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REVIEW ARTICLE
Applications of ozone therapy in dentistry
Shiva Gupta, D. Deepa

Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India

ABSTRACT
Ozone is an allotropic form of oxygen, which is effectively used in the treatment of different diseases for more than 100 years. In the
present era of increasing antibiotic resistance, ozone therapy is an alternative medical treatment that rationales to increase the amount
of oxygen to the body through institution of ozone into the body. Owing to its beneficial biological properties including antimicrobial
and immune‑stimulating effects, ozone therapy has opened new vistas in treatment modalities of dental pathologies for patients of all
ages. The objective of this article is to review the literature available on applications of ozone in dentistry.

Key words: Antimicrobial, dentistry, HealOzone, Nano bubble water (NBW3), ozone, ozone intoxication

Introduction is a chronic inflammatory disease of the supporting tissues

Ozone (O3) is also known as trioxygen or triatomic oxygen,
a higher energetic form of atmospheric oxygen (O2) which
consists of 3 atoms of oxygen. It is derived from the Greek
word “Ozein” which means odorant. It has a defensive role
in the earth’s ecological harmony as it occurs naturally in the
atmosphere and surrounds the earth at an altitude between 50,000
and 100,000 feet.[1] In the stratosphere when an oxygen molecule
is stroked by high energy ultraviolet (UV) radiation, it splits into
two free oxygen atoms, further these free oxygen atoms collide
with oxygen molecules leading to the production of ozone. It is
often created by thunder and lightning and is also known for its
interaction with industrial pollutants at ground level.
Ozone is a blue gas present in abundance in stratosphere with
a concentration of 16–20  mg/m. It swiftly gives up nascent
oxygen molecule to form oxygen gas, hence considered as an
unstable gas. Due to this instability, it has the highest oxidation
potential, approximately 150% greater than that of chlorine when
used as an antimicrobial agent. This strong oxidant property has
led to use of ozone in medical and dental fields. Periodontitis
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DOI:
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of the teeth caused by specific microorganisms or group of
specific microorganisms resulting in progressive destruction of
periodontal ligament and alveolar bone with pocket formation,
recession, or both.[2,3] Ozone has found to be effective against
Gram‑positive and Gram‑negative bacteria, fungi, and viruses.[4]
The concentration of ozone varies between 1 and 100 μg/ml
(0.05%–5%). The objective of this article is to summarize
literature available on applications of ozone in dentistry.
Historical Background
German chemist Christian Friedrich Schonbein, of University
of Basel in Switzerland was the first to discover ozone in
1840. The first ozone generator was developed by Werner Von
Siemens  (1857) in Germany and was first applied in medical
field by Dr.  C. Lender in 1870 to purify blood in test tubes.
The scientific community did not study ozone seriously until
1936 when Dr. Fish,[5] a Swiss dentist used ozone either as gas
or ozonated water in his practice. The lack of ozone resistant
materials such as Dacron, nylon, and Teflon was the cause of
restrictions and hitches of ozone therapy, until 1950 when
manufacturing of ozone resistant material began. The first ozone
generator for medical use was developed by Joachim Hänsler, a
German physicist and Hans Wolff, a German physician in 1957.
However, it was only at the end of 1980s, medical ozone became
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Address for correspondence:
Dr. D. Deepa,
Department of Periodontology, Subharti Dental College and How to cite this article: Gupta S, Deepa D. Applications of ozone
Hospital, Meerut ‑ 250 005, Uttar Pradesh, India. therapy in dentistry. J Oral Res Rev 2016;8:86-91.
E‑mail: deepa_arun@rediffmail.com

