INTRODUCTION 
The word ozone comes from the Greek “ozein” meaning 
odorant. Ozone (also known as triatomic oxygen and 
trioxygen) is an allotropic form of oxygen occurring naturally 
in the Earth's atmosphere. It surrounds the Earth at an altitude 
of between 50,000 and 100,000 feet. [1] It is created, when 
ultraviolet rays cause oxygen atoms to disassociate and 
temporarily recombine in groups of three. It is also formed by 
the action of electrical discharges on oxygen, so it is often 
created by thunder and lightning.

CHEMISTRY:
Ozone (O ) concists of three oxygen atoms, with molecular 3

weight is 47, 98 g/mol and thermodynamically highly unstable 
compound.[11] when compared to oxygen Ozone is 1.6-fold  
more denser and 10-fold more soluble in water .Ozone is an 
unstable gas and which  gives up nascent Oxygen molecule to 
form Oxygen gas.As it releases nascent Oxygen, it has been 
used in  medical eld to kill bacteria, fungi, to inactivate 
viruses and to control hemorrhages. [2] Medical grade ozone 
is made from pure medical oxygen. It is produced 
commercially in ozone generators, which involves sending an 
electrical discharge through a specially-built condenser 
containing oxygen.

History
First discovered in 1840 by the German chemist Christian 
Frederick Schonbein at the University of Basil in Switzerland, 
ozone was rst used in medicine by Landlerin the year 1870.  It 
was not studied or used until 1932 by the scientic community. 
Ozonated water was rst used as a disinfectant by Dr. E. A. 
Fisch, a Swiss dentist. By a twist of fate, a surgeon, Dr. E Payr 
(1871–1946) had to be treated for a gangrenous pulpite and 
remained astonished by the result achieved with local ozone 
treatment. He enthusiastically extended its application to 
general surgery.

At the time, ozone therapy was difcult and limited due to the 
lack of ozone-resistant materials, such as Nylon, Dacron, and 
Teon, until 1950 when ozone-resistant materials were 
manufactured. At that time Joachim Hänsler, a German 
physicist and physician, joined another German physician, 
Hans Wolff, to develop the rst ozone generator for medical 
use. Their design continues to be the basis for modern 
equipment.

 Ozone generators 
There are three different systems for generating ozone gas: [4]
Ultraviolet System: produces low concentrations of ozone, 
used in esthetics, saunas, and for air purication.

 Cold Plasma System: used in air and water purication.
Corona Discharge System: produces high concentrations of 
ozone. It is the most common system used in the medical/ 
dental eld. It is easy to handle and it has a controlled ozone 
production rate.

Medical grade ozone is a mixture of pure oxygen and pure 
ozone in the ratio of 0.05% to 5% of ₃ and 95% to 99.95% of O₂. 

Use of ozone in dentistry
The use of ozone in dentistry is gaining its place in every day's 
dental practice and is used in almost all dental applications. 
The undisputed disinfection power of ozone over other 
antiseptics makes the use of ozone in dentistry a very good 
alternative and/or an additional disinfectant to standard 
antiseptics.

Due to safety concerns, ₃ gas was not recommended for intra-

oral use. Only dissolved ozone in water and ozonated oils 
were and are still commonly used in different elds of 
dentistry. With the development of a foot pedal-activated 
dental handpiece with a suction feature, ₃ gas can now be 

used safely in situations where diffusion is an important factor, 
i.e. dental hard tissues.

According to  Fritz Kramer, ozone, such as in the form of 
ozonated water, can be used in the following ways.

1.  as a powerful disinfectant
2.  in its ability to control bleeding
3.  in its ability to cleanse wounds in bones and soft tissues.
4.  by increasing the local supply of oxygen to the wound 

area, ozone can improve healing.
5.  ozonated water can increase temperature in the area of 

the wound, and this increase the metabolic processes 
related to wound healing.

