Ozone Water in the Dental Office

Mason Elite Dentistry now utilizes ozonated water in all of our operatories. The benefits of ozonated water compared to distilled water treated with tablets is that the ozone kills virus, bacteria and fungi on contact without harsh chemicals. Ozonated water is safe at the dosages in our office and does not irrtate the lungs like vaporized ozone. There have been several great studies about ozone that I will link below.

"Ozone has been successfully used in medicine for over 100 years due to its microbiological qualities. Its powerful oxidation impact, which results in the production of free radicals, and its ability to cause the direct death of nearly all microorganisms is the basis for its bactericide, virucide, and fungicide properties. Ozone also has a medicinal impact that speeds up blood flow and aids wound healing. Ozone may be applied as a gas or dissolved in water for medical purposes.

5. The Uses of Ozone in Dentistry

Dr. Fisch (1899–1966) was the first dentist to employ ozonated water in his practice. Dr. Payr, a German surgeon, received it from him and began using it in surgery after that. He announced his findings at the 59th Congress of the German Surgical Society in Berlin (1935) [21].

5.1. Effect of Ozone on Soft Tissues

In dental surgery, ozone can be used as a gas or dissolved in water to limit bacterial growth, improve homeostasis, and increase local oxygen supply by increasing blood flow [64]. Similarly, ozone gas has been utilized to treat illnesses, including herpes and aphthous ulcers. It hastens the healing process and shortens the illness’s clinical course. Herpes vanished after three days if ozone gas was given early and frequently, while aphthous ulcers vanished after one day [65]. Additionally, the use of ozone is well indicated in all stages of gingival and periodontal diseases due to its beneficial biological effects, antimicrobial activity, oxidation of biomolecule precursors and microbial toxins implicated in periodontal diseases, and its healing and tissue regeneration properties [66].

5.2. Effect of Ozone on Dental Hard Tissues

Ozone has the potential to lower the bacterial population in active carious lesions. To prevent or delay the need for tooth repair, it may temporarily stop the progression of cavities in enamel or dentin [67]. Some of the studies that are now accessible evaluated how ozone affected open caries, non-cavitated occlusal carious lesions, pit and fissure caries, and primary root caries. With short-term follow-up, the results demonstrated a considerable decrease in the number of microorganisms in the carious lesions in vivo and in vitro [68,69,70,71,72,73].

As a result of the oxidative action of ozone against bacterial strains such as Enterococcus faecalis [74] and Candida albicans [75], ozone is indicated for use in endodontic therapy [76]. Another use of ozone gas is reducing dentin hypersensitivity [77].

Ozone is used in implantology to aid bone regrowth. The socket is traditionally prepared, and over the next 40 s, ozone is bubbled into the prepared socket. An implant is then inserted into the socket. This lessens the risk of infection and promotes bone regrowth [78]. Studies have also revealed encouraging reports of regeneration and the eradication of infection around the implant in cases of peri-implantitis [78,79].

5.3. Effect of Ozone on Physical Properties of Enamel and Dentin

In the same way, Marchesi et al., 2012, assessed whether gaseous ozone application affected the microleakage of two dental sealants or the immediate enamel bond strength [80]. The results showed that ozone did not significantly weaken the enamel’s bond strength or cause microleakage to increase. They concluded that ozone gas did not affect the tested materials’ ability to adhere; therefore, one can clean the enamel surface before applying a dental sealant without compromising its ability to perform clinically.

According to Pires et al., 2013, in evaluations of the effect of ozone pretreatment on the shear strength of an etch-and-rinse and a self-etch system to enamel, as well as an analysis of the corresponding failure modes, neither adhesive’s shear bond strength values tested on enamel were affected by the prior application of ozone gas [81].

Floare et al., 2022, studied the impact of ozone (O3) treatment on the microstructural changes in tooth enamel after the treatment at different time intervals [82]. The results showed that exposure to O3 for 40–50 s enhanced enamel microhardness and ensured a rate of remineralization of between 96.82 and 97.38%. They concluded that using O3 as an alternative therapy to classical solutions may be a viable solution in dentistry.

5.4. Ozone in the Management of Non-Cavitated Pit and Fissure Caries

Several studies evaluated the effect of different application times of ozone gas that ranged from 10 to 40 s on primary pit and fissure caries. The remineralization and progression or regression of caries were measured directly after ozone application or after a follow-up period varying from 2 to 12 months. The change in the mean DIAGNOdent reading and the combination of the clinical severity scores and DIAGNOdent readings were evaluated [69,70,83]. In other studies, an electric caries meter was used to measure the carious lesion’s remineralization [84,85]. These studies showed a decrease in the DIGNOdent reading and clinical severity scores and an increase in the electrical caries meter measurement, indicating caries regression.

To treat non-cavitated occlusal fissure carious lesions in first permanent molars, El Meligy and Almushayt examined the efficacy of ozone gas and fissure sealant [83]. The trial enrolled fifty patients. Ozone was found to be equally beneficial as the fissure sealant 12 months after treating first permanent molars with active, non-cavitated occlusal fissure carious lesions.

In a split-mouth study, Johansson et al. assessed the impact of ozone and fluoride varnish on occlusal caries in primary molars [84]. Treatment with ozone or fluoride varnish did not halt caries development in cavitated lesions. Children with low and moderate caries risk had non-cavitated lesions that either showed minimal or no progression after both treatments. The use of ozone or fluoride varnish treatments in this regimen must be questioned to stop the advancement of caries in primary molars. These treatments are used in addition to the regular use of fluoridated toothpaste.

