Ozone Information For Clinicians

Dental Care With Ozone

Chapter 2

© Dr Julian Holmes

Introduction to Dental Care With Ozone.

  • Introduction; The Modern Dental Practice.
  • Modern Dental Care.
  • Dental Disease Today.
  • Diagnosis.
  • Conventional Treatment.
  • Minimal Invasive Dentistry.
  • What is Ozone?
  • Patient Acceptance of Ozident® Dental Ozone Treatment.
  • Added Value.
  • Costs of Traditional Restorative Care.
  • Ozone and Caries Management.
  • Treatment of Deciduous Teeth Lesions.
  • Treatment of Permanent Teeth Lesions.
  • Treatment of Primary Pits & Fissure Carious Lesions (PFCLs).
  • Treatment of the Larger Carious Lesion.
  • Tooth Whitening.
  • Root Canal Therapy.
  • Treatment of Fractured Cusp Syndrome.
  • Fractured Teeth.
  • Dentine Hypersensitivity.
  • Post-Operative Pain.
  • Soft Tissue Lesions.
  • Treatment of Dry Sockets.
  • Treatment of Apthous Ulceration.
  • Sterilisation.
  • Dental Unit Water Lines (DUWL).
  • Enamel Demineralization Around Orthodontic Brackets.
  • Patient Compliance.
  • In Conclusion.
  • References.

  • Introduction to Dental Care With Ozone

    Author; Dr Julian Holmes, 2006.

    Introduction; The Modern Dental Practice

    A totally new technology is now available to the general public, and the dental profession, where waiting rooms are full of bright, cheerful adults and children; there are no traditional dental smells and the noise of the drill is seldom heard.

    Over the last few years, a number of researchers, lead by Professor Edward Lynch from Queen’s Dental Hospital and Belfast University, have opened a radically and revolutionary way forward. The dental profession no longer has to destroy tooth tissue to eliminate bacteria.

    A simple 40 - 120 second (average treatment time) treatment with a dental device called the Ozident®, a dental ozone unit manufactured by O3, South Africa will destroy all the bacteria that caused the infection and the decay process. Ozone destroys all the organic effluents that are produced by these bacteria, and by effectively sterilising the lesion, allows minerals from the patients own saliva to re-enter the areas of mineral loss to harden it. Once hardened, it is more resistant to future bacterial attack and mineral loss.

    There is in everyone’s mouths a natural balance. A tooth surface losses minerals into saliva at certain times during the day, usually just after an individual starts to eat. These acidic conditions favour mineral loss. As the saliva flow increases as food is eaten, the mouth becomes more neutral, and these conditions favour mineral uptake by the saliva-bathed tooth surface. This balance can be upset by a number of different factors, but the most important are the bacteria that normally live with everyone.

    When bacteria attach themselves to a tooth surface, they set up a complex community of some 450 different bacterial types over a period of time. If people try to skimp on routine oral hygiene and care, like using a tooth brush, or forgetting to use dental floss on a regular basis, these communities of bacteria evolve into one which produces large volumes of acids. These acids attack the tooth surface, dissolving out the minerals, leaving a hole, or cavity. As this cavity now gives the bacterial colonies a degree of protection, tooth brushing cannot remove the bacteria, so the process of decay is allowed to accelerate.

    Yet decay is only an infection process that leads to the softening of the tooth, and the formation of a cavity, so could this infection be treated with, say, antibiotics? The bacteria that cause tooth decay are often found deep within the physical structure of the tooth. Once the infection is into dentine, bacterial are ‘protected’ by the tubular structure of dentine. So the removal of the infected lesion has to date only been by removing the infected part of the tooth, or in other words, by amputation. Antibiotics and other pharmaceutical agents cannot penetrate deep enough through into tooth structure to eliminate these bacteria. This teaching and technique is based on sound engineering principles that originate from the Victorian era. Despite previous advances, there is no simple test that can be applied to a cavity to tell the dentist if they have removed all the infection. And if areas of infection are left behind, there is a good chance that the filling placed will fail at some time in the future.

    Studies over the years have shown that fillings do not last very long, any where from 6 months to several years. But once a tooth has had part of it removed or amputated, there is no going back. For each time the filling needs to be removed and replaced, there is a little less of the original tooth left and a larger filling has to be placed. This destructive approach to dental care and treatment belongs in the 20th Century.

    The dental professions goal is to help and educate the general population on how to avoid entering into this cycle of tissue loss and periodic filling replacement. Oral care education and modern toothpastes have helped reduce the number of cavities, but in poorer communities, those with disabilities and in long term institutions, as well as the aging population, decay is still prevalent. And diet advice is often lacking, so although the general population may think they are doing well at home, the process of decay continues unabated in most communities.

    Teeth have a distinct cycle of mineral loss and uptake in the oral cavity or the mouth. In the same way that lungs allow the body to take in oxygen, and release carbon dioxide into the air, so teeth have a similar cycle. Minerals, such as calcium and phosphate, are important building blocks that make up the hard structure of teeth. By adding in certain other elements, such as fluoride and strontium, research has shown teeth can be made more resistant to acid attack and mineral loss.

    The Ozident® dental ozone unit is a completely new way to look at infections in teeth. In the early stages of mineral loss, no use of the drill is required. The treatment is simple, inexpensive (certainly less than the cost of a filling), and requires no anaesthetics. This does of course depend on the use of modern diagnostic equipment, such as the DIAGNOdent (KaVo GmbH). This laser is more accurate than x-rays, and far superior to the traditional mirror and probe that dentists often use. The mirror and probe are tools that can find holes, not diagnose areas of first stage decay. And research has shown that x-rays are a very poor tool to visualise decay in a tooth surface, until it is 2-3 mm inside the inner layer of the tooth.

    If the area of decay is deeper, and more extensive, the Ozident® dental ozone unit still has a role to play. Some tissue removal may be required, but this can also be carried out with air abrasion. No anaesthetics are required, and the Ozident® dental ozone unit is used to sterilise the area of decay, without the need to remove a large volume of tooth structure. In this way, damage to the tooth is limited, and the inherent strength is preserved as much as possible. Even in really deep areas of decay, the Ozident® dental ozone unit can be used to preserve tooth tissue; in this instance, the time exposure of the decay lesion in the tooth needs to be increased.

