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Ozone was discovered over a hundred years ago and since then, it has been widely used in many areas, with the primary use as a disinfectant in various ways, but with applications in diverse conditions. More recently, the use of ozone has extended to other fronts, using it to treat different pathologies. Extensive studies have shown its effects, as well as the safety of its application in various modalities of use. Other studies showed its toxicity, which depends on the doses of use. Emerging evidence revealed that ozone also plays an important role in the wound healing and modulation of immune cells, describing the molecular pathways responsible for these actions and describing therapeutic actions in the treatment of wounds, pain, postoperative and infectious diseases. Ozone use has already been documented in different doses, forms of use and routes of application, depending on the clinical situation and an adaptation is necessary for a better result. Thus, this review summarizes the main clinical uses of ozone, presenting the molecular pathways responsible for its actions, as well as discussing the main routes of use, doses and, vehicles used in the clinic.
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© 2020 Ana Paula Pivot to, Fernanda Weyand Ba nhuk, Izabela Virgi nia Staffen, Maiara Aline Daga, Thaís Soprani Ayala and
Rafael Andrade Menoll i. This open access article is dist ributed under a Creative Co mmons Attr ibution (CC-BY) 3.0 l icense.
OnLine Journal of Biological Sciences
Literature Reviews
Clinical Uses and Molecular Aspects of Ozone Therapy: A
Ana Paula Pivotto, Fernanda Weyand Banhuk, Izabela Virginia Staffen,
Maiara Aline Daga, Thaís Soprani Ayala and Rafael Andrade Menolli
Laboratory of Applied Immunology, Center of Medical and Pharmaceutical Sciences,
UNIOESTE-Western Parana State University, Cascavel/PR, Brazil
Article history
Received: 07-01-2020
Revised: 12-02-2020
Accepted: 24-02-2020
Corresponding Author:
Rafael Andrade Menolli
Laboratory of Applied
Immunology, Center of
Medical and Pharmaceutical
Sciences, UNIOESTE-Western
Parana State University,
Cascavel/PR, Brazil
Abstract: Ozone was discovered over a hundred years ago and since then,
it has been widely used in many areas, with the primary use as a
disinfectant in various ways, but with applications in diverse conditions.
More recently, the use of ozone has extended to other fronts, using it to
treat different pathologies. Extensive studies have shown its effects, as well
as the safety of its application in various modalities of use. Other studies
showed its toxicity, which depends on the doses of use. Emerging evidence
revealed that ozone also plays an important role in the wound healing and
modulation of immune cells, describing the molecular pathways responsible
for these actions and describing therapeutic actions in the treatment of
wounds, pain, postoperative and infectious diseases. Ozone use has already
been documented in different doses, forms of use and routes of application,
depending on the clinical situation and an adaptation is necessary for a
better result. Thus, this review summarizes the main clinical uses of ozone,
presenting the molecular pathways responsible for its actions, as well as
discussing the main routes of use, doses and, vehicles used in the clinic.
Keywords: Ozone, Mechanism of Action, Immunomodulation, Antioxidant,
Wound Healing
Ozone (O3) is an allotrope of oxygen, which at room
temperature, is an explosive gas that absorbs UV
radiation in the range 220-290 nm (Eriksson et al.,
2007). Ozone is a gas with a pungent and characteristic
smell. It is formed through electrical discharges on the
oxygen molecule, which breaks down, releasing atoms
that bind to the other two molecules, generating O3. At
high concentrations in air, it turns blue, while at low
concentrations, it is a colorless gas, lighter than the air
(Wysok et al., 2006). Ozone loses only to fluorine in its
oxidizing power and oxidizes most inorganic compounds to
their final oxidative state, converting ferrous, manganous
and chrome ions to their respective higher oxidation states
(Loegager et al., 1992). Because it is exceptionally
oxidizing and unstable, ozone quickly returns to its
molecular oxygen form, but for medical use, it needs to be
synthesized through specific generators. Most medical
generators on the market use the corona effect to produce
the oxygen-ozone gas mixture. Some studies demonstrate
the generation of ozone in the antigen-antibody complex
in the human body, which proves that the production of
this molecule happens physiologically via the immune
system too (Nathan, 2002).
Ozone is an unstable molecule, so it is usually mixed
with oxygen in ozone therapy (Biçer et al., 2016). This
product has powerful oxidizing properties, forming
oxygen-free radicals that lead to the destruction of
microorganisms and improves stimulation of the process
of healing. As a result, the immune system is activated to
fight pathogens such as bacteria, fungi and virus
infections (Stübinger et al., 2006). Ozone therapy is
effective in managing many skin conditions, mainly
wound healing, primarily because of its ability to
promote inflammation in the body such as the secretion
of immunomodulatory products and, reduction of the
oxidative damage. Ozone therapy has been widely
studied in infected wounds, gangrene, burns and,
circulatory disorders, showing to be highly effective in
the outcome of these conditions (Gulmen et al., 2013).
Its characteristics as an activator of the antioxidant
system make this molecule capable of stimulating tissue
healing and an anti-inflammatory environment at low
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doses, but when used in high concentrations, it can lead
to an exacerbation of inflammation (Bocci et al., 2011).
Thus, this article aims to review the main aspects of
ozone therapy regarding its clinical uses, routes of
administration, toxicity, as well as the molecular
mechanisms, highlighting the benefits and also the main
challenges and difficulties of its use.
Uses of Ozone
Ozone was first suggested as a potable water
disinfectant in the nineteenth century because of its
powerful ability to inactivate microorganisms (Ohmuller,
1892) and it has been later confirmed by other
researchers that this substance, when used for limited
periods, can effectively disinfect the water supply
(Broadwater et al., 1973). It has been considered an
effective alternative antimicrobial agent to chlorine, even
with adverse toxicological problems arising from its use
in high concentrations (Morris, 1971).
Due to its ability to oxidize substances and destroy
microorganisms, ozone has been widely used to sterilize
air, clean water and remove odors. In addition, its
application is intended for medical use. Ozone therapy
has been used and studied extensively for many decades.
It has been used to treat infections, wounds and various
diseases (Elvis and Ekta, 2011).
