Application of Ozone Therapy in Paediatric Dentistry

Abstract

The therapeutic use of ozone has been suggested for a long time in general dentistry and paediatric dentistry for its antimicrobial, virucidal, disinfectant, and biocompatible properties. Ozone has also anti-inflammatory, analgesic, and immunostimulant properties, and it promotes tissue regeneration. Dental treatment in children is often complex and ozone could support the clinician to enhance the approach and prognosis with young patients, non-cooperant children, or special needs patients. The efficiency of ozone will certainly increase if studies continue to show positive outcomes in a growing number of dental paediatric conditions. This review explores the recent literature of ozone therapy in paediatric dentistry and suggests fields of application for future randomized controlled trials (RCTs).

1. Introduction

Ozone is a great oxidizing agent found in nature as a trivalent oxygen (O₃). It is a colorless gas with a strong smell [1]. It exists at the ground level as an air pollutant and a constituent of metropolitan smog, as well as in the Earth’s upper atmosphere, in the stratosphere, as a naturally defensive layer from ultraviolet rays [2].

The positive therapeutic effects of ozone and its derivatives, oil and ozonate water, have been investigated in several fields of medicine, since the XIX century.

The main health benefits of ozone therapy include the following:

• inactivation and elimination of pathogens: Gram-positive and Gram-negative bacteria, fungi, and viruses;
• stimulation of immune system and improvement of circulation;
• decrease in inflammation and pain;
• stimulation of humoral anti-oxidant system;
• restoration of appropriate oxygen metabolism;
• prevention of shock and stroke injury;
• induction of friendly ecological environment;
• increase in brain function and memory activities [3].

Ozone does not act directly through traditional drug–receptor pathways and, depending on the method of administration, different hydrophilic (mainly hydrogen) and lipophilic (mainly alkanals) small peroxide molecules will be produced (ROS and LOPs). These molecules specifically interact with protein moieties, controlling their epigenetic biological activities, acting on gene expression, enzyme activity, or cellular signals too [4].

Nevertheless, there is restricted agreement in the scientific community on its use and benefits; moreover, ozone cannot be useful, or it can even be toxic, if it is not used correctly [5]. There has yet to be a consistent and concord evaluation of the outcomes because of the need for more standardization of the treatment operating procedures (modality of administration, time of exposure, and dosage) [4].

The therapeutic use of ozone has been suggested for a very long time in dental fields—from 1980 until now—for its antimicrobial, virucidal, and disinfectant properties. It is biocompatible and has immunostimulant, anti-inflammatory, and analgesic properties, promoting tissue regeneration [3,6,7]. Ozone has shown positive effects in general dentistry for sterilization of equipment, management of surgical wound healing, dental caries and preventive conservative, gingivitis and periodontitis, oral lichen planus, halitosis, post-surgical pain, osteonecrosis of the jaw and prevention of post-extraction alveolitis, plaque and bio-films’ formation, root canals’ disinfection, reducing dentin hypersensitivity, controlling temporomandibular joint disorders, and enhancing teeth whitening [2,4,7,8,9,10,11].

Dental treatment in children is complex and modern technologies must support the practitioner to improve the approach and enhance prognosis with young patients, uncooperative children, or even patients with special needs [6,8]. Ozone therapy is a conservative and minimally invasive method—a relatively low-cost and painless treatment that could improve patient acceptability and compliance with a low risk of adverse effects [3].

At this time, a literature review about the field of application in paediatric dentistry has not been performed.

Pediatric clinicians are interested in improving and extending the dental practice of oxygen-ozone therapy and, at the same time, it could be interesting, for research groups too, to address the knowledge gaps related to less studied research protocols.

The aim of the present narrative review is to summarize the available literature on applications of ozone in paediatric dentistry and to suggest possible fields of application that should be further investigated with randomized controlled trials (RCTs).

2. Literature Review: Methodology and Results

PubMed-Medline, Embase, Web of Knowledge, Scopus, Cochrane Library, and Google Scholar were used as databases for this literature review.

At first, in October 2022, the operators conducted a search, ranging from 2012 to present, combining the following mesh terms or keyword topics “ozone therapy” with “primary teeth” or “paediatric dentistry” or “paediatric oral pathology” or “children” and “dentistry”. No other filters were added.

A total of 51 papers were found. Reading the title and abstract, 17 studies were excluded: 11 were duplicates, 3 were not about pediatric dentistry, and 3 were off topic. Analyzing the papers, the fields of application already investigated in the literature were collected [1,2,4,6,9,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41]. In

Table 1. Application of ozone therapy in paediatric dentistry and the main related references.