    When the Ozident® dental ozone unit is combined with traditional care, then there are a number of advantages that patients and the dental profession can make use of. The Ozident® dental ozone unit can be used to sterilise a cavity before a filling is placed, so there will be virtually no sensitivity after the local anaesthetic wears away. It can be used to eliminate sensitivity after new crowns or veneers are placed. And where wear facets have produced sensitive areas at the necks of teeth, in most cases a simple 40 second application with the Ozident® dental ozone unit can eliminate this sensitivity for at least 3-4 years. There are many more applications for the Ozident® dental ozone unit in a general dental practice, and the studies for some of these can be found on WWW.THE-O-ZONE.CC. This www site not only allows you to find a dental practice which has and uses the Ozident® dental ozone unit, but also allows you to view the research papers that have been published from centres around the world.

    So perhaps a Monday morning at a dental practice that has invested in modern technology and has been properly trained, is no longer the stressful or anxious visit that it used to be. The waiting people in these practices are full of smiles, people chatting to the dental team members as they wait with happy anticipation at being called through for their turn in the treatment room. Mums and dads with children have no fear or anxiety, as they are reassured that modern technology has opened a door for them, that most of the older population and dental profession had never believed possible.

    Some new research is looking into alternative ways to apply ozone. One of these, through a mouth guard, may open the idea of a spa-treatment for teeth. Every 3-4 months or so, a short – 5 minutes – treatment session floods a special tooth shield with ozone. Any areas of decay are treated, and the full health of teeth is maintained.

    And new products are being launched into the European and US markets. One of these, Tooth Moose® by GC, contains products that release minerals in the most adverse conditions. Research is now looking at combining these sorts of products into materials that can be simply painted onto teeth to prevent decay. For patients who want a product they can buy over the counter, these products will soon be available in chewing gum format.

    For both the patient and the dental practice, new technologies have a winning solution for both; the treatment is fast, it is predictable, it is painless, and also reduces the long-term cost of the treated tooth. For the dental practice, the treatment times are reduced, it is profitable, and the treatment less stressful. For the patient, modern technology has allowed them to have a 21st century treatment, rather than one that is old fashioned, and out-dated.

    Introduction Index
    Modern Dental Care v Conventional Dental Treatment

    In to-days so called Modern Dental practice, it is a salutary thought that at approximately 9 AM each working day, in every typical dental practice across the world, patients are lining-up, the dental drills are whistling-up to speed and another day of ‘drill’n fill’ begins. As tooth decay is the second most common disease in the world, this seems to form the bulk of traditional dental care!

    Those General Dental Practitioner’s (GDP’s) who are embedded in Socialised Dental Health Care Schemes around the world are super efficient at drilling and filling. Taken across the world that is a massive number of patients entering ‘the repeat restoration cycle’. The most common form of treatment results in more extensive and costly treatment options in the future.

    There is another way to treat this situation, which involves no local anaesthesia, no water spray, or high volume suction, no noisy hand pieces and it is a very quick procedure to perform. The patient and the GDP would undoubtedly prefer this option. The technology that has made this possible uses the well documented properties of ozone gas. There are a number of portable ozone generators designed especially for dental use, and the treatment of intra-oral lesions of the hard and soft tissues. The Ozident® (O3, South Africa & Europedental ozone unit and the HealOzone® unit (KaVo GmbH Germany) are the only CE marked units available in the world market at this point in time. The Ozident® dental ozone unit has been in use in dental hospitals and general dental practices in the world for several years now.

    Introduction Index
    Dental Disease Today.

    Over the past thirty years the various United Kingdom surveys, for example, of oral health of adults and children have revealed a reduction in the incidence and prevalence of dental caries in certain age groups (Nunn J et al. 2000). Whilst this is a welcome finding, there remain large areas of the country where dental diseases are rampant and continue to pose a major public health problem.

    Parts of Wales and Ireland are reputed to have some of the worst dental health in Europe. It also seems to follow that in areas of high dental disease activity, dental fear and phobia are also commonplace. Ignorance of dental health issues and diets rich in refined carbohydrates, sugar loaded fizzy drinks and children consuming considerable amounts of sticky confectionary are the norm. Even schools ignore the health hazards of dental and medical disease, in favour of the additional revenue generated by fizzy-drink dispensers.

    Every day some of these GDP’s come into contact with patients of all ages, with staggering levels of dental disease. Acute dento-alveolar abscesses, acute necrotising ulcerative gingivitis, pulpitis, broken down teeth and so on, are daily events for these practitioners in these areas, as well as fear and phobia towards dental treatment.

    Introduction Index

    The old model of caries described the loss of dental tissues as a process proceeding from the periphery to the centre, creating a crater in the hard tissues. If left untreated, these lesions proceed towards the blood supply system, and would lead to an infection in the bone. These lesions are easily detected visually, mechanically using a probe, and radio graphically.

    However, the new model of caries describes how caries starts at the enamel dentin junction (EDJ), as the consequence of bacterial penetration and colonisation via fissures, pores and fractures in the enamel surface of the tooth, which is looks untouched. Demineralisation and proteolysis proceed into dentine following the dentinal tubular structure. The lesion spreads into an “anchor” or “fishing hook” shape when seen on histological sections. If left untreated, caries destruction infects the tooth pulp tissue. These lesions are difficult to diagnose visually, as no or little visual evidence appears on the outer enamel surface except for pits and fissure stains; mechanically, as no macroscopic alteration in the enamel structure is present; radiographically (Christensen, G.1996), as a limited amount of minerals are lost, and radiographic evidence occurs only in later stages.

    Whatever the pathogenesis of this new model is, new diagnostic techniques have to be adopted to detect and evaluate these lesions. Magnification with aid of dyes, laser induced fluorescence, and chemical reactions to bacterial metabolites are the main tools that can be used clinically. These diagnostic methods differ from the classical procedures because they do not look for the loss of tissue, but are aimed to trace the metabolic processes involved. Specificity and sensitivity of such methods allow a very early detection in metabolic changes (Lussi A 1993; Lussi A, et al 2001; Anusavice KJ 2000; Attrill DC, et al 2001; Paterson RC, et al 1991; Pinelli C, et al 2002).

    Any further process which involves irreversible tissue destruction can only be described in terms of impairment, disability and handicap. And any later diagnosis can be assumed as the naturalistic observation of the absence of self-regenerative resources. At this stage the only possible intervention is amputation of infected and necrotic tissues, and prosthetic replacement when possible and where available to reintegrate loss of function and ensure protection.
    One of the consequences of early diagnosis is the rising of a new dental science, called minimally invasive dentistry. It still performs amputations, but due to early detection they are few millimetres wide. Procedures are quick, no or little pain is generated (and no local anaesthesia required in most cases), fillings are very small and consequently longer lasting (Christensen R 1999).

