Dental Science - Review Article

Application of ozone in the treatment of

periodontal disease
Adusumilli Srikanth, Manthena Sathish, Anumolu Venkatanaga Sri Harsha

Department of
Periodontics and
Implantology, Drs. Sudha
and Nageswara Rao,
Siddhartha Institute
of Dental Sciences,
Chinnaoutapalli,
Gannavaram, Vijayawada,
Andhra Pradesh, India
ABSTRACT
Gingivitis and periodontitis are most common inflammatory diseases of supporting tissues of teeth. Role
of microbial etiology and host response in progression of gingival and periodontal diseases has been well
established. Because of the beneficial biological effects of ozone, due to its antimicrobial and immunostimulating
effect, it is well indicated in the treatment of gingival and periodontal diseases. The objective of this article
is to provide a general review about clinical applications of ozone in treatment of periodontal diseases and to
summarize the available in vitro and in vivo studies in Periodontics in which ozone has been used.

Address for correspondence:

Dr. Adusumilli Srikanth,
E‑mail: srik37@yahoomail.
com

Received : 02-05-13
Review completed : 04-05-13
Accepted : 04-05-13 KEY WORDS: Anti‑hypoxic, immunostimulating, oxidizer

O  zone is a colorless gas form of oxygen and is present in

atmosphere. It is one of the most important gases in the
stratosphere due to its ability to filter ultraviolet rays, which is
critical for the maintenance of biological balance in the
biosphere. It has been used to purify water throughout the
world for many years as it is highly effective in killing bacteria
present in different forms. It effectively kills bacteria, fungi,
viruses and parasites at a lower concentration.[1]
Ozone is a chemical compound consisting of three oxygen
atoms (O3‑triatomic oxygen), a higher energetic form than
normal atmospheric oxygen (O2). Molecular weight of ozone
is 41.98 g/mol. It is a powerful oxidizer.[2]
It protects living organisms by surrounding the earth at
altitudes of 50,000‑100,000 feet. One molecule of ozone
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is equal to 3000‑10,000 molecules of chlorine and kills
pathogenic organism’s 3500 times faster. [3] The use of
ozonated fluids in dental care is upcoming. Extensive research
has been carried out over the past 50 years into the use of
ozonated fluids for infection control and wound management.
Ozone has been proposed as an alternative oral antiseptic in
dentistry. There are many known action of ozone on human
body such as immunostimulating, analgesic, antihypoxic,
detoxicating and antimicrobial properties. This new
notion has given rise to a number of procedures and aims
in eliminating only the infected and demineralized dental
tissue and hence conserves and protects the tooth structure.[4]
Ozone is naturally produced by the photo dissociation of
molecular oxygen into activated oxygen atoms which then react
with further oxygen molecules. This transient radical anion
rapidly becomes protonated, which in turn decomposes to an
even powerful oxidant, the hydroxyl radical OH.[5]
History

In 1785, Van Marum noticed that air near his electrostatic

DOI: machine acquired a characteristic odor when electric sparks
10.4103/0975-7406.113304 were passed. In 1801, Cruickshank observed the same odor
at the anode during electrolysis of water. In 1840, Schonbein

How to cite this article: Srikanth A, Sathish M, Sri Harsha AV. Application of ozone in the treatment of periodontal disease.
J Pharm Bioall Sci 2013;5:89-94.

Journal of Pharmacy and Bioallied Sciences June 2013 Vol 5 Supplement 1 S89 
 Srikanth, et al.: Application of ozone in the treatment of periodontal disease