It was considered as an autohemotherapeutic agent in
the treatment of HIV-infected patients in the 1980s
(Garber et al., 1991), however, subsequent studies have
proven that ozone therapy neither improves nor worsens the
dynamics of HIV-1 replication in vivo (Bocci et al., 1998).
Although ozone has been applied to treat over 100
diverse diseases with varying results, the supporting
evidence for most medical ozone applications is limited. In
1976, inhalation of ozone gas was able to induce lung
inflammation and pulmonary edema, and this led the US
Food and Drug Administration (FDA) to declare concern
about its toxicity, which was reiterated in 2006 (USFDA,
2019). The FDA also emphasized that effective therapeutic
ozone concentration should be as far as possible from
tolerable doses by humans and other animals (Wang, 2018).
Ozone has wide medical applications due to its
effective antimicrobial function (Ozturk et al., 2017),
antioxidant defense and the anticipation in wound
healing (Delgado-Roche et al., 2017; Elvis and Ekta,
2011; Mirowsky et al., 2016) and in the control of
bleeding (Gupta and Mansi, 2012). The effects on
immunoregulation and antioxidant defenses, as well as
the effectiveness of ozone therapies, have been gradually
recognized, although the mechanisms involved in
various conditions are still unclear. Due to its role as an
activator of antioxidant defenses, ozone is widely used
for cosmetic-related services (Borrelli et al., 2012) and
general health services (Di Paolo et al., 2005).
In another direction, depending on the exposure time
and dose, ozone may promote harmful effects to the
individual, knowing that inhalation of ozone gas, as well
as its intake, is harmful to health (Bocci et al., 2012), as
well as attaining motor and cognitive activity, leading to
brain dysfunction and memory loss, seen in experiments
with rats exposed to ozone (Rivas-Arancibia et al., 1998).
Route of Administration
Many clinical and laboratory in vitro and in vivo
animal studies have shown the effectiveness of ozone
therapy used in several pathways (Gautam et al., 2011;
Izadi et al., 2019; Martínez-Sánchez et al., 2005).
Generally, ozone therapy was conducted by introducing
the mixing of ozone with gases or liquids into the body
through various ways, including intravaginal, intrarectal,
intramuscular, subcutaneous or intravenous routes
(Wang, 2018). Ozone has hemodynamics and can also be
introduced into the body through autohemotherapy
(Garber et al., 1991).
The topical route is the main route used for wounds
and ulcers, such as those occurring in the diabetic foot
(Izadi et al., 2019; Martínez-Sánchez et al., 2005) and
also in cases of burns (Campanati et al., 2013). Also, the
use of topical ozone therapy was widely used in dental
procedures (Sivalingam et al., 2017). The primary
vehicles for topical uses are water, saline, or oil and the
ozonation of these vehicles can occur before or during
the procedure, the area to be treated can be submerged in
the ozonated vehicle or spread/applied directly over the
area (Campanati et al., 2013; Izadi et al., 2019).
Parenteral ozone therapy encompasses systemic and
local injection and is widely used mainly in the
treatment of low back pain, arthritis, coronary artery
disease, herniated disc, osteoarthritis, hepatitis C, muscle
pain, among other conditions (Babaei-Ghazani et al.,
2018; Celakil et al., 2017; Gautam et al., 2011;
Martínez-Sánchez et al., 2005; Zaky et al., 2011). Beyond
the practices of systemic ozone therapy are rectal
insufflation, as in the case of coronary artery disease and
also in the treatment of hepatitis C (Martínez-Sánchez et al.,
2012; Zaky et al., 2011) and intravenously, performing
autohemotherapy to treat the symptoms of hepatitis C
too (Zaky et al., 2011) and also in cases of diabetic foot
(Izadi et al., 2019). Intramuscular infiltration for acute
spinal pain (Paoloni et al., 2009), intradiscal for lumbar
disc herniation (Gautam et al., 2011) and intrapatellar
injection for osteoarthritis treatment in the knee (Babaei-
Ghazani et al., 2018) could be classified as local
injections but not systemic or topical applications.
Vehicles for the Use of Ozone Therapy
Ozone therapy is available through different types of
vehicles. It is commonly used in the form of gas, under
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topical treatment, where the skin is covered with a
plastic bag filled with ozone gas-oxygen mixture (Wang,
2018). It also can be used in the form of ozonated saline,
which consists of prior saturation of physiological saline
with an oxygen-ozone mixture (Clavo et al., 2013).
An ozone generator is used when the aqueous ozone
is needed, which mixes ozone with water. This format is
highly valid for many skin-related disorders and is
widely used to treat infectious diseases. However, the
disadvantage of ozone hydrotherapy is the short shelf
life and its instability, which makes this treatment an
option available only in equipped clinics (Wang, 2018).
Its short half-life is approximately 20 minutes in water
at 20°C, it is partially soluble in water and, like most
gases, increases its solubility as the temperature
decreases (Kim et al., 1999; Wysok et al., 2006). This
solubility of ozone in aqueous media will depend on the
content of organic matter in the medium, as the lower the
concentration of organic matter, the longer the half-life
of ozone in water. The decomposition of ozone in the
liquid phase is characterized by a rapid decrease in initial
concentration, with a later phase in which ozone
concentration decreases according to first-order kinetics,
with hydroxyl radicals (OH) being the main products of
this decomposition (Almeida et al., 2004; Bocci, 2004).
Ozone can react with organic compounds in aqueous
solution by a direct ozone reaction or by an indirect
reaction of OH radicals, formed from the decomposition
of ozone. This indirect reaction can promote an attack on
organic compounds approximately 100 times faster than
some oxidizing agents such as H2O2 and ozone itself.
Predominantly, the disinfection processes occur via
molecular ozone, whereas the oxidation processes can
occur through both direct and indirect processes
(Almeida et al., 2004; da Silva et al., 2011).
Ozonated water is applied to wounds and ulcers, at
different concentrations depending on the outcome
expected (disinfect or regenerate) and the type of tissue
to which it will be applied (Clavo et al., 2013). Ozonated
water is indicated for pain relief, disinfection and anti-
inflammatory effects in acute and chronic lesions, with
or without infection (Wang, 2018).
