Ozone Information For Clinicians

New Technologies For Dental Care - Part 2.

© Dr Julian Holmes
2015


Ozone Information

New Technologies For Dental Care - Part 1.
New Technologies For Dental Care - Part 2.
  • Introduction.
  • Early 'Prevention'.
  • Stains Versus Early Carious Lesions.
  • Reliable Data.
  • The Clinical Severity Index (CSI).
  • Amputating Tooth Tissue - what we do best!.
  • Follow-Up is Critical.
  • Results In Clinical Practice.
  • Ozone Technology Potential.
    New Technologies For Dental Care - Part 3.

  • New Technologies For Dental Care - Part 2.

    New Technologies For Dental Care - Part 2.

    Author; Dr Julian Holmes, 2006. 1st Published; "Dentistry" 16 May 2002.

    In this second article of three, Dr Julian Holmes explores arguably the most important advance in dental infection control or caries management since the development of filling materials. Dr Julian Holmes explains how dental ozone is used and what lessons are to be learnt about this new technology. New technologies can have the most profound effect, and not only on the public's desire for treatment. The articles have been updated and expanded from their original text. The pdf files are the original published articles.

    Introduction

    In my first article New Technologies For Dental Care - Part 1, I reviewed the current methods dental practitioners use to detect decay and briefly mentioned the DIAGNOdent from KaVo. The ‘niche environment’ theory of caries formation was introduced, and how ozone may have a part in the modern management and treatment of decay.

    To date, in many dental practices worldwide, caries detection, and therefore the elimination of decay, depends on visual recognition with the aid of a mirror, probe and X-ray analysis. Studies have shown that these traditional systems can be inaccurate; computerised analysis of digital radiographs, dyes and tests offer a little more accuracy.

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    Early 'Prevention'.

    Prevention with fissure sealants was also problamatical. Fissure sealants have been shown to leak, and cause decay. Some practitioners are old enough to remember the first fissure sealant preventative systems. We used these fissure sealants on teeth that were most at risk to decay, namely the first permanent molars, and by the time we got to treat these teeth, the fissure patterns were already stained.
    We used pumice to clean the tooth surface with a bristle brush, acid-etched the enamel surface, floated on the mixed varnish and waited for it to set. As an undergraduate, I was taught that once the sealant had been applied, no food substrate could reach any bacteria trapped deep in the fissures, so the carious process would be avoided. I now realise that, of course, the bristles could not clean out the fissure pattern totally, so most of the contaminated debris may be left in situ and we are aware that some bacteria are unaffected by acid etchants.
    I suspect that, like me, many of my contemporaries have seen cases years later where the decay process has slowly continued, leaving a hollow shell of enamel. This is explained by micro-leakage around the margins, allowing the ingress of food substrates to the trapped bacterial colonies, and minute fissures that remain unsealed, allowed bacterial substrate ingress and caries development. Later research has shown that the brisstle tips - quite apart from the tip of a dental probe, cannot engage with the full depth of the fissure we are supposed to evaluate or clean. Little wonder this early reventative approach lead to frustration and failures.
    The introduction of 'minimal-dentistry, with a range of fine diamond coated dental burrs opened the way to treat fissures with conservation in mind - the tissue removed in preparation was reduced. Advances in vision, lighting and air-turbines reduced the tissue destruction still further. Where caries was found, dyes show the extent of the demineralised tissue, and products such as Cari-Solv could be used to remove the denatured tooth tissue, rather than macro-tissue destruction with dental burrs.
    Treatment was improved by the introduction of air-abrasion. A minute stream of abraisvie particles was used to clean out the impacted debris, open the fissure pattern to allow visualisation and diagnosis, and then a micro-filling of preventative filling could be placed. This treatment modality heralded the advent of 'micro-dentistry'.

