Comparison Of Ozonated Water And 10 Percent Povidone Iodine As Subgingival Irrigant In The Management Of Chronic Periodontitis
Arunn Jaikumar Ram1, Arvina Rajasekar2*
1 Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai- 77, India.
2 Senior Lecturer, Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences [SIMATS], Saveetha University, Chennai- 77, India.
*Corresponding Author
Dr. Arvina Rajasekar,
Senior Lecturer, Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences [SIMATS], Saveetha University, Chennai-
77, India.
Tel: +91 9486442309
E-mail: arvinar.sdc@saveetha.com
Received: September 13, 2021; Accepted: September 22, 2021; Published: September 23, 2021
Citation:Arunn Jaikumar Ram, Arvina Rajasekar. Comparison Of Ozonated Water And 10 Percent Povidone Iodine As Subgingival Irrigant In The Management Of Chronic
Periodontitis. Int J Dentistry Oral Sci. 2021;8(9):4574-4578. doi: dx.doi.org/10.19070/2377-8075-21000931
Copyright: Dr. Arvina Rajasekar©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: Mechanical plaque control is the first line of management of chronic periodontitis. In recent years, a variety of
adjuncts including irrigants, chemical plaque controlling agents, vitamin supplements, systemic and local antibiotics, local drug
delivery, herbal extracts, probiotics and LASER are gaining importance.
Aim: The aim of the study was to assess the efficacy of ozonated water and 10 percent povidone iodine as sub gingival irrigant
in the management of chronic periodontitis.
Materials and Methods: The present randomized clinical trial was carried out from June 2020 to December 2020 among
40 chronic periodontitis patients who reported to the Department of Periodontics, Saveetha Dental College and Hospitals,
Chennai, India. Participants were assigned to two groups [Group 1 (10% povidone iodine), Group 2 (ozonated water)]. Scaling
and root planing was done for all the participants and then the pocket was irrigated with respective irrigant. The clinical parameters
including Loe and Silness Gingival Index (GI), Pocket Depth (PD), Silness and Loe Plaque index (PI) were recorded
at baseline and after 1 week. The data was analyzed using Statistical Package for Social Sciences (SPSS Software, Version 23.0).
Unpaired t-test was done to compare the mean values of gingival index, plaque index and pocket depth between the groups.
Results: In group 1, the mean gingival index was reduced from 2.89±0.03 to 2.20±0.03. In group 2, the mean gingival index
was reduced from 2.92±0.02 to 1.48±0.01. When plaque index was compared between both the groups, in group 1, the mean
plaque index was reduced from 2.87±0.02 to 2.40±0.03. In group 2, the mean plaque index was reduced from 2.86±0.05 to
1.42±0.01. When probing depth was compared between both the groups, in group 1, the mean plaque index was reduced from
5±0.02 to 3±0.03. In group 2, the mean plaque index was reduced from 4±0.05 to 2±0.01. The difference in all the clinical
parameters between both the groups was found to be statistically significant (p=0.000).
Conclusion: Significant improvement in gingival index, plaque index and pocket depth suggests that subgingival ozonated
water irrigation could be an effective adjunct to scaling and root planing in the management of chronic periodontitis.
2.Introduction
3.Materials and Methods
3.Results
4.Discussion
5.Conclusion
5.References
Keywords
Ozonated Water; Povidone Iodine; Subgingival Irrigation; Innovative Technique; Periodontitis.
Introduction
Periodontitis is an inflammatory condition caused by a specific
group of microorganisms. It affects the supporting structures of
the oral cavity leading to increased pocket depth, clinical attachment
loss, recession, mobility, bone loss, furcation involvement,
pathologic migration and tooth loss [1-7]. Even though the primary
etiology of the disease is dental plaque, the disease is aggravated
by variety of risk factors including smoking, stress, genetic
factors, systemic diseases and hormonal distress[8-16].
Scaling and root planing (SRP) therapy is considered as the gold
standard for periodontal disease [17]. However, SRP is subjected
to certain restrictions, such as the failure to insert deeper periodontal
pockets, bifurcations and the failure to eliminate microorganisms
because of their tissue invading nature [18-20]. To
overcome this, variety of adjuncts including irrigants, chemical
plaque controlling agents, vitamin supplements, systemic and local antibiotics, local drug delivery, herbal extracts, probiotics and
LASER are gaining importance.
