Ozone in Dentistry

Summary:

1. Ozone is a potent broad-spectrum antimicrobial in dentistry. It can also break biofilms and plaques, making dentistry safer and improve dental procedure outcomes.
2. Ozone therapy also stimulates healing, teeth remineralization, and jumpstarts stagnant immune functions. As a result, it often helps with refractory cases.
3. Ozone dentistry may involve gas, ozone water, or oil that can be injected, applied, or gargled during and after procedures.
4. Ozone treatment before, during and after dental procedures, such as periodontal and root canal treatments, may reduce pain, accelerate healing, reduce complications, and improve overall outcomes.

How does ozone dentistry work?

Ozone is a form of oxygen (O3) with three oxygen atoms. The benefits of ozone in dentistry is two-fold:

1. As an oxidative antimicrobial. When ozone meets cellular components, the reaction creates reactive oxygen species (ROS) such as ozonides and peroxides [1]. These interact with bacterial cell components, leading to microbial cell damage and death. In dental applications, ozone disrupts the cell walls of bacteria, fungi, viruses, and their biofilms, effectively sterilizing the treated area minimally invasively.  
2. Creating biologically active molecules. When ozone reacts to fats and other molecules with double bonds in your tissues, it creates molecules with biological activities. This is where ozone stimulates healing and delivers other health benefits beyond killing microbes. Ozone dentistry may also stimulate blood flow, stop minor bleeding from capillaries, enhance immune response, and promote tissue regeneration and teeth remineralization [2]. As a result, it tends to promote better outcomes for dental procedures. 

In dental offices, ozone is effective both to sterilize equipment and on the patient as a treatment. On the patient, ozone may be applied as a low-concentration gas, ozonated water, or ozone, it's used for:

• Disinfecting cavities
• Sterilizing deep surgical spaces such as root canals
• Treating periodontal diseases
• Treating any kind of infections or irritations around the mouth, face, or jaw areas
• Whitening teeth 
• Daily dental hygiene at home

How is ozone dentistry uniquely beneficial?

Antimicrobial

Ozone is a powerful antimicrobial for dentistry beyond any existing chemical antibiotics, antifungals, and antivirals because [3]:

1. It’s not specific to any particular microorganism. It just kills what it is exposed to. 

2. There is no risk of resistance from the microbes.

3. It also breaks down biofilms that make the microbes resistant to antimicrobials.

4. It destroys any products that dead microbes release, reducing the risk of die-off reactions.

5. It can be administered in various ways

6. The ozone gas, water, and oil can penetrate deep and hard-to-reach spaces such as periodontal cavities or space under root canals. 

Ozone gas, water, or oil can be topically applied to the mouth or infected small pockets that are hard to reach. In some cases, ozone ear insufflation can target the jaws or sinuses. Ozone gas, saline, or water can also be injected into joints or infected tissues as an antimicrobial. Lastly, ozone oil or water can be used as a daily mouthwash or for oil pulling so the patient can continue the treatment at home. 

In our ozone oil pulling article, we focus on ozone oil pulling at home. Whereas, for this article, we focus on ozone in the dental office, along with other ways ozone can be used in dentistry.

Accelerates healing and tissue regeneration

Aside from killing pathogens and reducing the microbe count in the saliva, ozone seems to promote healing responses in the tissue. 

In a cell study, ozonated water can mechanically cleanse and kill microbes in root surfaces without harming periodontal cells [4]. The ozonated water also seems to increase the cells’ metabolism, possibly through stimulating tissue oxygenation, blood circulation, and mitochondrial functions.

In a clinical trial involving 200 patients who received dental extraction, the treatment group applied ozone oil to their extraction socket. The control group received the standard of care treatments, including painkillers and antibiotics. While both groups experienced similar discomfort, the ozone group had significantly better wound healing [5]. 

Teeth remineralization

Enamel, the outermost layer of your teeth, is actually dynamic and living tissues that constantly gain or lose minerals. Eating corrosive foods or exposure to acids can increase demineralization (mineral loss). In between meals, the minerals in saliva, along with alkalinity, help mineralize teeth, which prevents tooth decay. When your teeth cannot remineralize or lose minerals faster than they gain, your enamel can wear out. This can lead to dental caries and subsequently cavities [6].