named the substance “Ozein” which is a Greek word for smell. • Cold plasma system: Used in air and water purification.
In 1856, ozone was used to disinfect operating rooms. In 1857,
Werner Von Siemens designed an ozone generator, cylindrical Advantages
dielectric type that makes up most of the commercially available
ozone generators and called it the “Siemens type” ozone • Disinfectant.
generator. In 1860, Monaco first used the ozone generator in • Anti‑inflammatory.
water treatment plant. In 1870, ozone was first used for the • Activation of intracellular metabolism of oral mucosa and
medical application, when Dr. C. Lender purified blood in test dental wounds.
tubes. In 1901, Wiesbaden used ozone in a municipal water • Improvement of regional circulation.
supply. In 1931, Dr. E. A. Fisch, a dentist used ozonated water • Stimulation of regenerative processes.
for dental procedures and pioneered its use in medicine.[6] • Hemostasis in capillary bleedings.
• Painless procedures.
Mechanism of Action
Disadvantages
Application of ozone in Periodontics comes as a result of its
physic‑chemical properties. Its known actions on human body • Ozone toxicity if the level increases at 0.0007% per
are antimicrobial, analgesic, immunostimulating, antihypoxic application.
and detoxicating.[7] • Instability.
• Not readily available.
Composition of Medical Grade Ozone
Indications
It is a mixture of pure oxygen and pure ozone in the ratio of
0.05‑5% of O3 and 95‑99.5% of O2. Due to the instability of • Chronic or recurrent infections in the oral cavity.[10]
O3 molecule, it must be prepared immediately before use and • Prophylaxis and prevention of dental caries.
cannot be stored over long periods of time.
• Remineralization of pit and fissure caries, root and smooth
surface caries.
Routes of Administration • Bleaching of discolored root canal treated teeth.
• Sterilization of cavities, root canals, periodontal pockets,
Gaseous ozone – Ozone can be used in gaseous form via an herpetic lesions.
open system or via a sealing suction system to avoid inhalation • Desensitization of extremely sensitive tooth necks.
and its adverse effects. • Pre‑washing of surgical sites.
• Plaque control.
Ozonated water – Ozonated water has been shown to be very
• Contamination control.
effective against bacteria, fungi and viruses.
Contraindications[11] Side effects[12]
Ozonized oil – In addition to gaseous and aqueous form, oils
that are ozonized also seems extremely convenient. Pregnancy Epiphora
Hyperthyroidism Rhinitis
Severe anemia Cough
Though gaseous ozone was shown to have more effective Severe Headache
microbicidal properties than aqueous form, due to its Active hemorrhage Nausea and vomiting
toxic effects if inhaled, ozonated water is the most preferred Thrombocytopenia
form for use in dentistry. Therefore a safe system for Cardiovascular instability
Patients on ACE inhibitors
applying gaseous ozone into the periodontal pocket that avoids
inhalation still needs to be developed.[8]
Goals of ozone therapy
Generators of Ozone
• Inactivates viruses, bacteria, yeast, fungus and protozoa.
The first ozone generator was developed by Werner Von Siemens • Stimulates the immune system, cleans arteries, veins, and
in Germany in 1857. There are several different techniques used improves circulation.[13]
to produce therapeutic grade ozone.[9] • Purifies the blood and lymph.
• Normalizes harmone and enzyme production.
They are: • Reduces inflammation and pain.
• Ultraviolet system: Produces low concentrations of ozone. • Stops bleeding.
It is used in esthetics, saunas and fro air purification. • Prevents shock and stroke damage.
• Corona discharge system: Produces high concentrations • Reduces cardiac arrhythmia.
of ozone. Most common system used in medical and • Improves brain function and memory.
dental field. It is easy to handle and it has a high controlled • Oxidizes toxins allowing their excretion, chelates heavy
ozone production. metals.

