Effectiveness of ozone therapy in the treatment of periodontal diseases: a systematic review

PALMA, Pamella Valente; CUNHA, Rafaela de Oliveira; LEITE, Isabel Cristina Gonçalves

doi:10.1590/1981-86372023000420210085

Brasil

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ORIGINAL • Rev Gaúch. Odontol. 71 • 2023 • https://doi.org/10.1590/1981-86372023000420210085 linkcopy

Effectiveness of ozone therapy in the treatment of periodontal diseases: a systematic review

Eficácia da ozonioterapia no tratamento de doenças periodontais: uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The aim of this study was to evaluate the effectiveness of ozone as an adjuvant factor in the treatment of periodontal diseases. A systematic review was carried out using the PubMed, LILACS/BIREME, CoChrane, and Scielo databases and manual searches. Clinical studies published in English, Spanish, Portuguese, and French, between 1950 and 2020 that evaluated the effects of ozone in the treatment of periodontal diseases were included. The search resulted in 178 articles, of which 24 met the proposed eligibility criteria and were selected for this review. The risk of bias was assessed for each selected study in accordance with the Cochrane risk-of-bias tool - version 5.1.0. The selected studies evaluated the effect of ozone therapy on periodontitis, gingivitis, and peri-implant diseases. It was observed that the ozone in its oily form presented the best clinical results. In cases of periodontitis, it was concluded that ozone therapy in the gaseous form did not bring any additional benefit. With respect to gingivitis, ozone provided faster remission compared to the control group. And in peri-implant disease cases, ozone had the capacity to reduce the development of mucositis. Regarding microbiology, it was observed that ozone can continuously and significantly reduce periodontal microorganisms; however, with no difference from control groups. Further studies with adequate control of biases are suggested, using ozone in the oily or aqueous form, which are the most promising forms, also evaluating the possible effectiveness of ozone by-products.