A clinical trial enrolled 40 children between 9 - 12 years old with non-cavitated fissure caries on both sides of their first permanent mandibular molar. For each child, one of their caried molar received ozone gas treatment, while the other received the control treatment. 20 children received ozone alone, while the other 20 received ozone and a remineralizing solution on their ozone treatment molar. For all children, the ozone-treated molar healed significantly more than the controlled molar, although there was no significant difference between the ozone and ozone + remineralization solution groups [7].

A test tube trial examined how ozone impacted microstructural changes in the enamel of 15 permanent human teeth. After exposure to ozone gas for 40 - 50 seconds, there was enhanced enamel microhardness and remineralization rate of 96.82 - 97.38% [8].

Stimulates local immune and healing responses

Your immune system uses some peroxides and lipid peroxides to attack microbes and as signaling molecules. Therefore, the peroxides from ozone therapy can temporarily stimulate some immune and healing functions, including [9].

• Activating immune genes and inflammatory pathways
• Stimulating growth factors and substances that attract immune cells
• Increasing pathogen responses
• Expanding immune responses, such as white blood cells and antibodies
• Jump-starting stagnant tissue healing

In ozone dentistry where ozone treatment is applied to the mouth, these regenerative effects are more localized to the immediate areas, such as the buccal lining, jaws, tongue, and gums. 

Activate anti-aging pathways and antioxidant responses

Oral conditions and infections often raise oxidative stress within the cell, hindering the healing process and may cause more damage [10]. Also, as you age, your cellular ability to heal and counteract oxidative stress decreases due to accumulating DNA damages and shortening telomeres. Ozone therapy provides a small dose of oxidative stress that jumpstarts cellular antioxidant genes. These include enzymes such as superoxide dismutase, glutathione peroxidase, and catalase. Overall, the right levels and dose of ozone exposure tend to help the tissues restore their oxidative balance [11].

How is ozone therapy used in dentistry?

Ozonated olive oil, ozone gas, and ozonated water have distinct characteristics and applications in dentistry, reflecting their different physical states and delivery methods:

• Ozone Gas:
  • Directly applied to treat and disinfect tooth cavities and root canals.
  • Used in gaseous form to reach difficult areas, offering deep disinfection.
  • Injected into the jaws or areas of need to stimulate healing
• Ozonated Water:
  • Used for rinsing and irrigating during dental procedures to kill bacteria.
  • Ideal for procedures requiring liquid form for cleaning or disinfection.
  • Used for gargle in office or between dental visits
• Ozonated Oil:
  • Applied topically for treating oral lesions, gum disease, and as a follow-up to dental surgeries to enhance healing.
  • The viscosity makes it suitable for sustained release of peroxides, providing prolonged antimicrobial and healing effects.
  • Used for gargle in office or between dental visits

Ozone/oxygen gas

Ozone gas or ozone/oxygen mix have many of the same uses in dental applications, such as [12]:

• Disinfection of Cavities
• Root canal treatment
• Periodontal therapy
• Oral lesions
• Preventive care, such as the treatment of tooth surfaces to prevent decay and to sanitize removable dental appliances

Ozonated water

Ozonated water is water that has been infused with ozone gas, and it has several uses in dentistry due to its potent antimicrobial properties [13]:

• Disinfecting Dental Equipment: Used for sterilizing instruments and washing equipment to eliminate bacteria, fungi, and viruses. It’s also powerful against biofilms [14].
• Oral Rinsing: Patients rinse with ozonated water before and after procedures to reduce microbial load in the mouth.
• Treating Periodontal Disease: Applied to clean periodontal pockets, it helps control infection and inflammation.
• Root Canal Irrigation: Ozonated water can be used to disinfect root canals, enhancing the elimination of pathogens.
• Wound Cleaning: Useful for cleaning extraction sites and other oral wounds to promote healing and prevent infection.

Ozone oil

Ozone oil is culinary oil that has been infused with the ozone gas. The oil then reacts with the ozone, creating byproducts such as ozonides and peroxides. Many of these byproducts have unique health properties, while others deliver many of the same effects as the ozone gas itself. The peroxides in ozone oil have antimicrobial and tissue-regenerating properties  [15]. 

All types of edible oils could be ozonated, although olive oil is the most popular option due to its fatty acid content and healing properties. Ozone oils could be applied to the mouth, skin, or gums topically or diluted and used as mouthwash (oil pulling). 

