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Profile in Oral Health Trisha O’Hehir, RDH, BS, Hygienetown Editorial Director

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An interview on ozone research with Professor Edward Lynch, MA, BDentSc, PhD
by Trisha O’Hehir, RDH, BS, Hygienetown Editorial Director
The body of ozone research has grown over the past decade to more than 100 published research studies. This new technology was used first in dental practices in the UK and Europe, and has been slow to gain recognition and prominence in the United States. It was first thought that ozone needed FDA approval to be used in the United States, but it has been grandfathered in because ozone was used in the medical and dental fields before the 1906 Pure Food and Drug Act.

Ozone is blue, has a strong odor and contains three oxygen atoms
(O3) and is primarily found in the earth’s upper atmosphere from about 10 km out to 50 km – the stratosphere. It is thinnest at the equator and thicker toward the poles. This ozone layer absorbs some of the sun’s harmful ultraviolet rays, protecting us from them. The term “ozone” comes from the ancient Greeks who noticed the strong smell after electrical storms and the good fishing that followed. Native Americans made the same connection and the custom of fishing after an electrical storm remains a custom today. Ozone is considered the agent of choice for the disinfection of public water supplies as it kills bacteria by rupturing cell membranes within two seconds. Medical uses for ozone date back to the mid 1800s when it was first used for purifying blood. Today it’s used for the management of circulatory disorders, viral diseases and cancer. Ozone used in dentistry penetrates tooth structures to eradicate bacteria and enhance remineralization.

The man behind most of the research is Professor Edward Lynch, of Warwick University in England. I’ve followed his research and asked him many questions on this subject over the past decade. Ozone therapy is already an integral part of both prevention and dental therapy carried out by more than 100,000 dental care professionals worldwide.

Why hasn’t ozone therapy been more readily accepted in the US?
Professor Edward Lynch: The generally perceived wisdom has always been that dental caries is an infective process and the only real treatment option was the cutting away, or amputation, of all diseased tissue and its replacement with some form of restorative material. This is the teaching that most dental students still receive at dental schools around the world today, and is practiced like a religion by the majority of dentists worldwide. Once entry into this religion is gained, the individual is condemned to a cycle of restorative care that becomes more expensive and complex as it fails and has to be replaced. Some individuals may attain a state of oral health that sees them achieve stability for many years, but the vast majority will continue within this cycle of restorative destruction and replacement.

In the past the restorative philosophy was “extension for prevention,” cutting away healthy tooth structure. Has that philosophy changed?
Lynch: There has been a move toward cutting smaller preparations, toward an approach of minimally invasive dentistry, with the associated benefits to both the clinician and patient. Many techniques, however, still involve the physical removal of tissue before the final restoration is placed. Ozone use fits perfectly into this philosophy as it allows up to 1mm of caries to be left on the cavity floor prior to ozone treatment and restoration.

What is the ideal treatment solution?
Lynch: The ideal treatment solution is the simple removal of the cause of the disease process with no associated loss of sound tissue and no associated physical discomfort for the patient. This means earlier intervention; before cavitation of the lesion with recent advances in the field of ozone treatment, this is now possible. For the first time, the dentist can break the ongoing circle of restorative dentistry, as it would appear placement of the initial restoration is no longer always necessary. Once a filling is placed, it will require eventual replacement and subsequent re-treatment. Ideal treatment is preventing the first restoration. Ozone of course should be combined with all our other preventive regimens.



When was ozone first used for dental care?
Lynch: The first record of ozone use in dental care was by a Swiss dentist, Dr. E.A. Fisch, who used ozone in dentistry before 1932, and introduced it to the German surgeon Dr. Erwin Payr, who used it from that time. However, ozone disappeared from usage in dental care until 2000 when the first scientific studies were published.

What did studies show?
Lynch: These studies showed that acids produced by bacteria were oxidized to less acidic products by the ozone treatment, for example pyruvic acid is oxidised by ozone into acetate and carbon dioxide. They also proved the excellent antimicrobial effectiveness of ozone. These antimicrobial effects and oxidative by-products adjusted the lesion pH to being more alkaline, so allowing a net gain of minerals by the lesion. This remineralization process is the fundamental by-product of ozone treatment that leads to predictable mineral uptake by a treated surface. By eliminating the ecological niche and acid niche environment, the lesion can undergo a natural mineral uptake, so healing itself.

Please explain the bacterial niche concept and how ozone works in this concept.
Lynch: According to “The Niche Environment Theory,” a “microbial niche” is established within a carious lesion. Microorganisms are far from the “simple bugs” having survived for billions of years, where humans have but a minute time frame of existence in comparison. The dental profession should not be surprised to learn that bacteria set up complex interactions with other bugs, talk to neighboring colonies when times are good, and call for help from others when their host attempts to change their environment. Protein coatings, plaque and debris are known to protect these colonies by reducing the effect of pharmaceutical agents designed to eliminate these microbial colonies. Ozone has the effect, through its powerful oxidizing properties, of not only removing the protein protection and being bactericidal, but also oxidizing the biomolecules that allow the niche to survive and expand. This has a severely disruptive effect on the bacterial population in the carious lesion and obliterates the cariogenic bacteria and their ecological niche, thereby swinging the equilibrium in favor of remineralization. No more acid can be produced within the lesion when the acid-producing microorganisms are eliminated or severely reduced.

After ozone therapy, the lesion will become populated with more normal mouth commensals, which do not produce significant acid.

Many studies have shown that caries reversal is possible, but how do you predict which lesions will, and which will not, reverse.
Lynch: Ozone treatment, combined with added oral hygiene products that increase the oral fluid concentration of bio-available minerals, makes this remineralization process predictable. New technology also provides objective rather than subjective diagnosis of the demineralizaton process. The more shallow the carious lesion the more predictable the remineralization will be.

