The materials presented in this section are kindly provided by
our Lebanese partner Dr. Fadi Sabbah, DDS.
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. Minimally Invasive
Dentistry is now the new Standard of Care in all disciplines of
dentistry, most importantly in preventive and operative dentistry.
So far, arresting and reversing the process of tooth caries without
invasive treatment are unpredictable and rely very much on patient's
compliance. Recent research and clinical studies on the use of ozone
in treating early tooth caries without cavitations are very promising
and are showing that it is now possible to arrest and reverse these
lesions in a predictable and repeatable way without invasive intervention.
These findings are establishing a paradigm shift, a revolution in
Due to safety concerns, O3 gas was not recommended for intra-oral
use. Only dissolved ozone in water and ozonated oils were and are
still commonly used in different fields of dentistry. With the development
of a footpedal-activated dental handpiece with a suction feature,
O3 gas can now be used safely in situations where diffusion is an
important factor, i.e.: dental hard tissues
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1. Operative Dentistry
After a comprehensive diagnosis and caries risks assessment, depending
on your preferred approach and management, you should be able to
classify the caries lesions according to a severity index upon which
you would be able to make a clinical judgment on how to proceed
1.1. Primary Pits & Fissures Caries Lesions
The following table is an aid on how to perform ozone therapy depending
on clinical cases. Remember that the availability of minimally invasive
diagnostic and operative equipment is of great value in conjunction
with the use of ozone.
CSI: Caries Severity Index
DV: Diagnodent Value
AA: Air Abrasion
EDJ: Enamel Dentin Junction
GIC: Glass Ionomer Cement
Ozone concentration: 3.5 - 5 µg/ml
Flow Rate: 0.5 - 1 L/min
It is advisable to apply a remineralizing agent after the ozone
application. Always emphasize on home oral hygiene and balanced
Treatment / Ozone
Prophylaxis and Preventive measures
might be needed
10 Sec O3 / Seal Fissures if indicated
10 - 19
Not Visible on X-Rays; Limited to
AA/Etch/40 Sec O3 / Seal Fissures
20 - 24
Caries at EDJ
Stained Pits and Fissures; not visible
AA/Etch/40 Sec O3 / Seal-Restore
25 - 29
Caries at 1-2 mm in Dentin
Infected Dentin; probably not visible
AA/Slow speed rotary. Remove only
infected very soft dentin to reach leathery dentin.
Etch/60 Sec O3/ GIC/Co-Cure
Caries at 3 mm + in Dentin
Infected Stained Dentin; probably
visible on X-Rays
AA/Slow speed rotary. Remove only
infected very soft dentin to reach leathery dentin.
Etch/60-120 Sec O3/GIC /Co-Cure
Very deep caries; maybe pulp involvement
Assess Pulp Vitality Decision Making
Remove all soft infected dentin; stop
at 1-2 mm from pulp; Etch/120 Sec O3/ GIC Fuji VII.
Re-assess at 4 month with X-Rays; remove GIC and look
for re-mineralization of the floor of the cavity. If
good results, put final restoration.
1.2. Proximal Caries Lesions
Proximal caries lesions are readily diagnosed with Bite-Wing
X-Rays unlike occlusal ones. Depending on the depth and speed onset
of the lesions, a decision is made on whether to open and access
the lesion or to use a non-invasive treatment.
As a general rule, in non-cavitated low speed onset lesions confined
in enamel or at the EDJ, a non-invasive protocol should be used
first. If the lesion extends in dentin, the final judgment should
be based on the caries risks assessment of the patient. In cavitated
lesions, restoration is a must.
Follow the same guidelines as described in the pits and fissures
1.3. Cervical Root(s) Caries Lesions
Follow the same guidelines as described in the pits and fissures
1.4. Hyper-Sensitive Teeth
Non-carious hypersensitivity is due to many contributing factors
among which are erosion, abfraction, bite pressure, recessed gum,
etc. After final diagnosis and elimination of the cause(s), ozone
application might alleviate almost instantly the pain felt by the
patients from hypersensitive teeth in some cases.