Ozone oil pulling seems to help with oral health by [15]:

• Reducing overall microbe count in the saliva
• Promoting a healthy oral flora
• Jumpstarting immune function, especially when it’s stagnant due to high oxidative stress and inflammation
• Improving oxygen and blood flow to the area
• Improving antioxidant and inflammation balance in the mouth
• Stimulating growth factor and collagen production
• Stimulating metabolism in the mouth, which provides more energy (ATP) for healing

Clinical trials suggest that regular ozone oil pulling can support the healing of gingivitis, gum issues, and other oral lesions.  

Dental ozone therapy at home 

In addition to regular brushing and flossing, you can incorporate ozone treatments for daily oral care. Dental ozone therapy at home involves using ozone for various oral health applications, aimed at reducing bacteria, improving healing, and preventive care. While professional guidance is crucial, some devices and applications include [16]:

• Ozone Generators: Medical-grade devices that produce ozone gas for oral health use, requiring careful handling to avoid ozone inhalation risks.
• Ozonated Water Rinses: Using ozonated water at home for mouth rinsing to reduce microbial load and improve oral hygiene.
• Ozonated Oil: Oil pulling or applied topically to gums, wounds, or lesions for its antimicrobial and healing properties.
• Dental Ozone Mouthpiece: A device designed for home use, delivering ozone directly to the oral cavity to treat gum disease, whiten teeth, or maintain oral health.

It's important to consult with an ozone dentist or dental hygienist before starting any at-home ozone therapy to ensure safety and effectiveness.

What is ozone used for in dentistry?

Ozone can prevent and treat many oral health conditions. In more complex conditions, ozone can be an adjunctive treatment to standard-of-care treatments.

Receding gums, gingivitis and periodontitis

Gingivitis is inflammation of the gums that may affect up to 90% of people, suggesting that most people who have it are unaware that they have it [17]. Accumulating debris, bacteria, and plaque under the gum leads to irritation, redness, swelling, and bleeding during brushing. Standard treatments usually involve deep flossing, better oral care habits, deep teeth cleaning, antibiotics, and teeth removal. 

Mild gingivitis can progress to become more severe or deeper periodontal disease. Also, gingivitis and all inflammatory conditions of the mouth can create systemic inflammation, worsening your wellbeing and disease risks. Several studies have linked gingivitis with elevated cardiovascular risk [18]!

Periodontitis is when the gum disease is so advanced that there is destruction of the structures supporting the teeth, including the bone under the gums. It can lead to tooth loss if left untreated.

In a clinical trial involving 16 patients with chronic periodontitis, participants with gingivitis received either chlorhexidine gel or ozonated water irrigation. The ozone group had 12%, 29%, and 26% greater reduction in plaque index, gingival index, and bleeding index compared to chlorhexidine [19].  

A randomized controlled trial compared the efficacy of ozone oil and chlorhexidine gel (control) on plaque-induced gingivitis among 20 subjects. Subjects were tasked with massaging either control or ozonate oil on their gingiva three times a day for three weeks. After three weeks, both chlorhexidine gel and ozonated oil significantly improved gingival health (p < 0.001) by reducing plaque and gingival index scores compared to pretreatment baselines. Although there was a higher reduction in plaque and gingival scores with ozone oil treatments, there was no significant difference between treatments. Therefore, ozone oil can be as effective as chlorhexidine gel in managing gingival health, providing an alternative treatment option [20].

In periodontal treatment, ozone water can irrigate the affected area during scaling, root surface planing, and non-surgical pocket curettage. Then, after the treatment, ozonated olive oil or water could be applied to the treatment site both in the office or at home [21].  

Tooth decay and cavities

Tooth decay is the damage to your tooth’s enamel that can lead to dental caries and cavities. It can arise from acid exposures, such as from bacteria, food or acid reflux, and mechanical damages.  

Ozone treatments have promising results in reversing early dental caries without painful treatments or drillings. It can arrest and stimulate remineralization, especially when combined with remineralization treatments. This may make ozone dentistry preferable for children and adults with dental phobia. However, deeper cavities may still need to be drilled, disinfected with ozone, and filled in [22]. 

Here is published evidence of how ozone therapy may help with dental caries and cavities. 

