Efficacy of Ozonated Sunflower Oil on the Periodontal Status of Brazilian Air Force Recruits: A Randomized Controlled Clinical TrialABSTRACT
Objective: To observe the impact of military training on the oral health of Brazilian Air Force (FAB) recruits in the first phase and to assess the efficacy of ozonated sunflower oil (Oleozon) in improving the periodontal indices of FAB recruits in the second phase.
Material and Methods: In the observational phase, PPD (periodontal probing depth), CAL (clinical attachment level), PI (plaque index), GI (gingival index), and DMFT (decayed, missed, and filled teeth) values were compared before and at the end of military training. In the interventional phase, a randomized, double-anonymized, placebo-controlled study was conducted to evaluate whether the daily use of oleozon added to toothpaste would improve periodontal indices.
Results: At the end of their military training, recruits exhibited a significant worsening in periodontal disease indicators, resulting in increased dental costs for FAB and increased duty absence. In the second phase, a substantial reduction in PPD and GI (p<0.004 and p<0.001) was observed in the oleozon group.
Conclusion: Oleozon, in association with toothpaste brushing, was superior to brushing alone in improving the periodontal health. Despite the need for further studies, it is proposed that oleozon should be included in the oral hygiene protocol for Brazilian Air Force recruits, thereby reducing periodontal risk and dental costs.
Keywords:
Ozone; Sunflower Oil; Periodontal Diseases; Military Medicine
Introduction
Dental diseases are well-documented problems within war operations scenarios. The literature indicates that military training is associated with increased indicators of periodontal diseases and dental caries [1,2]. Oral biofilm is deposited on the teeth, causing dental caries and gingival inflammation. If biofilm is not adequately removed, the initial subclinical inflammatory process progresses to gingivitis [3]. It is well-established that gingivitis is a risk factor for periodontitis [4], a condition characterized by a periodontal breakdown that can ultimately lead to tooth loss. Periodontal disease is associated with difficulties in chewing, reduced nutrient absorption, impaired physical performance, increased risk of cardiovascular events, and an increased likelihood of metabolic and neuropsychiatric disorders [5].
Periodontal diseases affect the tissues surrounding the teeth, and gingivitis is the most prevalent and least severe problem, affecting approximately 90% of the world's population, including Brazil [6]. It is an inflammation restricted to the gingival tissues caused by the accumulation of dental biofilm [7]. Since it is limited to soft tissues, gingivitis is reversible, provided that correct oral hygiene is maintained. On the other hand, periodontitis is a gingivitis progression involving the different structures of the periodontium and is a chronic, destructive, and irreversible inflammatory condition affecting 11% of the population. In periodontitis, bacteria invade the periodontal ligament, cementum, and alveolar bone, triggering an inflammatory response that destroys tooth support and ultimately leads to tooth loss [8]. It is believed that military personnel under training are more likely to develop periodontal problems [9,10].
Military personnel affected by periodontal diseases acquire serious outcomes in both actual and simulated situations. Older studies had already addressed the theme by assigning specific designations, such as "trench mouth," to rapid progression necrotizing diseases [11] often observed on the battlefields of World War I and II [12]. The increased interest is due to the loss of ability to fight and sometimes death from sepsis associated with such periodontal problems [13]. The causes of this worsening condition in combatants are listed as low immunity and changes in the microbial load of oral biofilm, which are caused by stress, smoking, poor nutrition, and inadequate oral hygiene [14].
Previous studies have reported severe necrosis of periodontal tissues as a common finding among combatants in missions and current conflicts, often resulting in aeromedical evacuation and non-fulfillment of the mission. Sixty-five percent of French soldiers who had these pathologies on missions in Afghanistan had to be evacuated from the conflict zone [11]. Given the importance of preventing this type of disease among combatants, the Israeli Army has a program for the prevention and treatment of oral diseases, mainly to avoid the discharge of soldiers in combat [15].
Several interventions are used to block the progression of periodontal diseases, aiming to remove and control dental biofilm [7]. Therapeutic strategies depend on the type and degree of periodontal diseases. In addition to mechanical control of dental biofilm, adjuvant methods have been reported, including the use of several therapeutic forms of ozone [16,17,18].
Ozone gas (O3) was discovered in 1785 by Martinus Van Marum. It is an allotropic form of oxygen that is highly reactive, oxidizing, and unstable. Ozone has been shown to have a potent, broad-spectrum antimicrobial action, promoting tissue oxygenation and exhibiting anti-inflammatory and immunostimulatory effects. Another relevant feature of military dentistry is its low cost [19,20,21].