Irrigants are effective at flushing out plaque, bacteria and their
toxins that become trapped in the small spaces between teeth and
under the gumline, preventing the buildup of harmful bacteria.
The most widely studied subgingival irrigants are chlorhexidine
and various percentages of povidone iodine solution. Chlorhexidine
(CHX) is considered a “gold standard” antibacterial solution
and is extensively used as a mouthwash and irrigating solution.
[21]. However, it has certain side effects on long term usage such
as loss of taste sensation, staining of the teeth and in some cases,
parotid swelling. Povidone iodine is the most broad-spectrum and
potent antiseptic available [21, 22].
It has a bactericidal effect against most bacteria including putative
periodontal pathogens, fungi, mycobacteria, viruses, and protozoa.
Povidone-iodine remains an effective antibacterial agent
when used directly into the periodontal pocket even at low concentrations
[23].
Currently, ozone therapy is gaining popularity as a modern noninvasive
method of treatment. It is a powerful oxidizing agent
with a high antimicrobial power against oral pathogens [24]. The
antimicrobial effect of ozone is a result of its action on cells by
damaging its cytoplasmic membrane due to ozonolysis of dual
bonds and also ozone-induced modification of intracellular contents
because of secondary oxidant effects [25]. Ozonated water
can be used to irrigate the subgingival area during scaling and root
planing [26].
Our team has extensive knowledge and research experience that
has translated into high quality publications[27-46]. Through extensive
literature search, it was revealed that there is a lack of
adequate studies comparing the efficacy of ozonated water and
10 percent povidone iodine as sub gingival irrigant in the management
of chronic periodontitis. In this context, the aim of the
study was to assess the efficacy of ozonated water and 10 percent
povidone iodine as sub gingival irrigant in the management of
chronic periodontitis.
Materials and Methods
Study Population:
The present randomized clinical trial was carried out from June
2020 to December 2020 among 40 chronic periodontitis patients
who reported to the Department of Periodontics, Saveetha Dental
College and Hospitals, Chennai, India. The ethical clearance
was obtained from the Institutional Ethical Committee and a
written informed consent was obtained from all the study participants.
Inclusion Criteria:
Patients who were systemically healthy, presence of at least 20
teeth, probing depth of 4-5 mm, presence of bleeding on probing
(BOP) and presence of plaque in at least 30% of the sites were
included in the study.
Exclusion Criteria:
Smokers, pregnant or lactating mothers, patients under long term
medications, systemically compromised patients were excluded
from the study.
Study Design:
The sample size was 40 with 20 participants in each group [Group
1 (10% povidone iodine), Group 2 (ozonated water)]. Participants
were assigned to the groups by a person not involved in the study.
Scaling and root planing was done for all the participants using
Gracey curettes and then the pocket was irrigated with respective
irrigant using a syringe. The syringe was gently inserted into
the depth of periodontal pockets to assure delivery of irrigant
solution. Repeated irrigation ensured that irrigant solution filled
up pockets for a period of 5 min and oral hygiene instructions
were reinforced. The clinical parameters including Loe and Silness
Gingival Index (GI), Pocket Depth (PD), Silness and Loe Plaque
index (PI) were recorded (baseline). All the subjects were recalled
after 1 week and the same parameters were recorded.
Statistical Analysis:
The data was analyzed using Statistical Package for Social Sciences
(SPSS Software, Version 23.0). Descriptive and inferential
statistics were done for data summarization and presentation. Unpaired
t-test was done to compare the mean values of gingival
index, plaque index and pocket depth between the groups. The
analysed data was interpreted as graphs and tabulations.
Results
In the present study 40 periodontitis patients were enrolled. 20
patients were enrolled in group 1 (10% povidone iodine), while
the remaining 20 patients were enrolled in group 2 (ozonated
water). Clinical parameters like gingival index, plaque index and
pocket depth were compared at baseline and after 1 week.
In group 1, the mean gingival index was reduced from 2.89±0.03
to 2.20±0.03. In group 2, the mean gingival index was reduced
from 2.92±0.02 to 1.48±0.01. The difference in gingival index
between both the groups was found to be statistically significant
(p=0.000). [Figure 1, Table 1].