Indexing terms Ozone; Peri-implantitis; Periodontal diseases

Study/ year of publication/country	Number and characteristics of participants	Intervention Group: Number of subjects and type of intervention	Control Group: Number of subjects and standard intervention	Outcome analyzed Results (Statistically significant difference)
GINGIVAL DISEASES
Martínez Abreu et al. (2006) [⁴] Cuba	100 patients with chronic edematous gingivitis^* * The term chronic edematous gingivitis has been replaced by gingivitis according to the new 2018 Classification of Periodontal and Peri-implant Diseases and Conditions.	N = 50 Scaling, root planing, and application of ozonated oil in the affected region.	N = 50 Scaling, root planing, and 0.2% chlorhexidine mouthwash.	Patients in the intervention group had faster remission compared to those in the control group (p=0.004).
Rosell et al. (2019) [²⁰] Cuba	60 patients with chronic edematous gingivitis^* * The term chronic edematous gingivitis has been replaced by gingivitis according to the new 2018 Classification of Periodontal and Peri-implant Diseases and Conditions.	N = 30 Application of ozonated oil in the gingival sulcus or pocket twice a week.	N = 30 Rinse with 0.2% aqueous chlorhexidine for 1 minute, once a day for 2 weeks.	No significant differences were found between groups of patients treated with ozonated oil and chlorhexidine, with remission of the condition in both groups.
Talmaç & Çalişir (2021) [²¹] Turkey	40 patients with gingivitis	N=40 Scaling and application of gaseous ozone for 60 seconds on each tooth every 2 days for 1 week.	N=40 Scaling and dental polishing.	No statistically significant difference was observed between intervention and control groups in terms of plaque index, gingival index, and probing depth (p>0.05). Statistically significant difference was observed only in the gingival bleeding time index between groups (p=0.0436).
PERIODONTITIS
Martínez Abreu & Sardinas (2005) [¹⁵] Cuba	84 patients with moderate chronic periodontitis	N = 42 Application of ozonated oil.	N = 42 0.2% aqueous chlorhexidine irrigation.	The reduction of signs and symptoms was faster in the group treated with ozone. The treatment efficacy at 180 days was considered good in 98% of patients in the experimental group and in 78% in the control group (p=0.00239).
Kshitish & Laxman (2010) [⁹] India	16 patients with generalized chronic periodontitis and aggressive periodontitis	N = 16 Ultrasound scaling and irrigation with ozonated water for 5 to 10 minutes (2nd and 3rd quadrants).	N = 16 Ultrasound scaling and irrigation with 0.2% aqueous chlorhexidine (1st and 4th quadrants).	Higher reduction percentage was observed in the plaque index (12%) (p=0.23), gingival index (29%) (p=0.042), and bleeding index (26%) (p=0.03) using ozone irrigation. The percentage reduction of Actinobacillus actinomycetemcomitans using ozone was 25% compared to no change using chlorhexidine. No antibacterial effect was observed on Porphyromonas gingivalis and Tannerella forsythensis with ozone or chlorhexidine. In addition, ozone had antifungal effect at baseline (37%) and on the 7th day (12.5%), unlike chlorhexidine, which showed no antifungal effect.
Skurska et al. (2010) [⁶] Poland	52 patients with chronic or aggressive periodontitis	Group 2 (N= 25 patients with chronic periodontitis) and Group 3 (N=15 patients with aggressive periodontitis): Scaling and gaseous ozone application.	Group 1 (N= 12 patients with chronic periodontitis): Scaling Group 4 (N= 14 patients without periodontal problems).	All clinical parameters evaluated in the study groups were reduced after treatment. Scaling with ozone therapy provided increase in MMP levels in patients with chronic periodontitis and reduction in MMP levels in patients with aggressive periodontitis. Scaling followed by ozone therapy does not lead to further improvement in clinical periodontal parameters in patients with chronic and aggressive periodontitis.