Uses of Ozone in Paediatric Dentistry	References
Dental caries management	[1,2,4,6,8,9,15,26]
Early childhood caries (ECC)	[12,13]
Molar incisor hypo-mineralization (MIH)	[1,40]
Root canal therapy	[2,4,9,14,15,17,19,26,28,39]
Remineralization	[1,2,4,9,41]
Dental hygiene and prophylaxis	[2,4,9,26,29]

, the applications of ozone therapy in paediatric dentistry, resulting from the first phase of the literature review, and the main related references are shown.

A second search was performed in October 2022, meshing “ozone” and “dentistry”, filtering for the reviews, ranging from 2012 to present. Starting from 12 reviews, only 6 were included [2,3,4,25,26,27] because they were about the plethora of uses of ozone.

The results of the first and second phases were compared, looking for fields of application already investigated or not in a pediatric population [1,9,16,30,31,32,33,34,35,36,37]. In

Table 2. Suggested fields of application of ozone therapy in paediatric dentistry that should be further investigated and the related references.

Other Possible Uses of Ozone in Paediatric Dentistry	References
Sensitivity of enamel developmental defects	[1,40]
Acceleration of healing (dental fistula or surgery extraction)	[26,30,31]
Herpes simplex infection or candida infection	[9,32,33]
Aphthous stomatitis	[34]
Pain management	[16,35,36]
Dental injuries or regenerative endodonticprocedures	[37,38]

, the main results of the comparison of the literature are shown.

The references of the studies were also analyzed to find other articles to be included.

The authors chose to perform a narrative literature review because of the heterogeneity or insufficiency of the results.

3. Clinical Use in Paediatric Dentistry

From the XIX century until now, the therapeutic application of gaseous ozone, ozonated oil, and water has been proposed in dental fields for many uses: in general dentistry, for sterilization of the equipment, caries control and preventive dentistry, and dentin hypersensitivity; in periodontology, for gingivitis and periodontitis; in endodontics, for root canal treatments and re-treatments; in stomatology, for infection of oral cavity; in prosthetics, for treatment of pressure ulcers and mucosal contact lesions; as well as in orthodontics and gnathology, dental hygiene and prophylaxis, dental surgery, and implantology [2,4,6,9].

Ozone therapy and other new technologies are revolutionizing dental treatment of young patients, making dental therapy easier and more predictable in pediatric patients. Special needs patients are often afraid and less co-operative, such as young patients, so ozone therapy could be applied to this kind of patient too. At this time, little research about the paediatric use of ozone therapy and no specific systematic review or meta-analysis have been found. The study designs of the papers of the past 10 years focus mainly on dental caries prevention, dental caries management, and pulpectomy management [4].

No papers have been found about other clinical uses of ozone in dentistry that could also be applied in paediatric dentistry, such as oral mucosal diseases (gingivitis, aphthous ulcer, cheilitis, candidiasis, and herpes simplex infection), healing after oral surgery and post-surgical pain management, halitosis, pain management or quality of life improvement of the developmental enamel defect, and for the management of pediatric traumatic dental injury.

3.1. Deep Dental Caries and ECC (Early Childhood Caries) Management

Today, dental caries and early loss of primary teeth are the most common childhood diseases affecting the quality of life in kids in the world. Studies have found cavity lesions of teeth of very young patients being left untreated as a cause of difficulty in management. Paediatric dentists need standardized efficient protocols to improve the approach and prognosis [10,17].

As first step, treatment of caries implicates the removal of carious tissue, with manual instrumentation or rotative burs, until sound dentin is found. The second step is the substitution of the missing tooth part with restorative materials. When the process is at an advanced stage, an endodontic treatment may also be required, removing the pulp tissue. This treatment induces an additional tooth weakening, which may involve more invasive conservative or prosthetic restorations [8]. The main aim of preventive dentistry and of the minimally invasive approaches of caries in paediatric dentistry is to avoid early loss of primary teeth, to preserve the development of the facial-skeletal system, and to arrest caries progression of primary tooth. It is desirable that teeth remain in the mouth until the natural exfoliation, in order to guarantee the integrity of primary dentition without causing the child pain and infection or risk of re-currant caries and, therefore, failure of dental restoration [6,10,11].

