The use of ozone in dentistry a case study Svea Baumgarten, Dr. med. dent., M Sc, accredited implantologist as per the criteria of the DGZI (German Association of Dental Implantology) 1 Ozone gas is a highly effective surface disinfectant for instruments, implants and prostheses. As a result of the spontaneous and catalyzed breakdown of the molecule, it is suitable for use in the mouth during surgical interventions; the positive biophysical properties mean that it promotes wound healing and epithelization and reinforces the natural antiradical principles of cells (by means of enzyme induction). Ozone gas can also support professional prophylaxis. In part 2 of this series, the application will be presented in a severe case of Parodontitis marginalis in the frontal region of the upper jaw, which it was possible to clinically significantly improve by repeated application of ozone gas (Prozone). Ozone gas also demonstrably helps in the treatment of surface caries (fissure, occlusal and root caries). Initial results indicate that ozone may also be used in the treatment of periimplantitis and endodontal infections. It is more biocompatible and less cytotoxic than sodium hypochlorite. Key words: Ozone disinfectant oral pathogenic microflora co-cultures of microorganisms and teeth ozone gas application for fissure and root caries, periodontitis and periimplantitis positive biophysical effects 1 Practice address: Bürgerweide 36, 20535 Hamburg, Germany Reprint requests: Dr. Svea Baumgarten, M Sc, Bürgerweide 36, 20535 Hamburg, Tel.: (0049)40-259303, Fax: 040-27145679; svea.baumgarten@t-online.de 1
We are reporting on the successful treatment of an advanced case of Parodontitis marginalis profunda in the frontal area of the upper jaw of a 42-year old female patient with local application of ozone gas. The patient introduced herself at our practice, inquiring about preserving the front teeth of her upper jaw, which were suffering from chronic periodontitis. We discovered general formation of pockets (> 10 mm), spontaneous bleeding and a degree of tooth mobility of 2/3, i.e. the teeth were candidates to be extracted. As an interim solution (it was a public holiday) until restoration could take place, we offered local ozone gas treatment. As an ozone gas source, we used Prozone, which, with the aid of plastic attachments, makes it possible to introduce ozone gas into the pockets in a pain-free manner. The local application of ozone gas was repeated three times, at weekly intervals. The patient was also made aware of necessary personal hygiene measures. Not only were we able to stop the bleeding, but we were also able to keep the degree of mobility of the teeth at a stable level (2) and reduce the measurable depth of the pockets. Case documentation: Fig. 1: Orthopantomogram; 2: Clinical aspect of region 12, formation of gas bubbles on the inflamed tissue. Continuous suction in the vicinity of the area of use; 3: Condition after ozone therapy. Chlorhexidine staining of the teeth; 4: Product photo (Prozone). The ozone gas generator from W&H (Prozone) is characterized by its ease of use and safety of application (preset tissue-compatible dosages in the indication areas of periodontitis and endodontitis). Prozone ensures a hygienic procedure during the gassing of the pockets thanks to its exchangeable plastic attachments (Perio tips or Endo tips). Treatment of pain is not necessary, as ozone displays pain-relieving properties (on slow-conducting C-fibres). The application of ozone gas can either be used as an additional treatment along with established methods or a monotherapy for periodontitis. How can the effect of ozone be understood? When dissolved in an aqueous medium (interstitial fluid), ozone reduces the level of microbial contamination and reduces organic material. It facilitates wound healing by disinfection and by the induction of positive biophysical mechanisms in the tissue (increased defence against radicals, induction of acute phase proteins, improved natural immunity, increased synthesis and release of growth factors, improved microcirculation, increased oxygen loading of erythrocytes, accelerated epithelial regeneration). Ozone dissolved in water is astonishingly biocompatible and less cytotoxic to oral cells than other established disinfectants (e.g. sodium hypochlorite). 2