When plaque index was compared between both the groups, in
group 1, the mean plaque index was reduced from 2.87±0.02 to
2.40±0.03. In group 2, the mean plaque index was reduced from
2.86±0.05 to 1.42±0.01.The difference in plaque index between
both the groups was found to be statistically significant (p=0.000).
[Figure 2, Table 1].
When probing depth was compared between both the groups,
in group 1, the mean plaque index was reduced from 5±0.02 to
3±0.03. In group 2, the mean plaque index was reduced from
4±0.05 to 2±0.01. The difference in plaque index between both
the groups was found to be statistically significant (p=0.000).
[Figure 3, Table 1].
Table 1. Comparison of mean gingival index, plaque index and pocket depth between the study groups using unpaired ttest.
Figure 1. Comparison of difference between ozonated water and 10% povidone iodine in terms of gingival index. X-axis depicts the types of subgingival irrigant and Y-axis depicts the mean gingival index. Blue bar depicts the baseline gingival index, green bar depicts gingival index after a week. The reduction in gingival index was higher among the patients who had undergone subgingival irrigation with ozonated water. The difference between both the groups was found to be statistically significant with the p value of 0.000 (unpaired t-test).
Figure 2. Comparison of difference between ozonated water and 10% povidone iodine in terms of plaque index. X-axis depicts the types of subgingival irrigant and Y-axis depicts the mean plaque index. Blue bar depicts the baseline plaque index, green bar depicts plaque index after a week. The reduction in plaque index was higher among the patients who had undergone subgingival irrigation with ozonated water. The difference between both the groups was found to be statistically significant with the p value of 0.000 (unpaired t-test).
Figure 3. Comparison of difference between ozonated water and 10% povidone iodine in terms of pocket depth. X-axis depicts the types of subgingival irrigant and Y-axis depicts the mean pocket depth. Blue bar depicts the baseline pocket depth, green bar depicts pocket depth after a week. The reduction in pocket depth was higher among the patients who had undergone subgingival irrigation with ozonated water. The difference between both the groups was found to be statistically significant with the p value of 0.000 (unpaired t-test).
Discussion
The present study assessed the effect of ozonated water and povidone iodine as an adjunct to scaling and root planing in the treatment
of chronic periodontitis.
Issac AV et al., [48] evaluated the effect of ozonated water as subgingival
irrigant on microbiologic parameters and clinical parameters.
The study results showed a greater reduction in pocket depth
and gain in clinical attachment. Also, the total anaerobic count
was significantly reduced by ozonated water subgingival irrigation
along with scaling and root planing compared to scaling and root
planing alone. Katti SS et al., [49] studied the clinical effects of
ozonated water on periodontal tissues. The study revealed that
subgingival irrigation with ozonated water is beneficial as an adjunct
to conventional scaling and root planing in the management
of chronic periodontitis.
Al Habashneh R et al., [50] determined the clinical and biological
effects of the adjunctive use of ozone in nonsurgical periodontal
treatment by conducting a randomized controlled clinical trial
and found improvement in periodontal health when irrigation
was done with ozonated water as an adjunctive therapy. Similarly
Vasthavi C et al., [51] evaluated the effect of ozone as an adjunct
to scaling and root planing in the treatment of chronic periodontitis
and found beneficial effects of ozone.
The results of the present study are in accordance with the previous
studies as there was significant reduction in gingival index,
plaque index and pocket depth when ozonated water was used
as a subgingival irrigant as compared with 10% povidone iodine
among patients with chronic periodontitis. However, more randomized
controlled trials need to be conducted with long term follow
ups to confirm the efficacy of ozone as a subgingival irrigant.
Conclusion
Significant improvement in gingival index, plaque index and pocket
depth suggests that subgingival ozonated water irrigation could
be an effective adjunct to scaling and root planing in the management
of chronic periodontitis.
Acknowledgement
The authors would like to acknowledge the help rendered by
Saveetha Dental College and Hospitals, Saveetha Institute of
Medical and Technical Sciences, Saveetha University, Chennai.
Source of Funding
The present project was sponsored by
• Saveetha Institute of Medical and Technical Sciences,
• Saveetha Dental College and Hospitals,
• Saveetha University,
• Aruna Exports Pvt. Ltd., Coimbatore.