The reported therapeutic ozone applications in dentistry have included injectable gas, ozonated water, and ozonated oil [22,23]. In periodontal diseases, ozone has been applied as ozonated irrigation water during root scaling (surgical or nonsurgical); gas is injected into the bottom and sides of periodontal pockets and the periodontium. Research also indicates that the patient can use ozonated oil topically during the ambulatory scaling procedure as an antiseptic agent [24,25,26]. The previously observed reduction of MMP-8 metalloproteinase may explain the anti-inflammatory action associated with ozonated oil [27].
A crucial issue is that ozone gas degrades rapidly (2 to 3 minutes) and must be applied immediately to the patient to achieve positive results [23,28,29]. Thus, once the therapeutic forms of ozone gas and ozonated water have been produced, they must be quickly applied to the patient. The ozone concentrations in gas and water influence the results obtained: low ozone concentrations (up to 20 µg/ml in the gas) are considered anti-inflammatory. In comparison, high concentrations have a disinfectant action (above 40 µg/ml in the gas) [25]. Similarly, ozonated water is quite effective in removing contaminated biofilms [30] at specific concentrations for bacteria, fungi, and viruses (the O3 concentration measured in water corresponds to approximately one-quarter of the values in the gaseous form) [17]. The way O3 dissolves in water is also crucial: the smaller the O3 bubbles dissolved in water, the higher the final O3 concentration, and the greater the antimicrobial effects [22].
The use of ozone in dentistry has been reported for its antimicrobial action, although its complete mechanisms of action still require further study [31]. Its antimicrobial action is attributed to the removal of glycolipids and glycoproteins from the cell membranes of microorganisms, thereby allowing ozone to enter the cell [32]. The chemical reactions of ozone in the cytosol produce free oxygen radicals, which modify the microorganism's internal environment, leading to its lysis [33]. Ozonated sunflower oil is a potent antimicrobial and anti-inflammatory agent. The literature indicates that topical use can reduce periodontal indices in periodontal diseases, thereby reducing the need for specialized treatment. Ozonated sunflower oil increases the number of leukocytes and monocytes, enhances granulocyte phagocytosis, and stimulates T-cell activity. [34]. Ozone increases the production of hydrogen peroxide [35]. The anti-inflammatory and healing properties of ozonated sunflower oil are attributed to the formation of 1-2-4 trioxolane, an endoperoxide that, once activated, releases reactive oxygen species [36], which is also responsible for its disinfectant action [37]. Studies evaluating the efficacy of ozonated sunflower oil in treating chronic periodontitis in adults compared with chlorhexidine have shown superior results for ozonated oil in reducing pocket depth, bleeding rate, and the recovery of typical gum characteristics [19,20,26,28,29,38]. Interestingly, ozonated sunflower oil has shown superior antibacterial activity compared to chlorhexidine and povidone-iodine against Streptococcus aureus and Porphyromonas gingivalis, the latter being a significant periodontal pathogen [39]. In another study, ozonated oil demonstrated higher immune activation of lymphocytes and the release of platelet growth factors [40, 41].
The Brazilian Air Force (FAB) provides dental treatment for all its service members. This way, proposals to improve the oral health of FAB's military personnel can save costs. Thus, the present research aimed to evaluate the impact of military training on the oral health of recruits. Additionally, the short-term efficacy of ozonated sunflower oil in reducing periodontal indices of FAB recruits was also evaluated.
Material and Methods
Study Design and Sample
This study was divided into two phases. In the first study, the oral health of recruits was compared at the beginning and end of their military training to verify the hypothesis that training has a negative impact on their oral health. The second interventional phase aimed to assess the efficacy of ozonated sunflower oil, thereby testing its ability to improve the periodontal status of recruits.
In the first part, an observational incidence study was conducted: the oral status of 62 Brazilian Air Force (FAB) recruits was analyzed at the beginning and at the end of a 5-month military mandatory training period. Recruits were young males aged 18 to 19 years.
The first part took place in São José dos Campos, SP, Brazil, during the first semester of 2022. The inclusion criteria were to be enlisted as a recruit in the 1st semester of 2022, to agree to undergo oral examinations, and to sign the Informed Consent Form (ICF). Of the 270 recruits, a total of 62 were selected (sample calculation: n = 18 for each group of independent unpaired variables, evaluated through a quantitative or numerical variable using Student's T-test, as obtained from the calculator developed by Lauris JRP, PhD, available on the http://calculoamostral.bauru.usp.br/calculoamostral/index.php website, accessed on September 13, 2021). PI, GI, PPD, NCI, and DMFT clinical indices were evaluated using the sample size calculation.
Clinical Data Collection
Whole-mouth (except third molars) periodontal parameters PPD (periodontal probing depth), NCI (clinical attachment level), GI (gingival index), and PI (plaque index), as well as DMFT (number of decayed, missing, and filled teeth), were measure by two previously calibrated dentists (Kappa agreement value = 0.81) at the beginning and the end of the military training.