    Starting from the definition of dental caries as a reversible metabolic process it is clear that the ideal treatment has two objectives: arresting any bacterial metabolism and boosting the natural host defences in a short period of time and with long lasting effects. Fluoride only partially fulfils these requirements, and as equally does any other disinfectant or antibiotic. Fluoride effects take a long period of time to establish protection, and they affecting the old caries model but not the new model of caries.

    Introduction Index
    Conventional Treatment.

    The generally perceived wisdom has always been that dental caries is an infective process and the only real ‘treatment’ option was the cutting away, or ‘amputation’, of all diseased tissue and its replacement with some form of restorative material (Attrill DC and Ashley PF 2001). This is the teaching that most dental students still receive at dental schools around the world today, and is practiced like a religion by the majority of dentists world-wide.

    This invasive process involves needles and drills. It is a highly stressful treatment for everyone concerned. This amputation approach has not really changed for over 100 years. What has improved in recent years are the GDPs understanding of the carious disease process. The prevention movement that established in the 1970’s has attempted to educate people that the real treatment of the disease is centred on changing the diet and in improving plaque control. It is known only too well that people are highly resistant to accepting messages of good health education. The typical GDP does not impact enough in presenting convincing dental health education messages to patients. Sitting in a dental surgery, surrounded by the tools of drilling and filling, is it little wonder that patients fail to ‘hear’ what the hard working dentist tells them!.

    Introduction Index
    Minimal Invasive Dentistry.

    The dental profession has seen a move away from conventional means of restoration of carious tissue to the approach of minimally invasive dentistry, with the associated benefits to both the GDP and the patient. Many techniques however still involve the physical removal of tissue before the final restoration is placed. The ideal treatment solution is the simple removal of the disease process with no associated loss of sound tissue and no associated physical discomfort for the patient. This is now available with recent advances in the field of ozone treatment and the Ozident® dental ozone unit delivery unit (Baysan A and Lynch E 2001; Baysan A et al 2001). For the first time, the GDP can break the ongoing circle of restorative dentistry, as it would appear that it is no longer necessary to place the initial restoration which will require eventual replacement and subsequent re-treatment.

    Introduction Index
    What is Ozone?

    Ozone is produced constantly in the upper atmosphere as long as the sun is shining, and since ozone is heavier than air, it begins to fall earthward. As it falls, it combines with any pollutant it contacts, cleaning the air. This is nature's wonderful self-cleaning system. If ozone contacts water vapour as it falls, it forms hydrogen peroxide, a component of rainwater, and one reason why rainwater causes plants to grow better than irrigation.

    Ozone is also created by lightning, giving the wonderful fresh smell after a thunder storm. Ozone is also created by waterfalls and crashing surf, which accounts for the energetic feeling and calm experienced near these sites. Another way ozone is produced is by photons from the sun breaking apart nitrous oxide, a pollutant formed by the combustion of hydrocarbons in the internal combustion engine. This ozone can accumulate in smog due to temperature inversions and is a lung and eye irritant. It is this duality of ozone, and the negative effects of ozone that tends to be focussed on by the media and the healing property of ozone is ignored (Bocci V 1996).

    Introduction Index
    Patient Acceptance of Ozident® Dental Ozone Treatment.

    In the past number of years continual advances in both materials science and treatment methods have brought outstanding benefits for our patients in terms of simplicity of treatment. Successful dentine bonding systems have obviated the need for the design of a retentive cavity in most cases and hence dramatically reduced the use of the air turbine to design what may be termed as classical cavities. These bonding systems have allowed GDP’s to concentrate almost exclusively on the removal of carious tissue whilst retaining as much sound hard tissue as is possible, a first step towards the minimally invasive approach now advocated. However this carious tissue has still to be removed whether by use of the handpiece, air abrasion (Domingo H and Holmes J. 2004), or with hand instruments (ART) (Holmes J, 2004) when used in conjunction with caries removing liquids and gels (e.g. Carisolv). Ozident® dental ozone unit treatment of dental caries removes the requirement for physical removal of diseased tissue as we are promoting remineralisation and not amputation of carious dentine.

    The benefits to patients are therefore obvious. Most patients fear and apprehension arises from their perception that the use of the handpiece may be an unpleasant and possibly traumatic experience (Domingo H, Holmes J, et al. 2003). This, combined with the requirement for local anaesthesia, the fear of which is virtually universal, has lead to the widespread view that the visit to the dental surgery is an unpleasant one. In the employment of Ozident® dental ozone unit treatment GDP’s now have the capability to alleviate those concerns and change the public perception of dental treatment as a whole. Of course there are still situations where treatment will follow more classical lines. However these instances are becoming increasingly rare. Patient acceptance is therefore universal. GDP’s can offer treatment of a wide variety of carious lesions where there is no need for local anaesthesia , no need for drilling, and treat many lesions in a very short space of time, totally painlessly and totally atraumatically. Patients are delighted after treatment and are particularly motivated towards oral hygiene and dietary control when they realize that in improving and concentrating on these areas they can effectively avoid the local anaesthesia / drill approach.

    Integration of the Ozident® dental ozone unit treatment unit into the surgery environment will totally change the GDP’s approach to the treatment of his or her patients. GDP’s have to completely reassess their diagnostic criteria when applied to dental caries and potential treatment of the carious lesion. The dental probe is no longer of any significant use for caries diagnosis and hence examination is based on the use of a digital intra oral camera combined with selective use of the DIAGNOdent. This has several advantages from the classical approach to the examination appointment. Firstly it is simple and without trauma for patients. It also involves the patient in their examination (as an additional benefit from this, dental surgeons see a dramatically increased awareness of oral hygiene), aids the explanation of any problems which may arise, and allows the patient to co-operate in the diagnosis and treatment planning of their dental treatment. From the clinicians point of view the advantages of intra oral imaging cannot be stressed highly enough. Images of the dentition can be magnified many times to assist in diagnosis, and the enlarged direct vision of the region being examined on the monitor is an essential adjunct to our direct vision intra orally. This imaging combined with the use of the DIAGNOdent in areas where caries may be suspected results in an extremely thorough and meticulous examination and gives GDP’s a quantitative assessment of any disease process present (Lussi A, Megert B, et al, 2001. Anusavice KJ, 2000). Explanation to the patient of the requirement for treatment is very simple when images can be shown on screen and the DIAGNOdent reading explained which only serves to enhance the patients’ confidence and educate the patient in oral hygiene and dietary requirements.