    However, most of these systems were removed to that wonderful store cupboard to be found in every practice - stuff we buy, use a couple of times, and then stop as time is a constraint that eventually gets to every dental practitioner. What the dental profession really needed was a system that eliminated the infection, without the need for wholesale tissue destruction, that was fast, very easy, and as number 1 on the list, was predictable. Not only does the dental practitioner want treatment to be predictable, but so does every patient that passes through the dental profession's clinics around the world. And at the end of the 20th Century, dental treatment was anything but predictable. Statistics from the UK show that even in 2004, the average life span of a restoration placed in socialised system or State-funded clinic was just 9 months! Where in some countries the state paid each time a filling was placed, one can understand the need to replace fillings to maximise income. However, from a patients'point of view, dental treatment was synominous with a cash-cow, no filling lasted longer than a year, and of greater importance, the surrounding tooth tissue was gradually - or suddenly (depending on the manual dexterity of the dentist concerned) reduced in volume, with certain failure at some time in the future - or replacement! - being the accepted norm.

    In a simple, but effective exercise, Professor Edward Lynch and Dr Julian Holmes evaluated that if a system that saved tooth tissue could be introduced into a socialised system, there were huge financial gains for;

  • the state in terms of reduced funded dental care, lost work time;
  • for the patient, in terms of reduced cost and time off work;
  • for the dental practioner, in terms of increased income, reduced time, reduced failure, and enhanced 'professionalism';
    This could be extended to every country in the world. And ozone offered just this pathway.

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    Stains Versus Early Carious Lesions

    So how can we improve our diagnosis of a stain versus an early carious lesion, as this is one of the hardest diagnoses to make? Part of the research into ozone technologies was to look at a reliable and reproducible way to measure decay. The DIAGNodent has been available since 1997 in Europe and works by shining a laser at the tooth surface. Once calibrated to the patient, the level of decay is expressed as a number on the screen and as an audible tone. The higher the number and tone pitch, the larger or more extensive the area of decay. What the machine actually measures is the fluorescence of bacteria and, indirectly, the density of tooth structure and the presence of decay. It is not without it's own problems, and every dental practitioner needs to be aware the limitations of each technology brought in to aid clinical diagnosis.
    The humble mirror, probe and x-ray have been shown to have severe limitations in their ability to 'diagnose' caries. These impliments do not really diagnose - they are an aid to data gathering that allow the dental practitioner to make an informed decision as to the clinical requirments. Sadly with a diagnostic criteria of just 50% or worse as shown by some studies by Professor Adrian Lussi in the late 1990's, dental practitioners make an informed guess.

    The late 1990's saw an increase in the equipment that the dental practitioner used to evaluate a tooth surface - magnification, improved lighting, and knowledge. But the key to making a diagnosis of if decay was present or not, was still a hit-or-miss affair. Research started to show that the 'simple' fissure pattern was anything but simple! Dental practitioners were told to sharpen the probes - then to blunt them as sharp probes could cause decay to start! Then of couse the profession discovered without a sharp probe not a great deal can be found with what had become a pointer at best. Then came the publications from New Zealand and the USA that showed fissures were 'bottle-shaped'- narrow at the top, opening to a large open area, that usually had decay at the depths and on the walls, intact occlusal enamel over laying caries, and the concept of 'hidden-decay'. Clearly the dental profession needed a new diagnostic system that allowed improved diagnosis and evaluation, without the need to drill open every occlusal surface just to look inside - and of course, if the dental practitioner was using a mirror and probe to look, they would not 'see' the incipiant demineralisation that would lead to decay or even the early lesion. The DIAGNodent was a huge leap forward in the ability to diagnose the incipient lesion, the demineralisation of enamel, and what was going on at depth under that seemingly pristine enamel surface.

