporization technique is due to the presence of bacteria. The use of ozone gas to both disintegrate the smear layer and disinfect the prepared teeth is highly recommended (Fig. 1 - 2). The use of Air Abrasion before ozone is an advantage to completely remove microscopic debris and smear layer from the surface of the abutments and to leave a clean dentin for ozone disinfection.
Prior to final prosthesis cementation, clean the prepared teeth with Air Abrasion, disinfect with ozone gas and seat the prosthesis according to your preferred method. Please note that recent research and published articles show that ozone use do not affect the adhesive bonding procedures.
Use ozone gas to disinfect the prosthesis. Ozonated water can also be used.
5.2. Removable Dentures
A common occurrence found in full dentures wearers is denture stomatitis, mainly due to Candida albicans (Fig. 3). Whether white patches or erythematous forms, ozone use, mainly ozonated water and oil, is highly efficient in this situation and also helps in the cleaning and disinfection of the dentures acrylic material.
Prepare ozonated water using Acquazone and soak the denture(s) after thorough cleaning and removal of hard deposits. Imbibe a 5x5 cm gauze with the prepared ozonated water and apply on the affected areas. Refresh the gauze with ozonated water frequently or replace with a new one.
Remove excess water from the dentures and apply few drops of ozonized oil on the inside of the denture(s) and seat firmly.
Supply the patient with enough ozonized oil in a disposable syringe and home use instructions. For dentures sores and ulcers, see Soft Tissue Lesions section.
6. Soft Tissue Lesions
All kinds of infectious, inflammatory, traumatic, burns, wounds, soft tissue lesions respond very well to topical ozone treatment. As mentioned earlier, the beneficial biological effects of ozone and its disinfectant / healing properties make the use of ozone highly recommended in these situations.
Some practitioners even recommend intra or peri-infiltration of ozone gas in soft tissue carcinoma lesions.
The most soft tissue lesions encountered are herpes, aphthae, removable denture ulcers, traumatic wounds and cuts, cheilitis, cysts, Candida, etc.
6.1. Ozone Gas Application
Seal the affected area with a PVC or silicone cap and apply ozone gas for 1-2 minutes. Repeat if necessary.
In case of cyst fistula, insert a plastic needle slowly in the passage of the fistula and inject 1-2 cc of ozone gas. Anesthesia might be indicated in this procedure.
6.2. Ozonated Water Application
In situations of large traumatic wounds, burns and cuts, the combined use of ozone gas and ozonated water are indicated. For ozone gas, follow the above-mentioned protocol. Prepare the ozonated water using Acquazone ozonated water column and irrigate for 10 minutes the affected area. In case of supra-infected lesions, use a strong preparation of ozonated water. During the healing phase, a mild solution is more appropriate.
6.3. Ozonized Olive Oil Application
In many instances, the soft tissue lesions we frequently see can be managed with only the daily at home application of ozonized olive oil. These oils have a greater advantage over commonly used antiseptics and ointments due to their wide range of activities during all phases of the healing process. Supply the patient with enough ozonized oil in a disposable syringe and home use instructions.
7. Other Applications
7.1. Whitening with Ozone
Due to the strong oxidation power of ozone, researchers started looking on the ability of ozone to whiten teeth. Ongoing in-vitro works are studying the effects of long time exposure of ozone on the dental hard tissues and the pulp, as well as the application forms of ozone (gas - ozonated water), concentrations, etc.
7.2. Dental Unit Water Lines Disinfection - Office Tap Water Disinfection
Ozone use in city water disinfection and purification worldwide is recognized as the best city water treatment today. It becomes only logical to use ozone for the dental office tap water disinfection and purification.
The result is a clean, odorless, colorless tap water. Dental unit water lines are known to carry hard to remove biofilms inside them. Besides the bad odors coming out of these dirty water lines, the microbial biofilm may represent a source of infection to patients, especially who have a deficient immune system or the elderly. Many studies showed almost complete disintegration and elimination of dental unit water lines biofilms with ozonated water.
7.3. Instruments Cold Disinfection
Ozonated water can also be used as a cold disinfection solution for medical and dental instruments, as well as for cabinets countertop disinfection. Ozonated water can also be used as hands wash disinfectant solution, fiber optic tips, contact lenses, surgical loupes lenses, etc.
7.4. TMJ Peri-Articular Ozone Gas Injection - Trigger Points
The biostimulation and anti-inflammatory effects of ozone help in the management of articulation inflammatory diseases and muscular trigger points. Chronic oxidative stress and elevated levels of pro-inflammatory cytokines are commonly found in these skeletal chronic inflammations where ozone gas infiltration can contribute in stimulating the anti-oxidant defense mechanism and in balancing the immune response by modulating the production of cytokines.