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Ozone Therapy in theDentistryThe materials presented in this section are kindly provided by our Lebanese partnerDr. Fadi Sabbah, DDS.The use of ozone in dentistry is gaining its place in every days dental practice andis used in almost all dental applications. The undisputed disinfection power ofozone over other antiseptics makes the use of ozone in dentistry a very goodalternative and/or an additional disinfectant to standard antiseptics. MinimallyInvasive Dentistry is now the new Standard of Care in all disciplines of dentistry,most importantly in preventive and operative dentistry. So far, arresting andreversing the process of tooth caries without invasive treatment are unpredictableand rely very much on patients compliance. Recent research and clinical studieson the use of ozone in treating early tooth caries without cavitations are verypromising and are showing that it is now possible to arrest and reverse theselesions in a predictable and repeatable way without invasive intervention. Thesefindings are establishing a paradigm shift, a revolution in dentistry.Due to safety concerns, O3 gas was not recommended for intra-oral use. Onlydissolved ozone in water and ozonated oils were and are still commonly used indifferent fields of dentistry. With the development of a footpedal-activated dentalhandpiece with a suction feature, O3 gas can now be used safely in situationswhere diffusion is an important factor, i.e.: dental hard tissues> more informationClinical Procedures1. Operative DentistryAfter a comprehensive diagnosis and caries risks assessment, depending on yourpreferred approach and management, you should be able to classify the carieslesions according to a severity index upon which you would be able to make aclinical judgment on how to proceed with treatment.1.1. Primary Pits & Fissures Caries LesionsThe following table is an aid on how to perform ozone therapy depending on clinicalcases. Remember that the availability of minimally invasive diagnostic andoperative equipment is of great value in conjunction with the use of ozone.Abbreviations:CSI: Caries Severity IndexDV: Diagnodent ValueAA: Air AbrasionO3: OzoneEDJ: Enamel Dentin JunctionGIC: Glass Ionomer Cement
Ozone concentration: 3.5 - 5 �g/mlFlow Rate: 0.5 - 1 L/minIt is advisable to apply a remineralizing agent after the ozone application. Alwaysemphasize on home oral hygiene and balanced diet. Clinical Description Treatment / CSI DV Aspect Diagnosis Ozone Prophylaxis and 10 Sec O3 / Probably Preventive Seal Fissures 1 < 10 Sound measures if indicated might be with GIC needed Not Visible AA/Etch/40 on X-Rays; 2 10 - 19 White Spot Sec O3 / Seal Limited to Fissures Enamel Stained Pits and AA/Etch/40 Caries at 3 20 - 24 Fissures; Sec O3 / Seal- EDJ not visible Restore on X-Rays AA/Slow speed rotary. Remove only Infected infected very Caries at 1- Dentin; soft dentin to 4 25 - 29 2 mm in probably reach leathery Dentin not visible dentin. on X-Rays Etch/60 Sec O3/ GIC/Co- Cure AA/Slow speed rotary. Infected Remove only Stained infected very Caries at 3 Dentin; soft dentin to 5 > 30 mm + in probably reach leathery Dentin visible on dentin. X-Rays Etch/60-120 Sec O3/GIC /Co-Cure Very deep Assess Pulp Remove all 6 > 99 caries; Vitality soft infected maybe pulp Decision dentin; stop at
involvement Making 1-2 mm from pulp; Etch/120 Sec O3/ GIC Fuji VII. Re-assess at 4 month with X-Rays; remove GIC and look for re- mineralization of the floor of the cavity. If good results, put final restoration.1.2. Proximal Caries LesionsProximal caries lesions are readily diagnosed with Bite-Wing X-Rays unlikeocclusal ones. Depending on the depth and speed onset of the lesions, a decisionis made on whether to open and access the lesion or to use a non-invasivetreatment.As a general rule, in non-cavitated low speed onset lesions confined in enamel or atthe EDJ, a non-invasive protocol should be used first. If the lesion extends indentin, the final judgment should be based on the caries risks assessment of thepatient. 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 LesionsFollow the same guidelines as described in the pits and fissures protocol.1.4. Hyper-Sensitive TeethNon-carious hypersensitivity is due to many contributing factors among which areerosion, abfraction, bite pressure, recessed gum, etc. After final diagnosis andelimination of the cause(s), ozone application might alleviate almost instantly thepain felt by the patients from hypersensitive teeth in some cases.Apply ozone for 40-60 sec on sensitive areas then a remineralizing agent. Repeat ifnecessary.1.5. Cracked Tooth SyndromeAccording to the clinical situation and symptoms, a conservative attempt can beused with ozone application. After revealing the crack and evaluation of the caseapply ozone gas for 60-120 sec and restore with a long term temporary filling, i.e.:GIC. Put the tooth slightly off occlusion.Reassess periodically.
