Ozone Information For Clinicians

Caries Prevention - Feature Article

© Dr Julian Holmes

Ozone Information

Caries Prevention
  • How Is Dental Caries Managed?
  • Why Monitor Lesions?
  • Is Remineralization Effective?
  • What Agents Are Effective?
  • Does Fluoride Usage Affect Caries Progression?
  • Has Fluoride Changed Caries Progression?
  • What Research To Manage Caries Is Being Conducted?
  • How Does Ozone Affect Carious Lesions?
  • How Is Ozone Appied In Practice?
  • What are the advantages of such treatment?
  • References:

  • Feature Article - Caries Prevention

    Authors; Dr. Layla Abu-Naba’a and Prof. Edward Lynch. 2002
    Caries Prevention


    How is dental caries managed?
    Answer: As with all diseases, dental caries is managed by eliminating the cause of the disease and then altering the conditions that favor future infection. Acids produced by microorganisms in the plaque overcome the natural defenses of the body and are the primary cause of dental caries.
    The body tries to reduce the harmful effects of these acids with various buffering systems present within saliva. Saliva also is hyper-saturated by salts that mend, or remineralize, the area dissolved by the acids. However, this balance of dissolution then remineralization can be upset by the proliferation of bacteria deep in the complex plaque away from the effects of saliva. When this happens, the dissolution phase then becomes longer than the remineralization phase. Furthermore, some of the proteins present in the lesion can act as inhibitors for the remineralization.1 The net result is a decay lesion in enamel and dentine of variant degrees. Ultimate dissolution causes the surface to breakdown into a cavity.

    The type of treatment used to fight the decay depends on the stage of the lesion. Treatment options for initial caries range from monitoring the lesion, sealing the tooth, or aiding remineralization, to providing minimally invasive treatment.

    A new approach uses ozone, a powerful biocide, to rapidly penetrate the bacteria and kill them in their protected niche. Ozone has been proven to halt root caries and even clinically reverse the lesions. It has been suggested that ozone also might play a role similar to other oxidants and alter the metabolic products of bacteria that inhibit remineralization.2 Further studies are being conducted on using ozone to treat occlusal caries in permanent and deciduous teeth.

    For advanced lesions, removal of the tissue invaded by the microorganisms is the only treatment choice. A variety of excavation techniques3 are available (see sidebar) and can be used with or without pulpal treatment. Teeth are then restored using the restorative material of choice.


    Is there any benefit from monitoring lesions?
    Answer: Yes, Caries is considered a chronic, slowly progressing disease with symptoms that might not be detected until years after the onset. 6 It has been advocated that practitioners concentrate on finding early signs of caries in patients who are considered at elevated caries risk.
    Caries risk assessment should be the result of an intellectual process involving a thorough oral examination and an evaluation of unique factors that may contribute to caries activity. Since low-risk patients have an overall low probability of caries onset, there is no urgent need for treatment.7 For low-risk patients the decision to restore is based on more lenient criteria and monitoring the lesions is preferred.

  • Lesions reaching through enamel and to the dentin-enamel junction are not restored at the first sight because treatment to control the causative agents may be implemented.
  • Progression of a proximal lesion to the dentin is not considered a valid indication for restoration in low-caries prevalent children since rapid progression of the lesion and cavitation are unlikely.Even if the lesion has progressed half-way through the dentin, the likelihood of cavitation is less than 50%.8 These lesions can lose a large amount of minerals without cavitation, so close monitoring and initiation of preventive measures is required to exclude pulpal involvement.

    Is remineralization an effective treatment modality? What agents seem most effective?
    Answer: Remineralization treatment represents the next era in dental care. The crystal structure resulting from this natural repair is usually stronger than the original structure since its salt makeup is more resistant to future attack. Remineralisation is considered a valid option when no cavitation is present even when lesion is beyond the enamel and DEJ, as the frontier of the lesions is the demineralisation zone rather than bacterial invasion. Dentists are faced by this problem more often as the abundance of fluoride leads to the fluoride syndrome: The presence of an extensive undermining lesion under an intact innocent looking surface or an occlusal fissure stain!!.

    In a statement issued by the National Institutes of Health Consensus Development Conference held in Bethesda, MD, USA on March, 2001 in 2001 on the diagnosis of caries and management this issue was reviewed and it was stated:

    “The caries process is endemic and potentially both preventable and curable. The latter can be achieved by identifying and arresting or reversing the disease at an early stage. Although more research is needed, clinical strategies to do this may already exist. The panel believes that existing strategies for primary prevention in the general population, as well as preventive strategies demonstrated to be effective in high-risk individuals, are also likely to be effective for arresting or reversing early lesions. These strategies include:

  • 1. Fluoride: Research data on fluorides in water and dentifrices support their efficacy. The data also support the use of fluoride varnishes. For fluoride rinse and gel applications the evidence is promising but not definitive.
  • 2. Chlorhexidine: For varnishes and gels, the data are promising. Research data showing effectiveness of chlorhexidine rinses are lacking.
  • 3. Sealants: The use of pit and fissure sealants is supported by the data.
  • 4. Combinations: Combinations of chlorhexidine, fluoride, and/or sealants are suggestive of efficacy.
  • 5. Antimicrobials: Although mutans streptococci is recognized as part of the pathology of caries and therefore an antimicrobial approach would seem reasonable, current data are inadequate to support antimicrobial treatments other than chlorhexidine and fluoride, both of which have antibacterial properties.
  • 6. Salivary enhancers: Although there are indications that pathologically low salivary flow, as a consequence of Sjögren's syndrome or as an effect of head/neck radiation treatment or xerostomic medications, is associated with caries, there is no evidence that low normal salivary flow produces a similar outcome.
  • 7. Behavioral modification: Most interventions require patient adherence, and current data provide some support for the efficacy of office-based behavioral interventions.”