Hayakumo et al. (2013) [⁸] Japan	22 patients with mild to moderate chronic periodontitis	N = 11 Mechanical debridement and irrigation with nano ozonated water bubbles.	N = 11 Mechanical debridement and water irrigation.	Significant improvements in all clinical parameters were observed after 4 weeks in both groups. Reduction in pocket depth and clinical attachment gain after 4 and 8 weeks in the intervention group were significantly greater than in the control group. Only the intervention group showed statistically significant reductions in the mean total number of bacteria in the subgingival plaque during the study period.
Yilmaz et al. (2013) [¹⁶] Turkey	30 patients with chronic periodontitis	N = 10 Scaling and root planing and gaseous topical ozone.	Group 1 (n=10): Scaling and planing and laser application. Group 3 (n=10): Scaling.	Statistically significant improvements in clinical parameters were observed within each group. All treatments reduced the number of total bacteria and the proportion of obligately anaerobic microorganisms. Although intergroup comparisons of microbiological parameters did not show significant differences, the clinical findings, including attachment gain and pocket depth reduction, were statistically significant in group 1.
Al Habashneh et al. (2015) [²²] Jordan	41 patients with chronic periodontitis	N = 20 Non-surgical treatment and irrigation with ozonated water for 30/60 seconds.	N = 21 Non-surgical treatment and irrigation with distilled water for 30/60 seconds.	The use of ozonated water as adjunctive therapy for subgingival scaling did not produce statistically significant benefits compared to subgingival scaling with distilled water irrigation in terms of clinical outcome and hs-CRP level.
Shoukheba & Ali (2014) [¹¹] Egypt	30 patients with aggressive periodontitis	N = 15 Scaling, root planing, and application of ozonated oil.	N = 15 Scaling and root planing.	The results showed improvement in all clinical parameters of the intervention group, which was maintained for up to 6 months (P < 0.05). However, this improvement was more perceived after one month, gradually decreasing at 3 and 6 months. Scaling alone resulted in significant improvement only in the first month for parameters bleeding on probing, probing depth, and attachment level, and up to 3 months for parameters plaque index and gingival index, compared to baseline values.
Sisto et al. (2015) [¹⁷] Cuba	48 patients with periodontitis	N = 24 Subgingival application of ozonated oil for 7 consecutive days topically and inside the pocket.	N = 24 Subgingival irrigation with 0.02% chlorhexidine for the same period as the experimental group.	Ozonated oil was statistically significant only for the clinical parameter evolution of periodontal pocket depth (p = 0.0376).
Chaudhari et al. (2016) [⁷] India	20 patients with chronic periodontitis	N = 20 Scaling, root planing, and irrigation with aqueous ozone.	N = 20 Scaling and root planing without irrigation.	In the experimental group, statistically significant reduction in the gingival bleeding index, probing depth, and total microbial count was observed. It could be concluded that the application of ozone can be effectively used to treat periodontal diseases non-surgically.
Pandya et al. (2016) [⁵] India	10 patients with severe periodontitis	Group 2 (N = 10): Scaling and subgingival irrigation with ozonated water (2nd quadrant).	Group 1 (N = 10): Scaling and irrigation with 0.2% chlorhexidine (1st quadrant). Group 3 (N = 10): Scaling and irrigation with saline solution (3rd quadrant). Group 4 (N = 10): Scaling and root planing (4th quadrant).	Chlorhexidine 0.2% is more effective than ozonated water and can be used as adjunct to mechanical therapy to achieve significant reduction in inflammatory periodontal changes and also in the reduction of periodontopathogenic microflora.
Saeed et al. (2017) [¹] Egypt	16 patients with moderate chronic periodontitis	N = 8 Scaling, root planing, and application of ozonated oil gel in the subgingival region.	N = 8 Scaling, root planing, and application of placebo gel.	Intergroup comparison revealed that the group treated with ozonated oil showed more favorable clinical and microbiological results, with continuous and highly significant reduction in P. gingivalis counted up to 3 months and with non-significant deterioration at 6 months.