Beretta and Federici Canova [6] suggest ozone therapy as part of a possible ultra-conservative atraumatic treatment of deciduous teeth with deep carious lesions, with a partial excavation of dentin. They introduced an excellent alternative for deep caries treatment in primary teeth to be clinically performed in one appointment. The essential advantage of this procedure is the removal of dental tissue avoiding the invasion of the pulp chamber and the progression of caries infection, as minimally as possible. The protocol proposed starts with dental isolation using a rubber dam; then, the clinician can clean the teeth and the cavity margin of enamel can be definitized. The top layer of carious dentin is removed using rosette burs, without exposing the pulp tissue. Gas ozone is then applied on the infected dentin that remains in the cavity for 60 s with a single-patient silicone cup of different sizes (Heal Ozone, Kavo^®, Biberach, Germany). The objective of this procedures is to kill bacteria involved in the carious process like S. mutans, L. acidophilus, and E. faecalis [12]. The protocol executes with a three-step technique bonding and restoration of the decayed tooth with the composite.

The American Academy of Pediatric Dentistry (AAPD) defines early childhood caries (ECC) as the presence of one or more decayed deciduous teeth, missing (as a result of caries) or restored before 71 months of age [12]. Studies have found ECC to be more prevalent among children with a lower socio-economic background and high percentages of the cavitated carious primary teeth in preschool children are left untreated [10]. Ozone therapy is a health-safe, simple, painless, and very conservative approach that might be suitable for monitoring caries progression in unco-operative children with traditional dental treatments until appropriate cooperation and compliance can be attained [13].

Ozone, despite its high oxidizing power, can kill or inhibit S. mutants and L. acidophilus in the carious lesion without removing the infected tissue. It can oxidize and induce the lysis of the bacterial cell wall and it is able to transform the pyruvic acid produced by the bacteria into acetic acid and carbon dioxide, arresting or reversing the progression of caries. Using ozone, it is possible to preserve a layer of dentin called “ex-carious”, preventing the exposure of the pulp and avoiding the subsequent pulpotomy in very young children [6,13].

Luppieri et al. [13] used a course of ozone therapy to treat unco-operative patients with primary teeth affected by ECC. The results were positive. After the first application, the treatment resolved the dentine hypersensitivity and improved the patients’ quality of life, as well as the co-operation and compliance. In the study protocol, an ozone therapy session was attended once a week for four successive weeks. The authors used a gas ozone generator medical device (OzoneDTA^®, Sweden and Martina, Due Carrare, Padova, Italy). The ozone generator was set on intensity program number 6, as suggested by the manufacturers. Teeth preparation consists of removing plaque and food residues using a rotating brush and isolating and drying the teeth using cotton pads and a saliva suction system. Then each tooth affected by caries was treated with ozone for 60 s, keeping the probe tip in constant motion and perpendicular to the carious surface at a distance of 1 mm. The protocol proposed was easy to use for operators and well accepted by all patients, even by less co-operative ones. Although the health benefits of ozone therapy have been demonstrated, studies suggest ozone could interfere with resin infiltration into enamel and dentin, compromising the polymerization of composite material. The use of reductant solution on the treated surface is suggested to allow reversal of the negative effect of oxidizing agents. Further research is essential to confirm that ozone does not interfere with or improve the stability of the adhesive interface over time [42,43].

3.2. Pulpectomy

Caries in primary teeth progresses rapidly and the complete elimination of all soft, demineralized carious dentin in asymptomatic teeth with deep caries may result in pulp exposure [14,44,45]. The pulpal damage is caused directly by bacteria and or by their derived toxins. The contamination of the tissue could be consequently irreversible, so endodontic treatment is indicated. As already mentioned in the previous paragraph, the elimination of the pulp organ causes an additional weakening of the dental structure and a consequent risk of fracture or reinfection. Early loss of primary teeth should be avoided; it can cause several problems, including space loss for successor permanent teeth as well as aesthetic, functional, or phonetic complications [14]. Control of infection is of fundamental importance because the ample medullary bone spaces favour dissemination of infection, and the developing permanent tooth germ is very close to the roots of the primary teeth and could be affected [15,16].

A successful primary root canal treatment depends on proper shaping and cleaning of the root canal system followed by obturation with hermetic root canal filling. However, the complex internal nature of primary teeth makes it difficult to achieve correct tooth shaping. Therefore, ideal irrigation and root canal disinfection are rising in importance with the current evidence in the literature [17].