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Gupta and Deepa: Ozone therapy in dentistry
a subject of dental research and practice. Subsequent to this, it
was used increasingly for medical and dental purposes.
Medical grade ozone is a mixture of pure oxygen (95%–99.95%)
and pure ozone (0.05%–5%). Due to its instability, it is impossible
to store ozone over long periods, as within less than an hour after
preparation only half of the mixture remains as ozone while
the other half is transformed into oxygen. Therefore, it must
be prepared immediately before use although association of
O3 with a vehicle with aqueous properties or viscous properties
promotes or retards the conversion into oxygen.
Goals of ozone therapy[4] include (i) inactivates and eliminates
pathogens, (ii) stimulation of immune system and improves
circulation, (iii) reduction of inflammation and pain, (iv) stimulates
humoral anti‑oxidant system, (v) restore proper oxygen
metabolism, (vi) prevention of shock and stroke damage,
(vii) induce friendly ecological environment, (viii) improvement
in brain function and memory.
Ozone Generating Systems
The three ozone generating systems are:[6]
1. UV system: This system emits UV light at 185 nm producing
low concentrations of ozone. An oxygen molecule absorbs
light energy in ground state when exposed to UV light and
then it dissociates. Later, the oxygen atoms react with other
oxygen molecules to form ozone
2. Cold plasma system: In this system, an electrostatic field is
formed as the voltage jumps between the anode and the cathode
rods. Air and water purification are applications of this system
3. Corona discharge system: This system generates high
concentration of ozone as a direct result of power dissipation.
Ozone is formed through an electrical discharge that is
diffused over an area using a dielectric to create a corona
discharge. Oxygen passed through this corona discharge is
converted into ozone. The handling of this design is easy
and the ozone production rate can be controlled, hence most
commonly used in the medical and dental fields.
Applications of Ozone in Dentistry
Ozone is a very good alternative and/or an additional disinfectant
to standard antiseptics due to its undisputed disinfection power
over other antiseptics.
According to Krammer,[7] a German dentist, aqueous ozone
can be used:
1. As a powerful disinfectant
2. To control bleeding
3. To cleanse wounds in bones and soft tissues
4. To improve healing by increasing the local supply of oxygen
to the wound area
5. To increase the metabolic processes related to wound healing
as ozonated water can increase the temperature in the wound
area.
87
Ozonated water may be used as a mouth rinse in cases of
gingivitis, oral thrush or stomatitis, as a spray to cleanse the
affected area and todisinfect oral mucosa, as a water jet in
treatment of painful gingivitis and stomatitis.
• Diagnostics ‑ vitality test
• Prosthodontics and Restorative dentistry‑crown disinfection,
cavity disinfection
• Dental diseases  ‑  caries, enamel cracks, root canal
treatment, tooth whitening, dentinal hypersensitivity,
abscess, granuloma, fistulae, aphthae, Herpes infection,
stomatitis – candidiasis
• Surgery  ‑  implantation, replantation, extraction, wound
healing, coagulopathy‑prolonged bleeding
• Orthodontics and Orthopedics ‑ temporomandibular joint
dysfunctions, trismus, relaxation, myoarthopathy.
Mechanism of action
a. Antimicrobial action: [Table 1][8]
• Ozone leads to destruction of bacteria, fungi, and
viruses
• The mechanism of action includes firstly the damage
to the cytoplasmic membrane of cells as a consequence
to ozonolysis of dual bonds and secondly modification
of intracellular contents because of secondary oxidant
effect that leads to oxidation of protein loss of
organelle function
• Due to the antioxidative ability the human body cells
are not damaged and the action remains non‑specific
and selective to microbial cells
• All vital functions of bacteria (incapable of developing
any self‑immunity) are stopped as a result of
few‑seconds‑application of ozone
• Gram‑positive bacteria are more sensitive to the action
of ozone than Gram‑negative bacteria.
b. Immunostimulating effect:[8,9]
• The immunocompetent cell proliferation and
immunoglobulin synthesis is stimulated as an influence
of ozone to cellular and humoral immune system
• The function of macrophages is activated due to
which sensitivity of microorganisms to phagocytosis
is increased
• This further leads to production of cytokines as a
consequence other immune cells are activated
• Biologically active substances such as interleukins,
prostaglandins, and leukotrienes, which helpin
reduction of inflammation and wound healing are
synthesized by ozone
• High or low concentration of ozone causes
immunodepressive or immunostimulating effect,
respectively.
c. Anti‑hypoxic effect:[9]
• Ozone results in change of cellular metabolism by
raising partial pressure of oxygen in tissues and
improving the transportation of oxygen in blood
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Gupta and Deepa: Ozone therapy in dentistry