Uraz et al. (2019) [²³] Turkey	18 patients with chronic generalized periodontitis	N = 18 Scaling, root planing, and gaseous ozone application 3 times for 30 s (every 3 days)for 1 week.	N = 18 Scaling and root planing.	Adjuvant ozone therapy did not provide additional benefits to clinical, microbiological, and biochemical parameters in relation to scaling and root planing without irrigation in patients with chronic periodontitis.
Dengizek et al. (2019) [²⁴] Turkey	40 patients with chronic periodontitis	N = 20 Scaling, root planing, and gaseous ozone application in the gingival sulcus on days 3 and 8, after periodontal treatment.	N = 20 Scaling and root planing plus placebo.	The findings indicate that gaseous ozone-associated scaling is not associated with significant improvement in periodontal recovery compared to scaling and root planing treatment without ozone therapy.
Kaur et al. (2019) [¹⁰] India	20 patients with chronic periodontitis	N = 20 Irrigation with ozonated water for two hours and 30 minutes.	N = 20 Irrigation with 0.2% Chlorhexidine was performed for two hours and 30 minutes with the same pressure as the other group.	The present study showed significant results in both groups regarding the improvement of clinical parameters. When comparison was made between the two groups, the ozonated water group showed slightly higher improvement than the chlorhexidine group. However, statistically significant difference was observed only for the plaque index.
Tasdemir et al. (2019) [²⁵] Turkey	36 patients with moderate to severe generalized periodontitis	N = 36 Scaling and root planing with topical gaseous ozone applied to periodontal pockets twice a week for 2 weeks.	N = 36 Scaling and root planing with ozone application simulation.	Ozone therapy had no additional effect on periodontal parameters. All inflammatory parameters, PTX-3, Hs-CRP, and IL-1β, were reduced at 3 months of follow-up. However, only PTX-3 levels were significantly lower at ozone sites compared to those at control sites at three-months.
Verma & Indurkar (2019) [¹⁸] India	22 patients with moderate to severe chronic periodontitis	N = 11 Scaling, root planing, and irrigation with ozonated water (4 mg/L) in the subgingival region.	N = 11 Scaling, root planing, and irrigation with 0.2% chlorhexidine.	Statistically significant reduction was observed in the mean values of plaque index, gingival index, probing depth, clinical attachment level, and in the four periodontal pathogens analyzed in both groups. However, differences were not statistically significant when control and intervention groups were compared.
Ameyaroy et al. (2020) [²⁶] India	22 patients with chronic generalized periodontitis	N = 22 Scaling, root planing, and subgingival irrigation with ozonated water.	N = 22 Scaling, root planing, and photodynamic therapy.	Both subgingival ozonated water therapy and photodynamic therapy improved clinical outcomes after scaling. No statistically significant difference was observed in clinical parameters between ozone therapy and photodynamic therapy when evaluated after 2 months, 4 months, and 6 months, although slightly better clinical outcome was observed with ozone therapy.
Nardi et al. (2020) [²⁷] Italy	96 patients with periodontitis	N = 48 Scaling, root planing, and mouthwash based on ozonated olive oil.	N = 48 Scaling and root planing.	Non-surgical periodontal treatment associated with the use of ozonated oil led to significant and faster reduction in MMP^* * The term chronic edematous gingivitis has been replaced by gingivitis according to the new 2018 Classification of Periodontal and Peri-implant Diseases and Conditions. ^* * The term chronic edematous gingivitis has been replaced by gingivitis according to the new 2018 Classification of Periodontal and Peri-implant Diseases and Conditions. -8 concentrations in the saliva in patients with periodontitis. Periodontal indices decreased both in the study group and in the control group, without statistical significance.
Vasthavi et al. (2020) [¹⁹] India	24 patients with chronic periodontitis	N = 12 Scaling, root planing, and subgingival irrigation with ozonated water.	N = 12 Scaling, root planing, and subgingival irrigation with distilled water.	Statistically significant difference in clinical and microbiological parameters was observed in the study group and in the control group from baseline to 2 months. However, no statistically significant difference was observed in clinical and microbiological parameters between groups.
PERI-IMPLANT DISEASES
McKenna et al. (2013) [²⁸] UK	20 subjects with 80 implants (4 each)	Group 1 (N = 20): Ozone and saline solution (NaCl 0.9%). Group 3 (N = 20): Ozone and hydrogen peroxide.	Group 2 (N = 20): Hydrogen peroxide (3%) and oxygen. Group 4 (N = 20): oxygen and saline solution.	The trends for significant benefits were in increasing order of effectiveness: oxygen + NaCl; oxygen + hydrogen peroxide; ozone + NaCl, and ozone + hydrogen peroxide. Ozone with or without hydrogen peroxide can reduce the development of peri-implant mucositis and should be considered in clinical trials to assess its effect in the treatment of peri-implantitis.
Isler et al. (2018) [²⁹] Turkey	41 patients with 60 implants	N = 20 Mechanical debridement, implant surface decontamination with saline solution (3 minutes) and ozone (30 seconds per surface) + surgical regenerative therapy.	N=21 Mechanical debridement, surface decontamination of implants with saline solution (3 minutes) + surgical regenerative.	At 12-month follow-up, Plaque index and Gingival index values were significantly higher in the ozone group (P < 0.05). Probing depth decreased from 6.27 ± 1.42 mm and 5.73 ± 1.11 mm at baseline to 2.75 ± 0.7 mm and 3.34 ± 0.85 mm at the end of the 12-month observation period in the ozone and control groups, respectively. Likewise, the clinical attachment level values changed from 6.39 ± 1.23 mm and 5.89 ± 1.23 mm at baseline to 3.23 ± 1.24 mm and 3.91 ± 1. 36 mm in the 12-month follow-up, in the ozone and control groups, respectively. According to radiographic evidence, defect filling between baseline and 12 months postoperatively was 2.32 ± 1.28 mm in the ozone group and 1.17 ± 0.77 mm in the control group, which was a statistically significant difference between groups (P < 0.05).