    But even the DIAGNodent has limitations. For instance, it can be fooled by flourescence that is non-bacterial - eg composites. The advent of naturel polymers that mimic tooth material has been one of the major leaps forward in cosmetic dental care. As the DIAGNodent relies on flourescece to 'diagnose' decay, any pre-existing sealants or fillings that have a flourescent quality have to be removed, or allowances in the DIAGNodent assessment made. The maximum value that the DIAGNodent can display is 99. At 98, you may have a true number and assessment of the lesion. But at 99, the assessment could be 99, or 120, or 250! You just do not know due to the physical limitations of the equipment. Just before those who use the technology place their DIAGNodents in the store room, or others conatct me to complain at my comment, please stop there! I my opinion, this technology should be used by EVERY dental practitioner, should be taught at dental schools, and should be one of the few required dental instruments that every evaluation is made with. It must be stressed that the DIAGNodent is a scientific instrument, should be handled with care, and be properly calibrated EVERY time it is used, and then cleaned (Note! you can of course use ozone to disinfect and sterilise the tip - it is fast, predictable, and works.)

    But aside from that slight digression, the DIAGNodent take away the guessed diagnosis, and gives the practitioner the scientific basis to decide to leave the tooth surface, or start treatment on it. So in the ozone technologies - irrespective of which ozone device you choose to buy, use the DIAGNodent to assess the treatment needs, and the entry criteria. And then, put it to one side, as the research has shown that remineralisation - part of the 'healing' process following ozone treatment of an area of decay, will take up minerals, as well as stains. So the use of the DIAGNodent to assess remineralisation is not a useful criteria as stains may give a false=positive, leading to further unnecessary dental treatment on a 'healed' and reversed lesion.

    For assessment after ozone treatment, the CSI is a far more useful tool, as this combines all the clinical criteria dentists were taught at dental school, but some how forgot as the holy cows called 'Mirror & Probe' took over. These are useful tools to point out the short commings of the efforts of oral hygiene in embraisures or around orthodontic brackets, or debris collections below the nasal passageways, or even wax from the auditory canal. But as diagnostic tools, forget them. Move on to a scientific system that actually will show you where you need to take a closer look.

    Once the fissure pattern has been opened, the walls and floor assessed, then treatment criteria can be made, and an informed treatment plan drawn up with the patient. What the use of the DIAGNodent does do more than any othjer tool in the dental practice - with the possible exception of the intra-oral camera - is bring the patient into their own treatment planning, and by giving the patient information, teaching and informing that person will allow them to make their own informed decisions about their dental - or medical - care.

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    Reliable Data

    In my practice, we used the PROPHYflex System from KaVo to clean the surface thoroughly, ensuring the DIAGNOdent measurement is not caused by impacted debris or stains. The working tip of the PROPHYflex pushes out a slurry mix of sodium bicarbonate and water, and it is very effective at stain and debris removal. The DIAGNOdent is then used to measure the occlusal areas that are suspect. We designed a custom screen in our computer management system to record this data. On molar teeth, we used the intraoral camera system first to photograph the tooth and then add notes of the readings over the surfaces. We note and treat values up to 10 with a preventative dose of ozone - 20 seconds is all that surface needs. The preventative aspect of ozone in dental care has not been reported on yet as a research topic, but it makes sense, as any areas of enamel demineralisation are treated at a very early stage of lesion formation. In the past, we would have treated any surfaces with readings of 10 to 15 using air abrasion and fissure sealants. We would now recommend the use of ozone to reverse the demineralisation that has been found. Moreover, with values over 20 where we would have removed tissue with either air abrasion or a drill, we now offer ozone as an alternative.

    The Ekstrand Index has 7 groups as follows;

    0 No or slight change in enamel translucency after prolonged air drying (>5s)
    1 Opacity (white) hardly visible on the wet surface, but distinctly visible after air drying
    1a Opacity (brown) hardly visible on the wet surface, but distinctly visible after air drying
    2 Opacity (white) distinctly visible with out air-drying.
    2a Opacity (brown) distinctly visible with out air-drying.
    3 Localised enamel breakdown in opaque or discoloured enamel and or greyish discolouration from the underlying dentine.
    4 Cavitation in opaque or discoloured enamel exposing the dentine beneath