Unal and Oztas studied the activation of remineralization following the administration of three fissure sealants (FSs) on non-cavitated early caries, either alone or in combination with gaseous ozone (GO), and assessed the clinical success of FSs [71]. They concluded that GO, along with Aegis FS, demonstrated the highest levels of remineralization and that at the end of 12 months, its clinical success was higher than that of other FSs.

5.5. Ozone in the Management of Cavitated Occlusal Carious Lesions

Using stepwise excavation, Safwat et al. assessed the clinical changes in the dentin of deep carious lesions in young permanent molars after ozone exposure with and without using a remineralizing solution [86]. Their findings showed that the dentin color and consistency of young permanent molars were unaffected by ozone application through stepwise excavation. Monitoring caries activity using DIAGNOdent was unreliable.

Using a tooth cavity model, Sancakli et al. assessed the efficacy of antibacterial surface pretreatment techniques against Streptococcus mutans (S. mutans) within the diseased dentin surface [73]. They concluded that antibacterial effects against S. mutans were produced by the use of the Er:YAG and KTP lasers, as well as their additional combinations, during the cavity pretreatment procedure with chlorhexidine and ozone treatments, whereas the use of chlorhexidine and antibacterial dentin bonding only produced the highest antibacterial effects.

The antibacterial efficiency of ozone therapy on cariogenic bacteria was assessed by Düzyol [87]. Ozone and chlorhexidine digluconate (CHX) treatment groups were created from 40 children with deep caries in the permanent first molar. Samples of cariogenic dentin were taken from permanent molars before and after 120 s treatment with ozone and 60 s treatment with 2% CHX solution. The colonies of S. mutans and Lactobacillus sp. were counted after 48 h of phosphate buffer incubation. Both zone and CHX had antimicrobial effects against S. mutans and Lactobacillus sp.; however, they had significant differences (p < 0.05). The amount of growth in the Lactobacillus sp. group was substantially reduced in the CHX group compared to the ozone group (p < 0.05). They concluded that cariogenic bacteria could be cleaned using ozone therapy. Krunić et al., on the other hand, concluded that the antibacterial effect of ozone on residual bacteria after inadequate caries eradication was comparable to that of 2% chlorhexidine [88]. Additionally, when treating deep carious lesions with an incomplete caries removal technique, ozone shows promise as a biocompatible and efficient cavity disinfectant.

Almaz and Sönmez reviewed clinical and in vitro research to determine the efficacy of ozone therapy in the treatment and prevention of caries [70]. Ozone has been cited as a promising alternative to traditional caries control techniques in most clinical research. Ozone has been proven in a few studies to be ineffective at stopping caries and minimizing bacteria in open occlusal carious lesions. Ozone may be a valuable technique to lessen and control oral infectious germs in dental plaque and dental cavities. The outcomes of in vitro investigations, however, are debatable. While some researchers claimed that ozone therapy had little to no impact on the survival of bacteria, others claimed it was quite efficient at eradicating Gram-positive and Gram-negative oral germs. Therefore, more research is necessary before ozone is approved as a substitute for current approaches to managing and preventing caries.

The Cochrane library sponsored a systematic review of ozone in clinical dentistry in 2004 to evaluate the efficiency of ozone gas in delaying or halting the spread of dental caries [23]. The authors concluded that there is insufficient solid proof that ozone administration arrests or reverses the decay process. The use of ozone gas in a primary care setting for the treatment of dental caries also requires additional suitable quality evidence. A similar systematic and meta-analysis review was carried out by Santos et al. to determine the efficacy and safety of ozone therapy for the treatment of dental caries [89]. They came to the same conclusion as the Cochrane library.

5.6. Role of Ozone in Oral Medicine and Periodontology

Ozone therapy’s potential efficacy against periodontal pathogens and Candida species is indeed an essential aspect to consider in the context of its application in dentistry. Numerous studies have investigated the antimicrobial properties of ozone and its potential as an adjunctive treatment in various oral conditions, including periodontal diseases and oral candidiasis [90,91]. When ozone is applied to the oral cavity, it can exert antimicrobial effects by disrupting the cell walls of microorganisms and interfering with their metabolic processes. This makes ozone an attractive option for treating infections caused by periodontal pathogens and Candida species, which are known to play significant roles in periodontal disease and oral thrush, respectively [92,93,94,95]. Several research papers have reported positive outcomes when using ozone therapy in conjunction with conventional dental treatments. These studies have shown that ozone can effectively reduce bacterial and fungal loads, leading to improved clinical outcomes in patients with periodontal infections and oral candidiasis [75,96,97,98].

5.7. Ozone and Dental Unit Water Lines

Contamination of the dental unit water line (DUWL) has become an issue [99,100]. While the unit is not in use, the water becomes stagnant. Dental operations may expose healthcare workers to bacteria, spatter, and aerosols [100]. Molds, bacteria, and yeasts that are dangerous to the healthcare provider and other patients during therapy have been found by Szymanska in biofilms [101]. From the mains water, opportunistic pathogens were cultivated. Another study claimed that DUWL biocides could negatively impact the resin’s ability to adhere to the enamel [102]. Ozone has been used to clean water because of its effectiveness and absence of adverse side effects. According to results published by Kohno et al., acidic electrolyzed water could be used as a suitable defense against bacterial contamination of the DUWL [103]. Ozone was applied briefly and at a very low dose, but it nevertheless reduced biofilms and viable bacteria in model DUWLs by 57% and 65%, respectively [104]. Table 2 shows recent studies featuring the use of ozone in dentistry."