 S90 Journal of Pharmacy and Bioallied Sciences June 2013 Vol 5 Supplement 1

Ozone Intoxification
• Patient must be placed in supine position
• Inhale humid oxygen
• Ascorbic acid
• Vitamin E
• Acetylcystein
Biological Actions
Antimicrobial effect
Ozone works destructively against bacteria, fungi and
viruses. The antimicrobial effect of ozone is a result of its
action on cells by damaging its cytoplasmic membrane
due to ozonolysis of dual bonds and also ozone‑induced
modification of intracellular contents because of secondary
oxidant effects. This action is selective to microbial cells but
does not damage human body cells because of their major
antioxidative ability.[14]
Immunostimulating effect
Ozone influences cellular and humoral immune system.
It stimulates proliferation of immunocompetent cells and
synthesis of immunoglobulins. It also activates function of
macrophages and increases sensitivity of microorganisms
to phagocytosis. Ozone causes the synthesis of biologically
active substances such as interleukins, leukotrienes, and
prostaglandins which is beneficial in reducing inflammation
and wound healing. Ozone in high concentrations causes
immunodepressive effect whereas in its low concentration
immunostimulating effect.[15]
Antihypoxic effect
Ozone improves the transportation of oxygen in blood, which
results in change of cellular metabolism‑activation of aerobic
processes (glycolysis, Krebs cycle, β‑oxidation of fatty acids) and
use of energetic resources. Ozone improves the metabolism of
inflamed tissues by increasing their oxygenation and reducing
total inflammatory processes.[16]
Biosynthetic effect
It activates mechanisms of protein synthesis increases amount
of ribosomes and mitochondria in the cells. These changes on
the cellular level explain elevation of functional activity and
regeneration potential of tissues and organs.
Application Modalities of Ozone in Periodontal
Therapy
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.[17]
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Srikanth, et al.: Application of ozone in the treatment of periodontal disease
Ozone in gaseous form
A customized suck down thermoformed hard or medium‑soft
dental appliance should extend 2‑3 mm beyond the
affected gingival area, leaving a free space for gas circulation.
2 ports should be attached for the gas inlet and outlet
respectively at the distal and mesial of the treatment area.
The edges of the appliance should be reclined with light or
medium body silicone. Light‑cured dam can also be applied as
an extra safety precaution to completely seal the borders. The
ports to the generator and the suction pump should then be
attached. This procedure will treat both hard and soft tissues
of the affected area. Poly vinyl chloride (PVC) or silicone cap
can be used to treat individually all the indicated areas in
difficult situations where such an appliance is hard to use or
uncomfortable to the patient.
Irrigation with ozonated water
Ozonated water can be used to irrigate the affected area during
and after scaling, root surface planning, and non‑surgical pocket
curettage.
In‑office and home use of ozonized olive oil
After in‑office treatment with ozone gas or ozonated water,
pockets can be filled with ozonized olive oil using a blunt 25 G
needle or any other appropriate tip. Patient can be given some
of the oils for home use. In‑office ozonized oil application can
be repeated once a week.
Surgical procedures
Ozonated water can be used as an irrigant during the surgical
procedure and/or as a final surgical site lavage. The sutures can
be covered with a thin layer of ozonized oil and the patient can
be instructed to apply the oil 3‑4 times a day.
Peri‑implantitis
Peri‑implantitis is very bothering to both the dentist and the
patient. Laser and/or manual debridement along with antiseptic
solutions and topical anti‑microbial medicines are commonly
performed with a varying degree of success. Ozone can play an
important role and be used as gas or in aqueous form. Ozone gas
infiltrations can also be used in this situation. Ozonated water
can be used as an irrigant during debridement and curettage.
Patient can be advised to apply ozonized oil on the treated area
3‑4 times/day.
Ozone in the Treatment of Periodontal Diseases
Periodontal disease is a multifactorial disease process in the
mouth. The role of microorganisms, hostresponse, in the
etiology of periodontal disease is well established.
The undisputed disinfection power of ozone over other
antiseptics makes the use of ozone in treatment of periodontitis
 Srikanth, et al.: Application of ozone in the treatment of periodontal disease
a very good alternative and/or an additional disinfectant to
standard antiseptics.
Ozonated water (4 mg/l) was found effective for killing
gram‑positive and gram‑negative oral microorganisms and oral
Candida albicans in pure culture as well as bacteria in plaque
biofilm and therefore might be useful as a mouth rinse to control
oral infectious microorganisms in dental plaque. In implant
dentistry, the use of ozone is currently being investigated for the
decontamination of the implant surface in Peri‑implant therapy.
Thanomsub et al. 2002 tested the effects of ozone treatment on cell
growth and ultra‑structural changes in bacteria (Escherichia coli,
Salmonella sp., Staphylococcus aureus and Bacillus subtilis). It was
discovered that ozone at 0.167 mg/min/l can be used to sterilize
water, which is contaminated with up to 105 cfu/ml bacteria within
30 min. Destroying of bacterial cell membrane was observed,
subsequently producing intercellular leakage and eventually
