Evaluating clinical and laboratory effects of ozone in non-surgical periodontal treatment: a randomized controlled trial

Abstract Objective: This study aims to evaluate the clinical and biochemical (oxidative stress and pro-inflammatory mediators) effects of the gaseous ozone use accompanied by scaling and root planning (SRP) in periodontal treatment. Material and Methods: The study population consisted of 40 patients with chronic periodontitis (CP) randomly sorted into two groups of 20. The experimental group received SRP plus 3 watts gaseous ozone in two separate applications five days apart, whereas the control group received SRP plus placebo. Clinical periodontal parameters were assayed and saliva samples were taken before the initial and one month after the second treatment. Periodontal examination assessed plaque index (PI), gingival index (GI), probing depth, and clinical attachment level (CAL). Total antioxidant status (TAS), total oxidant status (TOS), nitric oxide (NO), 8-hydroxy-2'-deoxyguanosine (8-OHdG), myeloperoxidase (MPO), glutathione (GSH), malondialdehyde (MDA), and transforming growth factor-beta (TGF-β) levels were evaluated from saliva samples. Results: Changes following treatment in PI, GI, probing depth, and CAL scores were similar for both groups (p>0.05). Of note, TGF-β levels were observed to be higher in the treatment group than in controls (p<0.05). Changes in 8-OHdG, TAS, TOS, NO, MPO, GSH and MDA levels, however, were not significantly different between groups (p>0.05). Conclusion: The findings of this study indicate that SRP plus gaseous ozone versus SRP alone does not correlate to a significant improvement in periodontal recovery.


Introduction
The complicated interaction between the immune inflammatory response and periodontopathogenic bacteria usually results in chronic periodontitis (CP).
In clinical terms, CP is characterized by periodontal pockets, gingival inflammation, and loss of attachment to and in the alveolar bone, which can eventually lead to tooth loss. 1  relation between PD, reduced salivary AO status, and increased oxidative damage. 5,6 An increase in levels of 8-hydroxy-2'-deoxyguanosine (8-OHdG), a biomarker of oxidative stress, has also been reported to be associated with periodontitis. 7 Treatments for periodontitis focus on reducing pathogens embedded in the subgingival biofilm. 8 Modalities range from oral hygiene instruction, non-surgical periodontal treatment (NSPT), and supra-and subgingival debridement, to periodontal surgery. NSPT may be applied by hand or via powered instrumentation. Studies conducted thus far indicate that NSPT reduces tooth loss risk, slows PD progression rate, and enhances gingival health, and NSPT is considered an indispensable therapy component against inflammatory PD. 9 However, effectiveness of NSPT is limited in certain areas, such as difficulty to reach and deep pockets. 10 The use of laser or ozone has been discussed as an alternative to this process, and recent reports include the use of ozone in dentistry as an alternative oral antiseptic component. 11 According to recent studies, gaseous and aqueous forms of ozone have high antimicrobial power against oral pathogens and are impervious to resistance. 12 Between 1880 and 1932, the ozone therapy method was widely used as an alternative medication in the United States, and many countries currently accept ozone therapy as a treatment modality. 13 Ozone is an unstable matrix of three oxygen atoms (O 3 ), and has been shown to be an impressive antiviral and antifungal agent. 14 It has been used as a therapeutic agent for chronic wounds (e.g., trophic and ischemic ulcers, diabetic wounds, etc.) in several empirical studies. 15

Study population
We utilized a randomized, parallel controlled, and The device was applied without ozone (placebo) in the control group.

Randomization of the study
Forty patients were distributed randomly between the two treatment groups. One researcher maintained the randomization list until patients were found to be eligible for the study. The clinician who performed the therapy was not informed about the modality of the treatment until the beginning of the first session for each patient. Results were evaluated blindly before and

Results
Socio-demographic characteristics of the study participants are shown in Table 1 After treatment, changes in the PI, GI, probing depth, and CAL were also similar for both groups (p>0.05) ( Table 2).
Baseline laboratory findings were similar for both groups (p>0.05). The increase of MPO and TAS was observed in both groups after treatment (p<0.05).
However, the increase of TGF-β levels was significantly greater in the test group compared with controls (p<0.05). Levels of 8-OHdG decreased in both groups after treatment (p<0.05) ( Table 3).
Changes in 8-OHdG, GSH, MDA, MPO, TAS, TOS, and NO levels were similar between groups (p>0.05). Statistically significant differences between the ozone and control groups were limited to TGF-β levels following treatment (p<0.05) ( Table 3).

Discussion
This is the first study to evaluate both clinical    of attachment loss, the decrease in pocket depth, and the elimination of inflammation. 25 In order to reach these goals, the first treatment option for patients whose pockets are not deep is non-surgical. 26 However, the success of non-surgical treatment with hand tools and cavitron is limited where pockets are difficult to reach. 10 In addition, the effectiveness of non-surgical treatment in tissue regeneration, a primary therapeutic target, is less than ideal. As such, changing the host In addition, TGF-β levels were evaluated as a biochemical marker for tissue recovery. Previous studies have reported that an increase in TGF-β levels was associated with a decrease in periodontal inflammation, leading to improved outcomes. 40 We did observe that TGF-β levels increased significantly in the ozone-treated group, supporting the claim that gaseous ozone treatment increases the regeneration activity of periodontal tissues. The difference in TGF-β levels could indicate that ozone therapy can contribute to periodontal treatment; however, we found that clinical recovery and changes to biochemical parameters were similar for both groups, confounding this result. The ozone application effect on whole oxidant and AO levels may be limited due to multiple factors involved in immune response and recovery.
Follow-up was limited to one month after second treatment application, which did not permit the evaluation of long-term periodontal outcomes.
Although this period was beneficial in terms of eliminating the differences in hygiene practices among the patients and evaluating the short-term host responses, further studies on the long-term effects of ozone treatment on PD are needed.

Conflict of Interest
There is no conflict of interest for this study.