Authors	Standard treatment type	Clinical markers	Complementary exams
GINGIVAL DISEASES
Martínez Abreu et al. (2006) [⁴]	Supragingival scaling. After interventions, all participants were instructed not to eat or wash their mouths until 2 hours after the procedure.	Probing depth, bleed on probing, color, consistency, texture gingival contour.	-
Rosell et al. (2019) [²⁰]	Supragingival scaling and bacterial plaque control.	Signs of inflammation: bleeding, consistency, stippling, size, contour and texture.	-
Talmaç & Çalişir (2021) [²¹]	Supra- and subgingival scaling and dental polishing.	Plaque index; gingival index; gingival bleeding time index; probing depth.	-
PERIODONTITIS
Martínez Abreu & Sardinas (2005) [¹⁵]	Not reported.	Presence of chronic gingival inflammation, depth of periodontal pockets.	Microbiological study with a sample of the gingival sulcus or periodontal pocket on the day of admission to the study and at 180 days of postoperative evolution.
Kshitish & Laxman (2010) [⁹]	Ultrasound scaling and root planing.	Plaque index, gingival index, gingival bleeding index.	Subgingival plaque was collected and analyzed by CRP.
Skurska et al. (2010) [⁶]	Scaling and root planing in groups 1, 2, and 3 (all with periodontal disease).	Plaque index, bleeding on probing, sulcus bleeding index, probing depth, clinical attachment loss.	On the clinical exam days, saliva at rest was collectedfor laboratory analysis of MMP-1 enzyme levels.
Hayakumo et al. (2013) [⁸]	Ultrasound scaling and root planing, supra-and subgingival.	Probing depth, clinical attachment level, probing percentage bleeding recorded at all six sites per tooth (mesial, distal, and middle on the buccal and lingual sides).	Microbiological exam performed immediately before and after treatment and 1 and 8 weeks after treatment.
Yilmaz et al. (2013) [¹⁶]	Scaling and root planing.	Plaque index, sulcus bleeding index, probing depth, attachment levels.	Samples from representative periodontal areas were collected for the evaluation of microbiological parameters at time 0 and 90 days.
Al Habashneh et al. (2015) [²²]	Scaling and root planing, supra- and subgingival, using manual and ultrasonic instruments.	Probing pocket depth, bleeding on probing, clinical attachment loss, gingival recession (all measured at 6 sites on each tooth - mesial, distal, and middle on the buccal and lingual sides). Plaque index and gingival index (assessed at 4 sites - mesial, distal, buccal, and lingual) in the Ramfjord teeth.	After examining each patient, 5 mL venous blood sample were obtained after a 10-hour fast period, at T0 and T1, to measure highly sensitive serum C-reactive protein concentrations.
Shoukheba & Ali (2014) [¹¹]	Scaling and root planing of all teeth using manual and ultrasonic instrumentation.	Plaque index, gingival index, bleeding on probing, probing depth, and clinical attachment level.	Before treatment, a subgingival plaque sample was collecetd from the deepest periodontal pocket (6 mm probe depth) for real-time CRP analysis.
Sisto et al. (2015) [¹⁷]	Not reported.	Color, contour, consistency, texture, edema, position, bleeding on probing, depth of periodontal pockets, corroborated by X-ray; basic periodontal Index.	-
Chaudhari et al. (2016) [⁷]	Scaling and root planing.	Gingival bleeding index, probing depth, attachment level (all recorded at baseline and at 3 weeks post intervention).	Plaque samples were collected for microbiological study at baseline and immediately at the following day, but without identification of microbiological types.
Pandya et al. (2016) [⁵]	Scaling and root planing of the entire mouth with irrigation.	Gingival index and probing depth at day 0 and 30 after treatment.	Plaque samples were collected for microbiological analysis from the mesial surface of the 1st molar of each quadrant 20 seconds after the end of the prescribed treatment.