causing cell lysis. Nevertheless, these ozone concentrations have
no significant effect on the cell viability in bacterial cultures at
higher concentrations of 106 and 107 cfu/ml.[18]
Ebensberger et al. in 2002 evaluated the effect of irrigation with
ozonated water on the proliferation of cells in the periodontal
ligament adhering to the root surfaces of 23 freshly extracted
completely erupted third molars. The teeth were randomly
treated by intensive irrigation with ozonated water for 2 min
or irrigation with a sterile isotonic saline solution, serving as a
control group. The periodontal cells of these teeth were studied
immunohistochemically to mark proliferating cell nuclear
antigen. It was observed that the labeling index (the number of
positive cells compared to the total number of cells suggesting
enhancement of metabolism) was higher among the teeth
irrigated with ozone (7.8% vs. 6.6%); however, the difference
was not statistically significant (P  =  0.24). They concluded
that the 2 min irrigation of the avulsed teeth with non‑isotonic
ozonated water might lead not only to a mechanical cleansing,
but also decontaminate the root surface, with no negative
effect on periodontal cells remaining on the tooth surface.[19]
Holmes in 2003, observed effect of Kavo healozone device
on Primary root carious lesions (PRCL)  followed‑by
professionally‑applied remineralizing solution containing
xylitol, fluoride, calcium, phosphate and zinc. This treatment
modality was applied to 89 patients, aged from 60 to 82 years.
After 18 months, 100% of ozone‑treated PRCL’s had improved. In
control group, where lesions were left without treatment, only 1
PRCL had improved. In 62% of cases the status remained leathery,
while in 37% of PRCL’s had worsened from leathery to soft.[5]
Nagayoshi et  al. 2004 tested the efficacy of ozonated water
on survival and permeability of oral micro‑organisms. Gram
negative bacteria, such as Porphyromonas endodontalis and
Porphyromonas gingivalis were substantially more sensitive
to ozonated water than gram positive oral streptococci and
c. albicans in pure culture. Furthermore ozonated water had
strong bactericidal activity against bacteria in plaque biofilm.
In addition, ozonated water inhibited the accumulation of
experimental dental plaque in vitro.[20]
 S92 Journal of Pharmacy and Bioallied Sciences June 2013 Vol 5 Supplement 1
Hems and Gulabivala, 2005 evaluated the potential of ozone
as an anti‑bacterial agent using Enterococcus faecalis as a test
species. Ozone was used both gasiform (produced by Purezone
device), and aqueous (optimal concentrations 0.68 mg/l).
It was concluded that ozone in solutions was antibacterial
against planctonic Enterococcus faecalis after 240 s treatment.
However it was not effective against Enterococcus faecalis cells
in a biofilm unless they were displaced into the surrounding
medium by agitation. Gaseous ozone was not effective on the
Enterococcus faecalis biofilm.[21]
Ramzy et  al. in 2005 irrigated the periodontal pockets by
ozonized water in 22 patients suffering from aggressive
periodontitis. Periodontal pockets were irrigated with 150 ml
of ozonized water over 5‑10 min once weekly for a clinical
4 weeks study using a blunt tipped sterile plastic syringe.
High significant improvement regarding pocket depth plaque
index gingival index and bacterial count was recorded related
to quadrants treated by scaling and rootplaning together with
ozone application. They also reported significant reduction in
bacterial count in sites treated with ozonized water.[22]
Huth et al. in 2006, in their study declared that the aqueous
form of ozone, as a potential antiseptic agent, showed
less cytotoxicity than gaseous ozone or established anti
microbials (chlorhexidine digluconate [CHX]: 2%, 0.2%; sodium
hypochlorite 5.25%, 2.25%; hydrogen peroxide‑H2O2 3%) under
most conditions. Therefore, aqueous ozone fulfills optimal cell
biological characteristics in terms of biocompatibility for oral
application.[23]
Muller et  al. in 2007 compared the influence of ozone gas
with photodynamic therapy (PDT) and known antiseptic
agents (2% chlorhexidine, 0.5 and 5% hypocholrate solutions)
on a multispecies oral biofilm in vitro. Actinomyces naeslundii,
Veillonella dispar, Fusobacterium nucleatum, Streptococcus
sobrinus, Streptococcus oralis and c. albicans were studied.
Gasiform ozone was produced by vacuum ozone delivery system
Kavo Healozone. They concluded that the matrix‑embedded
microbial populations in biofilm are well protected towards
antimicrobial agents. Only 5% hypochlorate solution was able
to eliminate all bacteria effectively. Usage of gasiform ozone or
PDT was not able to reduce bacteria in the biofilm.[24]
Kronusova 2007 used ozone in following cases: Prevention of
dental caries in fissures of the first permanent molars in children,
application of ozone in prepared cavity, after tooth extraction, in
case of post extractional complications, in patients with chronic
gingivitis, periodontitis and periodontal abscesses, herpes labialis,
purulent periodontitis, dentition difficilis, etc., Almost all patients
with gingivitis showed subjective and objective improvement of
their status, as well as patients with periodontal abscess, where
no exudation was observed. Application of ozone after tooth
extraction was found also quite useful – only 10% of patients
suffered from such complication as alveolitis sicca, but even in
these cases the clinical course was shorter and more moderate.[25]
Karapetian et  al. in a study of peri‑implantitis, treatment
with conventional, surgical and ozone therapy methods was