Current practice suggests using a decreased concentration of 2.5% sodium hypochlorite (NaOCl) in paediatric dentistry to avoid complications, which may occur depending on the pathological resorption areas on the primary root. The primary disadvantage of NaOCl irrigation, besides its taste and foul smell, is its cytotoxicity, especially when injected into periradicular tissues [17]. Furthermore, when co-operation is limited, such as in very young children or patients with special needs, control over all procedures may be reduced. Ozone advantages are as follows: its oxidation power; lack of mutagenicity and biocompatibility; rapid microbicidal effects, especially against anaerobes and E. faecalis; and ease of handling [13]. Ozone presents a neutral taste, no cytotoxicity, and higher biocompatible compared with other antiseptics such as sodium hypochlorite (NaOCl is not as biocompatible as ozone in the aqueous phase for human oral epithelial cells, periodontal cells, and gingival fibroblast cells). Recent literature points toward better acceptance of this irrigant in gasouse or water form in paediatric patients [11,17,18,19,20,46].

Kapdan et al. [14] compared the antibacterial effect of gaseous ozone with other antimicrobial techniques. They obtained positive results on the reduction of the E. faecalis bacterial load. They suggest the use of ozone therapy to aid NaOCl 2.5% in endodontic treatment of primary teeth and recommend the application at the end of instrumentation. In the study, gaseous ozone, applied with an ozone device (HealOzone, KaVo, Biberach, Germany) with a 4 g/m³ ozone concentration, was activated in dried root canals for 150 s using a hand piece, silicone caps (for sealing), and endodontic cannulas. This instrumentation avoids gas dissipation and guarantees the expected concentration even in root canals and endodontic space.

Agarwal et al. [19] evaluated in primary teeth the antimicrobial efficacy of aqueous ozone as an irrigant in pulpectomy procedures. They concluded that ozonated water can be used as an irrigant, owing to its neutral taste and powerful antimicrobial efficacy, especially against anaerobes. The proposed protocol starts with the anaesthesia and isolation with a rubber dam. Under strict aseptic conditions, the procedural tooth root canal access was performed with a high-speed air-rotor hand-piece and a round bur. Working length determination and biomechanical preparation were carried out with files three sizes beyond the first instrument. During instrumentation, the root canal was alternately irrigated with 2 mL of irrigant after every step of instrumentation.

Conversely, Öter et al. [17], evaluating the antibacterial efficiency of ozone (O₃, Ozonytron; Biozonix, München, Germany) in primary root canals, concluded that ozone was less effective in reducing the bacterial count when compared with NaOCl. Moreover, Goztas et al. [18] showed that NaOCI irrigation was found to be significantly more effective than ozonated water (O₃aq). Nevertheless, they concluded that O₃aq can be used as a primary root canal irrigation agent, especially for paediatric patients, owing to the absence of cytotoxicity and high biocompatibility.

Ozone has even been suggested as an obturating material for primary teeth [28,39].

Doneria et al. [39] proposed zinc oxide ozonated oil (ZnO-OO) as an obturating material or alternate treatment option for teeth requiring pulpectomy, resulting in 100% clinical and radiographic success rates over a 12-month period.

Effectively, numerous issues about the efficacy of ozone on endodontic microbiota, such as the ideal concentration, its depth of action in dentinal tubules, and the best time to attain a total antimicrobial effect, remain uncertain [18]. Further studies are needed to estimate the antibacterial efficacy of endodontic irrigants in different clinical situations, especially in primary teeth.

3.3. Initial Caries Lesions and Remineralization

Because its ease of use and the absolute comfort, ozone is proposed for direct decontamination of dentin or enamel, especially in primary teeth of young or not-collaborating patients, followed by the application of various products to obtain a remineralisation of the surface [47,48]. In initial caries lesion and in mild forms of molar incisor hypo-mineralization (MIH), it can eliminate bacteria present in demineralised tissues and stimulate remineralisation through the deposition of calcium and phosphate, and it could be useful to increase the effectiveness of topical products [1,7,21,49]. Ozone must be a component of a full preventive care regimen, which includes reducing the frequency of consumption of fermentable carbohydrates, increased use of fluoride-containing products, and improved oral hygiene [22,50,51]. Gaseous ozone may be useful together with fissure sealants with amorphous calcium phosphate, fluoride content, or nano-hydroxyapatite and for initial caries prevention [23,40,41].