Antimicrobials in the caries

Ozone gas reduces the presence of cariogenic bacteria in the saliva. About 60 seconds of exposure eliminate 99.9% of them [23]. 

In a clinical trial examining 65 root caries in 26 patients, 10 - 20 seconds of ozone application significantly reduced the total number of microorganisms in the cavity without eroding dentin [24].

Stimulating caries’ arrest and reversal

Aside from disinfecting the caries and killing caries-causing microbes, ozone therapy may also stop (arrest) or reverse the dental caries. Therefore, the ozone may stimulate the teeth’s own damage repair and remineralization [25, 26].

In a double-blind study with 89 subjects aged 60-82, the efficacy of an ozone delivery system combined with a remineralizing kit on non-cavitated leathery primary root carious lesions (PRCLs, often visible as brown spots on teeth) was evaluated. After 18 months, 100% of ozone-treated lesions had arrested, significantly outperforming the control group, where only one lesion had reversed and 37% worsened. The results demonstrate the effectiveness of ozone and remineralizing products in arresting leathery non-cavitated PRCLs and offering a non-operative alternative to traditional treatment methods [27].

In the uncontrolled trial of 65 root caries where ozone was applied for 10 - 20 seconds, most of the caries hardened or reversed. At 3 and 5.5 months after the treatment, 33 out of 65 lesions hardened, while 27 reduced in severity index from 2 to 1, whereas 5 caries remained the same. [24] 

The safety and efficacy of ozone treatment was assessed in a randomized controlled trial with 79 subjects and 220 root caries lesions. After 6 months, the ozone-only group showed a statistically significant improvement, with 38.1% of lesions hardened compared to none in the control group. Additionally, the combination of ozone and sealant demonstrated better outcomes in sealant integrity and dental caries reversal than the sealant-only group. These results suggest ozone treatment, especially when combined with a sealant, effectively manages leathery root caries [28].

Plaque and bacterial biofilm

Biofilms are microbial communities that embed themselves with polysaccharides or sticky substances that protect them from your saliva, medications, toothpaste, and anything else meant to eliminate them. Any attempt to kill these microbes can fail if it can’t penetrate or break biofilms [29]. 

Dental plaques are a type of biofilm that can cause dental caries, gum diseases, and other issues in the mouth. On medical devices, biofilms can be problematic because they resist many sterilization chemicals and techniques. Ozone treatments can effectively break down biofilms and the substances that they tend to release [30]. 

In the test tube, ozone water treatment (4 mg/mL) on dental plaque dental plaque from human subjects significantly reduced bacterial count. Ozone water also eliminated all viable bacteria from the dental plaque [31].

Oral infections and lesions

Ozone therapy is broadly effective against all types of microbes. It also stimulates immune response, oxygenation, and tissue regeneration. Therefore, ozone treatment may be beneficial either as a stand-alone or combined with other treatments for various types of oral lesions, whether from infections, autoimmunity, drugs, or other causes [28]. It may also relieve pain and sensitivity.

Ozone therapy can help with herpes and aphthous ulcers (canker sores). It has antiviral activity, and speeds up the healing process and reduces the duration of clinical symptoms. In a clinical trial of 60 patients, topical ozone water and oil application was compared with topical antiviral and weak laser treatment, which was standard of care. By the 7th day, all subjects in the ozone treatment had cleared up and had experienced significantly less pain than the control group [32].

In a clinical trial involving canker sores patients, ozone gas was applied for 60 seconds, whereas the control group only received air treatment. The ulcer size significantly reduced by the second day in the ozone group and fourth day in the control group. Also, pain significantly reduced from the first day in the ozone group and third day in controls. Therefore, ozone application to canker sores could significantly relieve pain and accelerate canker sore healing [33].

In a case study, ozone therapy successfully resolved a hard-to-treat ulcer from chemotherapy. A leukemia patient developed a soft palate oral ulcer due to chemotherapy. The lesion developed seven days during a 25-day course of chemotherapy treatment. Despite various medications and antimicrobials for 15 days, the lesion hadn’t healed and the patient was in significant pain. As a result, the treating oncologist suspended the chemotherapy to allow the lesion to heal, but the lesion still didn’t heal. After ozone gas and water treatment started, 5 applications for 2 minutes each at 10 - 100 mcg/mL, the pain significantly reduced. The patient could then resume swallowing and drinking. After 2 days, the size of the lesion, swelling, and candida growth significantly decreased, and the patient was able to cut out opioid medication. The treatment was repeated every 2 days until the lesion completely resolved at 22 days. On day 15 since starting ozone treatment, the oncology team resumed the chemotherapy [34]. 