    Following this examination records are made of any positive DIAGNOdent readings and the particular teeth these are related to. Treatment options are explained to the patient and Ozident® dental ozone unit treatment recommended where indicated. Images are saved via the intra oral camera of the teeth to be treated and ozone is applied. There is rarely any requirement to make further appointments for the patient apart from the ozone review visits.

    Hence the provision of ozone treatment is extremely time efficient, something which is valuable to clinician and patient alike. The patient’s visit to the surgery is completely painless and traumatic, and they leave well informed and educated on both the reasons for treatment and what is required for a successful outcome. In addition to these factors GDP’s can look at the effects of the employment of Ozident® dental ozone unit treatment on the dental profession as dentists. GDP’s naturally subject themselves to a degree of stress as GDP’s all desire to provide patients with pain free treatment as efficiently as possible. Using ozone treatment as the primary approach to the treatment of many incidences of dental caries completely removes any potential stressors. There is no local anaesthesia to give, no use of the drill and no packing of restorative material. The time spent on providing the actual treatment is also minimal in the extreme. GDP’s can therefore provide the most modern and most natural treatment available to their patients without fear that they may cause any physical or mental trauma – all the potential sources of stress for the surgeon in restorative treatment of the carious lesion are removed and yet GDP’s are providing the very best in dental care.

    Introduction Index
    Added Value.

    Over the past few years the dental profession has enjoyed many technological advances in equipment and materials. Whilst the dental practitioner and his/her team may feel proud with their new ‘toys’, all too often the patients are not that impressed. In all these practices, the introduction of the ozone concept, coupled with the DIAGNOdent has had a major impact with the patients and it has been quite remarkable. The ozone concept has had a significant impact on the dental team. The dental nurses and front of house staff have been very enthusiastic as they can see the effect the new treatment has on the patients. This adds to the positive atmosphere of the practice towards prevention and disease control. It does much to boost the morale of the team to witness nervous patients in much dental distress evolving into relaxed and appreciative individuals.

    Introduction Index
    Costs of Traditional Restorative Care.

    Filling materials fail at alarming rates. Costs can be measured in terms of pain, discomfort, and in financial terms such as lost productivity. In England and Wales, restorations carried out in the NHS dentistry cost a total of £1.25 billion in 2001. This does not include private treatment, which is currently estimated to be 50% of dentists’ income. The total costs of all dental treatment in England and Wales probably exceeded £3.26 billion in 2001 (General Dental Council UK, Annual Statistics, 2001).

    Most of these fees are ascribable to fillings, root fillings, dentures, crowns and bridges. Published reports suggest 50% of restorative items are replacements for previous restorations, and about half of these restorations are being replaced due to secondary caries. If only 50% of all fillings could be avoided with the use of ozone, enormous sums of money could be saved. The cycle of filling preparation, reduction in tooth strength (Mondelli J et al 1980) and subsequent replacement eventually may eventually lead to more complex restorative care requirements with increasing cost implications, such as the progression from a simple cavity, to a multi-surface one, to the fracture of the crown requiring root canal treatment, followed by restoration with a crown and core.

    In the United States, dental treatment is estimated to cost $52 billion per year, and half of this cost may be associated with restorative treatment and the cost of missed workdays and lost production due to oral disease. Despite advances in clinical and laboratory research, approximately 50% of the U.S. population over the age of 65 shows evidence of root caries. In all countries, from the advanced to poor and developing countries, there is a huge potential for a cost-effective way to prevent and reverse caries. In the ageing population, and those with reduced manual dexterity, a preventative and early intervention strategy needs to be found. In this respect, the use of ozone should be also considered for medically compromised patients, domiciliary care patients and homebound elderly people. The equipment required is limited and essentially portable compared to that required for conventional drill & fill. Therefore elderly patients who have limited access to the dental services can benefit from this treatment. In many poor, developing and highly populated countries, equipment, dental supplies, and dental services are inadequate due to high costs and lack of dentally trained personnel.

    Even if ozone therapies could save just 50% of all the fillings placed, the cost savings are huge. The research shows us that over 90% of fillings could be saved. In the modern world, where centralised welfare is being reduced to contain finances, the implications are enormous.

    Introduction Index
    Ozone and Caries Management.

    According to “The Niche Environment Theory”, a “bacterial niche” is established within a carious lesion. Bacteria are far from the ‘simple bugs’ as they are often referred to. They have survived for millions of years, where as humans have a minute time frame of existence in comparison. The dental profession should not be surprised to learn that bacteria set up complex interactions with other bugs, ‘talk’ to neighbouring colonies when times are good, and call for help from others when their host attempts to change their environment. Protein coatings, plaque and debris are known to protect these colonies by reducing the effect of pharmaceutical agents designed to eliminate these bacterial colonies.

    The concept of dental caries has changed in the last decade. Investigations into the deepest molecular processes have disclosed the exquisite mechanism of physiological demineralisation and remineralisation that takes place daily in oral hard tissues. The dental profession shares today a completely new vision of an old pathology. Decay starts as a metabolic imbalance, shifted towards acidity and demineralisation. Dental plaque is the medium in which this process develops. In such an environment acidophilic and acidogenic bacteria develop this ‘ecological niche’ and new methods of diagnosis need to be found (Pinelli C et al 2002; Tam LE and McComb D 2001; Ricketts D et al 1997; 47:259-265; Schupbach P et al, 1995; Ekstrand KR et al, 1998; Lynch E, 1996; Lynch E and Beighton D, 1997; Beighton D et al 1993). At an early stage in the development of a carious lesion, when enamel and dentine are demineralised and dentine has not been denatured by proteolysis, these dynamics can be reversed, and remineralisation occurs. When the bacterial ecological niche is eliminated remineralisation occurs.