Unal et al. [23] found an improved remineralization capacity of the fissure sealants with gaseous ozone on non-cavitated incipient pit and fissure caries. The protocol suggests at first the cleaning of dental surfaces using an air-flow device (Prophyflex 3, Kavo^®, Germany) and a strong saliva absorber and then isolation with sterile cotton rolls. Following the surface cleaning, teeth were washed with an air-water spray and dried. Ozone treatment was implemented via an ozone device (HealOzone, Kavo^®, Germany) for 40 s. The ozone device was calibrated to an ozone concentration of 2100 ppm and a 615 cm³/min flow rate. Then, the fissure sealants were applied as recommended by the manufacturer.

Beretta et al. [1] proposed ozone as an effective and comfortable solution in the treatment of MIH. In mild forms, it can promote remineralisation and increase the effectiveness of topical products; in medium and severe forms, ozone therapy can be crucial to intercept early cavitated lesions that could not be otherwise treated. Ozone could be applied in medium or moderate form of MIH for 60 s using a silicone cup (HealOzone, Kavo^®, Germany) to remove the biofilm, then bioactive materials must be used for surface sealing, or fluor prophylaxis, to increase the remineralising effect and reduce sensitivity. For the severe form of MIH, the primary purpose of the treatment is to maintain the vitality of the tooth and prevent cavities; therefore, after the ozone and bioactive material therapy, restoration with composite resin can be performed using a minimally invasive technique.

4. Possible Fields of Application in Paediatric Dentistry

Dental research should follow and support dental clinics in their everyday practice, improving the field of application of ozone in paediatric dentistry [52,53,54]. The positive outcomes of the use of ozone show the possibilities of the application of ozone in a plethora of oral pathology affecting young patients. In Table 2, the possible fields of application of ozone therapy that must be further investigated with RCTs in the paediatric population are summarized.

First, the treatment of enamel abnormalities affects the first permanent molar and other teeth of primary dentition. The prevalence of these pathologies is still increasing [1]. The high sensitivity of teeth and the subsequent pain led young patients to be less co-operative, either for home oral hygiene or in-office treatment, and induced a grade of discomfort that could alter the quality of life. Ozone is proposed for the treatment of dentin sensibilities, showing positive results [3]. Beretta et al. [1] suggest the use of ozone and bioactive materials to reduce the sensitivity of the first molar affected by enamel defects. More randomized controlled trials about the application of ozone therapy to reduce the pain associated with enamel structure defects could suggest efficient protocols for improving paediatric dental therapy.

Another interesting field of application of ozone is the regenerative endodontics of traumatic injuries, which has not yet been studied. Traumatic injuries often occur in very young patients and the preservation of the vitality of teeth is one of the main aims of paediatric dentistry. Ozone shows a high biocompatible and regenerative properties and, at the same time, antimicrobial capability. The outcomes of the study of Küçük et al. [37,38] showed interesting results. Considering the results of this study, 2 mg/L of ozonated water is the recommended concentration as a possible adjuvant irrigating agent for the regenerative endodontic procedures, with the aim to induce the proliferation of the pulp cells. However, the authors suggested the need for further studies to assess the biological response and odontoblastic differentiation mechanism of apical papilla stem cells to ozonated water. Further studies should also focus on connections between ozonated water and usual irrigating solutions.

5. Form of Application

Because of its instability, ozone has a strong oxidation potential, 1.5 times greater than chloride [5], which has led its use in medical and dental fields [55,56,57]. It is not possible to store ozone over prolonged periods—it has a half-life of 40 min at 20 °C [24]. Therefore, it must be arranged closely before use, although the association of O₃ with a vehicle with aqueous properties or viscous properties promotes or retards the conversion into oxygen [3]. The generator of ozone produces it from pure oxygen, passing through a high voltage gradient of 5 to 13 mV [2,24].

There are ozone generators that can produce ozone gas via an open system or a sealed suction system. There are adverse effects that may arise in an open system upon inhalation, so the sealed suction system is usually preferred [18]. When the application of ozone takes place within a closed circuit, ideal airtightness is compulsory for the application of ozone, ensuring no gaseous escape. Silicon cups of distinct size could be used. The concentration of ozone provided to the tissue is about 2100 ppm [12].

Ozone generators that produce ozone via an open system use a glass probe formed by a double glass camera and a mix of noble gases emitting electromagnetic energy. When the probe tip meets the body surface, emission of the energy all around the operation field begins. The ozone generated in the area of operation is 10 to 100 μg/mL [12]. It can be used in areas that are challenging to reach. The concentration of ozone produced from generators is not uniform for the different machines and change in the different programs. From 10 to 100 μg/mL, the flow rate is from 30 to 1000 mL/min. The application time proposed in the different protocols is from 30 s to 5 min. [25].