Another option is the ozonated oil, obtained by
bubbling ozone into cold-pressed oils such as olive oil,
sunflower oil and many other unsaturated fatty acids
(Menéndez et al., 2011). It has the advantage of the shelf
life of 2 years if stored in refrigeration and the topical
application of this formulation can be performed at home,
which decreases the visits of the patients to the medical
institutions. Ozone oil is used in many conditions,
including wounds, anaerobic, viral and fungal infections,
as well as ulcers, anal fissures, and vulvovaginitis,
without any visible side effects (Bocci, 2004).
The vehicle by which ozone is applied can also play a
role in the mechanism of ozone therapy. Ozonated oils and
water act as stimulators, with both forms improving blood
circulation, oxygen delivery, and regularized antioxidant
enzymes to activate the immune system and promote the
release of growth factors. These phenomenons happen
because ozone reacts with the polyunsaturated fatty acids
present in the stratum corneum to generate reactive
oxygen species and lipo-oligopeptides, substances that
can be partially absorbed by skin, capillary and
lymphatic antioxidants (Sega et al., 2010).
Direct ozonation of vegetable oils with unsaturated
fatty acids leads to the formation of the 1,2,4-trioxolane
portion (Sega et al., 2010), which represents an active
form of ozone in these materials. The trioxolane ring in
the ozonated vegetable oil rapidly produces compounds
that accelerate the healing process in wet wounds or ulcers
and are responsible for antimicrobial and antimycotic
treatments (Menéndez et al., 2011). In addition, the oil
itself can act as a moisturizer and protector, especially
for patients with the compromised skin barrier.
Studies using vegetable oils in their pure form have
found that oils obtained from plants popularly used as
healers have demonstrated their healing effect. In a study
by Oliveira et al. (2013), it was found that pumpkin oil
increased tensile strength and increased collagen
synthesis, possibly as a result of the action of fatty acids
(Oliveira et al., 2013). The sunflower seed oil has
positively contributed to wound healing (Coelho et al.,
2012; Rodrigues et al., 2004). Oleic and linoleic acids,
the main components of sunflower oil, also present in
extra virgin coconut oil, demonstrated that when
topically applied, promoted rapid and satisfactory
healing in mice (Cardoso et al. 2004).
Ozone Clinical Uses
Ozone therapy has been used to treat different
conditions as summarized in Table 1, seen in different
Randomized Clinical Trial (RCT) and reviewed by many
authors. The conditions already studied includes:
Tissue healing from inflammatory processes showed by
a systematic review that included only RCT for chronic
wounds (Fitzpatrick et al., 2018) and revised by
Travagli et al. (2010) and Valacchi et al. (2005); for
back pain revised by Braidy et al., 2018 and also showed
by Andrade et al. (2019) in a RCT; osteoarthritis showed
in a systematic reviews (Anzolin and Bertol, 2018;
Noori-Zadeh et al., 2019) and seeing in an RCT
(Babaei-Ghazani et al., 2018; Lopes de Jesus et al.,
2017) and in a clinical trial phase 2 (Calunga et al.,
2012); diabetic foot ulcers as showed by a RCT
(Zhang et al., 2014) and revised by others (Braidy et al.,
2018); dental problems such as caries and periodontitis
summarized in a review (Almaz and Sönmez, 2015); in
the treatment of systemic sclerosis, as seeing in a RCT
(Hassanien et al., 2018); multiple sclerosis, seeing in a
clinical trial phase 1 (Delgado-Roche et al., 2017;
Nowicka, 2017); among other conditions showed in
clinical trials (Vanni et al., 2016).
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Table 1: Ozone therapy results in different clinical conditions
Condition Outcome
Wound healing Increase in vessel numbers, collagen deposition and myofibroblasts numbers; Stimulation of
the growth factors and peroxide releases; Improvement in oxygenation of the affected area.
Gingival graft surgery Improvement in the healing process; Diminishment of the pain intensity.
Cardiovascular diseases Increase in oxygenation in ischemic sites
Chronic inflammatory diseases Improvement of the standard treatment; Reduction in pain sensation.
Balanitis xerotica obliterans Anti-inflammatory effect; Reduction in the levels of the gene transcription of cytokines;
Reduction in the TG2 enzyme.
Atopic dermatitis Reduction in the exudation, improvement of the erosion process.
Osteoarthritis Positive effect on the intra-articular redox balance; Pain reduction.
Multiple and systemic sclerosis Decrease inflammatory process and cellular oxidative stress; Improved joint mobility;
Reduction in the thickness of the skin.
Asthma Reduction in immunoglobulin (Ig)E and HLA-DR levels; Improvement of lung function
reduction of the symptoms related.
Fig. 1: The main mechanism behind ozone treatment
Ozone therapy is considered an alternative therapy
and has several positive effects, but depending on the
dose, it may result in harmful effects for the individual
(Travagli et al., 2010). The primary reported effects in
humans are based on three main functions: Antimicrobial
(Ozturk et al., 2017), in the antioxidant/oxidant balance
(Calunga et al., 2012) and immunomodulatory effects
(Zeng and Lu, 2018) (Fig. 1). It is as a topical treatment
that ozone therapy has been most widely used
(Solovăstru et al., 2015; Travagli et al., 2010; Zeng and
Lu, 2018), as ozone gas is highly toxic to the airways,
whereas and in skin, a transient exposure at low and
controlled doses (range from 10 to 50 µg/mL), may be
beneficial (Valacchi et al., 2005). In the different
scenarios of different RCT, the use of ozone acts
mainly to anticipate the healing process, such as
reducing the size of the diabetic foot injury in
individuals with different wound sizes (Zhang et al.,
2014), as well as improving the treatment and complete
closure of these wounds in association with usual
treatment (Wainstein et al., 2011). It also showed this
characteristic in the effective healing of the treatment of
digital ulcers of patients with systemic sclerosis,
improving from 44% to 96% the effectiveness of the
treatment when combining calcium channel blocker with
topical aqueous ozone (Hassanien et al., 2018).
