This article is included with the publisher's permission. More information about the journal can be found at the publisher's website at: http://www.dentalasia.net/index.htmRecurrent aphthous ulceration is a common mucosal disorder that can be painful and debilitating for patients. This type of ulceration
has been associated with systemic disease and it has been suggested that a variety of immunological, microbial and genetic factors may
all play a role in its aetiopathogenesis. A wide variety of treatment strategies for aphthous ulceration has been discussed in the
literature. This case report demonstrates the beneficial use of topical application of ozone using the Healozone‘ appliance (Kavo) in a
patient with long standing aphthous ulceration involving the lateral border of the tongue. The topical application of ozone provided an
effective means of producing resolution of clinical symptoms related to aphthous ulceration for this patient. Further clinical investigation
is required in order to determine the potential of this treatment modality in the treatment of recurrent aphthous ulceration.Richard Loga

Logan, Richard Martin

Adelaide Research &amp; Scholarship

48 Dental Asia • March / April 2005USER REPORTThe use of topical ozoneto treat recurrentaphthous ulcerationecurrent aphthous ulceration isa common mucosal disorder thatcan be painful and debilitatingheal within ten days or so withoutscarring. Major aphthous ulcers, on theother hand, are less common and areoften larger than the minor form. Theseulcers can persist for extended periodsof time and when they do eventuallyheal, heal with scarring. Major aphthae,like the minor variant are more likely tooccur on non-attached mucosa ratherthan areas such as the gingivae and hardpalate. The third and least common formof aphthous ulceration is the herpetiformvariant. These ulcers are small, only oneto two millimetres in diameter; howeverin some cases there may be up to 200ulcers present at any one time. Likeminor aphthae, these ulcers heal withina relatively short period and heal withoutscarring. Aphthous ulceration has alsobeen associated with various systemicdiseases, most importantly, Behçetsdisease and coeliac disease.1,2 It has alsobeen reported in association with HIVinfection.3 In addition aphthousulceration has been reported inassociation with various deficienciesincluding vitamin B12, folate and iron.4Because the aetiology of aphthousulceration is poorly understood,treatment options for patients are largelypalliative and aimed at reducingsymptoms thereby improving oralcomfort. A diverse range of treatmentstrategies have been reported in theRecurrent aphthous ulceration is a common mucosal disorder that can be painfuland debilitating for patients. This type of ulceration has been associated with systemicdisease and it has been suggested that a variety of immunological, microbial andgenetic factors may all play a role in its aetiopathogenesis. A wide variety of treatmentstrategies for aphthous ulceration has been discussed in the literature. This casereport demonstrates the beneficial use of topical application of ozone using theHealozone‘ appliance (Kavo) in a patient with long standing aphthous ulcerationinvolving the lateral border of the tongue. The topical application of ozone providedan effective means of producing resolution of clinical symptoms related to aphthousulceration for this patient. Further clinical investigation is required in order to determinethe potential of this treatment modality in the treatment of recurrent aphthousulceration.By Dr Richard LoganRfor patients. This inflammatory conditionhas no known aetiology and has a varietyof clinical manifestations ranging fromsingle to multiple ulcers affecting the oralmucosa. Three variants of aphthousulceration are recognised and includeminor aphthae, which are characterisedby round or oval shallow ulcers generallyless that a centimetre in diameter. Minoraphthous ulcers are the most commonlyencountered variant and usually occur onnon-attached mucosa such as is found onthe floor of mouth, labial mucosa andbuccal mucosa. These lesions generally 49Dental Asia • March / April 2005USER REPORTliterature and include topical agentsincluding analgesics and anaesthetics,steroids and antibacterial mouthwashesas well as systemic treatment includingdrugs such as prednisolone, azathioprineand thalidomide.5,6,7 These systemictreatments have potentially serious sideeffects that