Evaluation of ozone as an adjunct to scaling and root planing in the treatment of chronic periodontitis: A randomized clinico-microbial study.

BACKGROUND AND OBJECTIVES: Mechanical plaque control is an essential part of periodontal therapy. In the present study, the efficacy of ozone water irrigation as an adjunct to scaling and root planing was evaluated in the treatment of generalized chronic periodontitis.
MATERIALS AND METHODS: Twenty-four patients with chronic periodontitis selected for the study were randomly divided into Group A and Group B, receiving ozone water irrigation and distilled water irrigation, respectively, after scaling and root planing. Subgingival plaque was collected from the selected investigational teeth and was analyzed using BANA-Zyme™ Processor to evaluate the "red complex" periodontal pathogens. The clinical and microbiological parameters were recorded at baseline, 14 days, 21 days, and 2 months.
RESULTS: The mean probing pocket depth scores for Group A and Group B at the baseline were 6.833 ± 1.193 and 7.833 ± 1.276; on day 14th, they were 6.616 ± 1.403 and 7.083 ± 1.378; on day 21st, they were 5.166 ± 0.937 and 6.083 ± 1.443;and on the 2nd month, they were 4.500 ± 0.797 and 5.166 ± 1.029, respectively. At the 2nd month, in Group A, 9 samples showed BANA negative and 3 samples showed BANA positive, and in Group B, 12 samples showed BANA negative and 0 sample showed BANA positive. The microbiological analysis showed a reduction in periodontal pathogens in both the groups.
CONCLUSION: Significant improvement in both clinical and microbiological parameters suggests that subgingival ozonated water irrigation could be an efficient adjunct to scaling and root planing in the treatment of chronic periodontitis. Copyright:

INTRODUCTION

Chronic periodontitis is a polymicrobial infectious disease which is the sequel of overgrowth of oral microflora. Among the diverse organisms known to be collated with the clinical progression of the disease, “red complex” which encompass Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola are the most important pathogens of chronic periodontitis.[1]

Mechanical removal of dental plaque forms an integral part of controlling and treating periodontal disease that could be achieved both professionally and by the patient at home. However, for complete remission, there is a need to suppress and inhibit the growth of highly anaerobic subgingival microflora by changing the subgingival environment.[2] This can be achieved by various methods, including the application of oxygenating and redox agents, molecular oxygen, hyperbaric oxygenation, hydrogen peroxide, and recently, the use of ozonized water for subgingival irrigation.[3]

Recently, owing to its power antimicrobial properties without developing resistance, ozone is gaining attention in the field of dentistry. Hence, this study attempted to evaluate the efficacy of ozone as an adjunct to scaling and root planing in the treatment of chronic periodontitis.

MATERIALS AND METHODS

This randomized controlled clinical trial included a total of 24 patients within the age group of 30–65 years who reported to the outpatient department of periodontics of the institution. The study protocol was approved by the ethical committee of the institution. Systemically healthy individuals, diagnosed chronic periodontitis, with probing pocket depth (PPD) >5 mm and minimum 20 teeth remaining were included in the study. Patients using antibiotics in the past 6 months, those who underwent scaling in the past 6 months, patients who were allergic to active ingredients, pregnant or lactating women, smokers, and current users of any mouthrinses for any dental problems were excluded from the study.

Of the total 27 individuals examined for eligibility, 24 individuals were selected for the study. The sample size was calculated using G*Power software (Heinrich-Heine-University Dusseldorf) to obtain 80% of statistical power. Twenty-four individuals meeting the inclusion criteria were randomly assigned to one of the two following groups with a toss of a coin, 12 in each group.

Group A: Scaling and root planing + ozonated water irrigation

Group B: Scaling and root planing + distilled water irrigation.