Another RCT showed that the application of ozone
on the gingival graft surgery site improved the patient's
Oxidation of ph ospholipids
and lipoproteins
Treatment of m any skin
diseases: diabetic foot atopic
dermatitis psoriasis vulgaris
Damage to
the capside
Bacterias Virus
Antimic robian activit y
Improved lu ng
Wound healing
improved in flamma tory
response Imunno modulation
Release of growth
factors, VEFG, TGF-β,
M1 macrophages, IL-12
Pro inflam atory action
M2 macrophages, IL-10
anti infla matory action
Oxidant-antio xidant
H2O2 regulation
O2 affect area
Antioxidant e nzymes
doses O2
doses O2
Beneficial ef fect Toxicity
Prevention of metabolic,
inflam matory and
infectious diseases
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quality of life, as well as improved healing along with
lower pain intensity (Taşdemir et al., 2016). Ozone, due
to its antioxidant effect (Vanni et al., 2016), has had
positive effects in the treatment of cardiovascular diseases,
improving the patient's prognosis, such as increasing
oxygenation in ischemic sites, as has been demonstrated
by a RCT to be beneficial in coronary artery disease and
heart failure (Martínez-Sánchez et al., 2012) and showed
in a clinical trial to treat peripheral arterial disease
(Coppola et al., 2002), besides, reviewed by Mauro et al.
(2019), ozone also showed to be beneficial in the
prevention of ischemic damage in an in vitro experiment
of ischemia (Frosini et al., 2012) and in a myocardial
infarction animal model (Di Filippo et al., 2010).
In chronic inflammatory diseases, the use of ozone
therapy as an adjuvant has been shown to improve the
reference treatment of back pain in patients studied under
an RCT (Andrade et al., 2019; reviewed by Bocci et al.,
2015). Another clinical practice is in the treatment of
disc herniation, which consists in injecting a gaseous
oxygen-ozone mixture into the intrasomatic space, site of
the disc herniation, or paravertebral muscle, showed in
an RCT to be beneficial to the patients, decreasing the
pain mainly. This practice was successful in treating this
condition (Paoloni et al., 2009). In 2011, a case report of
oral osteonecrosis was treated with an ozonated oil
suspension, achieving therapeutic success effectively and
safely (Ripamonti et al., 2011).
Ozone therapy has also been used in diseases such as
Balanitis Xerotica Obliterans (BXO). An RCT with male
children showed that ozonized olive oil produced a
powerful anti-inflammatory effect demonstrated by the
reduction in the levels of gene transcription of cytokines
examined in the treated tissues. In addition, it was
discovered that ozone treatment was able to reduce the
expression of the levels of the Transglutaminase 2 (TG2)
enzyme, supporting its anti-inflammatory role in the
foreskin affected by BXO (Currò et al., 2018).
Recent data shows the use of ozone also in
autoimmune diseases, such as atopic dermatitis and
psoriasis vulgaris. An RCT divided sixty children into
two groups, the first received ozonated water 3 to 5
times a week and ozonized oil twice a day, the second
group received only base oil and a moisturizer for 2
weeks. After 3-5 days of topical ozone therapy, the
exudation of the skin was reduced, and the erosion
healed. The effective rates were 80.0% and 20.0% in the
treatment and control group for 1 week and 89.6% and
30.7% for 2 weeks, respectively, with a significant
difference between the 2 groups (P<0.001), these data
show the effectiveness of topical ozone therapy in this
condition (Qin et al., 2018). A clinical trial phase 1
shows the efficiency of ozone in the treatment of
psoriasis vulgaris, in which 39 patients whit this
condition received medical ozone therapy during the
nursing intervention. The cure rate was 38.5% and the
total efficiency was 84.7%, showing that this substance
can be also a good alternative in the treatment of this
disease (Le, 2012).
An RCT to study the effect of ozone as a therapy
to treat osteoarthritis also showed to be a successful
approach to treat and relieve the pain of the patients
under this condition (Babaei-Ghazani et al., 2018;
Lopes de Jesus et al., 2017). Also, a clinical trial
showed that a combination of the usual treatment to
knee osteoarthritis with ozone therapy had a positive
effect on the intra-articular redox balance, reducing
the pain of these patients, increasing their quality of
life (Calunga et al., 2012).
Ozone was also beneficial to treat multiple sclerosis and
systemic sclerosis (Delgado-Roche et al., 2017; Nowicka,
2017). In a clinical trial phase 1, Delgado-Roche et al.,
2017, showed that ozone therapy decreases inflammatory
process and cellular oxidative stress, promoting a
possible neuroprotective effect, where ozone therapy
could be used together with the usual treatment,
diminishing its toxicity (Delgado-Roche et al., 2017).
Also, in a systemic sclerosis clinical trial, Nowicka
(2017) presented results where ozone, alone or together
with the usual treatment, improved the clinical
parameters and skin temperature of these patients,
increasing the movability of the joints and decreasing the
thickness of the skin (Nowicka, 2017).
Safety Dose and Clinical Protocol
The safe dose of ozone is variable depending on the
location of therapy and the goal of the treatment
(Smith et al., 2017). Currently, it has been proposed that
ranging from 10 up to 80 µg/mL of ozone, is beneficial
leading to the positive effects and no toxicity, depending
on the tissue, shown in in vitro and in vivo in animal
models (El-Sawalhi et al., 2013; Frosini et al., 2012;
Orakdogen et al., 2016; Thiele et al., 1997; Sweet et al.,
1980; Smith et al., 2017). In humans studies, the safe
dose range varies between 15 and 50 µg/mL and it will
depend on the type and goal of treatment as well as the
local of application.
Several clinical protocols have been used to treat the
different pathologies already mentioned here. Depending
on the extent of the disease and the goal of the treatment,
the protocol may vary from one week up to months. In the
case of diabetic foot ulcers, many studies use ozone
treatment in conjunction with conventional treatment
(Liu et al., 2015). Clinical studies perform submersion
treatment of the lower limb in a bag of water and constant
ozonation for 30 min, at an approximate concentration of
50 µg/mL (Izadi et al., 2019; Martínez-Sánchez et al.,
2005; Zhang et al., 2014). Different studies have different
endpoints, some of them, in the case of the diabetic foot or
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open wounds, treat until complete wound closure or until
the reepithelialization process is identified (Izadi et al.,
2019), others establish a limit of days, such as 20
consecutive days or so (Zhang et al., 2014). Besides, the
use of ozone oil is widely used in topical therapy and the
preparation is spread over the wound and left to act for
30 minutes, at an average concentration of 40 µg/ml
(Fitzpatrick et al., 2018).