    Progression of the carious lesion occurs when conditions are suitable for acidogenic bacteria to release acid as a metabolic by-product. The acid produced may lead to a breakdown of mineralized tooth structure. At times, an equilibrium situation may occur when the rate of re-mineralisation equals the rate of de-mineralisation. Ozone has the effect, through its powerful oxidizing properties, of not only removing the protein protection and being bactericidal, but also oxidising the biomolecules that allow the niche to survive and expand. This has a severely disruptive effect on the bacterial population in the carious lesion and obliterates the cariogenic bacteria and their ecological niche, thereby swinging the equilibrium in favour of re-mineralisation. No more acid can be produced within the lesion when the acid-producing bacteria are eliminated. For example, the acid Pyruvate, one of the strongest naturally occurring acids manufactured by bacteria, and implicated in the progression of caries, is oxidised by ozone to acetate acid and carbon di-oxide (Lynch E et al, 2001). Acetate acid is less acidic than pyruvate, and this de-carboxylation reaction leads to mineral uptake due to the more alkaline conditions in a carious lesion. The lesion will become populated with normal mouth commensals which do not produce acid, after ozone therapy.

    Ozone has been shown to be safe (Baysan A and Lynch E, 2001) and clinically to be effective in the management of root caries lesions (Baysan A et al, 2000; Baysan A and Lynch E, 2001; Baysan A et al 2001; Baysan A 2002; Holmes J, 2003). These lesions often present in the elderly who may have associated medical problems, which complicate their dental management. Using ozone therapy, such lesions are easily treated. The portability of the Ozident® Dental Ozone Unit facilitates its use in the domiciliary setting and treatment is also simplified because the clinician does not need to carry a range of restorative materials on such visits. Dentists using the Ozident® Dental Ozone Unit for caries management, encourage their patients to regularly use a fluoride-containing mouthwash, that will enhance the efficacy of ozone by promoting re-mineralisation and to reduce the frequency of consumption of fermentable carbohydrates.

    Using ozone treatment as their primary approach to the treatment of many incidences of dental caries completely removes any potential stressors. There is no local anaesthesia to give, no use of the drill and no packing of restorative material. The time spent on providing the actual treatment is also minimal in the extreme. GDP’s can therefore provide the most modern and most natural treatment available to patients without fear that they cause any physical or mental trauma – all the potential sources of stress for the surgeon in restorative treatment of the carious lesion are removed and yet providing the very best in dental care.

    All these factors also apply to the final restoration of the ozone treated tooth. Where the remineralised lesion is not visible it can be left without further intervention. The only reasons to place a final restoration are:

  • (1) To prevent food packing and food trapping which may lead to caries in adjacent teeth, or localized periodontal disease (if interproximal) or may simply cause concern to the patient if on the occlusal surface).
  • (2) Cosmetic reasons (remineralised tooth tissue may darken considerably). This can obviously lead to cosmetic concerns, especially in the anterior region and hence placement of a restorative material may be required purely for appearance.

    Following on from the core philosophy of ozone treatment and of minimally invasive dentistry, restorative care is generally with a bonded resin. Restoring, using 15 seconds etch (enamel) and a maximum of 5 seconds etch (dentine) followed with a dentine bonding agent and finally composite resin, is again a totally atraumatic and simple procedure for the patient and surgeon alike. Any regions of remineralisation that have darkened during the course of treatment can be simply and effectively masked. The authors have found in many cases that previously active root caries lesions are easily masked using one of the flowable composite materials. These are extremely simple and rewarding materials to use and, if placed correctly require no polishing, simplifying the treatment process even more.

    Introduction Index
    Treatment of Deciduous Teeth Lesions.

    Dental treatment of young people can have long lasting effects. If dental care is painful and unpleasant, as these patients grow into adults, they will tend to only attend when if pain. As all dentists know, at this stage, restorative care tends to be more difficult and more extensive. The use of ozone (Abu-Salem OT et al, 2003) and mineral releasing glass ionomers can play a significant role in the dental management of these patients. As confidence in the treatment by the patient and parents or guardians is gained, so the compliance with important oral hygiene message will be increased.

    Where caries is found, it is simple to treat and the application of, for example, FujiVII (GC Japan) will supply long-term fluorine and mineral release, as well as preventing ingress of food debris and re-establishment of the acid-niche environment. Treatment is simple, fast (the average ozone time for practitioners using the Ozident® dental ozone unit is 30 seconds) and involves little preparatory work. The loose debris is first cleaned away, until a leathery base is reached. This can be done with hand instruments. Ozone is applied, the lesion wetted with a remineralising wash and then the glass ionomer can be applied. This modified ART technique has been reported by Holmes (Holmes J, 2004).

    Allied to this ozone has been used in the treatment on deciduous molar teeth with hopeless prognoses as a result of caries. In some parts of the UK and USA it is upsetting to find so many children at 3 and 4 years of age with gross decay. For these patients the usual outcome is a general anaesthetic and extraction. These lesions are treated with ozone and have found that the majority of children are co-operative and actually enjoy the experience. What has been found of great interest is that the toothache in young children has been reduced and even abolished after ozone treatment, with much relief for the parents. Ozone treatment seems to be an excellent palliative treatment for such youngsters.

    Introduction Index
    Treatment of Permanent Teeth Lesions.

    Ozone (Abu-Naba’A L et al, 2002; Holmes J & Lynch E, 2003) is used instead of fissure sealants at the eruption of permanent dentition and as prophylaxis in population at risk of rampant carious lesions. It is possible that the current fissure sealant technique needs to be re-examined. Current protocols for fissure sealants are the use of a bristle brush and pumice to clean the occlusal surfaces of teeth prior to sealing. However, it is know that food debris and bacteria will remain impacted at the depths of the fissures. And micro-leakage will allow the acid-niche to resume its activity, and over a period of time, the surface will collapse into a large carious cavity.

    Alternative preparation systems, such as the KaVo PROPHYflex or similar, or air abrasion could be used. Bristles used to manufacture the bristle brushes are often larger than the fissures being cleaned. However, air abrasion powders (average particle size 27microns) will flush out the debris, prepare the fissure for acid etching, and produce a more reliable sealing along the fissure edges.

    Introduction Index
    Treatment of Primary Pits & Fissure Carious Lesions (PFCLs).

    Early diagnosis of primary pits and fissure caries is of great importance in children and adults because of the rise of a new model of carious lesion which is difficult to diagnose with the traditional methods as oral radiographs and probe. Low sensitivity to visual, probing and bitewing examination leads to a significant number of teeth with dentinal caries being undetected. Lesions have a natural history of deepening into dentine leaving a macroscopically undamaged enamel surface. Minimal mineral loss prevents x-rays to show evidence of decay, and no macroscopic cavitation shows any probe stickiness. Systems using indirect light fluorescence have been demonstrated effective in the clinical diagnosis of decays in permanent and in deciduous dentition.