OZONE THERAPY IN PERIODONTICS (REVIEW)

Original Research Paper

Dr. Mrs.Veena. A. 
Patil

MDS Periodontics, HOD and Professor, Department of Periodontia, H.K.E.S. 
S.N Dental College, Kalaburagi.

  X 19GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS

Dental Science 

The usage of ozone in dentistry has been proposed because of its  various biological properties like 
disinfection, antimicrobial activity, biocompatibility and healing properties. In the last few years, various 

therapeutic protocols with ozone have been developed in various elds of dentistry. Inspite of many advantages, therapeutic 
ozone's application in dentistry is limited because of its possible side effects. Hence, dentists has to know the appropriate usage 
of ozone therapy which can provide better patient care and considerably cut down the time and cost of the treatment.

ABSTRACT

KEYWORDS : 

VOLUME-8, ISSUE-11, NOVEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Dr. Ayesha MDS-postgraduate Studying In Hkes S.n Dental Collage,kalaburagi

Dr. Sobia tahseen 
Ansari*

MDS-postgraduate Studying In Hkes S.n Dental Collage,kalaburagi 
*Corresponding Author



20 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS

Biological actions
The application of ozone in dentistry comes as a result of 
physico-chemical properties: There are several known actions 
of ozone on human body, such as immunostimulating and 
analgesic, antihypoxic and detoxicating, antimicrobial, 
bioenergetic and biosynthetic (activation of the metabolism of 
carbohydrates, proteins, lipids) etc.

1. 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 modication of intracellular contents (oxidation of 
proteins loss of organelle function) because of secondary 
oxidants effects. This action is non-specic and selective to 
microbial cells; it does not damage human body cells because 
of their major antioxidative ability. Ozone is very efcient in 
antibiotics resistant strains. Its antimicrobial activity increases 
in liquid environment of the acidic pH. In viral infections the 
ozone action lies in the intolerance of infected cells to peroxides 
and change of activity of reverse transcriptase, which takes part 
in synthesis of viral proteins. [6]

2. Immunostimulating Effect- Ozone inuences 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 micro-organisms to phagocytosis. [6] As a 
response to this activation through ozone, the body's immune 
cells produce special messengers called cytokines. These 
molecules in turn activate other immune cells, setting off a 
cascade of positive change throughout the immune system, 
which is stimulated to resist diseases. This means that the 
application of medical ozone is extremely useful for immune 
activation in patients with a low immune status and/or 
immune decit. [8] Ozone causes the synthesis of biologically 
active substances such as interleukins, leukotrienes and 
prostaglandins which is benecial in reducing inammation 
and wound healing. [6] Ozone in high concentration causes 
immunodepressive effect whereas in its low concentration 
immunostimulating effect. [7]

3. Antihypoxic effect- Ozone brings about the rise of pO2 in 
tissues and improves  transportation of oxygen in blood, 
which results in change of cellular metabolism – activation of 
aerobic processes (glycolysis, Krebs cycle, �-oxidation of fatty 
acids) and use of energetic resources. Repeating low doses of 
ozone activate enzymes: super-oxide dismutases, catalases, 
dehydrogenase, and glutatione peroxidases. They are part of 
complex enzymatic systems which protect organisms against 
the action of oxygen-free radicals. It also prevents formation of 
erythrocytes aggregates and increases their contact surface 
for oxygen transportation. Its ability to stimulate the 
circulation is used in the treatment of circulatory disorders 
and makes it valuable in the revitalizing organic functions. [6] 

4. Biosynthetic Effect- It activates mechanisms of protein 
synthesis, increases amount of ribosomes and mitochondria 
in cells. These changes on the cellular level explain elevation 
of functional activity and regeneration potential of tissues and 
organs. [6] 

5. Ozone causes secretion of vasodilators such as NO, which is 
responsible for dilatation of arterioles and venules. [6] It also 
activates angiogenesis. [7]