    Is there research to indicate that the use of fluoride affects the progression of caries?
    Answer: Documented research on the role of fluoride in the reduction of dental caries has been primarily conducted as surveys designed to study the effect of the presence of fluoride in various forms and to correlate that information to the level of dental decay (see “Evidence of fluoride effectiveness,” page xx). Water fluoridation gained a great deal of interest over the decades as being the safest, most cost-effective, and most equitable method of reducing tooth decay, regardless of the fluoride's source.9,10,11,12,13,14,15 Furthermore, fluoride prevents needless infection, pain, suffering, and loss of teeth; improves the quality of life; and saves vast sums of money in dental treatment costs.9 Additionally, fluoridation conserves natural tooth structure by preventing the need for initial fillings and subsequent replacement fillings.16

    Different groups in the whole population have proven to benefit from fluoridation.

  • Small children: Baby bottle tooth decay seriously affects babies and toddlers in some populations. Water fluoridation is highly effective in this age group and is an accepted practice since it does not require a dental visit or motivation of parents and care-givers.35,36,37,38,39,40,41 A cumulative review of the level of decay reduction achieved through water fluoridation in industrialized countries showed: 30%-60% in the primary dentition or baby teeth; 20%-40% in mixed dentition (ages 8 to 12). 28
  • Adults: Fluoride has both a systemic and topical effect and is beneficial to adults in two ways. The first is through the remineralization process in enamel. Frequent exposure to small amounts of fluoride can arrest early decay and even reverse it. The previous review also showed a caries reduction of 15%-35% in the permanent dentition or adult teeth (ages 14 to 17); and the same percentage reduction was seen in the permanent dentition of adults and seniors.28

    Another protective benefit for adults is the prevention of root decay. Studies have demonstrated that fluoride is incorporated into the structure of the root surface, making it more resistant to decay.42,43,44,45,46 A Swedish study investigating decay activity among adults in optimal- and low-fluoride areas revealed that not only was decay significantly lower in the optimal fluoride area, but also the discrepancy could not be explained by differences in oral bacteria, buffer capacity of saliva, or salivary flow. The fluoride concentration in the drinking water was solely responsible for decreased decay rates.47

  • Lower socioeconomic status: Of most concern was the high decay rate among young children from low-income families. Specifically, children whose families were lifetime residents of non-fluoridated communities and whose income was more than 200% below the U.S. Federal Poverty Level had 39% more decay in their baby teeth when compared to counterparts who were lifetime residents of optimally fluoridated areas.18 Using data from the dental surveys in 1991-1992 and 1993-1994, a British study demonstrated that children with the greatest dental need benefit the most from water fluoridation.40

    For patients to whom fluoride treatments have been administered, or who drink fluoridated water, has fluoride affected a change in the characteristics of caries progression altering the behavior of the mineralized tissue during the acid attack?
    Answer: Maximum decay reduction is realized when fluoride is incorporated systemically during all stages of tooth formation and applied topically after eruption.48 Systemic fluorides that are ingested regularly while teeth are developing are deposited throughout the entire tooth surface and provide longer-lasting protection than fluorides applied topically.48 Additionally, the presence of systemic fluoride in saliva provides a reservoir of fluoride ions that can be incorporated into the tooth surface to prevent decay.49 Systemic fluorides also can give topical protection because ingested fluoride is present in saliva, which continually bathes the teeth providing a reservoir of fluoride that can be incorporated into the tooth surface to prevent decay. Fluoride also becomes incorporated into dental plaque and facilitates further remineralization.50 However, topical fluoride applied to teeth in an adult's mouth during the initial formation of decay not only stops the decay process, but also makes the enamel surface more resistant to future acid attacks. Researchers have observed fluoride’s decay preventive effects through three specific mechanisms:51,52

  • Fluoride ions in and at the enamel surface convert the mineral component (hydroxyapatite) into a less soluble form (fluorapatite), resulting in fortified enamel that is more resistant to the acid.
  • Fluoride exerts an influence directly on dental plaque by reducing the ability of plaque organisms to produce acid. Fluoride has well been established as a potent inhibitor of the enzyme enolase, a key enzyme for bacterial metabolism. This is thought to reduce the amount of acid produced in the plaque by decay-causing bacteria. Other effects could include less binding of bacteria and the reduction of plaque growth and thickness.
  • Fluoride promotes the remineralization or repair of tooth enamel in areas that have been demineralized by acids and in which early decay does not enlarge.