Apply ozone for 40-60 sec on sensitive areas then a remineralizing
agent. Repeat if necessary.
1.5. Cracked Tooth Syndrome
According to the clinical situation and symptoms, a conservative
attempt can be used with ozone application. After revealing the
crack and evaluation of the case apply ozone gas for 60-120 sec
and restore with a long term temporary filling, i.e.: GIC. Put the
tooth slightly off occlusion.
Caries Management with a silicone cap and Dental Handpiece
Cervical Root Abfraction
2. Root Canal Therapy - Peri-Apical Lesions
Ozone is highly indicated in root canal therapy due to its strong
disinfection property and absence of cytotoxicity as well as other
negative side effects at the recommended used concentration and
form (gas or dissolved in water). Ozonized oils can also be used
as a temporary canal(s) dressing in infected necrotic cases. In
peri-apical lesions, ozone gas infiltration contributes in the non-surgical
management of these lesions.
2.1. Vital Root Canal Therapy
After final shaping and cleaning of the canal(s), adapt a 25-27
G needle on the delivering central tip of the handpiece, making
sure not to obliterate the free gas circulation inside the round
tapered housing. Cut a piece of PVC or silicone tube according to
the clinical situation in order to seal the access cavity with the
needle inside the canal. The needle should not block the intra-canal
gas circulation towards the canal orifice.
Fill the canal with saline or distilled water and apply ozone for
2-3 minutes per canal at 5µg/ml, 0.5 - 1 L/min flow rate.
During the canal shaping and irrigation, ozonated water can be
used as a disinfectant and irrigant. Use Acquazone ozonated water
column to easily prepare ozonated water for the entire root canal
procedure. Irrigate at demand with large volumes.
2.2. Necrotic Root Canal Therapy
In some situations, there is a need to disinfect the root canal
system with a temporary dressing until the symptoms are relieved
and the canal(s) ready to be filled. Follow the same protocol as
above and use ozonized olive oils as a temporary disinfection dressing.
Fill a 1cc disposable syringe with the oil and adapt a 25G needle.
Insert the needle as deep as possible inside the canal and inject
slowly while retrieving the needle slowly out of the canal. You
can also use a Lentulo to fill the canal with the ozonized oil.
2.3. Peri-Apical Lesions
Local anesthesia is recommended in this procedure.
In maxillary peri-apical lesions, ozone infiltration is performed
the same way you give a local anesthetic injection on the buccal
side. Depending on the size and severity of the lesion, the concentration
varies between 5 and 10 µg/ml at a volume of 1-3 cc. Inject the
gas very slowly as close as possible to the site of the lesion.
Repeat the infiltration once a week until resolution of the symptoms.
In mandibular peri-apical lesions, the use of an intra-osseous
needle to deliver the ozone gas right into the bone is indicated.
Use your preferred technique to perforate the cortical bone, making
sure to stay away of the alveolar inferior canal and mental nerve.
The access point is usually 2-3 mm under the free gingival level
where the cortical bone is easily perforated. Inject very slowly
as described above.
An adapted silicone cap and 25G needle for ozone gas canal
In case a silicone cap is unpractical put the suction tip
close to the canal orifice
3. Periodontal Therapy
Gingival and Periodontal diseases represent a major concern both
in dentistry and medicine. The majority of the contributing factors
and causes in the etiology of these diseases are reduced or treated
with ozone in all its application forms (gas, water, oil).
The beneficial biological effects of ozone, its anti-microbial
activity, oxidation of bio-molecules precursors and microbial toxins
implicated in periodontal diseases and its healing and tissue regeneration
properties, make the use of ozone well indicated in all stages of
gingival and periodontal diseases.
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.
3.1. Gas application via a customized thermoformed dental appliance
Prepare a suckdown thermoformed hard or medium-soft dental appliance
extending 2-3 mm beyond the affected gingival area, leaving a free
space for gas circulation. Attach 2 ports for the gas inlet and
outlet respectively at the distal and mesial of the treatment area.
Reline the edges of the appliance with light or medium body silicone.