References
-
[1]. Rajeshwaran N, Rajasekar A, Kaarthikeyan G. Prevalence of Pathologic Migration
in Patients with Periodontitis: A Retrospective Analysis. J. Complement.
Med. Res. 2020;11(4):172-8.
[2]. KARTHIKEYAN MURTHYKUMAR DR, KAARTHIKEYAN DG. Prevalence of Tooth Loss Among Chronic Periodontitis Patients-A Retrospective Study. Int. J. Pharm. Sci. Res. 2020 Jul;12(2).
[3]. Murthykumar K, Rajasekar A, Kaarthikeyan G. Assessment of various treatment modalities for isolated gingival recession defect- A retrospective study. Int. j. res. pharm. sci. 2020;11:3–7.
[4]. Sabarathinam J, Rajasekar A, Madhulaxmi M. Prevalence of Furcation Involvement Among Patients with Periodontitis: A Cross Sectional Study. Int. j. res. pharm. sci. 2020;11:1483–7.
[5]. Rajeshwaran N, Rajasekar A. Prevalence of Angular Bone Defects in Chronic Periodontitis Patients with and without Systemic Diseases. Indian J. Forensic Med. Toxicol. 2020 Oct 1;14(4).
[6]. Evaluation of Antiplaque and Antigingivitis Effects of A Herbal Mouthwash. Int. J. Pharm. Res. 2021;13.
[7]. S TA, Thanish AS, Rajasekar A, Mathew MG. Assessment of tooth loss in chronic periodontitis patients with and without diabetes mellitus: A crosssectional study. Int. j. res. pharm. sci. 2020;11:1927–31.
[8]. Chaffee BW, Weston SJ. Association between chronic periodontal disease and obesity: a systematic review and meta-analysis. J Periodontol. 2010 Dec;81(12):1708-24.
[9]. B G, Geethika B, Rajasekar A, Chaudary M. Comparison of periodontal status among pregnant and non-pregnant women. Int. j. res. pharm. sci. 2020;111923–6.
[10]. Rajasekar A, Lecturer S, Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, et al. Assessment Of Periodontal Status among Post Menopausal Women: A Retrospective Study. Int. J. Dent. Oral Sci. 2020. p. 1063–6.
[11]. Kandhan TS, Rajasekar A. Prevalence of Periodontal Diseases Among Patients with And Without Systemic Diseases–A Retrospective Study. J. Complement. Med. Res.2020;11(4):155-62.
[12]. Assessment of periodontal health among patients with diabetes mellitus: a retrospective study. J. contemp. issues bus. gov. 2021;26.
[13]. SHAH P, RAJASEKAR A, CHAUDHARY M. Assessment of Gender Based Difference in Occurrence of Periodontal Diseases: A Retrospective Study. J. contemp. issues bus. gov. 2021 Feb 16;27(2):521-6.
[14]. MOHD AZLAN SUNIL NS, RAJASEKAR A, DURAISAMY R. Evaluation of Periodontal Health Adjacent to Class V Restoration. J. contemp. issues bus. gov. 2021 Feb 15;27(2):324-9.
[15]. RAJASEKAR A, CHAUDARY M. Prevalence of Periodontal Diseases Among Individuals Above 45 Years: A Retrospective Study. J. contemp. issues bus. gov. 2021 Feb 19;27(2):527-33.
[16]. Rajasekar A, Mathew MG. Prevalence of Periodontal Disease among Individuals between 18-30 Years of Age: A Retrospective Study. Ann Med Health Sci Res. 2021 Jun 30.
[17]. Cobb CM. Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing. J Clin Periodontol. 2002 May;29 Suppl 2:22-32.Pubmed PMID: 12010523.
[18]. Sindhura H, Harsha RH, Shilpa RH. Efficacy of subgingival irrigation with 10% povidone-iodine as an adjunct to scaling and root planing: A clinical and microbiological study. Indian J. Dent. Res. 2017 Sep 1;28(5):514.
[19]. Anandakumar S, Malaiappan S. Effect of Subgingival Irrigation with Natural Products as an Adjunct to Scaling and Root Planing in the Treatment of Chronic Periodontitis-A Systematic Review. J Clin Diagn Res. 2018 Aug 1;12(8).
[20]. Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. The lancet. 2005 Nov 19;366(9499):1809-20.
