Ozone Information For Clinicians

Sensitivity & Cracked Teeth - Treatment with Ozone

© Dr Julian Holmes
2015


Ozone Information

Sensitivity & Cracked Teeth - Treatment with Ozone
  • Introduction
  • Treatment Protocol
  • References

  • Sensitivity & Cracked Teeth - Treatment with Ozone

    Authors; Dr Julian Holmes1 and Dr Tom Daley2, 2003.
    Sensitivity & Cracked Teeth - Treatment with Ozone

    Dental pain affects some 30-50% of the UK population, with around a third of these experiencing dentine hypersensitivity (Tooth Wear and Sensitivity, Martin Addy, 2000) and a recent report from Leeds Dental School indicated that tooth sensitivity affects around 20% of the UK population.

    Dental pain affects some 30-50% of the UK population, with around a third of these experiencing dentine hypersensitivity

    Treatment may be carried out simply by the patient at home using desensitising toothpaste or in the surgery by the dentist using more advanced procedures and even laser treatments. The success of such treatments can be disappointing. I have had a number of abrasion cavities on the buccal aspects of my upper molars from years of abuse with a toothbrush. Despite glass ionomer fillings, sealants and hard & soft laser treatment, the sensitivity never really changed. Persistent use of desensitising toothpaste did not help either. However, access to a new technology has given me the relief I craved for and sought. And all from a single 20 second treatment. But before I excite you too much, let me review what has research has show us to date.

    Past research has revealed that tooth sensitivity is caused by the stimulation of nerve fibres in the tooth and can be treated with a variety of new methods. Sensitivity is due to the exposure of dentine on the root surface of the tooth that becomes exposed in the mouth. This dentine surface is linked by minute tubes directly to the nerve tissue within the tooth. When the surface of the exposed dentine is touched or stimulated by fluids or certain chemicals, this causes fluid to move from the tubule to the surface. This fluid movement in turn stimulates the nerve fibre, and pain is experienced.

    Chairman of Australian Dental Health Week 2001, Dr Don Wilson, says that tooth sensitivity is debilitating and painful for those who suffer in the extreme form.

    "The over stimulation of the nerve fibres in the tooth comes via naturally occurring fine tubules which travel from the surface to the nerve," Dr Wilson said. "If they are exposed, the cold causes a change in fluid pressure in the tubules and the nerve is excited. There are thousands of these tubules every square millimetre resulting in a significant wave of pain. People who eat acidic foods such as lemons or suffer from gastric reflux also get sensitivity because the acid erodes away the tooth surface and exposes open tubules.”

    Dentists currently have a range of procedures that can be used to help and a variety of new methods are being used by the dental profession to block these tubules including;

  • prescribing de-sensitising toothpastes
  • using special de-sensitising varnishes
  • bonding resin to the tooth surface
  • using dental lasers that can fuse the tubules closed.

    But each time the agents and methods become more invasive, the potential for increased sensitivity also increases. For example, the chemical preparation by phosphoric acid of a surface prior to bonding composite and glass ionomer fillings left my molar teeth more sensitive after the procedure, than they were before.

    A recent paper from the Department of Oral and Maxillofacial Surgery, University of Sheffield, UK, by HD Rodd and FM Boissanade looked at caries-induced changes in pulpal innervation. These two researchers looked at the comparison between primary and permanent teeth. They found that two pain-related chemicals— substance P (SP) and calcitonin-related gene peptide (CGRP) — were found in significantly higher amounts in permanent teeth than in primary teeth. Even higher amounts were found in teeth with tooth caries. This was true for two different areas of each tooth. These different levels may explain why primary teeth are less sensitive to pain than permanent or decaying teeth. SP and CGRP are involved in pain perception. For many years dentists have thought that primary teeth are less sensitive to pain than permanent teeth, and teeth with decay are yet more sensitive. This study has shown that there is a biological basis for this anecdotal evidence.

    SP and CGRP are involved in pain perception. This study shows the biological basis why decayed teeth are more sensitive, & primary teeth lees sensitive.

    In a recent study by J Holmes (Clinical Reversal of Primary Occlusal Fissure Carious Lesions (POFCLs) Using Ozone in General Dental Practice, 2002), ozone was used as a novel way of controlling and reversing decay. Some of the patients in this study had dentine sensitivity, and these areas were exposed to ozone for 20 seconds. In many of these patients (26 patients had sensitivity issues in this study) the sensitivity had resolved (22 patients had sensitivity relief after ozone treatment) within a short time (from 30 seconds, to 24 hours). As this aspect of dental care was not within the study criteria, no control lesions were set-up to monitor and the evidence is anecdotal only. But this is supported by other cases at UKSmiles, and by other members of the HeaIOzone Pathfinder Group.