    In superficial root caries or early pit and fissure carious lesions, ozone alone may be sufficient to treat these lesions (Baysan A and Lynch E, 2001; Baysan A, 2002; Holmes J, 2003; Abu-Naba’A L et al, 2002; Holmes J & Lynch E, 2003). However, in situations where severe breakdown of tooth structure has occurred, ozone may be used initially to promote re-mineralisation and when this has occurred the cavity may be restored with a suitable restorative material.

    Practitioners who use ozone are placing a restorative material, such as FujiVII (GC Japan) or a composite to prevent food packing and food trapping which may lead to caries in adjacent teeth, or localized periodontal disease (if interproximal). If there are cosmetic concerns, such as remineralising stains that are dark and unsightly especially in the anterior region, placement of minimal restorations may be required purely for appearance.

    Following on from the core philosophy of ozone treatment and of minimally invasive dentistry, the group of practitioners who have integrated ozone into their clinical practice will place a restorative material. The material of choice for these practitioners is composite. Restoring using 15 seconds etch (enamel) and a maximum of 5 seconds etch (dentine) followed with a dentine bonding agent and finally composite resin is a totally atraumatic and simple procedure for the patient and surgeon alike. Any regions of remineralisation that have darkened during the course of treatment can be simply and effectively masked. GDP’s have found in many cases that previously active root caries lesions are easily masked using one of the flowable composite materials. These are extremely simple and rewarding materials to use and, if placed correctly require no polishing, simplifying the treatment process even more.

    Introduction Index
    Treatment of the Larger Carious Lesion.

    The larger lesions need special care. It must be stressed that larger lesions are not those to be treated with ozone alone; most will require a combined approach of traditional therapy, as well as ozone. As before, the aim is to allow natural remineralisation to take place on a predictable basis, without the wholesale destruction of tooth tissue. Where the lesion extends deep into the dentine, the action of ozone will take a longer time period of treatment, or may require several treatment periods over time. The basic protocol is the same; the soft debris is removed along with any unsupported enamel. If possible, denatured dentine is removed to the leathery layer. Ozone is applied from 40 seconds or longer. Some practitioners are using 2 to 3 minutes for large deep lesions that extend on x-ray almost to the pulp chamber. Then, the remineralising wash is applied.

    There are two options of choice at this stage of treatment that Ozident® dental ozone unit practitioners are using;

  • a. The lesion is left as self cleansing, and the patient is instructed with modified oral hygiene instructions. After routine brushing and rinsing, they are asked to place a small amount of the paste directly into the cavity. Then they spray two puffs of the remineralising solution directly into their mouths. This is repeated at least three times each day. In between this brushing protocol, these patients are also topping up their oral bio-available mineral concentrations by an additional two puffs, one in the morning, and another in the afternoon. This concerted loading of the patient’s saliva mineral content has lead to reports from these practitioners of complete hardening and reversal of the carious lesions within 6 weeks on average.
  • b. The lesion is restored using a mineral-releasing glass ionomer, such as FujiVII or a resin-bonded composite (Holmes J, 2004). This will allow remineralisation to occur, without the possibility of ingress of food debris and re-colonisation of the cavity. Where this has been carried out, for example in the Class II type lesions extending into the approximal contact areas, practitioners are reporting complete remineralisation at 3-4 months on average. X-rays taken show remineralisation, which will occur both from the material, as well as the pulpal tissues.

    It must be stressed that all these practitioners commented that it is vital to control both their own, and their patients expectations. If the pulpal tissue has already died, no amount of ozone will bring it back to life. Either root canal therapy or tooth removal is the only two viable options at this stage. However, the good news at this point, is that ozone can be used both in root treatment cases, and to manage potential pain post-removal by eliminating opportunistic infections in the socket and exposed soft tissue before healing has taken place. Ozone may also hasten the healing potential, and reduce the time taken to heal.

    Introduction Index
    Tooth Whitening.

    Teeth may be whitened using ozone, due its strong oxidising properties. The situation that is often encountered is the discoloured incisor that has been previously root-filled. This condition is readily treated with hydrogen peroxide and sodium perborate mixture or car amide peroxide gel and is practised as the ‘Walking Bleaching’ system. The application of ozone to the mixture will greatly enhance the whitening effect. The chosen whitening agent can be applied to the access cavity in the usual way and ozone applied from the Ozident® Dental Ozone Unit. The cavity is sealed with an acid-etched composite to retain the mix inside the cavity, and the tooth left for a period for the whitening to occur. Studies are currently under way using ozone as a means of bleaching vital teeth.

    Introduction Index
    Root Canal Therapy.

    The aim of conventional root canal therapy is to provide a clean, shaped, root canal that facilitates the placement of an adequate root filling. There may be multiple canals, frequently linked by a “web” of accessory canals. There is the so-called “apical delta” and the common lateral canals. Until recently, the dental profession relied on irrigants reaching these areas to disinfect and dissolve organic debris where it is impossible to instrument mechanically.

    In this situation, current procedures can again be modified, as with whitening, to greatly improve the quality of treatment for patients. When irrigating with the usual irrigant solution, for example sodium hypochlorite, ozone can be applied to the hypochlorite solution in the root canals. This technique allows the root canal system to be thoroughly disinfected and possibly be sterilised. In cases where previous root canal treatment has failed, Enterococcus faecalis seems particularly prominent and especially difficult to eradicate. Ozone will eliminate this bacterial type (Chang H et al, 2003). It is also postulated that ozone will penetrate through the apical foramen, and enter into the surrounding and supportive bone tissue. The effect of ozone on these tissues will be to encourage healing and regeneration (Bocci V, 1996).

    Introduction Index
    Treatment of Fractured Cusp Syndrome.

    The symptoms of sensitivity and pain on release of pressure related to the fracture of a cusp can again be successfully treated with Ozident® dental ozone. The exact location of the fracture is helpful in our approach to ozone treatment and can be ascertained through careful examination and the use of intra oral imaging. Once the fracture area is diagnosed a seal is obtained covering the cusp and fracture line in question and application of 40 to 60 seconds of ozone followed by a remineralising solution wash leads to elimination of symptoms. This obviously cannot cure the underlying problem of tooth fracture however the removal of acute symptoms by such a simple means is most beneficial for clinician and patient alike.