[21]. Anderson GB, Bowden J, Morrison EC, Caffesse RG. Clinical effects of chlorhexidine mouthwashes on patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop. 1997 Jun 1;111(6):606-12.
[22]. Bajaj N, Tandon S. The effect of Triphala and Chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth. Int J Ayurveda Res. 2011 Jan;2(1):29-36.Pubmed PMID: 21897640.
[23]. Bhat N, Mitra R, Oza S, Mantu VK, Bishnoi S, Gohil M, et al. The antiplaque effect of herbal mouthwash in comparison to chlorhexidine in human gingival disease: a randomized placebo controlled clinical trial. J Complement Integr Med. 2014 Jun 1;11(2):129-37.
[24]. Nardi GM, Fais S, Casu C, Mazur M, Di Giorgio R, Grassi R, et al. Mouthwash Based on Ozonated Olive Oil in Caries Prevention: A Preliminary In- Vitro Study. Int J Environ Res Public Health. 2020 Dec 6;17(23):9106. Pubmed PMID: 33291253.
[25]. Singh G, Srivsatava S, Shekhar A, Chaturvedi A, Bhatia LK, Gupta A. Ozone Applications In Dentistry: A Biological Therapy. Onlinegatha; 2020 Dec 27:125.
[26]. Grechi G. Ophthalmology: ozone therapy applied to dystrophic maculopathy. Ozone Ther. 2017 May 30;2(1).
[27]. Ramesh A, Varghese S, Jayakumar ND, Malaiappan S. Comparative estimation of sulfiredoxin levels between chronic periodontitis and healthy patients - A case-control study. J Periodontol. 2018 Oct;89(10):1241-1248.Pubmed PMID: 30044495.
[28]. Paramasivam A, Priyadharsini JV, Raghunandhakumar S, Elumalai P. A novel COVID-19 and its effects on cardiovascular disease. Hypertens Res. 2020 Jul;43(7):729-30.
[29]. S G, T G, K V, Faleh A A, Sukumaran A, P N S. Development of 3D scaffolds using nanochitosan/silk-fibroin/hyaluronic acid biomaterials for tissue engineering applications. Int J Biol Macromol. 2018 Dec;120(Pt A):876- 885.Pubmed PMID: 30171951.
[30]. Del Fabbro M, Karanxha L, Panda S, Bucchi C, Doraiswamy JN, Sankari M, et al. Autologous platelet concentrates for treating periodontal infrabony defects. Cochrane Database Syst Rev. 2018(11).
[31]. Paramasivam A, Vijayashree Priyadharsini J. MitomiRs: new emerging microRNAs in mitochondrial dysfunction and cardiovascular disease. Hypertens Res. 2020 Aug;43(8):851-853.Pubmed PMID: 32152483.
[32]. Jayaseelan VP, Arumugam P. Dissecting the theranostic potential of exosomes in autoimmune disorders. Cell Mol Immunol. 2019 Dec;16(12):935-936. Pubmed PMID: 31619771.
[33]. Vellappally S, Al Kheraif AA, Divakar DD, Basavarajappa S, Anil S, Fouad H. Tooth implant prosthesis using ultra low power and low cost crystalline carbon bio-tooth sensor with hybridized data acquisition algorithm. Comput Commun. 2019 Dec 15;148:176-84.
[34]. Vellappally S, Al Kheraif AA, Anil S, Assery MK, Kumar KA, Divakar DD. Analyzing Relationship between Patient and Doctor in Public Dental Health using Particle Memetic Multivariable Logistic Regression Analysis Approach (MLRA2). J Med Syst. 2018 Aug 29;42(10):183.Pubmed PMID: 30155746.
[35]. Varghese SS, Ramesh A, Veeraiyan DN. Blended Module-Based Teaching in Biostatistics and Research Methodology: A Retrospective Study with Postgraduate Dental Students. J Dent Educ. 2019 Apr;83(4):445-450.Pubmed PMID: 30745352.
[36]. Venkatesan J, Singh SK, Anil S, Kim SK, Shim MS. Preparation, Characterization and Biological Applications of Biosynthesized Silver Nanoparticles with Chitosan-Fucoidan Coating. Molecules. 2018 Jun 12;23(6):1429.Pubmed PMID: 29895803.