Occlusal Caries Management with a silicone cap and Dental Handpiece Hyper-Sensitive Cervical Root Abfraction2. Root Canal Therapy - Peri-Apical LesionsOzone is highly indicated in root canal therapy due to its strong disinfectionproperty and absence of cytotoxicity as well as other negative side effects at therecommended used concentration and form (gas or dissolved in water). Ozonizedoils 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-surgicalmanagement of these lesions.2.1. Vital Root Canal TherapyAfter final shaping and cleaning of the canal(s), adapt a 25-27 G needle on thedelivering central tip of the handpiece, making sure not to obliterate the free gascirculation inside the round tapered housing. Cut a piece of PVC or silicone tubeaccording to the clinical situation in order to seal the access cavity with the needleinside the canal. The needle should not block the intra-canal gas circulationtowards the canal orifice.Fill the canal with saline or distilled water and apply ozone for 2-3 minutes per canalat 5�g/ml, 0.5 - 1 L/min flow rate.During the canal shaping and irrigation, ozonated water can be used as adisinfectant and irrigant. Use Acquazone ozonated water column to easily prepareozonated water for the entire root canal procedure. Irrigate at demand with large
volumes.2.2. Necrotic Root Canal TherapyIn some situations, there is a need to disinfect the root canal system with atemporary dressing until the symptoms are relieved and the canal(s) ready to befilled. Follow the same protocol as above and use ozonized olive oils as atemporary disinfection dressing. Fill a 1cc disposable syringe with the oil and adapta 25G needle. Insert the needle as deep as possible inside the canal and injectslowly while retrieving the needle slowly out of the canal. You can also use aLentulo to fill the canal with the ozonized oil.2.3. Peri-Apical LesionsLocal anesthesia is recommended in this procedure.In maxillary peri-apical lesions, ozone infiltration is performed the same way yougive a local anesthetic injection on the buccal side. Depending on the size andseverity of the lesion, the concentration varies between 5 and 10 �g/ml at avolume of 1-3 cc. Inject the gas very slowly as close as possible to the site of thelesion. 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 theozone gas right into the bone is indicated. Use your preferred technique toperforate the cortical bone, making sure to stay away of the alveolar inferior canaland mental nerve. The access point is usually 2-3 mm under the free gingival levelwhere the cortical bone is easily perforated. Inject very slowly as described above. An adapted silicone cap and In case a silicone cap is25G needle for ozone gas canal unpractical put the suction tip disinfection close to the canal orifice3. Periodontal TherapyGingival and Periodontal diseases represent a major concern both in dentistry andmedicine. The majority of the contributing factors and causes in the etiology ofthese 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 andits healing and tissue regeneration properties, make the use of ozone well indicatedin all stages of gingival and periodontal diseases.According to the clinical case, different applications modalities are available usingozone gas, irrigation with ozonated water and in-office use of ozonized oil as wellas home use.3.1. Gas application via a customized thermoformed dental appliancePrepare a suckdown thermoformed hard or medium-soft dental appliance extending2-3 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 thetreatment area. Reline the edges of the appliance with light or medium bodysilicone. Light-cured dam can also be applied as an extra safety precaution tocompletely seal the borders. Attach the ports to the generator and the suctionpump. This procedure will treat both hard and soft tissues of the affected area. Youcan