may contraindicate their usein some patients and should only beprescribed by experienced practitioners.This case reportdemonstrates theapparent beneficialuse of topical ozoneapplication using theHealozone appliance(Kavo) in a patientwith long standingaphthous ulcerationinvolving the lateralborder of the tongue.Case reportA 56 year oldfemale was referredto the Special NeedsUnit of the AdelaideDental Hospitalwith a two yearhistory of recurrentoral ulceration. Apart from a history ofsino-nasal polyposis and asthma she wasmedically well. Initial examination of thepatient demonstrated multiple minoraphthous ulcers involving the lowerlabial mucosa. A larger ulcer was presenton the lateral border of the tongue andaccording to the patient this had beenpresent for a period of two years or more.This ulcer was deep and had raisedfibrotic margins. This ulcer had, in factbeen biopsied previously because of itsclinical similarity to a squamous cellcarcinoma. The patient had previouslyhad a thorough investigation with respectto the ulceration and no underlyingnutritional deficiency or associatedsystemic disease was detected. Theulcers were localised to her mouth.Topical steroids were initially usedto treat the ulcers without much success.Generally the minor aphthae affectingthe labial and buccal mucosae and floorof the mouth healed within seven days,however within this time new ulcers hadstarted to form. The deeper ulcer on thetongue persisted. Subsequently thepatient developed pneumonia related toher asthma and as part of her treatmentwas placed on systemic prednisolone.During the period that she was on thismedication the oral ulceration resolved,the tongue ulcer persisted but symptomsassociated with it were reduced. Oncessation of the prednisolone theulceration promptly returned. The patientwas reviewed again one month followingthe cessation of prednisolone duringwhich time she had ceased using allforms of topical preparations. During thistime, the Special Needs Unit of theAdelaide Dental Hospital gained accessto a Healozone‘ appliance (Kavo) and itwas felt that it would be interesting tosee whether the use of ozone had anyimpact on the aphthous ulceration in thispatient. The patient agreed to have theozone applied to her ulcers, particularlythe tongue ulcer which was causing thegreatest degree of discomfort (Figure 1).Initially the ozone was applied for aperiod of sixty seconds (Figure 2). Thepatient did not experience any pain ordiscomfort from this procedure. Thepatient was reviewed again 2 days laterand clinically there was no change to theulceration. A further treatment of ozonewas applied to the lesion for sixtyseconds. On review, one week later, thepatient reported a slight improvement insymptoms, however clinically the tongueulcer was still present. Various treatmentFig. 1: Photograph demonstrating the clinical appearance of a major aphthous ulceron the left lateral border of the tongue. The raised fibrotic margins are evident clinically.Fig.2 : Photograph demonstrating the clinical application oftopical ozone to the ulcer using the Healozone‘ appliance(Kavo).50 Dental Asia • March / April 2005USER REPORToptions were discussed with the patientincluding excision of the ulcer, howeverthe patient was not keen on this andneeded to consider her options. It wasdecided to review the ulceration withinone month. At the review appointmentthe patient reported that the ulcer hadcompletely healed. Clinically this wasapparent with no evidence of residualulceration on her tongue (Figure 3). Thepatient had not used any topical agentsor taken any systemic medication duringthe time subsequent to the application ofozone.DiscussionAphthous ulceration can be a painfuland debilitating problem for patients,particularly when multiple ulcers occursimultaneously. As a consequence, theoccurrence of ulceration often impactson normal function resulting indifficulties with eating and speaking.Effective treatment and management ofpain is essential for patients affected bythese lesions.There are very few reports of the useof ozone as a treatment modality in theliterature. The earliest in 1957 reportedthe beneficial effects of ozone on thehealing of leg ulcers.8 The beneficial useof ozone on the healing of chronic legulceration was reported by Thwaites andDean in 1985.8 They reported that out of73 patients with chronic leg ulcers whowere treated with ozone, 59demonstrated satisfactory healing. Morerecent reports of