PPD was evaluated by measuring the distance in millimeters from the gingival margin to the bottom of the gingival sulcus or periodontal pocket using a periodontal probe and applying gentle force until resistance was encountered [1]. NCI was measured in millimeters from the cementoenamel junction (CEJ) to the gingival margin [1]. PI and GI were qualitative, i.e., the score related to the absence (0) or presence (1) of dental plaque and gingival bleeding after 30 seconds [2] had also been evaluated, respectively. Six measurements were performed per tooth: mesio-buccal, mid-buccal, disto-buccal, mesiolingual, mid-lingual, and distolingual surfaces.
A randomized, double-anonymized, placebo-controlled clinical trial with an additional 62 participants was also conducted in São José dos Campos, São Paulo, during the second semester of 2022, aiming to evaluate the efficacy of ozonated sunflower oil on their periodontal status.
As in the first part, 62 recruits who did not participate in the observational phase were selected (the sample size calculation indicated n=18 for each group, using the PPD, NCI, PI, and GI indices for two groups of independent unpaired variables evaluated through a quantitative or numerical variable (Student's T test). A sample calculation was obtained using the calculator prepared by Lauris JRP, PhD, available on the http://calculoamostral.bauru.usp.br/calculoamostral/index.php website, accessed on September 13, 2021.
These 62 recruits were divided into two treatment groups (n = 31): The control group (placebo) and the test group (Oleozon). Groups were formed by randomization with the aid of the C++ software, using the Mt19937 routine of the STL (Standard Library) of C++ 2017 itself (version std=c++17) and an operational seed of the C++17 system through the std: random device directive. The distribution used was std::uniform_int_distribution <int>, which generated a distribution list of numbers from 1 to 62 in two groups, ensuring a reliable random distribution. An independent research assistant implemented the random list.
The inclusion criteria were to be a recruit in the 2nd semester of 2022, to agree to and sign the ICF, and to report some gingival bleeding or inflammation. A lecture was given explaining the importance of oral brushing to recruits. Recruits were informed about the research objectives, risks, and benefits of using ozonated sunflower oil. It should be noted that recruits had access to dental treatment, including specialists in Periodontics, provided by FAB, for at least 11 months, including the study period.
The Control group received a bottle containing 15 ml sunflower oil (Helianthus annuus) to be added in 3 drops to the toothpaste during daily toothbrushing. The Oleozon group received a bottle containing 15 mL of ozonated sunflower oil (peroxide index approximately 600 mmol-eq/Kg) to be used in the same manner as the Control group. Sunflower oil and ozonated sunflower oil were purchased from the same company (Blustratum, São José dos Campos, São Paulo, Brazil, Anvisa registration No. 25351.191000/2022-74), the former being used in the production of the latter. Groups were periodontally analyzed at two separate time points: before the use of sunflower oil and 30 days after the initial use of sunflower oils. The indices were obtained as described in the first part of the study.
Data Analysis
PPD, CAL, PI, GI, and DMFT indices obtained in the first part and PPD, CAL, PI, and GI obtained in the second part of the study were analyzed using the Student's t-test for paired groups (p<0.05) (Jamovi Software, https://www.jamovi.org, accessed on May 6, 2024).
Ethical Clearance
This study was conducted in accordance with the standards for the development of research involving human subjects, as outlined in Resolution 466/12 of the Brazilian National Health Council, and it was approved by the Research Ethics Committee, under protocol 5.179.971.
Results
For the first part of the study, the Student's t-test (Table 1) for paired samples revealed a statistically significant difference for PPD (p<0.05). The t-value measures the difference in relation to the variation in the sample data; the higher the t-value, the greater the evidence against the null hypothesis [2]. In null-hypothesis significance testing, the p-value represents the probability of obtaining test results at least as extreme as the observed result, assuming the null hypothesis is true [3].
Significant worsening of PPD at the end of military training was observed, which was clinically observed as a higher incidence of inflammatory characteristics in the gingival tissue of recruits compared to the beginning of their training. No significant difference was observed between the other indices. Regarding the study's first phase, the graph below (Figure 1) illustrates the difference in average values of each index analyzed at the beginning and end of the military training.
In the comparison of averages, the DMFT index stands out, with an upward trend in relation to the initial average, despite the relatively short time frame for this specific parameter. The worsening of the oral condition of recruits during their training was the motivation for the second part of this study. Below are the results of the Student's T-test in the Control group (Table 2). The bar graph (Figure 2) illustrates the averages of each index before and after the placebo oil study.
Periodontal parameters at baseline (1) and one month after daily use of sunflower oil (2), i.e., the control group.
The control group's results showed statistically significant differences when comparing data observed at the beginning and the end of the military training, specifically in the GI index of recruits; that is, a substantial reduction in gingival bleeding was observed with toothbrushing using a placebo. Figure 2 illustrates the difference between periodontal indices at baseline and 30 days after the use of sunflower oil (control group).