6. Ozone, when acting on the organic substance of 
mineralized tooth tissues intensies  their remineralization 
potential. At the same time, it is capable of “opening” dentinal 
tubules, which enables the diffusion of calcium and 
phosphorus ions to the deeper layers of carious cavities. [9]

A high concentration of ozone kills bacteria very quickly and is 
thousand times more powerful than other bacterial killing 
agents. The average concentration of ozone used in 
treatments is 25 gm of ozone per milliliter of oxygen/ozone gas 
mixture that translates into 0.25 parts of ozone to 99.75 parts of 
oxygen. Evidence-based research has shown that at this 
concentration, ozone effectively kills bacteria, fungi, viruses 
and parasites. [10] As an antimicrobial agent, it is a powerful 
oxidizer at a dramatically lower concentration than chlorine 
with none of the toxic side effects. [10] Studies have revealed 
that it only takes 10 sec to kill 99 % of bacteria, fungi and 
viruses. [11] It can oxidize many organic compounds and it is a 
powerful germicide. [12] Some of the other effects are 
circulatory enhancement, disruption of tumor metabolism and 
stimulation of oxygen metabolism. [13]
According to most authors, a 10-sec-application of ozone 
causes the destruction of 99% of bacteria, and a 20-sec-
application even of 99.9%. In this way, so-called ecological 
niche appears.

However, it is not conducive to their repeated colonization 
within 4 to 6 weeks. [14,15] Ozone is not toxic when it is given in 
the amount of 0.05 ppm for 8 hours. During ozone therapy a 
maximum concentration of ozone in oral cavity amounts to 
0.01 ppm.

Goals of ozone therapy
Setting the standard-of-care and therapeutic goals are based 
on sound evidence-based science is critical. Therapeutic 
goals are inclusive and not exclusive of standard of care. The 
goals of oxygen/ozone therapy are: [10]

1.  Elimination of pathogens.
2.  Restoration of proper oxygen metabolism.
3.  Induction of a friendly ecologic environment.
4.  Increased circulation.
5.  Immune activation.
6.  Simulation of the humoral anti-oxidant system.

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 

VOLUME-8, ISSUE-11, NOVEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra



periodontitis 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 
biolm 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 
signicant 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  b 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 signicant 
(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 
Pr imary root  car ious lesions (PRCL)  fo l lowed-by 
professionally-applied remineralizing solution containing 
xylitol, uoride, 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 efcacy 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 biolm. 
In addition, ozonated water inhibited the accumulation of 
experimental dental plaque in vitro.[20]

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 biolm unless they were 

displaced into the surrounding medium by agitation. 
Gaseous ozone was not effective on the Enterococcus faecalis 
biolm.[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 
signicant 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 signicant 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-H  O  2 2

3%) under most conditions. Therefore, aqueous ozone fullls 
optimal cell biological characteristics in terms of 
biocompatibility for oral application.[23]

Muller et al. in 2007 compared the inuence of ozone gas with 
photodynamic therapy (PDT) and known antiseptic agents 
(2% chlorhexidine, 0.5 and 5% hypocholrate solutions) on a 
multispecies oral biolm 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 biolm 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 
biolm.[24]

Kronusova 2007 used ozone in following cases: Prevention of 
dental caries in ssures of the rst 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 
difcilis, 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., 

thbaseline (0 days) to the 7  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 O  and chlorhexidine, there was no anti-bacterial 3

effect on Porphyromonas gingivalis (Pg) and Tannerella 

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VOLUME-8, ISSUE-11, NOVEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra



forsythensis. The anti-fungal effect of ozone from baseline 
th(37%) to 7  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 efcacy 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 inuence 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]

CONCLUSION
Since its introduction in 1840, ozone therapy is proving to be a 
new therapeutic modality with great benets to the patients. 
Ozone with its potent antimicrobial power and competency  to 
stimulate the circulatory system and modulate the immune 
response, accomplish a  therapeutic agent of choice in the 
treatment of medical pathologies and infectious oral 
diseases.There is good evidence of in vitro biocompatibility of 
aqueous ozone with human oral epithelial cells, gingival 
broblast 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 efcacy 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. 