    Dr Tom Daley in Essex has in general terms had really positive results where vital teeth which have had cracks and which were symptomatic have been treated. In many cases he has completely eliminated all the symptoms of pain on pressure in long-term intractable problem teeth. It has not been 100% successful (however it has been much better than the traditional treatments and probably has reduced his need to drill and fill in these occasions by about 70%).

    Dr Daley comments, “On a number of patients with very sensitive teeth the ozone treatment has had immediate effects (within a day). There have also been a few cases where it has not been successful. This has been more noticeable on teeth which have been root filled. “

    “One of my associates had a karate accident about 10 years ago on his central incisor and it has been tender for very many years. It was still vital and we were trying to avoid a root filling on the central. He ozonated it for 10 seconds on the day we got the machine and it quietened down instantaneously. It however became sensitive again about a week later. This time he ozonated it for 40 seconds and painted Duraphat on it and it has been totally symptom free since then.”

    In some of the food and wine industries, sensitivity is a real occupational hazard. A study among Western Cape winemakers indicated tooth sensitivity and even loss of tooth surface, caused by the acids in wine. Winemaking is associated with tooth sensitivity and, in some instances, loss of tooth surface - caused by the acids in wine which must be tasted frequently during the winemaking process. Prof Usuf Chikte, head of the Department of Community Dentistry, Western Cape University, presented these findings at a recent conference of the International Association for Dental Research, held in Nice, France. Prof Usuf Chikte emphasised that only people who taste wine regularly as part of their work, were affected, and not ordinary wine drinkers. Prof Usuf Chikte and Dr S Naidoo-Bresselschmidt conducted a study among 21 winemakers in the Western Cape to determine the prevalence of tooth surface loss among winemakers. The wives of 15 of the winemakers were used as a control group.

    The appearance of tooth surface loss was higher among the winemakers - caused primarily by the acid in the wine. Prof Usuf Chikte pointed out that during the process of winemaking, winemakers taste wine of varying acidity. Depending on the season, they can be exposed to between 12 and 100 tastings per day. It is important, however, that preventative measures do not interfere with taste, so some of the dental professions’ methods for dealing with sensitivity will not be appropiate for this group of patients.

    Cracked tooth syndrome (CTS) is a common occurrence in modern general practice too. Patients pesent in pain, which can vary from mild sensitivity to very severe. It is usually episodic, that is the pain appears during or after feeding. This is not surprising, considering the forces placed on the human dentition and the effect restorative dentistry has on the strength of tooth structure. We know that a filling that extends out of the occlusal surface onto one or more facial surfaces can reduce the strength of the remaining tooth by up to 50%. The traditional Black cavity preparation, sadly still adheared to by some practitioners, with sharp internal line angles, has been shown to create stress points that can lead to fracture formation. Factor in the 3-dimensional expansion of amalgam by corrosion, and you have a recipe designed to lead to fracture and failure. Other teeth show severe cracks that even the most detailed history from the patient can ilicit no causitive event. Road traffic accidents, blows to the lower face, and grinding have all been implicated in the aetiology of cracks.

    But the problem often for our patients is not trying to sort out what happened, but permanently sorting the crack out. Modern adhesive dentistry can help by first sealing the crack with dentine bonding agents, and then ’sticking’ the fractured tooth parts together. However, beware bulk placement and polymerisation shrinkage, as this can of course lead to a fracture in its own right, as the photographs show. In this particular case, as the plasma curing light was switched on, I just happened to be taking a photograph, as this buccal cusp fractured. But despite this fracture, the tooth has remained symptom free, and attached.

    Dr Tom Daly says “My pattern of treatments have changed in that my first line of attack would be ozone treatment because we have absolutely nothing to lose, and may win big-time. If it fails I simply revert to whatever my pre-ozone treatment would have been. I had one lady in about 3 months ago with a very sensitive lower left second molar (#37). A hairline fracture was obvious lingually and mesially. She was very sceptical regarding using ozone treatment, (I think she thought it was wishful thinking on my part). The symptoms totally resolved within a day.”