Light-cured dam can also be applied as an extra safety precaution
to completely seal the borders. Attach the ports to the generator
and the suction pump. This procedure will treat both hard and soft
tissues of the affected area. You can always use the PVC or silicone
cap and treat individually all the indicated areas in difficult
situations where such an appliance is hard to use or uncomfortable
to the patient.
3.2. Irrigation with Ozonated Water
Prepare the ozonated water using Acquazone and generously irrigate
the affected area during and after scaling, root surface planning,
and non-surgical pocket curettage.
3.3. In-office and Home Use of Ozonized Olive Oil
After in-office treatment with ozone gas or ozonated water, fill
the pockets with ozonized olive oil using a blunt 25G needle or
any other appropriate tip. Give the patient for home use some of
the oils and instruct him/her on proper application. Repeat the
in-office ozonized oil application once a week.
4. Post-Extractions - Surgery
In dental/oral surgery, the use of ozone is indicated during the
surgical intervention as well as post-surgery as a topical disinfectant
and healing agent. In these procedures, the use of ozone gas is
not convenient due to the inability to properly seal the treated
area. Ozonated water and oils are therefore the forms of application.
After final debridement of the socket, irrigate with copious amounts
of ozonated water and then use gauze imbibed with ozonated water
to compress the extraction site. Before retiring the patient, fill
the socket with ozonized oil and cover it with gauze.
4.2. Post-Extraction Alveolitis
After thorough assessment, remove the necrotic plug and debris
from the extraction site, irrigate with large amounts of ozonated
water then fill the alveoli with ozonized oil. Antibiotic coverage
may be indicated. Instruct the patient to apply ozonized oil 3-4
times a day until total healing.
4.3. Surgical Procedures
Ozonated water can be used as an irrigant during the surgical procedure
and/or as a final surgical site lavage. Cover the sutures with a
thin layer of ozonized oil and instruct the patient to apply the
oil 3-4 times a day.
Peri-implantitis is very bothering to both the dentist and the patient.
After thorough assessment and if a decision is taken to salvage
the case, different modes of therapy are used in order to save the
implant from total loss. 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. Cut an appropriate length
of PVC or silicone cap and cover fully the abutment. In case the
crown is still present, it is advisable to remove it for proper
sealing of the abutment and the gingival borders around the implant.
Ozone gas infiltrations are also helpful in this situation. Ozonated
water can be used as an irrigant during debridement and curettage.
Advise the patient to apply ozonized oil on the treated area 3-4
5. Crowns & Bridges - Veneers - Removable Dentures
5.1. Crowns & Bridges - Veneers
A common occurrence we sometimes see during the temporization phase
in crowns, inlays/onlays and veneers procedures is hypersensitivity.
Many factors might contribute in this event, one of which is the
presence of bacteria left inside the opened dentinal tubules during
preparation. It is paramount to remove the smear layer and disinfect
the prepared teeth before temporization and before seating of the
The black stain that we see under the temporaries, mainly in the
shrink-wrap veneers temporization technique is due to the presence
of bacteria. The use of ozone gas to both disintegrate the smear
layer and disinfect the prepared teeth is highly recommended (Fig.
1 - 2). The use of Air Abrasion before ozone is an advantage to
completely remove microscopic debris and smear layer from the surface
of the abutments and to leave a clean dentin for ozone disinfection.
Prior to final prosthesis cementation, clean the prepared teeth
with Air Abrasion, disinfect with ozone gas and seat the prosthesis
according to your preferred method. Please note that recent research
and published articles show that ozone use do not affect the adhesive
Use ozone gas to disinfect the prosthesis. Ozonated water can also
5.2. Removable Dentures
A common occurrence found in full dentures wearers is denture stomatitis,
mainly due to Candida albicans (Fig. 3). Whether white patches or
erythematous forms, ozone use, mainly ozonated water and oil, is
highly efficient in this situation and also helps in the cleaning
and disinfection of the dentures acrylic material.