To treat disc herniated low back pain and acute back
pain, patients received for five consecutive weeks, three
intramuscular injections of an oxygen and ozone mixture
at an average concentration of 20 µg/mL (Paoloni et al.,
2009). Protocols that perform rectal insufflation,
generally indicated for the treatment of low back pain,
osteoarthritis, arthritis, multiple sclerosis, among others,
use an ozone concentration of approximately 20 µg/mL
during approximately 2-3 times per week for 3 months
(Anzolin and Bertol, 2018; Delgado-Roche et al., 2017)
and also 20 applications for 4 weeks in the case of
rheumatoid arthritis (León Fernández et al., 2016). In the
case of coronary artery disease, a concentration of 40
µg/mL once a day for 20 days was effective in
decreasing oxidative biomarkers generally present in this
condition (Martínez-Sánchez et al., 2012). The
autohemotherapy protocols use the patient's collected
blood, which is then ozonated at a dose of 20 µg/mL
and reinserted intramuscularly or intravenously, as in
the treatment of complications of hepatitis C (Zaky et al.,
2011) and individuals with peripheral arterial disease
(Di Paolo et al., 2005).
In local injection, such as intradiscal injection, used
mainly for back pain such as disc herniation, an average
of 50 µg/mL of ozone is usually injected into an
ozone/oxygen mixture (Niu et al., 2018). Also, there are
intrapatellar ozone injection protocols at an average
concentration of 15 µg/mL that is effective in treating
osteoarthritis (Babaei-Ghazani et al., 2018).
Molecular Mechanisms of Action
The mechanism of action of ozone therapy lays
mainly in three aspects: Immunomodulation (Bocci,
2006; 2007), antimicrobial activity (Polydorou et al., 2012;
Thanomsub et al., 2002) and the capacity to interplay with
the oxidant/antioxidant balance (Soares et al., 2019).
Altogether, another main aspect of the mechanism of the
ozone treatment is the wound healing property and the
main mechanism behind this is the capacity to interact
with the skin epithelization system (Borges et al., 2017;
Eroglu et al., 2018), as summarized in Fig. 1.
Ozone therapy, especially in its topical forms, has
been used clinically as an adjuvant in wound healing
(Borges et al., 2017). Ozone promotes an increase in the
epithelialization process increasing matrix deposition and
cell proliferation. Ozone-treated wounds also demonstrate
a granulation tissue with fewer inflammatory cells and a
higher number of myofibroblast-compatible spindle cells.
As well as increased vessel numbers and collagen
deposition (Soares et al., 2019). Several endogenous
growth factors, such as vascular Endothelial Growth
Factor (VEGF), Transforming Growth Factor-beta
(TGF-β), Fibroblast Growth Factor (FGF) and Platelet-
Derived Growth Factor (PDGF), play an essential role in
early wound healing (Eroglu et al., 2018), so it becomes
crucial for the healing process the stimulation of the
expression of these growth factors.
Another mechanism by which ozone leads to wound
healing involves its interaction with wound exudates that
lead to the breakdown of ozone into peroxides and
stimulates tissue repair, improving oxygenation in the
affected area. Oxygen-responsive species stimulate
platelet aggregation and lead to the release of growth
factors, that as mentioned above, play a key role in wound
healing (Wang, 2018). According to recent researches,
ozone increases endogenous growth factors (Eroglu et al.,
2018) such as the expression of VEGF, TGF-β and PDGF,
all involved in the cicatrization process (Zhang et al.,
2014). Fibroblast Growth Factor 2 (FGF2), also known as
basic FGF, is an essential protein that activates
myofibroblastic angiogenesis-associated pathways and
proliferation (Svystonyuk et al., 2015). FGF2 expression
was associated with fibroblast activation, resulting in
higher tissue collagen production. Soares et al. (2019), who
used ozone to treat skin wounds in rats, observed that FGF2
was overexpressed in macrophages and myofibroblasts,
which may indicate an improvement in wound healing
events. This finding corroborates with the hypothesis that
these cells, under topical ozone treatment, secrete growth
factors and cytokines that are essential to the healing
process. Besides, ozone has been reported to induce an
increase in the number of macrophages associated with a
higher number of myofibroblasts, as well as proliferative
neovascularization and vascular regression in a wound
remodeling phase. So, the mechanism of action of ozone
may be associated with FGF2 overexpression and
myofibroblastic differentiation (Soares et al., 2019).
Additionally, ozone activates the immune system by
inducing secretion of interferon-γ and tumor necrosis
factor-α, Interleukin 2 (IL-2) and other factors involved
in the inflammatory response (Bocci 2006; 2007). The
underlying mechanism involves the interaction of ozone
with wound exudates, which leads to the breakdown of
ozone into peroxides and stimulates tissue repair,
improving oxygenation in the area (Xiao et al., 2017).
Species of oxygen, released by the macrophages,
stimulate platelet aggregation and lead to the release of
growth factors, which aid in wound healing
(Valacchi and Bocci, 1999). However, studies should be
performed to highlight the phenotype of macrophages
that produce and secrete FGF2 during wound healing
(M1 or M2 macrophages). Characteristically, M1
Ana Paula Pivott o et al. / OnLine Journal o f Biologica l Sciences 2020, 20 (1): 37.49
DOI: 10.3844/ojbsci.2020.37.49
macrophages induce inflammation, negatively regulating
the early healing process, producing IL-12 and M2
macrophages positively regulate the healing process in
an IL-10 mediated process (Mills, 2012).
Ozone therapy has been shown to increase tissue
oxygenation and metabolism, interfering with
oxidant/antioxidant balance. Based on this mechanism,
ozone is capable of reducing the levels of hydrogen
peroxide (H2O2) by regulating the levels of antioxidant
molecules. Also, peroxides produced through ozone
improve oxygen availability by regulating antioxidant
molecules in red blood cells, favoring the metabolism
and the release of cytokines, autacoids and growth
factors that are fundamental in the treatment of
metabolic, inflammatory and infectious diseases
(Soares et al., 2019). However, this release of peroxides
in a large amount can cause harm to humans, as is
evidenced in some studies that show structural changes in
lung tissue (Buell et al., 1965), low resistance to
respiratory bacterial infection and reduced lung function
(Holzman et al., 1968). In addition, a pre-clinical study on
the reaction of ozone with amino acids indicates that
cysteine and methionine are easily oxidized, as well as
tryptophan, histidine, tyrosine, cystine, and phenylalanine
(Mudd et al., 1969). This oxidation of amino acids can be
responsible for the toxic reactions of ozone to plants and
animals. The studies above were performed mainly at
ozone levels between 1.0 and 5.0 ppm (Leh, 1973).