Table 1: Studies on the use of ozone in periodontics

Form of Authors Findings Experimental design
ozone
Ozone Ebensberger 2 min irrigation with ozonated 23 freshly extracted completely erupted third molars
water et al., 2002[20] Water (4 mg/l) leads to mechanical cleansing, randomly treated by irrigation with ozonated water for
decontaminates the root surface, no negative effect 2 min or irrigation with a sterile isotonic saline (control
on periodontal cells remaining on the tooth surface group). The periodontal cells of these teeth studied immune
histochemically to mark PCNA
Ozone Nagayoshi et al., Ozonated water is effective for killing Gram‑positive Dental plaque samples were treated with 4 mL of ozonated
water 2004[21] and negative oral microorganisms and oral Candida water for 10 s
albicans in pure culture as well as bacteria in plaque
biofilm
Ozone Ramzy et al., High significant improvement regarding pocket depth, Periodontal pockets in 22 patients suffering from aggressive
water 2005[22] PI, GI and reduction in bacterial count reported in sites periodontitis (age range from 13 to 25 years) were irrigated
treated with ozonized water with 150 ml of ozonized water over 5-10 min once weekly
using a blunt tipped sterile plastic syringe
Ozone Huth et al., Aqueous ozone is less cytotoxic than gaseous ozone Aqueous form of ozone, as a potential gaseous ozone or
water 2006[14,23] or established antimicrobials established antimicrobials (CHX 2%, 0.2%; NaOCl 5.25%,
2.25%; H2O2 3%) were compared
Gaseous Müller et al., Only 5% hypochlorite solution was able to eliminate Mature 6 species oral biofilms treated with gasiform vacuum
ozone 2007[24] all bacteria effectively. Usage of gasiform ozone or ozone or vacuum alone, PDT and antimicrobial solution
PDT was not able to reduce significantly or completely immersions of biofilms for 60 s in 0.2% and 2% chlorhexidine
eliminate bacteria in the biofilm or 0.5% and 5% hypochlorite solution
Ozone Kshitish and A higher percentage of reduction in PI (12%), GI (29%) A randomized, double‑blind, crossover split‑mouth study on
water Laxman 2010[25] and bleeding index (26%) using ozone irrigation as 16 patients suffering from generalized chronic periodontitis.
compared to chlorhexidine Subgingival irrigation of each half of the mouth with either
ozone or chlorhexidine was done at different time intervals
Ozone Dodwad et al., Ozone application serve as potent atraumatic, Oral irrigation with ozonated water, 0.2% chlorhexidine
water 2011[26] antimicrobial agent to treat periodontal disease and 10% providine iodine done in patients with chronic
non surgically both for home care and professional periodontitis
practice
Gaseous Hauser‑Gerspach Gaseous ozone showed selective efficacy to reduce The antimicrobial efficacy of gaseous ozone on bacteria
ozone et al., 2012[27] adherent bacteria on titanium and zirconia without adhered to saliva‑coated titanium and zirconia disks served
affecting adhesion and proliferation of osteoblastic as substrates for the adherence of Streptococcus sanguinis
cells and Porphyromonas gingivalis was evaluated. The test
specimens were treated with gaseous ozone (140 ppm;
33 mL/s) for 6 and 24 s
Ozone Hayakumo et al., Subgingival irrigation with NBW3 is valuable adjunct Clinical and microbiological effects of NBW3 irrigation as
NBW3 2013[28] to periodontal treatment an adjunct to subgingival debridement for periodontal
treatment
Ozone Shoukheba and The results showed improvement in all clinical Thirty patients were randomly selected and equally divided
olive oil Ali 2014[29] parameters in (Group II). Whereas SRP alone resulted into: Group I received SRP only, Group II received SRP and
in a significant improvement only up to 1 month for ozonated olive oil gel (Oxactiv). Subgingival application of
BOP, PPD and CAL parameters and up to 3 months for ozone gel was performed following initial SRP and at 7, 14,
the PI and GI scores as compared to baseline values and 21 days. Clinical measurements and plaque samples
for PCR were recorded at baseline, 1, 3 and 6 months after
treatment
Ozone Carinci et al., Statistically significant reduction in 6 microbial species The efficacy of supportive periodontal therapy alone versus
water 2015[30] and for CBT in sites treated with ozone therapy in Aquolab® ozone therapy used in association with SRP in the
comparison with SPR alone. Results were obtained treatment of chronic periodontitis in 20 adult patients were
with a single local application of ozone therapy just compared; a split mouth design
after SRP and with a molecular control 7th day after
treatment
PI: Plaque index, GI: Gingival index, CBT: Total bacterial loading, PCNA: Proliferating cell nuclear antigen, PCR: Polymerase chain reaction, NBW3: Nano bubble water,
PPD: Probing pocket depth, BOP: Bleeding on probing, CAL: Clinical attachment level, PDT: Photodynamic therapy, CHX: Chlorhexidine digluconate, NaOCl: Sodium hypochlorite,
H2O2: Hydrogen peroxide, SRP: Scaling root planning, SPR: Selective posterior rhizotomy