Written informed consent was obtained from all the participants recruited in the study. The participant data were recorded in a case history pro forma. The clinical parameters assessed were plaque index (PI),[4] gingival index (GI)[5], and PPD, recorded at baseline and at 14th day, 21st day, and 2nd month [Flow Chart 1]. The participants from the Group A received subgingival irrigation with ozonated water that was released from an ozone generating device that released a single pulsating stream of ozone from the nozzle into sterile water. The participants from Group B received subgingival irrigation with distilled water. Subgingival irrigation was done using a 20-gauge blunt needle syringe inserted subgingivally for a period of 30–45 s for both the groups.

Flow Chart 1

The above study design is represented in flow chart which is as follows

Microbiological analysis

Subgingival plaque was collected from selected investigational teeth in each patient at sites that showed PPD of 5 mm or greater at the baseline. The same sites were used for plaque sampling at the 21st day and 2nd month. After removing supragingival plaque, subgingival plaque was collected using a sterile Gracey curette, by inserting it subgingivally into the maximum probing depth portion of the periodontal pocket parallel to the long axis of the tooth and moving it coronally by scraping along the root surface. The samples were analyzed using BANA-Zyme™ Processor to evaluate the “red complex” periodontal pathogens.

The primary outcome variable was the difference in the mean reduction of GI scores from baseline to 2 months. The secondary outcome variables were the differences in the mean reduction of PI and PPD scores from baseline to 2 months.

The following methods of statistical analysis were used in this study. The data collected were entered in Microsoft Excel, and the statistical analyses were performed using SPSS version 20 software (Mission Hills, California, United States). Mann–Whitney U-test and unpaired t-test were used to test the difference between the groups, and intragroup analysis of Gram-positive and Gram-negative microorganisms and spirochetes was done using the Wilcoxon signed-rank test. A paired t-test was performed to determine the difference between pretreatment and posttreatment measurements. In the above-used tests, P < 0.05 was considered statistically significant.

RESULTS

The mean PI scores for Group A and Group B at the baseline were 2.505 ± 0.318 and 2.488 ± 0.288 (P = 0.889); on the 14th day, they were 1.825 ± 0.580 and 1.811 ± 0.544 (P = 0.954); on the 21st day, they were 1.857 ± 0.554 and 1.647 ± 0.439 (P = 0.328), and on the 2nd month, they were 1.416 ± 0.372 and 1.574 ± 0.407, respectively. The mean difference in scores between the groups was not statistically significant [Table 1].

Table 1

Plaque scores comparison between groups at different time intervals using the unpaired t-test

Unpaired t-test
	Groups	n	Mean±SD	P
BLPI	Group A	12	2.5058±0.31822	0.889
	Group B	12	2.4883±0.28825
DAY14PI	Group A	12	1.8250±0.58029	0.954
	Group B	12	1.8117±0.54421
DAY21PI	Group A	12	1.8517±0.55440	0.328
	Group B	12	1.6475±0.43944
MON2P1	Group A	12	1.4164±0.37263	0.333
Group B	12	1.5742±0.40775

P<0.05 is considered statistically significant. n – Number of participants; BLPI – Baseline plaque index; DAY14PI – Day 14 plaque index; DAY21PI – Day 21 plaque index; MON2PI – Month 2 plaque index; P – Probability; SD – Standard deviation

The mean GI scores for Group A and Group B at the baseline were 2.569 ± 0.336 and 2.320 ± 0.471; on the day 14th day, the scores were 2.036 ± 0.423 and 1.991 ± 0.590; on the 21st day, the scores were 1.880 ± 0.416 and 1.813 ± 0.337; and on the 2nd month, the scores were 1.512 ± 0.406 and 1.620 ± 0.368, respectively. The mean difference in scores between the groups was not statistically significant [Table 2].