Finally, Table 3 and Figure 3 show the results of the test group that used Oleozon daily. Unlike the control group, the Oleozon group also significantly reduced PPD and GI indices. There was no significant difference in clinical attachment level (NCI) or plaque index (PI) after 30 days of oleozon use. Figure 3 illustrates the difference in the averages of periodontal indices analyzed before and 30 days after using oleozon.
Periodontal parameters at baseline (1) and one month after daily use of ozonized sunflower oil (2), i.e., Oleozon group.
Averages of periodontal indexes for the Oleozon group at baseline (green) and after 30 days (red).
Discussion
The results of the first part of this study corroborate the existing literature regarding the deterioration of oral health among military personnel in training or combat situations across various countries. Despite the relatively good initial periodontal health, the PPD index worsened after training. Although causal factors were not analyzed in this study, the literature indicates that stress is a preponderant factor for this finding, combined with poor oral hygiene and low immunity) [1,2,11]. Clinically, a significant worsening of the PPD index was observed with the increase in gingival inflammatory condition at the end of the five-month training period. The DMFT index did not show a significant difference between the beginning and the end of the military training, but the graph illustrates a worsening trend. In other words, the final average DMFT was higher than the initial value, suggesting that this condition may be better understood after a more extended follow-up period. Clinically, it is worth noting that an increase in the number of white lesion precursors of caries was observed at the end of the training period. If, on the one hand, the confirmation of data indicates the need for a future study with a time interval longer than 5 months to investigate a possible difference in the DMFT index, on the other, it would not be ethical to follow the evolution of white spots to carious lesions. The results indicate the need for additional preventive measures during training. Similarly, from the perspective of FAB, the increase in the PPD index observed at the end of recruit training will translate into an increase in demand for specialized dental care.
In the second part of the study, a significant reduction in the PPD index was observed in the Oleozon group, indicating the potential of using ozonated sunflower oil as an adjuvant to toothbrushing in the effective reduction of periodontal disease indexes. Despite being an isolated parameter, the short evaluation period warrants highlighting, as it suggests that a one-month improvement in PPD could lead to more robust impacts with prolonged use. These results corroborate several recent studies that have shown statistically significant reductions in periodontal indices with the use of ozone, particularly in the form of ozonated oil and gel, which are more stable in conjunction with nonsurgical periodontal therapy and home care [18,20,33,38,42,43,44,45,46,47,48].
This work used ozonated sunflower oil, which has significantly higher stability than ozone gas and ozonated water (2 years) [36] and can be applied topically by the patient during brushing. This therapeutic modality proved effective in the military population, as it can be carried in a combatant's backpack during training exercises.
The results of the Control and Oleozon groups showed a significant reduction in gingival bleeding, which was attributed to improved oral hygiene. Such a result was expected due to the mechanical action of toothbrushing as a reducing agent of gingival inflammation, which is consistent with dental literature [3]. This result reinforces the already-established importance of removing dental plaque through daily brushing. Recruits were motivated to brush their teeth to improve oral health, whiten their teeth, and reduce bleeding. Several of them mentioned improvement in the above conditions after the 30 days of brushing with a placebo.
Regarding PI, there was no intragroup or intergroup difference, suggesting the need for additional professional guidance. The significant reduction in PPD observed in the oleozon group corroborates the described action of ozonated sunflower oil in reducing the inflammatory process of dental plaque and pathogenicity rather than the amount of biofilm.
Conclusion
Military training negatively impacts the oral health of Brazilian Air Force recruits and that using ozonated sunflower oil in conjunction with toothpaste brushing can serve as an adjuvant in maintaining the periodontal health of these soldiers. Thus, it is suggested that ozonated sunflower oil can be used in a protocol manner in Brazilian Air Force military organizations to help control gingival inflammation.
Acknowledgments
We thank company Blustratum, in the person of Prof. Wilfredo Urruchi, for the donation of material for the research, Giovana Medeiros for collaboration in this clinical research, Willians Principe Fernandes for statistical support and Priscila Correia Fernandes for text revision.
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Financial Support
This project received the donation of part of the sunflower oil used in the research from company Blustratum, São José dos Campos, SP, Brazil. We also thank No. 405522/2022-3 Brazilian National Council for Scientific and Technological Development – CNPq that granted text translation.
Data Availability
The data supporting the findings of this study can be made available upon request to the corresponding author.
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Edited by
-
Academic Editor:
Alessandro Leite Cavalcanti
Publication Dates
-
Publication in this collection
28 Nov 2025 -
Date of issue
2026
History
-
Received
30 Sept 2024 -
Reviewed
27 Dec 2024 -
Accepted
06 Feb 2025