• Certain enzymes such as dehydrogenase, superoxide
dismutases, glutathione peroxidases and catalases are
activated by repetitive low doses of ozone
• Ozone increases oxygenation and reduces local
inflammatory processes, thus improving the metabolism
of inflamed tissues.
d. Biosynthetic effect
• Ozone causes activation of protein synthesis
mechanism with increased amount of mitochondria
and ribosomes in cells that leads to elevation of
functional activity and regeneration potential of tissues
and organs.[9]
e. Vasodilators (nitric oxide) that are responsible for dilatation
of arterioles and venules are secreted by ozone.[9]

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Gupta and Deepa: Ozone therapy in dentistry
f. Ozone intensifies remineralization potential when acting on
the organic substance of mineralized tooth tissues.
g. Also enables the diffusion of calcium and phosphorus ions
to the deeper layers of carious cavities by opening of the
dentinal tubules.[10]
Routes of Ozone Administration
Gaseous form
Gaseous ozone could be administered topically either by an open
system or by a sealing suction system to avoid inhalation and
adverse effects. Most frequently used in restorative dentistry and
endodontics. It is a noninvasive therapy for treatment of dental
caries and may be used as a disinfectant before the placement of a
direct restoration and also as therapy for hypomineralized teeth.[11]
Ozonated water
It has been shown to be efficacious against Gram‑positive and
Gram‑negative oral microorganisms as well as bacteria in plaque
biofilm. In comparison to other chemical cleaners, it appears
to be less expensive.[12] Gaseous ozone may be used as a dental
disinfectant if applied for 3 min and is considered more effective
microbicide than the aqueous form.[13] If ozone gas is inhaled
into the respiratory tract[14] it has toxic effects, hence to control
oral infections and various pathogensozonated water may be
useful.[15] Commercially available as ultra‑pure, tripple ozone
treatment system.
Ozonized oil
It is competitive antimicrobial agent due to wide accessibility
of sunflower oil. It is found efficacious against Streptococci,
Enterococci, Staphylococci, Pseudomonas, Escherichia coli and
especially Mycobacteria and is used for the cure of fungal
infections.[16] Commercially available as Oleozone, Bioperoxoil.
Other Applications
HealOzone by KaVo
It is an air‑based system in which gas is applied in a closed
circuit. Its surplus is sucked out and manganese ions neutralize
it. The concentration of ozone is 2100 ppm in the cap adjacent
to the tissue. Perfect air tightness of the cap is the necessity for
the application of ozone. The cost ranges between Rs. 60,000
and Rs. 65,000.
OzonyTron by MYMED
The power of high frequency and voltage is used by this appliance.
With the current strength, adjustment of ozone concentration
could be done in 5 levels. A double glass camera forms the glass
probe which consists of mixture of noble gases which conducts
and emits electromagnetic energy. Energy is emitted around the
treated area as the tip of the probe gets in contact with the body
that causes splitting of environmental diatomic oxygen in singular
atomic oxygen and ozone. Ozone concentration in the operation
field is 10–100 μg/ml. Therefore, ozone could be applied to the
areas that are difficult to reach and inaccessible such as gingival
89
pockets or root canals, as there is no closed circuit here. The cost
ranges between Rs. 13,000 and Rs. 15,000.
Product photo (Prozone) by W and H
Prozone is easy to use and safe to apply as the tissue compatible
dosages can be preset according to the indication areas of
endodontitis and periodontitis. A hygienic procedure is ensured
during the gassing of the pockets as the plastic attachments (Perio
tips or Endo tips)[17] are exchangeable. The cost ranges between
Rs. 5000 and Rs. 10,000.
Ozotop
It is a compact, easy to use table top unit having a free flow ozone
delivery system which utilizes corona discharge. Root canals and
periodontal pockets could be easily penetrated. In this system,
ambient air is utilized that is filtered and dried before it is passed
over a ceramic plate, later high voltage is applied which then
finally produces ozone. As this is an open system, high volume
suction is required.[18] Depending on requirement of treatment
ozone is applied at 6, 12, 18, 24 s (e.g., 12 s – surgical disinfection,
18 s – periodontal disinfection).
Customized thermoformed dental appliance
For application of ozone gas hard‑ or medium‑soft thermoformed
dental appliance could be prepared which extends 2–3 mm
beyond the affected gingival area and a free space for gas
circulation is left. For the inlet and outlet of gas, 2 ports should
be attached at distal and mesial of the treatment area, respectively.
Light or medium body silicone is used to recline edges of the
appliance and light‑cured dam applied for complete sealing of