    “I saw a similar case this week and had to work hard to persuade this lady to even try ozone treatment. I succeeded in using it eventually and I explained that if the symptoms did not resolve then we would drill (and root fill) as necessary. I have not seen her back yet but even if am unsuccessful we have lost nothing except a bit of time. (I will see her immediately should any more severe problems arise.) Her concern was that the ozone might hide a more severe underlying problem. I personally feel that a severely hairlined symptomatic tooth is as serious as it gets.”

    Both Dr Holmes and Dr Daley have had the ozone technology in their practices for the last 9 months. “We started to experiment, as any clinician ultimately does, with new technology. The research group in London and Belfast had made several comments about other modalities of treatment that ozone may have a part to play in.”

    “We started trying ozone treatment for cracked teeth, and then areas of sensitivity. We know it works, but only recently have we worked out why after discussion with Professor Edward Lynch “ says Dr Holmes. “Dr Daley & I swapped information with the Pathfinder Group, and found that all of us were having success.”

    Professor Edward Lynch comments “We believe sensitivity is a change in the dentinal tubules, which causes messages to be sent by the nerve fibres. This in turn is appreciated as sensitivity or pain by the individual.”
    “In the primary decay studies in our ozone research, a decayed lesion consists of areas that are loaded with acidic bacterial products, as well as aciduric bacterial colonies. The pellicle that normally covers a tooth surface is a protein layer, and in the presence of this protein barrier and acid conditions, natural minerals from saliva cannot start the process of re-mineralisation. This barrier keeps them out. Ozone breaks down this protein barrier, quite apart from destroying the pathogens responsible for the decay process and their metabolites.”

    “Whilst there are no clinical trails to substantiate these results yet, we believe ozone works as follows; Let’s use, for example a buccal sensitive area. It is exposed to ozone and the protein barrier is destroyed. Once the protein barrier is removed, minerals in the form of phosphates and calcium ions can enter the opened channels. The process of mineral deposition, or remineralisation in the dentinal tubules occurs immediately after ozone treatment. So for many patients, the relief of sensitivity is almost instant. As an added bonus, treatment of the lesion with ozone leads to bacterial elimination, and the break down of their metabolites; now re-mineralisation occurs faster that re-establishment of the aciduric niche, so the whole balance of de- and re-mineralisation in tipped in favour of re-mineralisation. There is no reason why this should not be the case for the success of ozone treatment for cracked tooth syndrome too.”

    Oh, and what about sensitivity issues for we ordinary wine drinkers? I guess it does depend on how much you drink! "They can confidently enjoy their wine without fear of their teeth being affected," said Prof Usuf Chikte. "Wine tasters, however, should exercise care with their oral hygiene, especially during and after testing sessions. A fluoride mouth rinse may be a good way to counteract possible tooth surface loss. Of much more importance, the dental profession is well aware of the dangers of acidic and carbonated drinks that have been implicated in extensive tooth erosion.” So when you travel through your favourite wine area next, beware the sensitivity issue you may face with excess tasting sessions!


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    Treatment With Ozone
    The theory of sensitivity is that fluid movement within the dentinal tubule stimulates the dentinal nerve hair, which is appreciated as a painful stimulii by the attached host. Where the enamel has been removed or lost by what ever process, the dentine tubules are exposed, and sensitivity becomes an issue. It can vary from occaisional and mild, to severe and debilitating. The historical approach has been to seal the surface. The issue for patients that have been treated in this way is that the treatment last for 24 hours to a couple of weeks, but then comes back as strong as ever. With ozone treatment, the approach is to seal the deep tissues of the dentine, as well as turn off the painful nerve stimulii, and allow a remineralisation process to obliterate the tubular structure. In essence, this remineralisation process is exactly the same process when ozone is used to treat areas of demineralised dentine or enamel.

    Ozone works as follows; When a cleaned dentine surface is exposed to ozone gas, the surface micro-biological films are oxidised. As more ozone is applied, the gas oxidises the bacterial debris impacted in the opening of the dintinal tubules, and further oxidation eventually 'cleans' the tubular structure. A recent unreported study (2007) has shown that if left at this stage of treatment, there is a tendency for the lesions to become more sensitive - which one would expect a proportion to do.