Table 2

Gingival scores comparison between groups at different time intervals using the unpaired t-test

Unpaired t-test
	Groups	n	Mean±SD	P
BLGI	Group A	12	2.5692±0.33619	0.151
	Group B	12	2.3208±0.47116
DAY14GI	Group A	12	2.0367±0.42331	0.832
	Group B	12	1.9917±0.59019
DAY21GI	Group A	12	1.8800±0.41613	0.694
	Group B	12	1.8183±0.33739
MON2GI	Group A	12	1.5125±0.40672	0.501
	Group B	12	1.6208±0.36828

P<0.05 is considered statistically significant. n – Number of participants; BLGI – Baseline gingival index; DAY14GI – Day 14 gingival index; DAY21GI – Day 21 gingival index; MON2GI – Month 2 gingival index; P – Probability; SD – Standard deviation

The mean PPD scores for Group A and Group B at the baseline were 6.833 ± 1.193 and 7.833 ± 1.276; on day the 14th day, they were 6.616 ± 1.403 and 7.083 ± 1.378, on day the 21st day, the scores were 5.166 ± 0.937 and 6.083 ± 1.443, and on the 2nd month, the scores were 4.500 ± 0.797 and 5.166 ± 1.029, respectively. The mean difference in scores between the groups was not statistically significant [Table 3].

Table 3

Probing pocket depth scores comparison between groups at different time intervals using the unpaired t-test

Unpaired t-test
	Groups	n	Mean±SD	P
BLPPD	Group A	12	6.8333±1.19342	0.059
	Group B	12	7.8333±1.26730
DAY14PPD	Group A	12	6.1667±1.40346	0.121
	Group B	12	7.0833±1.37895
DAY21PPD	Group A	12	5.1667±0.93744	0.079
	Group B	12	6.0833±1.44338
MON2PPD	Group A	12	4.5000±0.79772	0.090
Group B	12	5.1667±1.02986

P<0.05 is considered statistically significant. n – Number of participants; BLPPD – Baseline probing pocket depth; DAY14PPD – Day 14 probing pocket depth; DAY21PPD – Day 21 probing pocket depth; MON2PPD – Month 2 probing pocket depth; P – Probability; SD – Standard deviation

The mean PI scores of Group A at the baseline and after 2 months were 2.505 ± 0.318 and 1.416 ± 0.372, respectively, showing a statistically significant difference (P < 0.001). The mean GI scores of Group A at the baseline and after 2 months were 2.569 ± 0.336 and 1.512 ± 0.406, respectively, showing a statistically significant difference (P < 0.001). The mean PPD scores of Group A at the baseline and after 2 months were 6.833 ± 1.193 and 4.500 ± 0.797, respectively, showing a statistically significant difference (P < 0.001) [Table 4].

Table 4

Intragroup comparison using paired t-test at baseline and at the end of 2 months of plaque index, gingival index, and probing pocket depth

Paired t-test
Group A	Mean	n	SD	P
PI
BLPI	2.5058	12	0.31822	<0.001
MON2PI	1.4164	12	0.37263
GI
BLGI	2.5692	12	0.33611	<0.001
MON2GI	1.5125	12	0.40672
PPD
BLPPD	6.8333	12	1.19342	<0.001
MON2PPD	4.5000	12	0.79772

P<0.05 is considered statistically significant. n – Number of participants; BLPI – Baseline plaque index; MON2PI – Month 2 plaque index; BLGI – Baseline gingival index; MON2GI – Month 2 gingival index; BLPPD – Baseline probing pocket depth; MON2PPD – Month 2 probing pocket depth; P – Probability; PI – Plaque index; GI – Gingival index; PPD – Probing pocket depth; SD – Standard deviation

At the baseline, in Group A, 4 (33.3%) samples showed BANA negative and 8 (66.7%) samples showed BANA positive, and in Group B, 8 (66.7%) samples showed BANA negative and 4 (33.3%) samples showed BANA positive; there was no statistically significant difference in proportion of samples in both the groups with respect to BANA test result (P = 0.102). At the 21st day, in Group A, 11 (91.7%) samples showed BANA negative and 1 (8.3%) sample showed BANA positive, and in Group B, 12 (100%) samples showed BANA negative and 0 (0%) sample showed BANA positive; there was no statistically significance difference in proportion of samples in both the groups with respect to BANA test result (P = 1.000). At the 2nd month, in Group A, 9 (75%) samples showed BANA negative and 3 (25%) samples showed BANA positive, and in Group B, 12 (100%) samples showed BANA negative and 0 (0%) sample showed BANA positive; there was no statistically significance difference in proportion of samples in both the groups with respect to BANA test result (P = 0.217) [Table 5].