    Introduction Index
    Fractured Teeth.

    Posterior teeth with fractures along the pulpal floor, often present with symptoms associated with reversible pulpitis. This is thought to be due to bacteria tracking along the line of the fracture and resulting in inflammatory pulpitis. Such lesions have been traditionally difficult to treat, but if the restoration is removed, the fracture site determined and ozone applied, resolution of the pulpitis may be obtained as the bacterial load is reduced within the fracture line. The base of the cavity may then be sealed with a dentine bonding agent or glass ionomer cement prior to restoration with a suitable restorative material.

    Where patients attend with fractured anterior teeth, conventional teaching tells the dental practitioner that after any time, the nerve tissue is infected, and will die. Several practitioners from the pathfinder group have treated such cases up to 48 hours after injury. Local anaesthetics should be used prior to treatment. The exposed nerve tissue can be trimmed if required, and once bleeding has been controlled, ozone applied. In these cases, 2 minutes of ozone seems to be the average applied. From the work of Professor V Bocci (Bocci V, 1996) in Italy, it is known that ozone not only sterilises the tissue, but also induces the reparative and regenerative mechanisms. Once the exposed pulpal tissue and surrounding tooth structure has been sealed (it has been shown by John Kanka III, USA that acid etch and resins will not kill nerve tissue) the tooth can be reconstructed. Several pathfinder dentists have maintained vital teeth at 24 months for their patients treated in this way.

    Introduction Index
    Dentine Hypersensitivity.

    Exposure of the dentinal tubules with related symptoms of sensitivity is an extremely common problem presenting to the general dental practitioner. All treatment methods are directed at the sealing of these tubules and vary from the application of fluoride varnishes to the placement of next generation bonding systems on the root surface. The “hydrodynamic theory” proposed to explain dentine hypersensitivity has been around for some time. As well as fluid movements within the dentinal tubules, bacteria have also been shown to be associated with the tubules. This problem can be simply and immediately eliminated with the use of Ozident® dental ozone treatment.

    Ozone penetrates exposed tubules, eliminating bacterial contamination and effectively opening tubules to allow mineral ingress and subsequent sealing. It is vital that the seal obtained allows ozone delivery to the area being treated and in these cases the use of liquid rubber dam is a great aid to achieving this seal around the marginal gingivae. Once a seal is obtained, an ozone delivery of 40 seconds is followed by painting the treated area with a remineralising solution.

    This protocol is usually sufficient to completely eliminate any symptoms from the area undergoing treatment. In more severe cases, a second 40 second application of ozone may be required. A final application of fluoride varnish may be performed and the patient is given oral hygiene instruction before leaving to ensure correct brushing technique in order that future problems of this nature can be prevented. Over the last 3 years, several of the pathfinder group have only had to re-treat 2 or three cases each at about 3 months after the initial treatment. It seems that ozone not only allows deep dentinal tubular remineralisation, but also stimulates the pulpal tissue to switch off the pain signals. The results of their observations were published by Holmes J and Daly T in 2002 in Dental Practice.

    Introduction Index
    Post-Operative Pain.

    This is commonly reported, following cavity or crown preparations. Traditionally this has been explained as being due to thermal trauma to the pulpal tissues. Current thinking suggests that, associated with the pulpal trauma, there may also be an inevitable bacterial ingress into the dentinal tubules. This bacterial contamination of dentine may lead to an acute inflammatory reaction within the pulp. The patient with the resulting pulpitis will complain of hypersensitivity to thermal changes, and often spontaneous pain. The pulpitis may become irreversible and this may necessitate endodontic procedures to relieve the symptoms.

    If ozone is applied to cavity and crown preparations when completed and prior to restoration placement, the degree to which the dentine becomes infected with bacteria is reduced. This reduction in bacterial count may reduce the symptoms of post-operative pain and thus reduce the need for endodontic procedures in such situations.

    Introduction Index
    Soft Tissue Lesions.

    There is anecdotal evidence to support the use of ozone therapy for soft tissues lesions, such as apthous ulcers, “cold sores”, and dry sockets. The mode of action is thought to be due to a reduction in the bacterial population associated with such lesions, due to the bactericidal effects of ozone. This use of ozone is also supported from the many studies in general medicine where ozone has been used in ‘bagging’ techniques.

    Introduction Index
    Treatment of Dry Sockets.

    Post operative infection following extraction is unfortunately a common complication. Again, as ozone is totally bactericidal, in theory GDP’s should be able to treat such problems very simply. All the practitioners have had great success using ozone for this application. Once a seal is obtained around the infected area, a delivery of 60 seconds ozone has lead, in all cases treated ( 12 to date ) to complete resolution of symptoms within 24 hours. Ozone seems totally effective in the management of dry sockets and prevents the requirement for systemic antibiotic treatment.

    Introduction Index
    Treatment of Apthous Ulceration.

    The symptoms of major apthous ulceration can be severe and extremely distressing for dental patients. Current modalities of treatment are primarily aimed at symptomatic relief as generally the aetiology of apthous ulceration is idiopathic. It is simple to form a seal over the ulcer using a large cup and deliver 40 seconds of ozone to the lesion. In all cases the symptoms had dramatically decreased within 24 hours and in 3 cases completely resolved within 48 hours. Again this is a very relevant application as apthous ulceration can be a very severe problem for some patients and in the absence of causative factor ozone treatment may be extremely useful to aid in the resolution of the symptoms our patient’s experience.

    Introduction Index

    The sterilization of all instruments and handpieces between patients is an essential procedure in general dental practice. Standard autoclave cycles can take up to 6 minutes to complete and, although effective against all bacteria and viruses are ineffective against the prions that are the causative factor in human variant CJD. Ozone completely eliminates these prions and the sterilization cycle would take a time of around 5 seconds. There is no heat build up in the instruments and they can be removed totally dry and ready for use with the assurance that they are completely sterile. This is a potentially huge application for ozone use, not only in dentistry but also in any operative environment. It may also be applied to the sterilization of the water lines in the dental practice. Ozonation of these lines could easily be performed in between patients, again ensuring we are working with totally sterile equipment. The effect of the use of ozone in eradication of microorganisms colonizing dental unit water lines has undergone investigation and conclusive evidence of the efficacy of ozonation of such lines has been produced.

    Introduction Index
    Dental Unit Water Lines (DUWL).