    Ozone has also been shown by Profession V Bocci, Italy, to control the alpha nerve fibres - those that send painful stimulii to the brain. Bocci uses ozone to control pain, and in cases where teeth are fractured or cracked, where directly exposed nerve tissue exists, ozone can be used to control pain, bleeding and the degree of wettness to allow direct resin capping prior to restoration.

    To allow the body to 'close' up these opened tubules, a mineral wash can be applied over the treated surface. Mineral deposition deep within the exposed dentine tubules blocks the movement of tubular fluid and 'swiches-off' the sensitivity. The remineralisation process is pH dependent - too acid, and minerals are lost from the enamel surface. Ozone changes the deep pH of the dentine and enamel, setting up the chemistry that is necessary for the remineralisation process to start and continue. By instructing the patient to continue to use a remineralising wash or tooth paste smeared over the treated lesion, this remineralisation process will continue.

    Treatment Protocol

  • Assess degree of sensitivity; place local anaesthetic if required, keeping the area only lightly sedated.
  • Clean the lesion with care; remove all gross debris.
  • Do NOT dry, as this will be painful - leave damp; the damp surface will aid the dissolution of ozone into the lesion surface.
  • Apply ozone to the area for 60 seconds to begin with. Keep the delivery tip over the lesion.
  • Note: At the point of application, there may be a sudden but transitory sensitivity or pain, but this should pass within seconds. Remember to keep the high volume suction close to the point of ozone application, but not so close to cause pain!
  • Note: Ozone is a dry gas, and the lesion will appear to be dessicated immediately after ozone treatment.
  • After the first ozone treatment of 60 sconds, apply a mineral wash to the lesion. Use a micro-brush to gently 'rub' the mineral wash into the lesion.
  • Repeat the mineral wash application, making sure the whole lesion and the adjacent dentine & enamel has been treated.
  • Assess sensitivity with the 3-in-1 dental syringe - first air, then water, then air/water spray.
  • If there is any residual sensitivity, repeat the 60-second ozone treatment and mineral wash.

    Notes:

    - Some lesions will require anaesthesia to allow treatment; re-assessment, and possible re-treatment, must be carried out at a later appointment.

    - Some lesions will need more than 2 or 3 60-second ozone treatments.

    - Some lesions will require re-treatment at 2-3 months after the first ozone treatment, or periodic ozone treatment. In these cases, look for other factors - bruxism, brushing, diet.

    - The patient should be instructed on tooth brushing methods and diet to reduce sensitibity issues.

    - The patient should be sent home either with a remineralising kit, especially a mineral-containing mouth rinse. This will continue the deep remineralisation of the open dentine tubules, and treatment of sensitivity. As an alternative, the patient can be instructed to smear a small amount of flouride-based tooth paste over the treated area(s) every day.



    I have outlined how a new technology first researched to reverse dental decay, is having a greater impact in general dental practice. Further research is needed to establish the basis for this anecdotal evidence, but our first observations are very encouraging.

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    References

    Aust-Dent-J. 1998 Aug; 43(4): 217-22:
    Cracked tooth syndrome (CTS) is a common occurrence in modern general practice. This article reviews the forces placed on the human dentition and the effect restorative dentistry has on the strength of tooth structure. The study reports on the incidence of CTS in a general practice, finding a far higher incidence in teeth which have had the marginal ridge restored than those which have not. The various types of treatment modalities advocated and their relative merits are discussed.

    Zuckerman-GR: The cracked tooth. N-Y-State-Dent-J. 1998 Jun-Jul; 64(6): 30-5
    Fractured molars and premolars are very common. Fractures usually result from cracks that develop and slowly extend until the tooth separates into buccal and lingual fragments. Sometimes, as these cracks expand, the patient exhibits symptoms of what is commonly referred to as "cracked tooth syndrome" (CTS). When CTS occurs, an opportunity exists to diagnose and treat these patients, to relieve their discomfort and prevent sequelae that would require more extensive treatment.

    Tatum-RC: Two new schemes for classifying propagating cracks in human tooth structure. Compend-Contin-Educ-Dent. 1998 Feb; 19(2): 211-4, 216-8
    Currently, the dental profession has no comprehensive classification method or scheme to identify the many types of propagating cracks in human tooth structure. This article presents two new and practical classification systems that encompass numerous types of cracks. The first is the more simplified--the Surface and Position Classification System. The second and more comprehensive system is the Directional Crack Propagation System.

    All comments and inquiries to Dr Julian Holmes.

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    January 2015
    The-O-Zone © Dr Julian Holmes