Ozone gas is an effective surface decontaminant (see Oizumi et al. 9 ) for removable prostheses. 90% of the streptococci (S. mutans) and staphylococci (S. aureus) were inactivated within 1 minute and, after 3 minutes exposure, no more pathogenic bacteria were detectable. This is a remarkable disinfection effect, given that 1 ppm of ozone in air (1 ml ozone/litre) contains only one five-hundredth of the number of molecules compared to the concentration of ozone in water (1 ppm = 1 mg ozone/litre of water). The effectiveness of ozone gas is dependent on the relative air humidity: the more moisture there is in the air, the stronger the effect of the ozone gas (radical reactions in the water). Ozone as an antimicrobial principle in models of dental infections Nagayoshi et al. 6 have studied the efficacy of three different concentrations of ozone water (0.5, 2, and 4 mg/ml in distilled water) on the time-dependent inactivation of cariogenic, periodontopathogenic and endodontopathogenic microbes (Streptococcus, Porphyromonas gingivalis and endodontalis, Actinomyces actinomycetemcomitans, Candida albicans) in culture and in biofilms. Depending on the dosage, the oral microbes were inactivated after 10 seconds. Anaerobes were particularly sensitive to ozone. Candida was more resistant (approx. 90% reduction after incubation with the highest ozone concentration). Baysan et al. 10 have studied the antibacterial effect of ozone gas (HealOzone) on moist lesions of primary root caries (0.25% ozone in air with a gassing rate of 13.3 ml/sec.) in freshly extracted human teeth in vitro. 40 soft lesions were divided into two groups, in order to compare the efficacy of 10 and 20 seconds of exposure to ozone. Each lesion was first divided into two halves using a sterile blade; one half was exposed to ozone, the other half was left as a control. Both types of sample were then put in an anaerobic culture medium and incubated for 4 days at 37 C. In the samples treated with ozone gas, the microbe concentration was significantly and time-dependently reduced. Nagayoshi et al. 11 used dentin blocks from cows teeth to study the role of bacteria in endodontal infections and caries. Colonies of Enterococcus faecalis and Streptococcus mutans were co-incubated with sterilized dentin blocks for 6 days. The root canals of the infected dentin blocks were either irrigated with ozone water for 10 minutes or treated with ozone water plus ultrasound; as a control, they were also treated with distilled water with and without ultrasound. Sodium hypochlorite (NaOCl; 2.5%, i.e. the clinical concentration) was used as a reference disinfectant; it 3
eliminated all living bacteria in the dentin. Ozone water reduced the amount of streptococci and enterococci in the dental tubules; when ozone was combined with ultrasound treatment, more than 90% of the bacteria were killed. From these results, the authors have concluded that ozone water can be considered to be a potential root canal disinfectant that is less cytotoxic than NaOCl. NaOCl can cause necrosis while ozone water is exceptionally biocompatible 12. Steier and Steier have suggested combining a less cytotoxic concentration of NaOCl (1.25%) with ozone 13. The results of Nagayoshi et al. 11 have been confirmed by Huth et al. (2008) 14 in a root canal culture model (biofilm formation after incubation of teeth with Pseudomonas aeruginosa, Enterococcus faecalis, Peptostreptococcus micros and Candida albicans): Depending on the dose and species, ozone gas and/or ozone water reduce the amount of bacteria. Lynch and Swift (2008) 15 have acknowledged the published information on the role of ozone as an optional, complementary root canal disinfectant and concluded that as ozone is the most powerful antimicrobial and oxidant we can use in endodontics, and as aqueous ozone revealed the highest level of biocompatibility compared with commonly used antiseptics, then it is fairly obvious that ozone should be used to help combat the microorganisms associated with infected root canals. 4
Bibliography. 8. Brauner, A: Klinische Untersuchung über den therapeutischen Erfolg von ozonisiertem Wasser bei Gingivitis und Parodontitis. [A clinical investigation of the therapeutic success of ozonized water in treating gingivitis and periodontitis]. Zahnärztl. Praxis. 1991; 2, 48-50. 11. Nagayoshi, M, Kitamura, C, Fukuizumi, T, Nishihara, T, Terashita, M: Antimicrobial effect of ozonated water on bacteria invading dentinal tubules. J Endod. 2004b; 30: 778-781. 22. Lynch, E, Swift, EJ: Evidence-based caries reversal using ozone. J Esthet Restor Dent. 2006; 20 (4): 218-221. 23. Baumgarten, S: Einsatzmöglichkeiten für Ozon in der Zahnheilkunde und in der Implantologie eine Übersicht. [Possible uses of ozone in dentistry and implantology - an overview]. Implantologie. 2006; 14: 193-198. ruitment of stem cells (see references no. 23 and 24) 5