Published studies have shown a caries reversal rate of from 84 percent to 99 percent, depending on which protocol is followed. Where only one variable is used, for example ozone or no-ozone, the reversal range is from 84 percent to 92 percent. Compare this to periodic ozone treatment in combination with oral hygiene instruction, strict usage of remineralization products, and including only shallow lesions, and reversal rates of up to 100 percent are achieved. Following this treatment protocol provides outcomes that are more predictable.

How will diagnosis of caries lesions change with this more preventive approach?
Lynch: Clinicians have to completely reassess their diagnostic and detection criteria when applied to dental caries. The International Caries Detection and Assessment System (ICDAS) provides a new visual assessment tool with excellent criteria. The dental explorer is no longer of any significant use for caries detection and hence examination is based on the use of a digital intraoral camera combined with selective use of the DIAGNOdent, which has been extensively tested against the Electric Caries Monitor (Lode, Belgium) and against conventional diagnostic criteria. Looking for holes with an explorer is a concept that cannot be part of modern dental care. The detection of demineralization within the enamel layer is of paramount importance, before the carious process has an opportunity to penetrate into the dentin below. Measuring the results of ozone therapy show immediate and lasting results, based on changes in DIAGNOdent reading.*

Most people, myself included, don’t enjoy having local anesthesia and drilling on our teeth. How do your patients react to ozone treatment?
Lynch: Patients are delighted after treatment and are particularly motivated toward oral hygiene and dietary control and fluoride use when they realize that in improving and concentrating on these areas they can effectively avoid the local anesthesia/drill approach for shallow lesions. Of course, there are still situations where treatment will follow more classical lines. However, these instances are becoming increasingly rare. Treatment acceptance of my patients and of those reported in the research is usually 100 percent. Patients, especially parents, prefer preventing the need for any anesthesia and drilling for their children.

Is ozone used for more than remineralization?
Lynch: A wide variety of carious lesions can be treated with no need for local anesthesia, no need for drilling, and in a very short appointment, totally painless and totally atraumatic. Where caries has penetrated into the deeper dentinal tissue, ozone still has an important role to play. In these cases, the loose debris is first removed to the leathery subsurface, ozone is applied, and then remineralizing solutions and glass ionomers can be applied. Carious tissue still has to be removed whether by use of the handpiece, air abrasion, or with hand instruments (ART) when used in conjunction with caries removing liquids and gels (e.g. Carisolv). Ozone treatment of dental caries removes the requirement for physical removal of diseased tissue as the dental profession is now promoting remineralization and not amputation of carious dentin.

Can ozone be used for root surface caries?
Lynch: Yes, ozone is clinically effective in the management of root carious lesions. These lesions often present in the elderly who may have associated medical problems, which complicate their dental management. Using ozone therapy, such lesions are easily treated. The portability of ozone units facilitates its use in the domiciliary setting and treatment is also simplified because the clinician does not need to carry a range of restorative materials on such visits. Dentists using ozone units for caries management, encourage their patients to regularly use a fluoride- containing mouthwash, that will enhance the efficacy of ozone by promoting remineralization and to reduce the frequency of consumption of fermentable carbohydrates. Dr Julian Holmes has published a double blind randomized controlled clinical trial proving the reversal of shallow root carious lesions using the HealOzone.

Is ozone used with fissure sealants?
Lynch: Ozone should be used prior to the placement of every fissure sealant.

How are carious lesions treated in deciduous teeth with ozone?
Lynch: Treatment is simple, fast (the average ozone time for practitioners using ozone is 30 seconds) and can involve little preparatory work. The loose debris is first cleaned away, until a leathery base is reached. This can be done with air abrasion or hand instruments. Ozone is applied, the lesion wetted with a remineralizing wash and then a glass ionomer can be placed. Ozone treatment eliminates the bacteria and the glass ionomer will supply long-term fluoride and mineral release, as well as preventing ingress of food debris and re-establishment of the acid-niche environment.

What ozone delivery systems are available to clinicians?
Lynch: Two systems have been proven safe for dental use, the HealOzone for treating tooth surfaces and reversing caries and the TherOzone for treating water. The HealOzone system produces ozone-oxidizing gas filtered through a dental handpiece fitted with a special silicone cup to direct and control the ozone gas safely to the tooth surface and back into the system.

Many dental offices use TherOzone treated water to control microbial growth in unit waterlines, instead of regular water in power scalers for scaling and root planing, and as the final irrigant during root canal therapy.** Teeth may be whitened using ozone gas or ozonated water combined with hydrogen peroxide, due to its strong oxidizing properties.

A new unit, the CMU3 by Lime Technologies, allows a free flow of ozone without a seal. Instead of returning back into the unit and being converted to oxygen, the ozone is released into the air around the application tip and is captured using high volume evacuation. The risk with this delivery system is not removing all the ozone or removing ozone before it has had sufficient treatment time on the tooth surface.

The newest products available are ozonated oils and creams that can be used topically, delivered subgingivally or delivered in a full-mouth tray system. Grey Cell Enterprises in South Africa manufactures organic ozonated oils and creams, also available in the USA.

Thank you Professor Lynch. It’s clear that ozone therapy provides an exciting treatment modality with considerable benefits for dental patients of all ages. This treatment is simple and completely safe. As a dental hygienist focused on prevention of dental disease, ozone is sure to become an important tool in this endeavor.

*Lynch, E. Evidence-based caries reversal using ozone. J Esthet Restor Dent. 2008;20(4):218-22.
**Lynch, E. Evidenced-based efficacy of ozone for root canal irrigation. J Esthet Restor Dent. 2008;20(5):287-93
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