Root canal

Root canal treatment is often associated with long-term health complications, such as cardiovascular and autoimmune diseases, due to microbial toxins from the root canal [35]. Ozone dentistry can help enhance the disinfection process and significantly reduce the microbes within the root canal system. This is critical in treating and preventing endodontic infections.

Ozone treatment helps:

• Destroy bacteria, fungi, and viruses
• Promotes oxygenation of the periapical tissues (around the root). Most microbes in root canals are anaerobes–they don’t thrive in a high oxygen environment. So, improving tissue oxygenation also inhibits these microbes.
• Facilitates tissue healing

Ozone gas, ozonated water, or ozonated oils are introduced into the root canal after mechanical preparation. This ensures deep penetration and elimination of microorganisms in complex root canal systems. Research indicates that ozone therapy can enhance the outcomes of root canal treatments by reducing post-operative symptoms and improving healing. For example, a study demonstrated that the adjunctive use of ozone in root canal disinfection significantly lowered the presence of Enterococcus faecalis and Candida albicans [36].

Ozone gas or water irrigants may also be combined with bleach and chlorhexidine [37]. After the procedures, ozone water or oil pulling can be used as an antimicrobial from home. 

Currently, the evidence is very limited and inconclusive on whether ozone dentistry improves root canal outcomes or provides superior results to other disinfection options [38].

Dental surgeries

With every dental procedure comes the concern of an infection risk, pain and discomfort during healing, and other complication risks. Ozone has long been a companion to dentistry as it noninvasively delivers unique benefits without creating antibiotic resistance. 

Ozone water irrigation and lavage during dental surgery can help inhibit microbes. In the case of peri implantitis or when a dental implant develops an infection, ozone gas or water can be applied during removal of the damaged tissue. Ozone treatment and follow-up use tends also to reduce pain, accelerate healing, reduce complications, and improve quality of life. 

In a randomized controlled trial involving 33 patients, ozone was applied to deepithelialized gingival grafts. The ozone group had significantly better blood perfusion into the grafted tissue, less pain, and better quality of life [39].

In a trial involving 60 patients randomized into low-level laser therapy (LLLT), ozone, and no treatment groups, the researchers evaluated pain and muscle spasm levels after a third-molar extraction. The pain and painkiller use were significantly lower in the ozone and LLLT groups. Muscle spasms and swelling were lower in the LLLT than in the ozone and control groups [40]. 

Ozone treatment may reduce the incidences of dry sockets, a common complication after a tooth extraction surgery. It is a painful condition that may occur after a blood clot dislodges. A pilot study involving 30 patients requiring impacted third molar removals compared 12 seconds of ozone application with saline irrigation (control). 16.67% of the control group developed dry sockets, compared to 3.33% in the ozone treatment group. While this result was only marginally significant, it suggests that ozone therapy is likely beneficial for mitigating the risk of dry sockets  [41].

Teeth whitening

The oxidative effects of ozone gas may help whiten teeth. Overall, ozone could improve teeth appearance by:

• Removing plaque and microbes that stain teeth
• Neutralizing stains from food and other sources
• Improving overall oral health 

In a rat study, ozone could successfully lighten the yellowing of teeth due to tetracycline [42].  

A systematic review looking at four clinical trials evaluated the effectiveness of ozone (O3) in enhancing tooth bleaching and managing sensitivity. The degree of teeth whitening was comparable with ozone alone, ozone + hydrogen peroxide (HP), or HP alone. Ozone alone did not induce hypersensitivity, but when combined with HP, sensitivity was noted only if ozone application came before HP application. Although ozone is not superior to HP in changing tooth color, it may be used as the sole treatment to minimize hypersensitivity risks associated with bleaching [43].

TMJ

Ozone therapy has been explored as a treatment for temporomandibular joint (TMJ) disorders, focusing on its anti-inflammatory and oxidative stress modulation. The ozone gas or water could be injected into the joint to stimulate tissue regeneration, relieve pain, and improve joint mobility. Ozone oil could be massaged into the jaw area. 