Despite the possible deleterious dose-dependent
effect, ozone therapy can increase oxygen metabolism in
erythrocytes, increasing the rate of glycolysis,
consequently leading to increased oxygen release into
the tissues (Di Filippo et al., 2015). Ozone increases
oxidative pyruvate carboxylation and ATP production
during the Krebs’ cycle, reducing NADH and oxidizes
cytochrome C. Indeed, it increases the production of
enzymes such as glutathione peroxidase, catalase, and
superoxide dismutase that serve as sequestrators of free
radicals and protectors for healthy cells (Nathan, 2002).
Ozonization in asthmatic patients effectively reduces
Immunoglobulin (Ig)E and HLA-DR levels, thus
improving lung function and reducing related symptoms.
A study suggested that the therapeutic efficacy of ozone in
reducing IgE and inflammatory mediators are associated
with its immunomodulating and regulating properties of
the oxidative stress (Wang, 2018). Another study showed
a decrease in IgE and HLA-DR levels in asthmatic
patients treated with systemic ozone therapy with the
consequent increase in lung function and improvement in
the symptoms (Hernández Rosales et al., 2005).
Evidence shows that moderate oxidative stress
induced by low doses of ozone activates nuclear factor
erythroid 2-related factor 2 (Nrf2), suppresses
transcriptional factor-kappa B (NF-κB) and reduces
inflammatory responses. Over the past decade, evidence
has suggested that Nrf2 activation induces transcription of
Antioxidant Response Elements (ERA). ERA
transcription leads to the production of antioxidant
enzymes such as Superoxide Dismutase (SOD),
Glutathione Peroxidase (GPx), Glutathione S-Transferase
(GST), Catalase (CAT), Heme-Oxygenase-1 (HO-1),
NADPH-Quinone Oxide reductase (NQO-1), phase 2
enzymes of drug metabolism and heat shock proteins.
Thus, the Nrf2 system contributes to the protection against
carcinogenesis, liver toxicity, chronic respiratory and
inflammatory diseases, neuronal ischemia and renal
problems. Systemic administration of ozone through
ozonated saline could activate this mechanism (Re et al.,
2014). In a study by Pecorelli et al. (2013), it was shown
that ozonated plasma can positively regulate HO-1
expression in endothelial cells and activate Nrf2 in dose-
dependent serum ozone concentration.
On the other hand, severe oxidative stress triggered
by high concentrations of ozone activates NF-κB,
leading to elevated inflammatory responses and tissue
damage by the production of Cyclooxygenase 2 (COX2),
Prostaglandin E2 (PGE2) and cytokines. So, the strength
of oxidative stress determines the effectiveness and
toxicity of ozone (Wang, 2018). This effect was shown
on the skin, demonstrating that ozone is capable of
interacting with skin antioxidant molecules (Thiele et al.,
1997), besides causing an increase in the expression of
the COX-2, with an increase in heat shock protein (HSP)
(Valacchi et al., 2005). The ozone dose that can cause
toxicity is not yet defined, varying according to the
clinical condition, route of administration and the
individual's own organism (Bocci, 2006).
Ozone inactivates bacteria, viruses, fungi, yeast, and
parasites through different mechanisms. In bacteria,
ozone disrupts the integrity of the bacterial cell wall
through oxidized phospholipids and lipoproteins
(Polydorou et al., 2012; Thanomsub et al., 2002). In
fungi, ozone inhibits its growth, while in viruses, ozone
damages the viral capsid, preventing contact between the
virus and the cell. Cells vulnerable to virus invasion are
coated with oxidation-susceptible enzymes and can be
eliminated from the body by interacting with ozone
(Gupta and Brintnell, 2013; Travagli et al., 2010).
Main Challenge and Difficulties
The biggest challenge is the lack of standardization of
ozone doses used in the studies, many not even
mentioning this concentration. This may be due to the fact
that ozone is a very unstable gas, which makes it difficult
to remain in vehicles and, consequently, to measure the
dose (Bocci et al., 2011). Another problem is the fact that
in many countries medicine does not consider the use of
ozone as a therapy, which makes it difficult to develop
clinical treatment protocols (Re et al., 2012).
Ana Paula Pivott o et al. / OnLine Journal o f Biologica l Sciences 2020, 20 (1): 37.49
DOI: 10.3844/ojbsci.2020.37.49
The use of ozone in clinical practice has numerous
benefits in the treatment of various diseases, mainly
through the modulation of the immune system and of the
oxidant/antioxidant balance and is applied to treat a wide
of clinical conditions, both on local skin and systemic.
The significant routes of use include the topical,
intrarectal, subcutaneous and intravenous routes, carried
out by different vehicles, as the main ones being saline,
water, and ozone oil. The main characteristic of
ozonetherapy is the anticipation of the healing process,
which is related to the increase of endogenous growth
factors and in the increase of oxygenation of the affected
area. As well as its physiologic effect, ozone also
inactivates microorganisms by its oxidizing capacity.
This review evidenced that the toxicity of this compound
is inherent to the concentration of ozone, being a higher
dose responsible for causing exacerbation of the immune
system with detrimental effects and a lower dose
contributing to the reduction of inflammatory responses
and increasing the production of antioxidant enzymes,
thus improving the treatment of a range of pathologies.
Altogether, ozone as a therapy has been used
successfully in a wide range of medical conditions,
however, it should be used in the correct concentration,
paying attention to the dose range to avoid possible
adverse effects due to toxicity of high concentration.
The authors thank Coordenação de Aperfeiçoamento
de Pessoal de Nível Superior (CAPES) - the Brazilian
government funding agency, for the fellowships
Funding Information
FWB. and IVS received a master's degree and TSA
received a postdoctoral fellowship from the Coordenação
de Aperfeiçoamento de Pessoal de Nível Superior
(CAPES) - the Brazilian government funding agency.