    The theory is that fluoride is concentrated in the surface of the mineralized tissues and then is released to the plaque biomass as the acids demineralize the tooth surface. The remineralization effect of fluoride is of prime importance, allowing enamel to repair, or remineralize, early dental decay caused by acids from decay-causing bacteria.48,54,55,56,57,58,59

    However, enamel-forming pits and fissures do not receive the same level of caries protection from fluoride as does smooth surface enamel. It also may partially explain why occlusal caries is responsible for almost 60% of the total caries experienced even though occlusal surfaces account for only 12.5% of the total number of tooth surfaces exposed to cariogenic challenges. If caries occurring in pits and fissures on buccal and lingual surfaces are considered, then pit and fissure caries would account for at least 80% of the total caries experienced in all children and adolescents. Over 90% of dental caries occurs in occlusal and buccal-lingual surfaces in fluoridated communities and comprise, almost exclusively, pit and fissure caries.59

    This particular problem can be explained by the presence of fluoride.60,61,62 Referred to as “the fluoride syndrome,” the increased fluoride intake causes the highly caries-resistant occlusal enamel to obscure a spreading dentinal lesion. So the lesion progresses and undermines the intact enamel reaching the dentin without cavitation.


    What research on methods to manage carious lesions is currently being conducted at Queens University?
    Answer: We are currently researching the use of ozone (O3) to manage dental caries as well as to treat dental unit waterlines.

    In our research we are using the most advanced technologies to measure objectively the various aspects of dental caries behavior with ozone treatment. For the clinical diagnosis, we are applying the clinical criteria developed by Kim Ekstrand, one of the foremost experts on fissure caries classification. This was further tested at the school and was found to be a valid method for diagnosing caries.68

    For the subjective quantification of the lesions, we are using the Diagnodent caries detection laser from Kavo as well as the Electrical Caries Monitor (ECM) from Lode B.V. These devices allow us to see the lesions, measure them numerically, and then periodically monitor them over the period of our study measuring any remineralization (lesion reversal) or further demineralization (lesion progression).

    The Diagnodent was found to be highly correlated with the histological true extent of caries.68 Ozone treatment had an immediate effect on these readings, lowering them significantly. 68 Any progression of the caries leading to cavitation undetected by the eye can be detected with an advanced laser scanning device that scans the surface of teeth or oral tissue in a matter of seconds and then sends the resultant image to a computer system. Complex calculations and procedures from the image produce data that accurately measures the surface.

    Another application of this scanning device is to measure the fissure sealant applied over the occlusal surface. (Figs. 2a,2b,2c) It can measure sealant volume and depth as well as detect any change in volume due to retention loss or wear.69

    Altering the organic substance in the plaque70, saliva71 and in the lesion72 by the application of ozone was tested by use of high-resolution proton spectroscopy (1H NMR). With the help of 1H NMR, examination of the organic acid status of primary root carious lesions has added information about the molecular profile and concentrations of microbial-derived organic acids in carious dentin as demineralization parameters involved in the induction, development, and progression of dental caries.73 Finally the disinfection of microorganisms within the lesions is tested microbiologically. This was done in-vitro to check its activity against various cariogenic bacteria and was proven to dramatically reduce them in root caries. 74,75

    Preliminary results from the first study conducted on root caries,76 which is the most prevalent form of caries in elderly patients, was very positive and shown to reverse the lesions clinically as well as to be safe for both patient and dentist.77

    New products on the market, The Ozi-cure from O3, South Africa and the HealOzone unit, manufactured by CurOzone in the U.S. can successfully treat dental unit waterlines with ozone to easily and very effectively control microorganisms using current dental unit designs.78 Once more it was tested with the 1H NMR and shown to alter the organic substance in water with bacterial contamination.79


    How does ozone work and affect the carious lesions?
    Answer: Ozone is a powerful agent that disinfects by destroying, neutralizing, or inhibiting the growth of pathogenic microorganisms. It has been found to be an effective alternative biocide to chlorine and possesses the added advantages of acting rapidly in lower concentrations and of having no side effects such as taste and odor, which are characteristic of other disinfecting agents.

    Ozone also decomposes to a harmless, non-toxic, environmentally safe material (oxygen). An old-new methodology, ozone was first suggested as a disinfectant for drinking water in the 19th century because of its powerful ability to inactivate microorganisms, but medical applications for it are relatively new. The use of ozone for managing caries is considered a breakthrough that is expected to be a cornerstone of dental care in the near future. Ozone can not only halt decay by killing the main acid-producing bacteria but also reverse dental caries by allowing the natural remineralization process to take place without the use of anaesthesia, drilling, or filling.

    How do dentists apply or use ozone in the practice? What are the advantages of such treatment?
    Answer: Ozone is supplied through medical devices, such as the O3 Ozi-cure or the HealOzone. Ozone is produced in the unit by passing air though high voltage. The ozone is then moved through tubing to a handpiece. The treatment is simple, time saving, efficient, effective, and conserves natural tooth structure.

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    January 2015
    The-O-Zone © Dr Julian Holmes