    Table 1; The Ekstrand Index

    The modified and adopted index is known as The Clinical Severity Index (CSI). It has 5 groups;

    The Clinical Severity Index (CSI), combined with treatment needs and protocols

    CSI Index DIAGNodent Value What you see Extent of Caries Assessed Treatment Needs Tx with Ozone (sec)
    5
    > 30
    visible on X-rays
    3+ mm into dentine
  • Lesion requiring drilling and filling
  • defined as deemed to have infected dentine where clinical infected demineralisation of the underlying dentine 3+ mm is deemed to be present.
  • Lesion may be cavitated.
  • Open lesion, remove and soft debis to leathery layer.
  • Ozone treat, remineralising solution, FugiVII.
  • Review, re-assess mineralisation at 12 weeks
  • Restore if remineralised, repeat ozone if undecided
  • 60+ seconds ozone
    3
    25~29
    ? visible on X-rays
    1-2mm into dentine
  • Lesion requiring drilling and filling.
  • Define this as deemed to have infected dentine where clinical infected demineralisation of the underlying dentine=/<2mm is deemed to be present.
  • Lesion will appear frosted or white when dried.
  • Open lesion, remove any soft debis to leathery layer.
  • Ozone treat, remineralising solution, FugiVII.
  • Review, re-assess mineralisation at 12 weeks
  • Restore if remineralised, repeat ozone if undecided
  • 60 seconds ozone
    2
    20~24
    stain
    at the edj
  • Lesion possibly requiring drilling and filling
  • Defined as possibly deemed to have infected dentine where clinical infected demineralisation of the underlying dentine is possibly considered to be present).
  • Lesion may appear frosted or white when dried.
  • Open lesion, remove any soft debis to leathery layer.
  • Ozone treat, remineralising solution, FugiVII.
  • Review, re-assess mineralisation at 12 weeks
  • Restore if remineralised, repeat ozone if undecided
  • 40 seconds ozone
    1
    10~19
    white spot
    confined to enamel
  • Lesion requiring a pharmaceutical approach but not drilling and filling
  • Defined as deemed to have infected demineralised dentine which is reversing and getting smaller. This scenario is where clinical remineralisation of the underlying dentine is considered to be in the process of remineralising the demineralised dentine but is not yet complete.
  • Lesion may appear white or frosted when dried.
  • Remove superficial debis.
  • Ozone treat.
  • Remineralising solution, Restore.
  • 40 seconds ozone
    0
    < 10
    n/a
    n/a
  • Lesion arrested
  • Defined as deemed to have had infected dentine which reversed and where clinical remineralisation of the underlying dentine is considered to be complete, with no infection remaining in the dentine.
  • The lesion is hard, shiny when dried.
  • Ozone treat for prevention.
  • Remineralising solution, Restore.
  • 30 seconds ozone

    Table 2; The Clinical Severity Index (CSI), combined with treatment needs and protocols

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    Amputating Tooth Tissue

    At an early stage in their career and before entry into the dental profession, dental students are taught the Victorian principles of engineering; to amputate the diseased tissue from a tooth. As a slight digression, engineering principles state that foundations have to be placed on firm and secure foundations for the ediface to last. It is no different to any restoration placed in a tooth; any area of decay not amputated will lead to further decay, and the restoration will fail as the decay process undermines the integrgity of the restoration. For the traditional approach to tissue ampution where infection exists, this is the only way to erradicate caries.

    As a profession, dentists are taught to amputate the diseased tissue from a tooth, and they have a wide range of systems to help to do just that

    The dental clinician has a wide range of systems to help us do so. We have the traditional turbine, diamond coated and carbide burs, ultra-sonic tips, air abrasion, and chemicals, such as Carisolv, to remove tooth tissue. All are very effective but they all amputate tooth tissue. In the first article, I outlined the ozone research results produced by Professor Edward Lynch and his team at Queen’s University, Belfast, which showed that a single 10-second exposure to ozone gas deactivated 99% of bacteria, viruses and fungi in-vitro. When the bacteria involved in the carious lesion are exposed to ozone gas, the bacteria and their bio-molecules are oxidised to CO2 and Acetate Acid. As the pH of the lesion is now altered from an acidic lesion to a basic lesion, the majority of lesions remineralise with just a single 60-second in-vivo ozone treatment.