the borders. Both hard and soft tissues of the affected area
could be treated with this appliance. Indicated areas where such
an appliance is hard to use or uncomfortable to the patient,
polyvinylchloride (PVC) or silicone cap might be used.
Irrigation with ozonated water
As ozone water is highly effective in killing of both Gram‑positive
and negative micro‑organisms, areas affected during and after
scaling, root planing and non‑surgical pocket curettage might be
irrigated with ozone water. In plaque biofilm, the bactericidal
activity of ozone water against bacteria is strong.
Ozone Nano bubble water
As the half‑life of ozonated water is about 20 min only because
of which it degrades back into oxygen, hence its potency must
be assured by using it within first 5–10 min after production.
To overcome such a problem CHIBA and TAKAHASHI
developed ozone Nano bubble water (NBW3) in 2008. In an
electrolyte solution, a micro‑bubble  (≤50 μm in diameter)
collapses by means of a physical stimulus like shock leading to
the production of Nano bubble (<100 nm in diameter) under
high temperature and pressure. If protected against UV rays
exposure, the oxidation ability of NBW3 is retained as aqueous
ozone for more than 6 months. NBW3 is used as an adjunctive
antiseptic in periodontal treatment due to its bactericidal efficacy
and usability. The bactericidal activity of NBW3 is more potent
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Gupta and Deepa: Ozone therapy in dentistry
against periodontopathic bacteria than an established oral
antiseptic, 0.2% chlorhexidine digluconate.
In‑office and home use of ozonized olive oil
A blunt 25‑G needle or any other appropriate tip can be used
to fill pockets with ozonized olive oil and the application can be
repeated once a week.
Peri‑implantitis
Gaseous or aqueous form of ozone may be used in cases of
peri‑implantitis. The abutment is fully covered by cutting an
appropriate length of PVC or silicone cap. The gingival borders
around the implant should be properly sealed. Ozone gas
infiltrations can also be used in this situation. During debridement
and curettage, irrigation is done with ozonated water. On the treated
areas, 3–4 times daily application of ozonized oil can also be advised.
Desensitization of sensitive root necks
Repeated application of ozone spray for 60 s followed by mineral
wash on the exposed dentine provides quick and prompt relief
from root sensitivity. The penetration of ionic calcium and
fluorine deep into the dentinal tubules is prevented by smear
layer present over the exposed root surfaces. This smear layer
removal by ozone causes opening of the dentinal tubules by
broadening their diameter and thus, the calcium and fluoride ions
flow into the tubules easily and deeply. Plugging of these Dentinal
tubules prevents the fluid exchange through these tubules. The
root sensitivity problem can be effectively terminated by ozone
within seconds and also lasts longer than those by conventional
methods.[19]
Advantages
• Simple, noninvasive, less time consumption eliminates dental
phobia.
Disadvantages include
Ozone toxicity if the level increases at 0.0007% per application,
not readily available, instability.
Ozone toxicity
When administered of 0.05 ppm for 8 h ozone is not toxic.
A maximum concentration of ozone in oral cavity amounts to
0.01 ppm, during ozone therapy. Certain side‑effects are cough,
nausea, vomiting, headache, epiphora, rhinitis, upper respiratory
irritation, shortness of breath, and heart‑related problems.[31]
Contraindications include
Acute alcohol intoxication, pregnancy, severe anemia, recent
myocardial infarction, hyperthyroidism, active hemorrhage, and
thrombocytopenia.
Ozone intoxication
• Patient must be placed in supine position
• Vitamin E
• Ascorbic acid
• Inhale humid oxygen
• N‑Acetylcysteine.[6]
Journal of Oral Research and Review Vol. 8, Issue 2, | July-December 2016
Conclusion
Ozone therapy is more in contrast to the present conventional
therapeutic modalities as it is a minimally invasive and
conservative approach, quite inexpensive, painless therapy
which increases the acceptability and compliance of patient with
minimal adverse effects. However, further research is still needed
to justify the routine uses of ozone in dentistry.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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E-Pub for hand-held devices

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Click on [EPub] from Table of Contents page.
There are various e-Pub readers such as for Windows: Digital Editions, OS X: Calibre/Bookworm, iPhone/iPod Touch/iPad: Stanza, and Linux:
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E-Book for desktop

One can also see the entire issue as printed here in a ‘flip book’ version on desktops.
Links are available from Current Issue as well as Archives pages.
Click on View as eBook

91 Journal of Oral Research and Review Vol. 8, Issue 2, | July-December 2016