investigate and it was found that the most effective bacteria
reduction was in the ozone‑treated group.[26]
Kshitish and Laxman in 2010 conducted a randomized,
double‑blind, crossover split‑mouth study on 16 patients suffering
from generalized chronic periodontitis. The study period of
18 days was divided into two time‑intervals, i.e., baseline (0 days)
to the 7th day, with a wash out period of 4 days followed by a
second time‑interval of 7 days. Subgingival irrigation of each
half of the mouth with either ozone or chlorhexidine was done
at different time intervals. They observed a higher percentage
of reduction in plaque index (12%), gingival index (29%), and
bleeding index (26%) using ozone irrigation as compared to
chlorhexidine. The percentile reduction of Aa (25%) using ozone
was appreciable as compared to no change in Aa occurrence
using chlorhexidine. By using O3 and chlorhexidine, there was
no anti‑bacterial effect on Porphyromonas gingivalis (Pg) and
Tannerella forsythensis. The anti‑fungal effect of ozone from
baseline (37%) to 7th day (12.5%) was pronounced during the
study period, unlike CHX, which did not demonstrate any
anti‑fungal effect. No anti‑viral property of ozone was observed.
The anti‑viral efficacy of chlorhexidine was better than that
of ozone. They concluded that despite the substantivity of
chlorhexidine, the single irrigation of ozone is quite effective
to inactivate microorganisms.[27]
Fillippi. A  observed the influence of ozonized water on the
epithelial wound healing process in the oral cavity. It was found
that ozonized water applied on daily basis can accelerate the
healing rate in oral mucosa.[28]
Huth, et al. in 2011 compared the effectiveness of ozone with
that of the established antiseptic CHX, against periodontal
microorganisms. There were no significant differences in the
effectiveness of aqueous ozone (20 μg ml  [−1]) or gaseous
ozone (≥4 g [−3]) compared with 2% CHX but they were more
effective than 0.2% CHX. Therefore, high‑concentrated gaseous
and aqueous ozone merit further investigation as antiseptics in
periodontitis therapy.[29]
Dodwad et al. in 2011 compared the effect of oral irrigation with
ozonated water, 0.2% Chlorhexidine and 10% Povidone iodine
in patients with chronic periodontitis. The study concluded
that local ozone application can serve as potent atraumatic,
antimicrobial agent to treat periodontal disease non‑surgically
both for home care and professional practice. It may also serve
as good tool during supportive periodontal therapy.[30]
Conclusions
Since its introduction in 1840, ozone therapy is proving to be
a new therapeutic modality with great benefits to the patients.
The potent antimicrobial power of ozone, along with its capacity
to stimulate the circulatory system and modulate the immune
response, makes it a therapeutic agent of choice in the treatment
of medical pathologies and infectious oral diseases. Oxidative
effect of ozone on the microbiota has been shown in several
studies. There is good evidence of in vitro biocompatibility
of aqueous ozone with human oral epithelial cells, gingival
Journal of Pharmacy and Bioallied Sciences June 2013 Vol 5 Supplement 1 S93 
Srikanth, et al.: Application of ozone in the treatment of periodontal disease
fibroblast cells and periodontal cells. Further, the use of ozone
is an easy and painless treatment modality.
The clinical application of ozone has not achieved strong level
of efficacy and cost effectiveness. This divergence of the study
outcomes may be related to the methodological differences
linked to the lack of in vitro and in vivo, long term randomized
controlled trials and double blind studies. There is still a need
for the highest level of evidence, i.e., well designed; double‑blind
randomized clinical trials to justify the routine use of ozone as a
treatment modality in dentistry. Scientific support, as suggested
by demonstrated studies, show ozone to be a potential use in
dentistry.
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Source of Support: Nil, Conflict of Interest: None declared.
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