As with any joint and pain issue, low blood flow and oxygen can increase pain. By improving tissue oxygenation, ozone therapy can relieve TMJ pain. 

A review included 8 studies with 404 participants with impaired function and pain related to TMJ disorders. Results suggest that ozone therapy can diminish pain and improve maximal mouth opening in TMJ patients [44].

However, comprehensive clinical trials and more extensive research are necessary to fully understand its benefits and mechanisms for TMJ disorders.

Pediatric dentistry

Just like adult dentistry, ozone can also be used in children. Because it’s less invasive and doesn’t cause pain, ozone dentistry is particularly suitable for children who may have dental anxiety [45].

It's applied in various forms, including gas, ozonated water, and ozonated oils, to treat:

• Dental caries without drilling
• Disinfect cavities
• Promote the healing of oral lesions
• Support teeth remineralization 

The use of ozone in pediatric dentistry supports the preservation of healthy tooth structure while effectively eliminating pathogens. This approach aligns with the goals of modern pediatric dentistry to provide child-friendly, less traumatic dental care experiences.  

Bad breath/halitosis

Bad breath (halitosis) often stems from bacteria in the mouth producing foul-smelling sulfur compounds, such as Porphyromonas gingivalis. Poor oral hygiene, dry mouth, infections or can exacerbate it. [46]. 

Regular use of ozone water or oil to manage microbe levels in the mouth, in addition to routine brushing and flossing, can help manage bad breath. The ozone gas and oxidant molecules in the ozone water and oil can also neutralize foul-smelling substances [47]. 

Dentin Hypersensitivity or Sensitive Teeth

Ozone treatment may reduce teeth sensitivity, especially when other treatments failed.  

Although promising, two trials that applied ozone gas to the teeth observed no significant difference from the control group. Possibly, this is because the ozone gas doesn’t penetrate the gum as well as ozone oils or water. Many ozone dentists still find ozone therapy beneficial for sensitive teeth. 

One trial completed with 35 participants (20 in the ozone group, 15 in the air group). Both groups experienced significant reduction in teeth sensitivity after two applications, although the two groups were not significantly different [48]. 

Another trial enrolled 26 adult patients who received ozone or placebo treatment on two different teeth. They found a moderate (16.2%) but significant pain relief (p<0.012) on 57.7% of all treated teeth. However, there was no significant difference between ozone or placebo treatment [49].

Is ozone good for teeth?

Ozone is beneficial for teeth due to its strong antimicrobial properties, which help eliminate bacteria, fungi, and viruses that can cause dental caries, gum diseases, and other oral health issues. It also promotes wound healing and may aid in the remineralization process, making teeth stronger and more resistant to decay. 

More importantly, routine ozone oral care, such as with ozone oil or water, can help reduce microbes in deep periodontal pockets. It may also reduce pain and teeth sensitivity.

At concentrations used for ozone dentistry, ozone does not erode dentin or damage oral mucosa.

While ozone therapy in dentistry offers a plethora of benefits, there are potential downsides to consider. These may include:

• Risk of ozone toxicity if not properly handled or administered
• Potential irritation to the respiratory system
• Need for specialized equipment and training for safe application 

Careful consideration and professional oversight are essential to mitigate these risks and ensure the effective and safe use of ozone in dental care.

Ozone dental treatment side effects and contraindications

Ozone therapy in dentistry, while beneficial, comes with its side effects and contraindications. Side effects may include:

• Ozone inhalation: Risk of respiratory irritation or ozone toxicity if inhaled in large quantities.
• Mucosal irritation: Possible temporary oral mucosa or gum irritation upon direct exposure.
• Tooth sensitivity: Some patients may experience increased tooth sensitivity after ozone treatment.

Contraindications may include:

• Respiratory conditions: Individuals with respiratory diseases like asthma should avoid ozone treatments due to potential inhalation risks.
• Allergies: Although rare, allergies to ozone itself can occur.
• Systemic conditions: Patients with specific systemic diseases or immunocompromised states should consult their healthcare provider before undergoing ozone dental treatments.

It's crucial to undergo ozone therapy under the supervision of a trained dental professional to minimize risks and tailor the treatment to individual health profiles [50].

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