    As the acidic carious niche environment can take from 16 weeks to years to establish, it is unlikely that the niche will redevelop before remineralisation takes place. But how does this help us in practice, away from the research laboratories?

    There are various dental ozone devices available (for example, the HealOzone, KaVo GmbH, Ozi-cure, O3 South Africa). Both these dental ozone units deliver ozone gas at pre-set concentrations, through a hose and handpiece that is placed in close proximity to the tooth surface requiring treatment. Each unit has it's advantages and disadvantages. The HealOzone unit is aimed at just the dental market. In comparison, the Ozi-cure is aimed at a wider health-care market for the dental, medical and the vetinary market.

    At the end of a 30- to 60-second ozone exposure, a mineral wash is placed over the treated area to kick-start the remineralisation process.

    In just 40 seconds, ozone can eliminate the micro flora that cause decay and start the ‘healing’ process of a carious lesion

    So, in just 40 seconds on average, dentists can now, and very predictably, eliminate the micro flora that cause decay process and start the ‘healing’ process of a carious lesion. Once ozone treatment has been completed as necessary, the patient is sent away with an ‘at-home care kit’. This consists of a dentifrice and remineralising mouth rinse, with patient information detailing the instructions they must follow for the treatment to be successful. This phase of oral hygiene instruction is an important part of the process. The reduction in fermentable carbohydrates, improved debris removal and diet, are all important keys to health, not just dental caries. As a very (!) short digression, increased obesity is linked to general body-rot, so the dental team can play a key role in general health at this point in their patient's lives.

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    Follow-Up is Critical

    The follow-up appointment for the larger lesion is critical to the success of this technology. The research team recalled patients at three- and six-month intervals to re-measure the treated lesions. Having cleaned the treated surfaces using the PROPHYflex, the initial data records and photographs are compared to the current records, using the CSI to record new values in the original data locations. To date, all results mirror those achieved by the research team in Belfast.

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    Results In Clinical Practice

    Average results with ozone in dental care

    In the first study, we selected 82 surfaces with occlusal decay. Each was measured with the DIAGNOdent and the CSI following our protocol. The most common tooth that needed treatment was the upper right 7 molar. The most common start DIAGNOdent value was 85 and the most common finish value after treatment was 24. We saw most patients at a recall period of 64 days after the first ozone treatment and the most common change was 20 units.

    In the second study, the average first value was 70 and the average second value was 15, giving an average ‘healing’ index of 55. On average, we saw patients 79 days after the first application of ozone.

    Patients are as astounded as is every practitioner who has bought into the ozone technology, to be partof the success of this painless technology. I am sure that, like myself, many of my colleagues who have attended the presentations are questioning when to use this technology and when to use a traditional filling. In my case, I have found that we no longer have to place any filling materials in the majority of lesions. I mentioned earlier that dentists have been pre-conditioned to restore a cavity when one is detected.
    It has to be remembered that traditional means of caries elimination demands the amputation of diseased lesions. In most cases, it is impossible to define the exact limits of this, so we tend to remove far more tissue than is actually required. In so doing, we severely weaken the entire tooth structure, which could lead to catastrophic tooth failure and its eventual removal. Even if you use caries dyes, there is no indication of what tissue is soft, to that which can be remineralised. Caries dyes only show the demineralised extent of the lesion. So even if you practice traditional amputation dental care, there is no idication of what is 'infected' as opposed to 'clean'.
    Ozone eliminates 99% of the micro flora and so the decay process halts. Once remineralisation begins, the naturally restored tissue is far more resistant to decay. This has been shown in previous studies. We already know that it can take years for the niche environment to develop, so provided the patient’s oral hygiene remains at an improved level, and the remineralisation process continues, there is no need to place any restoration at the first visit.