[37]. Alsubait SA, Al Ajlan R, Mitwalli H, Aburaisi N, Mahmood A, Muthurangan M, et al. Cytotoxicity of different concentrations of three root canal sealers on human mesenchymal stem cells. Biomolecules. 2018 Sep;8(3):68.
[38]. Venkatesan J, Rekha PD, Anil S, Bhatnagar I, Sudha PN, Dechsakulwatana C, et al. Hydroxyapatite from cuttlefish bone: isolation, characterizations, and applications. Biotechnol Bioprocess Eng. 2018 Aug;23(4):383-93.
[39]. Vellappally S, Al Kheraif AA, Anil S, Wahba AA. IoT medical tooth mounted sensor for monitoring teeth and food level using bacterial optimization along with adaptive deep learning neural network. Measurement. 2019 Mar 1;135:672-7.
[40]. PradeepKumar AR, Shemesh H, Nivedhitha MS, Hashir MMJ, Arockiam S, Uma Maheswari TN, et al. Diagnosis of Vertical Root Fractures by Conebeam Computed Tomography in Root-filled Teeth with Confirmation by Direct Visualization: A Systematic Review and Meta-Analysis. J Endod. 2021 Aug;47(8):1198-1214.Pubmed PMID: 33984375.
[41]. R H, Ramani P, Tilakaratne WM, Sukumaran G, Ramasubramanian A, Krishnan RP. Critical appraisal of different triggering pathways for the pathobiology of pemphigus vulgaris-A review. Oral Dis. 2021 Jun 21.Pubmed PMID: 34152662.
[42]. Ezhilarasan D, Lakshmi T, Subha M, Deepak Nallasamy V, Raghunandhakumar S. The ambiguous role of sirtuins in head and neck squamous cell carcinoma. Oral Dis. 2021 Feb 11.Pubmed PMID: 33570800.
[43]. Sarode SC, Gondivkar S, Sarode GS, Gadbail A, Yuwanati M. Hybrid oral potentially malignant disorder: A neglected fact in oral submucous fibrosis. Oral Oncol. 2021 Oct;121:105390.Pubmed PMID: 34147361.
[44]. Kavarthapu A, Gurumoorthy K. Linking chronic periodontitis and oral cancer: A review. Oral Oncol. 2021 Jun 16:105375.
[45]. Vellappally S, Al-Kheraif AA, Anil S, Basavarajappa S, Hassanein AS. Maintaining patient oral health by using a xeno-genetic spiking neural network. J. Ambient Intell. Humaniz. Comput. 2018 Dec 14:1-9.
[46]. Aldhuwayhi S, Mallineni SK, Sakhamuri S, Thakare AA, Mallineni S, Sajja R, et al. Covid-19 Knowledge and Perceptions Among Dental Specialists: A Cross-Sectional Online Questionnaire Survey. Risk Manag Healthc Policy. 2021 Jul 7;14:2851-2861.Pubmed PMID: 34262372.
[47]. Kshitish D, Laxman VK. The use of ozonated water and 0.2% chlorhexidine in the treatment of periodontitis patients: A clinical and microbiologic study. Indian J Dent Res. 2010 Jul 1;21(3):341-8.
[48]. Issac AV, Mathew JJ, Ambooken M, Kachappilly AJ, Pk A, Johny T, et al. Management of chronic periodontitis using subgingival irrigation of ozonized water: A clinical and microbiological study. J Clin Diagn Res. 2015 Aug;9(8):ZC29-33.
[49]. Katti SS, Chava VK. Effect of Ozonised water on Chronic Periodontitis - A Clinical Study. J Int Oral Health. 2013 Oct;5(5):79-84.Pubmed PMID: 24324309.
[50]. Al Habashneh R, Khader YS, Jabali OA, Alchalabi H. Prediction of preterm and low birth weight delivery by maternal periodontal parameters: receiver operating characteristic (ROC) curve analysis. Matern Child Health J. 2013 Feb;17(2):299-306.Pubmed PMID: 22392602.
[51]. Vasthavi C, Babu HM, Rangaraju VM, Dasappa S, Jagadish L, Shivamurthy R. Evaluation of ozone as an adjunct to scaling and root planing in the treatment of chronic periodontitis: A randomized clinico-microbial study. J Indian Soc Periodontol. 2020 Jan-Feb;24(1):42-46.Pubmed PMID: 31983844.