Saeed et al. (2017) [¹]	Scaling and root planing with manual and ultrasonic instrumentation, entire mouth polishing in 1 session.	Probing depth, clinical attachment level, bleeding on probing, plaque index (all measured before treatment, and 1, 3, and 6 months after treatment).	Plaque samples collected for CRP analysis.
Uraz et al. (2019) [²³]	Scaling and root planing performed under local anesthesiausing manual and ultrasonic instruments in a single consultation for each quadrant.	Plaque index, gingival index, bleeding on probing, and probing depth.	In the 3 pockets ≥ 5 mm in depth, gingival fluid and plaque were collected at time 0 and 1 and 3 months after treatment for CRP analysis by Elisa.
Dengizek et al. (2019) [²⁴]	Scaling and root planing, supra- and subgingival, throughout the mouth with irrigation, with manual and ultrasonic instruments.	Plaque index, gingival index, probing depth, clinical attachment level (performed one month after the second ozone application).	Total antioxidant status and total nitric oxide oxidizing status, 8-hydroxy-2’-deoxygguanosine, myeloperoxidase, glutathione, malondialdehyde Transforming growth factors were evaluated from saliva samples collected before and one month after the second application of each treatment.
Kaur et al. (2019) [¹⁰]	Scaling and root planing of the entire mouth.	Gingival index, probing depth, clinical attachment level.	-
Tasdemir et al. (2019) [²⁵]	Scaling and root planing through manual instrumentation andlocal anesthesia.	Plaque index, gingival index, probing depth, bleeding on probing, percentage of sites with bleeding on probing, and clinical attachment level.	Gingival fluid, interleukin-1β, and high-sensitivity CRP protein were evaluated.
Verma & Indurkar (2019) [¹⁸]	Half-mouth supra-and subgingival scaling and root planing with irrigation, with manual and ultrasonic instruments.	Plaque index, gingival index, probing depth, and clinical attachment level.	Subgingival plaque samples were collected on the preliminary visit and after 6 weeks, and sent for analysis (CRP). The following periodontal pathogens were analyzed: Aggregatibacteractinmycetemcomitans Porphyromonasgingivalis Tannerella forsythia Prevotella Intermedia
Ameyaroy et al. (2020) [²⁶]	Total scaling and root planing.	Gingival index, probing depth, and clinical attachment level.	-
Nardi et al. (2020) [²⁷]	Scaling and root planing.	Probing depth, plaque index, bleeding on probing.	Active salivary matrix metalloproteinase levels were analyzed by PerioSafe® (Dentagnostics, Jena, Germany), a diagnostic test for the prevention of periodontal and peri-implant disease.
Vasthavi et al. (2020) [¹⁹]	Scaling and root planing.	Plaque index, gingival index, and pocket depth.	Subgingival plaque was collected from selected teeth in each patient at sites that showed pocket depth of 5 mm or more at T0, T2, and T3. Samples were analyzed using the BANA-Zyme™ processor to assess periodontal pathogens of the “red complex”.
McKenna et al. (2013) [²⁸]	Cleaning without using mouthwash two weeks before and at the beginning of the trial. The entire mouth was cleaned with the exception of the implant region, for mucositis induction.	Plaque index, bleeding index, and modified gingival index.	-
Isler et al. (2018) [²⁹]	Regenerative surgical treatment with mechanical debridement, implant surface decontamination with sterile saline solution and ozone therapy and bone graft + PRF.	Plaque index, gingival index, clinical attachment level, gingival recession, probing depth, and bleeding on probing.	CGF: concentrated growth factors.

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[1] Note:

[TFN01] ^*
The term chronic edematous gingivitis has been replaced by gingivitis according to the new 2018 Classification of Periodontal and Peri-implant Diseases and Conditions.

[TFN02] ^**
MMP = extracellular matrix metalloproteinases.