Ozonated water is used as a mouthwash or in irrigation solutions [18]. As the half-life of ozonated water is only about 20 min, because of which it degrades back into oxygen, its effectiveness must be assured by using it within the first 5–10 min after production [3]. It is not toxic for use and no negative gastrointestinal effects have been found from its ingestion [26]. When using bi-distilled water and a high-quality ozone generator, a minimum saturation of 4 μg ozone/mL and a maximum saturation of 20 μg ozone/mL, at room temperature, can be obtained [4,25,27].

Ozonated oil can be convenient and offer greater permeation [2] and, because the oil remains in contact with the surface for a longer period, it exercises its functions for a longer period [28]. Clinicians can administer ozone in the form of oil, commercially available as ozonated olive oil or ozonized sunflower oil [26]. Ozonated oil’s peroxide value is unclear [25].

The form of administration of ozone differs for dosage of production of its derivate and the clinician must keep in mind that all of the effects are linked to the relationship between reactive oxygen species (ROS) and lipid oxydation substances (LOPs) produced after the interaction between ozone with blood, tissue or serum. Specific oral pathological conditions require specific protocols in treatment [58,59,60].

6. Contraindication and Adverse Effect

Despite its beneficial uses, it is necessary to keep in mind that ozone can be toxic after inhalation when the concentration is more 0.01 ppm in the oral cavity during therapy. Pulmonary complications could occur as side-effects, causing a sore throat, increase in asthma, and even damage to lungs. If not used correctly or in excessive amounts, long-term exposure of the operator to ozone is related with various side effects: irritation of the upper airways, epiphora, rhinitis, coughing, bronchoconstriction, headaches, and vomiting [5,26,60]. Ozone therapy is contraindicated in the case of acute alcohol intoxication, pregnancy, severe anaemia, recent myocardial infarction, hyperthyroidism, active hemorrhage, and thrombocytopenia [3].

Floare at al. [5] evaluated the possible toxic impact of ozone on the resident cells (keratinocytes and fibroblasts) of the gingival tissue that come in close contact with this agent. They found a time exposure correlation of ozone and cells’ sensitivity, but all of the changes were reversible after 48 h. However, ozonated water seem to be more biocompatible than gaseous ozone.

7. Limitation of the Study

This literature review is an overview of last 12 years of research into the uses of ozone therapy in pediatric dentistry. The main purpose is to summarize the field of application to suggest future clinical trials. The main limitation of this review is the inconsistency of the study design found in the literature. There is high variability in methodologies among the studies regarding ozone treatments in pediatric and special needs patients. The main discrepancies are due to very different ozone application protocols. In general, studies use different equipment that generates ozone, ozone concentrations, physical states of ozone, and application times and techniques. There is a lack of a critical approach in all proposed fields. Not all clinical trials are discussed or confronted with gold standard protocols. Owing to the considerable discrepancy in methodologies between studies, the best application protocol for ozone therapies remains unclear. Higher quality research is undoubtedly desirable. With this background, owing to difficult comparison between all of the treatments applied and the various study designs of included studies, a narrative review was performed. Therefore, the grade of evidence and the strength of this review are considered to not be very high. However, the overall wholeness of this manuscript has reached acceptable standards, representing the best effort to put together the highest available knowledge regarding ozone performance in pediatric dentistry. For this reason, its pertinency remains significant.

8. Conclusions

Ozone therapy is suggested in the management of deep dental caries, ECC, MIH, root canal therapy, remineralization, dental hygiene, and dental prophylaxis, in young children and unco-operative pediatric patients. Ozone is a simple and pain-free technique. Not least is the advantage of its ability to reduce the patient’s anxiety and stress level by improving co-operation. All researchers agree on this point.

Ozone therapies with conscious sedation, laser therapy, “atraumatic restorative technique”, and other minimally invasive techniques are part of modern paediatric dentistry. Its main aim is to guarantee quality care, in both very young patients and patients with special needs.

The fields of application in paediatric dentistry are still limited, including diseases of the oral mucosa (gingivitis, aphthous ulcer, cheilitis, candidiasis, and herpes simplex infection), acceleration of healing after oral surgery, halitosis, post-surgical pain management, pain management or improvement of the quality of life of the enamel developmental defect, and management of traumatic tooth injuries. The results in the adult population are encouraging and it is important to investigate further with standardized clinical trials to ensure greater knowledge on the use of ozone in paediatric dentistry and to propose efficient protocols to clinicians.