Author’s Contributions
Conceptualization: APP and RAM; Literature review:
APP, FWB, IVS, MAD and TSA; Validation: RAM;
Writing – original draft: APP, FWB, IVS, MAD, and
TSA; Review and editing: RAM and TSA.
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... Este gás, forma radicais oxidantes na presença de água, que penetram e atacam as membranas celulares, afetando o equilíbrio osmótico, promovendo a oxidação dos aminoácidos e ácidos nucléicos, causando lise celular dependente da extensão das reações (Bocci et al., 2011). Devido a sua alta capacidade oxidante e de formação radicais livres de oxigênio que levam à destruição de microorganismos, o sistema imunológico é ativado para combater patógenos como bactérias, fungos e infecções por vírus (Pivotto et al., 2020). A dose segura de ozônio é variável, dependendo da localização e do objetivo do tratamento. ...
... A ozonioterapia é considerada uma terapia alternativa e tem vários efeitos positivos, mas, dependendo da dose, pode resultar em efeitos nocivos para o indivíduo. Os principais efeitos positivos relatados em humanos são baseados em três funções principais: antimicrobiano, equilíbrio antioxidante/oxidante e efeitos imunomoduladores (Pivotto et al., 2020). ...
... Além disso, segundo o estudode Eick et al. (2012) Candida albicans sobreviveu em parte após a dupla exposição de 18 seg a água ozonizada na concentração de 140 ppm, tendo taxa de inativação das cepas estabelecida em de 94%.Atualmente, propõe-se que a variação de 10 a 80 μg/mL de ozônio seja benéfica, levando a efeitos positivos e sem toxicidade, dependendo do tecido, demonstrados in vitro e in vivo em modelos animais. Nos estudos em seres humanos, a faixa de dose segura varia entre 15 e 50 μg/mL e depende do tipo e objetivo do tratamento, bem como do local de aplicação(Pivotto et al., 2020).Quanto aos métodos para confirmação ou não do efeito que o ozônio tem sobre leveduras do gênero Candida, observou-se que Amin (2018) utilizou coloração histológica de Hematoxilina e Eosina (HE) além de expressão imunohistoquímica para observar reatividade de CD3. A cultura de líquido sinovial foi também utilizada em um estudo in vivo que relatou que o ozônio tenha causado a destruição local de C. parapsilosis, ...
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O gênero Candida é o mais comumente associado ao desenvolvimento de infecção nos tecidos orais, denominada candidose oral. O manejo terapêutico dessa patologia é bem complexo e inclui a utilização de agentes antifúngicos de aplicação tópica ou sistêmica, dependendo da severidade da infecção. Nesse contexto, o objetivo desse estudo foi, por meio de uma revisão de literatura, avaliar a ação antifúngica do ozônio sobre leveduras do gênero Candida, visando aplicação em cavidade oral, pelo fato de o ozônio ser sugerido como terapia alternativa devido a sua ação oxidante. Para tanto, foi realizada busca pelo termo “ozone and Candida” nas bases de dados PubMed, SciELO e BVS por artigos publicados até abril de 2020. Após avaliação foram selecionados 23 artigos que se enquadram nos critérios. Pode-se concluir que o ozônio apresenta uma significante ação antimicrobiana sobre leveduras do gênero Candida. O presente estudo sugere que o seu uso tem a possibilidade de atenuar a resposta curativa dessa infecção, visto que inúmeros estudos tenham relatado melhora nos quadros infecciosos e diminuição de unidades formadoras de colônia. Todavia, novas investigações e comparações de perfil de toxicidade são necessários para estabelecer corretos protocolos de uso clínico.
... Portanto, uma dose apropriada de ozônio pode induzir modulações genéticas que restauram atividades de produção de substâncias cicatriciais, antinflamatórias e analgésicas pelo próprio organismo do paciente, agindo de forma indireta na reparação da lesão. Por isso dizemos que este segundo mecanismo de ação é um mecanismo indireto, mediado pelo estresse oxidativo (Pivotto et al., 2020). ...
... Portanto, uma dose apropriada de ozônio pode induzir modulações genéticas que restauram atividades de produção de substâncias cicatriciais, antinflamatórias e analgésicas pelo próprio organismo do paciente, agindo de forma indireta na reparação da lesão. Por isso dizemos que este segundo mecanismo de ação é um mecanismo indireto, mediado pelo estresse oxidativo (Pivotto et al., 2020). ...
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RESUMO Ozonioterapia é uma técnica de tratamento de diversas doenças locais e sistêmicas por meio da administração de uma mistura oxigênio-ozônio. O gás pode ser aplicado diretamente no corpo do paciente ou ainda ser diluído em soro ou sangue, a chamada auto-hemoterapia ozonizada. Seus efeitos são mediados por mecanismos de oxidação direta ou indireta de células ou patógenos. Dentre os efeitos de oxidação direta, destaca-se a microporação na superfície de microorganismos incapazes de se protegerem por antioxidantes, resultando em destruição física de suas membranas e/ou paredes celulares, o conhecido efeito antisséptico ou desinfetante da ozonioterapia local, tópica ou cavitaria. Ao entrar em contato com sangue ou outros fluidos biológicos, o gás ozônio imediatamente se combina com a água resultando em radicais livres e oxida lipídeos, formando os lipoperóxidos. Os radicais livres e lipoperóxidos passam a ser os mediadores dos efeitos do ozônio em diversas células, como as hemácias, leucócitos, plaquetas, fibroblastos, entre outras. Como resultado, obtém-se os efeitos de melhora de perfusão e oxigenação tecidual, modulação da inflamação, analgesia, cicatrização e produção de antioxidantes enzimáticos. Porém, o planejamento terapêutico deve compreender a escolha das vias adequadas de tratamento, concentrações, doses de aplicações sistêmicas e frequência de aplicação para que os resultados sejam maximizados. Além disso, o profissional deve estar corretamente capacitado e conhecer todas as limitações e efeitos adversos possíveis da técnica. PALAVRAS-CHAVE: Ozônio. Cães. Equinos. Ruminantes. Boas práticas. SUMMARY Ozone therapy is a technique for treating various local and systemic diseases by administering an oxygen-ozone mixture. The gas can be applied directly to the patient's body or diluted in serum or blood, the so-called ozone auto-hemotherapy. Its effects are mediated by mechanisms of direct or indirect oxidation of cells or pathogens. Among the direct oxidation effects is microporation on the surface of microorganisms that are unable to be protected by antioxidants, resulting in physical destruction of their membranes and/or cell walls, the well-known antiseptic or disinfectant effect of local, topical or cavitating ozone therapy. When in contact with blood or other biological fluids, ozone gas immediately combines with water resulting in free radicals and oxidizes lipids, forming lipoperoxides. The free radicals and lipoperoxides become the mediators of ozone effects on various cells, such as red blood cells, leukocytes, platelets, fibroblasts, and others. As a result, we obtain the effects of improved tissue perfusion and oxygenation, modulation of inflammation, analgesia, healing, and production of enzymatic antioxidants. However, the therapeutic planning must include the choice of adequate treatment routes, concentrations, doses of systemic applications, and frequency of application so that the results are maximized. In addition, the professional must be properly trained and know all the possible limitations and adverse effects of the technique.