Table 5

Intergroup comparison BANA-Zyme™ test results at different time intervals

Chi-square test
BLBANA	Group		P
	Group A	Group B
BLBANA
Negative			0.102
Count	4	8
Percentage within group	33.3	66.7
Positive
Count	8	4
Percentage within group	66.7	33.3
Total
Count	12	12
Percentage within group	100.0	100.0
DA21GBANA	Group		P
	Group A	Group B
DAY21GBANA			1.000
Negative
Count	11	12
Percentage within group	91.7	100.0
Positive
Count	1	0
Percentage within group	8.3	0.0
Total
Count	12	12
Percentage within group	100.0	100.0
MON2BANA	Group		P
	Group A	Group B
MON2BANA
Negative			0.217
Count	9	12
Percentage within group	75.0	100.0
Positive
Count	3	0
Percentage within group	25.0	0.0
Total
Count	12	12
Percentage within group	100.0	100.0

P<0.05 is considered statistically significant. BLBANA – Baseline BANA; DAY21GBANA – Day 21 BANA; MON2BANA – Month 2 BANA; P – Probability

DISCUSSION

The primary goal of periodontal therapy is to arrest the disease progression and maintai a healthy functional periodontium. It mainly involves patient motivation, mechanical removal of supra- and subgingival plaque, and calculus deposits. However, a complete removal of subgingival deposits and effective and reliable control of the subgingival vital flora have been shown to be extremely challenging and difficult goal to achieve with nonsurgical approach.[6] To overcome these limitations, a large variety of adjunctive measures to improve the outcome of mechanical debridement have been tested.

Recently, ozone therapy is gaining popularity in various treatment modalities in the field of dentistry. Ozone, being an unstable gas, releases nascent oxygen molecule instantly. This property has been used since long in medical field to kill microorganisms.[7] This randomized clinical trial evaluated the effects of adjunctive ozone water irrigation on clinical outcomes in participants with chronic periodontitis. The results indicated that the greatest clinical benefits (PI, GI, and PPD) were achieved if scaling and root planing was combined with ozone water irrigation. This is in accordance with the studies by Katti and Chava,[8] Ramazy et al.,[9] and Hayakumo et al.[10] The results of our study are also in agreement with an in vitro study conducted by Nagayoshi et al.,[11] who found that dental plaque formation on decalcified human tooth was inhibited when treated with ozonized water suggestive of disinfectant properties.

Pandya et al.[12] compared 0.2% chlorhexidine gluconate with ozonated water as subgingival irrigants and concluded that chlorhexidine was more effective in improvement of the assessed clinical as well as microbial parameters. Seydanur Dengizek et al.[13] in their randomized controlled trial, comparing ozone as an adjunct to scaling and root planing found no significant improvement in periodontal recovery with the use of ozone, in contrast with the results of our study.

In the present study, statistically significant difference in clinical and microbiological parameters was seen in the study group as well as in the control group from the baseline to 2 months. However, there was no statistically significant difference was seen in clinical and microbiological parameters between the groups which is in accordance with the study done by Kaur et al. in 2014.[14]

In our study, both types of treatment showed statistically significant pocket depth reduction from the baseline to 2 months with no statistically significant different between the groups in our study, concurring with the conclusions of study conducted on patients with chronic and aggressive periodontitis by Skurska et al.[15]

CONCLUSION

The present randomized clinical trial was performed to assess the effect of ozone water irrigation, on various clinical parameters describing periodontitis and on the microflora of periodontal pocket in humans.

From the results obtained, the following conclusions could be drawn from this study:

Ozone water irrigation into the periodontal pockets is a promising modality of treatment, offering benefits over scaling and root planing alone

Ozone is an antimicrobial agent which can be used safely in the treatment of periodontal pockets.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.