    Average results with ozone in dental care

  • In the first study, we selected 82 surfaces with occlusal decay. Each was measured with the DIAGNOdent and the CSI following our protocol. The most common tooth that needed treatment was the upper right 7 molar. The most common start DIAGNOdent value was 85 and the most common finish value after treatment was 24. We saw most patients at a recall period of 64 days after the first ozone treatment and the most common change was 20 units.
  • In the second study, the average first value was 70 and the average second value was 15, giving an average ‘healing’ index of 55. On average,we saw patients 79 days after the first application of ozone.

    As I have commented earlier, it is important to realise that the DIAGNodent cannot give reliable values at follow-up appontments. The uptake of food stains will render the remineralised tissue as having a greater value than possibly at the pre-treatment value, returning a false positive. Various studies (see the Evidence-Based Research Into Ozone In Dentistry – An Overview.) do show a reduced DIAGNodent value after ozone treatment. This is to be expected, as ozone is an excellent oxidising agent - or put in a different way, this is the bleaching or whitening effect of ozone. However, in the clinical situation, we need to focus on the result at 2-3 months and there after, not the immediate effect of ozone, as the longevity of any restorative care is dependent on sound, remineralised tooth tissue.

    One important factor that needs to be remembered is that during the initial stages, the treated areas of decay will be relatively soft and will not support any restoration. Therefore, if a restoration is planned after ozone treatment, it should be planned at the review appointment at 2-3 months after the initial ozone treatment by which time, the research data suggests, the remineralisation process will be well advanced, the lesion static and reversed, and the tissue hard enough to support a transitional restoration.
    A waiting time of three months or more may decrease the amount of tooth tissue that may have to be removed to obtain a cosmetic result. This, in turn, preserves as much of the original tooth as possible. Lastly, studies have shown that if the lesion if left open - a strange concept for both the patient and the clinician - the remineralisation occurs in about 6-8 weeks. In this situation, clearly improved oral hygiene and the use of remineralising washes will hasten the 'healing' effect. If a logical approach is taken to the remineralisation of lesions once 'sterilised' by ozone, then the patient's own saliva is the best mineral source. The remineralisation effect can be improved by the use of a remineralising mouth wash and tooth paste to increase the bio-availability of minerals such as calcium, phosphate, and flouride.
    One promising area of research is the caesin proteins from dairy products. GC have recently launched 'Tooth Moose'. Tooth Moose releases minerals in both acidic and basic conditions, so forms the perfect base for remineralisation. A potential for development would be the incorporation of the caesin protein release system, with Fugi VII. This would combine the 'smart' filling technology with the mineral release during all phases of oral pH change.
    Where a transitional filling is placed, the 'healing' time is longer - 3 months. It is suggested that remineralisation in this situation occurs from the pulp tissue and not from the oral cavity fluids. This has been observed by many of the pathfinder group members, and their x-rays suggest this is an area for further research.

    The last part of this 3-part article will look at how we promote this technology in our practice, how we cost it and the reaction of our patients.

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    Ozone technology potential.

    In the future, this technology may have other indications, including the decontamination of dental unit water lines that are especially vulnerable to bacterial contamination and colony growth due to the static layer of water at the inner tube surface or surface bacterial growth known as a "biofilm".
    Other uses may be for the treatment of periodontal disease and the re-washing of surgical sites prior to, for example, implant placement. A number of studies are currently being undertaken, including those by Dr Hubert Chang in London on the cleaning of root canals utilising ozone in endodontic treatment and a study looking at its use as a tooth whitening system. New studies in Europe are beginning to look at periodontal treatment with ozone, and in Egypt looking at a try application for prevention.

    Part 1 & Part 3 of this series of articles will look at the use of ozone in the dental practice in more detail.

    1st Published; "Dentistry" 16 May 2002.

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    January 2015
    The-O-Zone © Dr Julian Holmes