always use the PVC or silicone cap and treat individually all the indicated areasin difficult situations where such an appliance is hard to use or uncomfortable to thepatient.3.2. Irrigation with Ozonated WaterPrepare the ozonated water using Acquazone and generously irrigate the affectedarea during and after scaling, root surface planning, and non-surgical pocketcurettage.3.3. In-office and Home Use of Ozonized Olive OilAfter in-office treatment with ozone gas or ozonated water, fill the pockets withozonized olive oil using a blunt 25G needle or any other appropriate tip. Give thepatient 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 - SurgeryIn dental/oral surgery, the use of ozone is indicated during the surgical interventionas well as post-surgery as a topical disinfectant and healing agent. In theseprocedures, the use of ozone gas is not convenient due to the inability to properlyseal the treated area. Ozonated water and oils are therefore the forms ofapplication.4.1. Post-ExtractionAfter final debridement of the socket, irrigate with copious amounts of ozonatedwater and then use gauze imbibed with ozonated water to compress the extractionsite. Before retiring the patient, fill the socket with ozonized oil and cover it withgauze.4.2. Post-Extraction AlveolitisAfter thorough assessment, remove the necrotic plug and debris from the extractionsite, irrigate with large amounts of ozonated water then fill the alveoli with ozonizedoil. Antibiotic coverage may be indicated. Instruct the patient to apply ozonized oil3-4 times a day until total healing.4.3. Surgical ProceduresOzonated water can be used as an irrigant during the surgical procedure and/or asa final surgical site lavage. Cover the sutures with a thin layer of ozonized oil andinstruct the patient to apply the oil 3-4 times a day.4.4. Peri-ImplantitisPeri-implantitis is very bothering to both the dentist and the patient. After thoroughassessment and if a decision is taken to salvage the case, different modes oftherapy are used in order to save the implant from total loss. Laser and/or manualdebridement along with antiseptic solutions and topical anti-microbial medicines arecommonly performed with a varying degree of success. Ozone can play animportant role and be used as gas or in aqueous form. Cut an appropriate length of
PVC or silicone cap and cover fully the abutment. In case the crown is still present,it is advisable to remove it for proper sealing of the abutment and the gingivalborders around the implant. Ozone gas infiltrations are also helpful in this situation.Ozonated water can be used as an irrigant during debridement and curettage.Advise the patient to apply ozonized oil on the treated area 3-4 times/day.5. Crowns & Bridges - Veneers - Removable Dentures5.1. Crowns & Bridges - VeneersA common occurrence we sometimes see during the temporization phase incrowns, inlays/onlays and veneers procedures is hypersensitivity. Many factorsmight contribute in this event, one of which is the presence of bacteria left insidethe opened dentinal tubules during preparation. It is paramount to remove thesmear layer and disinfect the prepared teeth before temporization and beforeseating of the final restoration.The black stain that we see under the temporaries, mainly in the shrink-wrapveneers temporization technique is due to the presence of bacteria. The use ofozone gas to both disintegrate the smear layer and disinfect the prepared teeth ishighly recommended (Fig. 1 - 2). The use of Air Abrasion before ozone is anadvantage to completely remove microscopic debris and smear layer from thesurface 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 preferredmethod. Please note that recent research and published articles show that ozoneuse do not affect the adhesive bonding procedures.Use ozone gas to disinfect the prosthesis. Ozonated water can also be used.