the use of ozone includethe treatment of skin reactions followingradiotherapy9 and the treatment of lowerlimb ischaemia.10 The reported benefitof using ozone is equivocal. Thebeneficial effect of ozone has beenattributed to improved bloodoxygenation, reduced blood viscosityand lower aggregation of platelets.8Ozone also has properties that make iteffective in destroying variousmicroorganisms including bacteria,viruses, fungi and protozoa.8,10 In termsof wound healing it has been suggestedthat the use of ozone potentiates theinflammatory reaction that occurs.8,9,10The use of topical ozone for thetreatment of recurrent aphthousulceration requires further investigationbefore it can be advocated as a validtreatment option for these lesions.Further investigation is also required todetermine the exact aetiopathogenesis ofaphthous ulceration in order to helpdevelop specific and targeted treatmentsfor this potentially debilitating condition.In the meantime however, topical ozoneapplication may be a further option forpatients with this debilitating conditionfor whom other treatment options havebeen exhausted or for whom systemictreatment is contraindicated.References1. Verpilleux MP, Bastuji-Goren SA,Revuz J, “Comparative analysis ofsevere aphthosis and Behçet’sdisease: 104 cases” Dermatology,1999; 198(3): 247-512. Field EA, Allan RB, “Review article:oral ulceration – aetiopathogenesis,clinical diagnosis and managementin the gastrointestinal clinic” AlimentPharmacol Ther, 2003; 18(10):949-623. Kerr AR, Ship JA, “Managementstrategies for HIV-associatedaphthous stomatitis” Am J ClinDermatol, 2003; 4(10): 669-804. Weusten BL, Van de Wiel A,“Aphthous ulcers and vitamin B12deficiency” Neth J Med, 1998; 53(4):172-55. Scully C, Gorsky M, Lozada-Nur F,“The diagnosis and management ofrecurrent aphthous stomatitis: aconsensus approach” JADA, 2003;134: 200-76. Natah SS, Konttinen YT, EnattahNDS, Ashammakhi N, SharkeyKA,Häyrinen-Immonen R, “Recurrentaphthous ulcers today: a review of thegrowing knowledge” Int J OralMaxillofacial Surg, 2004; 33: 221-347. Feminano F, Gombos F, Scully C,“Recurrent aphthous stomatitisunresponsive to topical cortico-steroids: a study of the comparativetherapeutic effects of systemicFig. 3: Photograph demonstrating the clinical appearance of the left lateral border ofthe tongue one month following the clinical application of ozone.DA 51Dental Asia • March / April 2005USER REPORTprednisone and systemic sulodexide”Int J Dermatol, 2003; 42: 394-78. Thwaites M, Dean S, “Chronic legulcers: ozone and other factorsaffecting healing” Aust Fam Phys,1985; 14(4): 292-89. Jordan L, Beaver K, Foy S, “Ozonetreatment for radiotherapy skinreactions: is there an evidence basefor practice?” Eur J Oncol Nurs,2002; 6(4): 220-710. Tafil-Klawe M, Wozniak A, DrewaT, Ponikowska I, Drewa J, Drewa G,Wlodarczyk K, Olszewska D, KlaweJ, Rozlowska R, “Ozone therapy andthe activity of selected lysosomalenzymes in blood serum of patientswith lower limb ischaemiaassociated with obliterativeatheromatosis” Med Sci Monit, 2002;8(7): 520-5Dr Richard M Logan BDS MDSDr Richard Logan is currently Senior Lecturerand Head of Oral Pathology at the Dental School,The University of Adelaide, Australia. He qualifiedin Dentistry at The University of Adelaide in 1992and completed a Master of Dental Surgery in OralPathology in 1997.In 1997 he was appointed Consultant in theSpecial Needs Unit of the Adelaide Dental Hospitaland in 2003 was appointed as a Consultant Oral Pathologist in the Divisionof Tissue Pathology at the Institute of Medical and Veterinary Sciences,Adelaide. In 2000 he was awarded the Inaugural Royal Australasian Collegeof Dental Surgeons Research Fellowship. He has lectured extensively andpublished articles relating to oral manifestations of HIV and hepatitis C aswell as infection control.He currently actively involved in various areas of research in the field ofOral Pathology with a particular interest in the oral side effects of oncologytreatment.

The use of topical ozone to treat recurrent aphthous ulceration

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The use of topical ozone to treat recurrent aphthous ulceration

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Adelaide Research & Scholarship

The use of topical ozone to treat recurrent aphthous ulceration

Abstract

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Adelaide Research &amp; Scholarship

Adelaide Research & Scholarship