    These have been shown to be heavily contaminated with biofilm and high bacterial counts have been recorded in the water from dental units. This does not seem to have any serious effects in the general dental practice setting but may be more worrying where immuno-compromised patients are concerned. Biofilm contamination plays havoc with dental units, often causing annoying blockages in couplings, hand pieces and 3:1 syringes.

    Initial research on the use of ozone, applied to water lines via the dental unit water supply, has shown greatly reduced numbers of bacteria present and also a significant reduction in the biofilm present (Abu-Naba’A L et al, 2001). It is interesting to note that the Ozident® dental ozone unit may be adapted to allow ozone to be applied to the water lines via the “clean water system” water bottle. Significant savings may be made by the resulting reduction in blockages of hand pieces, couplings, etc.

    Introduction Index
    Prevention of Enamel Demineralization Around Orthodontic Brackets.

    This is a well recognized problem following fixed appliance treatment in orthodontic cases. Accumulation of cariogenic bacteria in bracketed areas can lead to demineralization surrounding the bracket in patients where oral hygiene control is not meticulous. If demineralisation is allowed to take place, the optical properties of the tooth enamel will change, and white or coloured lesions will appear. By regularly eliminating the micro-organisms, and supporting this with regular oral hygiene instruction, these lesions may be avoided. Sadly, once the lesions have developed, remineralisation will not return the optical properties of the effected enamel to their original state.
    Ozone treatment has the capability of preventing this presence of cariogenic bacteria and, if repeated at 8 to 14 week intervals GDP’s and orthodontists have the potential to eliminate the possibility of any demineralization occurring with its subsequent problems related to cosmetic appearance and susceptibility to decay. When used in a preventatative role such as this, the application of ozone to the treatment area is performed for 10 seconds. Achieving a seal around many orthodontic brackets can be troublesome and again in this case the use of liquid rubber dam can prove invaluable. Applied in a circular fashion around the bracket it makes it relatively simple for the operator to seal and deliver the required ozone dose.

    Introduction Index
    Patient Compliance.

    The majority of Ozident® dental ozone unit practitioners noted that patients tend to respond enthusiastically to the concept of ozone therapy and the DIAGNOdent has proved to be surprisingly popular by patients of all ages. Patients are also keen to become involved in the DIAGNOdent readings. The audible signal produced by the instrument when it encounters a suspect area has proved a revelation in itself. It is remarkable how the patient responds to this signal and child and adult alike remember their DIAGNOdent reading! Children even remember the colour of the soft rubber cup that was used and often chirp, “You used the blue one last time!”

    It has been noted the much-improved oral hygiene in the patients when offered the ozone treatment. The patients seem to ‘switch on’ to the concept and appear to be much more receptive to oral hygiene advice and are keen to participate in the use of mouth rinses. The general experience in these practices has seen previously nervous individuals who normally do not like sitting in the dental chair, literally hopping in the chair to have ozone therapy. More smiles, more laughter, more enthusiasm all round.

    In some Pathfinder Practices, other related research has shown that the patients all scored the highest marks for the procedure being comfortable and they all confirmed the experience was a positive one. Nervous patients stressed how they appreciated the treatment and that it gave them confidence about visiting the dentist. Everyone questioned said they felt motivated to modify their sugar intake and to improve their oral hygiene as a result of the ozone experience.

    This is an interesting finding as when questioned further, as the patients felt a degree of inevitability when faced with conventional fillings, even tending towards ‘why should I bother’ in terms of improving their diet and plaque control because ‘I’ll have to have a filling anyway’. Yet when they received the ozone therapy they reported feeling more optimistic and positive about changing their habits. Certainly, it is the general experience that the use of the DIAGNOdent and ozone, coupled with oral hygiene does have a powerful impact on patients. Interestingly when this group of patients are offered the ozone pathway, the Ozident® dental ozone unit practitioners have discovered a major change in their attitude toward oral health and these patients become excellent at keeping their appointments.

    Introduction Index
    In Conclusion.

    In conclusion, ozone therapy provides a treatment modality with considerable benefits for dental patients of all ages. It is applicable to a wide range of conditions of the intra-oral hard and soft tissues. The treatment of carious lesions is effective and made much more acceptable for the patient. This makes it especially relevant to the younger patient, who may find conventional treatment unacceptable and also for the elderly, who may have medical problems, which may complicate conventional dental treatment. The treatment is simple, completely safe to provide and often renders the need to introduce potentially toxic restorative materials unnecessary.

    Patients are delighted and it can create a ‘buzz’ in the local community. Any innovation that can help halt dental disease and the fear of the dentist has to be welcomed. The Ozident® dental ozone unit Users experiences have shown that the ozone concept enhances the GDP’s ability to communicate with patients who rapidly warm to the idea. It seems to stimulate their interest and the therapy has the potential to be a financial asset. v Consider the proposed treatment with ozone respects the criteria of precision, responsibility, realism, ecology and measurability. The precision of treatment consists in the high oxidative action on substrates and bacteria; realism of treatment is supported by the very rapid kinetics of ozone oxidative reactions, and by the long lasting effects of remineralisation; responsibility of treatment is well identified and involves the entire oral environmental system, whilst operational responsibility relies on the dentist, and the patient’s compliance. Compliance is limited to those specific cases in which a fluoride therapy is preferable after ozone treatment. Further clinical and technical studies on non invasive ozone treatment in oral and dental pathologies are necessary to fill the gap between the naturalistic observations and the comprehension of these complex mechanisms and pathways. Now perhaps the dental community can share the awareness that ozone heralds new preventive and therapeutic possibilities never before achieved and allows a new vision which complies with needs and demands of the public for non invasive and effective preventive dental care.

    From a dental public health point of view, with dental caries being such a problem in large areas of the country and with such a shortage of clinicians here in some parts of the UK and Europe, the ozone therapy has potentially a major part to play in the prevention and treatment of dental caries. The Ozident® dental ozone unit machine and the DIAGNOdent are totally portable and it is possible to envisage units being used with great effect in dental practices and community clinics. It takes such little time to treat several teeth that it may be possible to help many more patients compared with conventional treatment. Being so simple to use, dental hygienists and therapists are ideally suited to providing the treatment for all categories of patient.

    However, perhaps the dental profession needs to return to the basic concepts of a preventative approach. The diagnosis of caries is a prevention failure in this context. Ozone certainly has a major role to play in a preventative-orientated dental practice.

    Introduction Index


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  • January 2015
    The-O-Zone © Dr Julian Holmes