5.2. Removable DenturesA common occurrence found in full dentures wearers is denture stomatitis, mainlydue to Candida albicans (Fig. 3). Whether white patches or erythematous forms,ozone use, mainly ozonated water and oil, is highly efficient in this situation andalso helps in the cleaning and disinfection of the dentures acrylic material.Prepare ozonated water using Acquazone and soak the denture(s) after thoroughcleaning and removal of hard deposits. Imbibe a 5x5 cm gauze with the preparedozonated water and apply on the affected areas. Refresh the gauze with ozonatedwater frequently or replace with a new one.Remove excess water from the dentures and apply few drops of ozonized oil on theinside of the denture(s) and seat firmly.Supply the patient with enough ozonized oil in a disposable syringe and home useinstructions. For dentures sores and ulcers, see Soft Tissue Lesions section.Fig. 1: Disinfection of prepared teeth and sulcus after cordpacking and impression taking. Fig. 2: Disinfection with ozone gas after cleaning with Air Abrasion. Note the different length of the silicone caps.
6. Soft Tissue LesionsAll kinds of infectious, inflammatory, traumatic, burns, wounds, soft tissue lesionsrespond very well to topical ozone treatment. As mentioned earlier, the beneficialbiological effects of ozone and its disinfectant / healing properties make the use ofozone highly recommended in these situations.Some practitioners even recommend intra or peri-infiltration of ozone gas in softtissue carcinoma lesions.The most soft tissue lesions encountered are herpes, aphthae, removable dentureulcers, traumatic wounds and cuts, cheilitis, cysts, Candida, etc.6.1. Ozone Gas ApplicationSeal the affected area with a PVC or silicone cap and apply ozone gas for 1-2minutes. Repeat if necessary.In case of cyst fistula, insert a plastic needle slowly in the passage of the fistula andinject 1-2 cc of ozone gas. Anesthesia might be indicated in this procedure.6.2. Ozonated Water ApplicationIn situations of large traumatic wounds, burns and cuts, the combined use of ozonegas and ozonated water are indicated. For ozone gas, follow the above-mentionedprotocol. Prepare the ozonated water using Acquazone ozonated water column andirrigate for 10 minutes the affected area. In case of supra-infected lesions, use astrong preparation of ozonated water. During the healing phase, a mild solution ismore appropriate.6.3. Ozonized Olive Oil ApplicationIn many instances, the soft tissue lesions we frequently see can be managed withonly the daily at home application of ozonized olive oil. These oils have a greateradvantage over commonly used antiseptics and ointments due to their wide rangeof activities during all phases of the healing process. Supply the patient withenough ozonized oil in a disposable syringe and home use instructions.
7. Other Applications7.1. Whitening with OzoneDue to the strong oxidation power of ozone, researchers started looking on theability of ozone to whiten teeth. Ongoing in-vitro works are studying the effects oflong time exposure of ozone on the dental hard tissues and the pulp, as well as theapplication forms of ozone (gas - ozonated water), concentrations, etc.The results so far are promising. The use of ozone in teeth whitening mightrevolutionize our present techniques.7.2. Dental Unit Water Lines Disinfection - Office Tap Water DisinfectionOzone use in city water disinfection and purification worldwide is recognized as thebest city water treatment today. It becomes only logical to use ozone for the dentaloffice tap water disinfection and purification.The result is a clean, odorless, colorless tap water. Dental unit water lines areknown to carry hard to remove biofilms inside them. Besides the bad odors comingout of these dirty water lines, the microbial biofilm may represent a source ofinfection to patients, especially who have a deficient immune system or the elderly.Many studies showed almost complete disintegration and elimination of dental unitwater lines biofilms with ozonated water.7.3. Instruments Cold DisinfectionOzonated water can also be used as a cold disinfection solution for medical anddental instruments, as well as for cabinets countertop disinfection. Ozonated watercan also be used as hands wash disinfectant solution, fiber optic tips, contactlenses, surgical loupes lenses, etc.
7.4. TMJ Peri-Articular Ozone Gas Injection - Trigger PointsThe biostimulation and anti-inflammatory effects of ozone help in the managementof articulation inflammatory diseases and muscular trigger points. Chronic oxidativestress and elevated levels of pro-inflammatory cytokines are commonly found inthese skeletal chronic inflammations where ozone gas infiltration can contribute instimulating the anti-oxidant defense mechanism and in balancing the immuneresponse by modulating the production of cytokines.