Prepare ozonated water using Acquazone and soak the denture(s)
after thorough cleaning and removal of hard deposits. Imbibe a 5x5
cm gauze with the prepared ozonated water and apply on the affected
areas. Refresh the gauze with ozonated water frequently or replace
with a new one.
Remove excess water from the dentures and apply few drops of ozonized
oil on the inside of the denture(s) and seat firmly.
Supply the patient with enough ozonized oil in a disposable syringe
and home use instructions. For dentures sores and ulcers, see Soft
Tissue Lesions section.
Fig. 1: Disinfection of prepared teeth and sulcus after cord
packing and impression taking.
Fig. 2: Disinfection with ozone gas after cleaning with Air
Abrasion. Note the different length of the silicone caps.
6. Soft Tissue Lesions
All kinds of infectious, inflammatory, traumatic, burns, wounds,
soft tissue lesions respond very well to topical ozone treatment.
As mentioned earlier, the beneficial biological effects of ozone
and its disinfectant / healing properties make the use of ozone
highly recommended in these situations.
Some practitioners even recommend intra or peri-infiltration of
ozone gas in soft tissue carcinoma lesions.
The most soft tissue lesions encountered are herpes, aphthae, removable
denture ulcers, traumatic wounds and cuts, cheilitis, cysts, Candida,
6.1. Ozone Gas Application
Seal the affected area with a PVC or silicone cap and apply ozone
gas for 1-2 minutes. Repeat if necessary.
In case of cyst fistula, insert a plastic needle slowly in the
passage of the fistula and inject 1-2 cc of ozone gas. Anesthesia
might be indicated in this procedure.
6.2. Ozonated Water Application
In situations of large traumatic wounds, burns and cuts, the combined
use of ozone gas and ozonated water are indicated. For ozone gas,
follow the above-mentioned protocol. Prepare the ozonated water
using Acquazone ozonated water column and irrigate for 10 minutes
the affected area. In case of supra-infected lesions, use a strong
preparation of ozonated water. During the healing phase, a mild
solution is more appropriate.
6.3. Ozonized Olive Oil Application
In many instances, the soft tissue lesions we frequently see can
be managed with only the daily at home application of ozonized olive
oil. These oils have a greater advantage over commonly used antiseptics
and ointments due to their wide range of activities during all phases
of the healing process. Supply the patient with enough ozonized
oil in a disposable syringe and home use instructions.
7. Other Applications
7.1. Whitening with Ozone
Due to the strong oxidation power of ozone, researchers started
looking on the ability of ozone to whiten teeth. Ongoing in-vitro
works are studying the effects of long time exposure of ozone on
the dental hard tissues and the pulp, as well as the application
forms of ozone (gas - ozonated water), concentrations, etc.
The results so far are promising. The use of ozone in teeth whitening
might revolutionize our present techniques.
7.2. Dental Unit Water Lines Disinfection - Office Tap Water
Ozone use in city water disinfection and purification worldwide
is recognized as the best city water treatment today. It becomes
only logical to use ozone for the dental office tap water disinfection
The result is a clean, odorless, colorless tap water. Dental unit
water lines are known to carry hard to remove biofilms inside them.
Besides the bad odors coming out of these dirty water lines, the
microbial biofilm may represent a source of infection to patients,
especially who have a deficient immune system or the elderly. Many
studies showed almost complete disintegration and elimination of
dental unit water lines biofilms with ozonated water.
7.3. Instruments Cold Disinfection
Ozonated water can also be used as a cold disinfection solution
for medical and dental instruments, as well as for cabinets countertop
disinfection. Ozonated water can also be used as hands wash disinfectant
solution, fiber optic tips, contact lenses, surgical loupes lenses,
7.4. TMJ Peri-Articular Ozone Gas Injection - Trigger Points
The biostimulation and anti-inflammatory effects of ozone help
in the management of articulation inflammatory diseases and muscular
trigger points. Chronic oxidative stress and elevated levels of
pro-inflammatory cytokines are commonly found in these skeletal
chronic inflammations where ozone gas infiltration can contribute
in stimulating the anti-oxidant defense mechanism and in balancing
the immune response by modulating the production of cytokines.