REFERENCES
1.  Chemical technology an encyclopedic treatment, Vol 1, New York: Barnes 

& Noble, Inc. 1968; 79.
2.  Garg R, Tandon S. Ozone: A new face of dentistry. The Internet Journal of 

Dental Science. 2009;7:2.
3.  Fish E. Apparatus for the production and use of ozone in therapeutics. United 

States Patent 2,054,367. September 15, 1936.
4.  Nogales CG, Ferrari PA, Kantorovich EO, Lage-Marques JL. Ozone Therapy in 

Medicine and Dentistry. J Contemp Dent Pract. 2008 May; (9)4:075-084.
5.  Krammer F. Ozone in the dental practice. Medical applications of ozone. 

Norwalk, CT: International ozone association, Pan American committee. 
1983; 258-65.

6. Seidler V, Linetskiy I, Hubalkova H, Staňkova H, Šmucler R, Mazanek J. Ozone 
and Its Usage in General Medicine and Dentistry. A Review Article. Prague 
Medical Report. 2008; 109(1): 5–13.

7.  Teresa B, Wolanska E, Cieszko- Buk M, Orlowski M, Chalas R. Practical use of 
ozone in dentistry – comments. Annales Universitatis Maria Curie- 
Sklodowska Lubin- Polonia. 2008; VOL. LXIII, N 1, 28 SECT IO D

8. Seaverson K, Tschetter D, Kaur T. Patient guide to oxygen/ozone therapy. 
Health centered cosmetic dentistry. [Online]. [Cited 2010 January 13]

9.  Lynch E. Leczenie próchnicy z wykorzystaniem system HealOzon. eDentico. 
2004;134,3.

10.  Mollica P, Harris R. Integrating oxygen/ ozone therapy into your practice. 
[Online]. [Cited 2010 January 13];[4 screens].

11.  Ozone dental therapy. [Online]. [cited 2010 January 13] [1 screen].Safe 
dentistry. Co. uk / ozone –dental therapy.

12.  Gum GP and Bone Regeneration Procedures. Australian Institute of Implant 
Dentistry [online]. [Cited 2010 January 13].

13.  Ozone Therapy Oxygen Therapies.Applied ozone systems. [Online].[Cited 
2010 January 13].

14.  Baysan A, Whiley RA, Lynch E. Antimicrobial effect of novel ozone generating 
device on microorganisms associated with primary root carious lesions in 
vitro. Caries Research. 2000; 498,6,34.

15.  Holmes J. Zastosowanie ozonu do leczenia pierwotnych zmian 
próchnicowych bruzd. Por. Stomat.,39, 4 Baysan A, Whiley RA, Lynch E. 
Antimicrobial effect of novel ozone generating device, 2004.

16.  Azarpazhooh A, Limeback H. The application of ozone in dentistry: a 
systematic review of literature. J Dentist. 2008;36:104-116.

17.  Huth KC, Jakob FM, Saugel B, Cappello C, Paschos E, Hollweck R, et al. Effect 
of ozone on oral cells compared with established antimicrobials. Eur J Oral 
Sci. 2006;114:435-440.

18.  Nagayoshi M, Kitamura C, Fukuizumi T, Nishihara T, Terashita M. 
Antimicrobial effect of ozonated water on bacteria invading dentinal tubules. 
J Endod. 2004;30:778-781.

19.  Huth KC, Jakob FM, Saugel B, Cappello C, Paschos E, Hollweck R, et al. Effect 
of ozone on oral cells compared with established antimicrobials. Eur J Oral 
Sci. 2006;114:435-440.

20.  Kronusova M. Aplikace atomarniho kysliku v ordinaci praktickeho zubniho 
lekaře. Progresdent 3. 2007; 34–36.

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