... With our best wishes. (10,16). Tedavideki temel sorun ideal ozon konsantrasyonunun, uygulama sayısının ve uygulama yönteminin seçiminin belirsizliğidir. ...
... Different types of oxygen therapy are introduced as complementary treatments for dozens of diseases, including certain types of cancer, emphysema, AIDS, arthritis, cardiovascular diseases, multiple sclerosis, and Alzheimer's disease. 3 Ozone therapy is often preferred as an auxiliary treatment method in many diseases. Some of these can be listed as follows: circulatory disorders, cancer, eye diseases, bacterial and fungal infections. ...
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Ozone (O3) gas is the triatomic state of oxygen and it is used as a disinfection agent due to its strong oxidizing effect, since its discovery in the mid-nineteenth century. Ozone therapy is also an alternative therapeutic approach for some diseases like circulatory disorders, AIDS, asthma, cardiovascular diseases, and certain types of cancer by increasing the oxygen levels in the blood by external addition of ozone to the body. In this study, the therapeutic potential of ozone therapy was examined by inhibiting the growth of breast cancer cells in a dose-dependent procedure. Ozone concentrations varying from 5 to 20 μg/ml were applied to the MDA-MB-231, human breast adenocarcinoma and HUVEC, human umbilical vein endothelium, cell lines, and MDA cells demonstrated an increased rate of death while its migration potential decreases. RT-PCR analysis showed mRNA expression levels of pro-apoptotic genes demonstrated higher folds in MDA cells after 10 μg/ml treatment. In the same context, Annexin V/PI and cell cycle analysis also concluded that ozone therapy causes apoptotic cell death on breast tumor cells. The use of ozone therapy for cancer treatment requires further and extensive research. However, this research has shown that ozone therapy is a promising source for cancer treatment in a way by inhibiting the proliferation of breast tumor cells.
Bu çalışmada ratlarda hidroflorik asit (HFA) ile deneysel olarak oluşturulan asidik deri yanıklarında ozon tedavisinin klinik etkinliğinin araştırılması amaçlanmıştır. Çalışma materyalini 20 adet, sağlıklı erkek, 200-250 gr ağırlığındaki ratlar oluşturdu. Çalışmaya dahil edilen hayvanlar her bir grupta 10 adet hayvan olacak şekilde deney ve kontrol grubu olarak gruplandırıldı. Grupları oluşturan tüm hayvanlarda genel anestezi altında %38’lik HFA ile asidik deri yanığı oluşturuldu. Deri yanığı oluşturulan çalışma grubundaki tüm hayvanların yara bölgesine 7 gün boyunca günde bir kere ozonlanmış sıvı vazelin, kontrol grubundaki tüm hayvanlara ise %0.9’luk serum fizyolojik 7 gün süre ile günde bir kere uygulandı. Çalışmada klinik olarak değerlendirmeye alınan bül, eritem, nekroz, iyileşme, tüylenme ve oluşan hasarlı alan verileri- nin istatistiksel analizleri karşılaştırıldı. İstatistiksel analiz sonucunda deney ve kontrol grupları arasında bül, eritem, nekroz, iyileşme ve oluşan hasarlı alan bakımından anlamlı farklılık olmadığı, ancak tüylenmede 5. günden itibaren anlamlı farklılık olduğu tespit edildi (P
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RECURRENCE RATES AFTER MODIFIED LIMBERG FLAP PROCEDURE FOR THE TREATMENT OF PILONIDAL DISEASE VARY BETWEEN 0%-10%: WHY IS THERE SUCH A BIG DIFFERENCE WITHIN RECURRENCE RATES? Mehmet Eren Yüksel, Ankara Yıldırım Beyazıt University School of Medicine, Intensive Care Unit, Ankara, Turkey e-mail: Abstract: Introduction: Modified Limberg flap technique is applied for the treatment of pilonidal disease. Aim: We aimed to determine recurrence rates after modified Limberg flap procedure. Method: A Pubmed search between 2009-2021 was performed in order to identify studies reporting complications and recurrence rates after modified Limberg flap procedure for the treatment of pilonidal disease. Nineteen studies were identified. Results: Recurrence rates after modified Limberg flap procedure were 5.4% (Can et al., 2010), 0.97% (Akin et al., 2010), 10% (Aren et al., 2010), 1.67% (Elshazly et al., 2011), 4.2% (Kaya et al., 2012), 0% (Karaca et al., 2012), 2.8% (Ahmed et al., 2013), 3% (Bessa et al., 2013), 3.3% (Shabbir et al., 2014), 0% (Yildiz et al., 2014), 6.8% (Bayhan et al., 2015), 6.5% (Tokac et al., 2015), 0.8% (Yoldas et al., 2015), 2% (Saydam et al., 2015), 4.5% (Sabuncuoglu et al., 2015), 2% (Sarhan et al., 2016), 3.7% (Kose et al., 2017), 3.3% (Sabry et al., 2018) and 7.4% (Abdelnaby et al., 2018), respectively (Table 1). Discussion and Conclusion: Recurrence rates after modified Limberg flap procedure for the treatment of pilonidal disease vary between 0%-10%. Dispersion of the pits in the gluteal sulcus, various flap sizes, hairiness of the gluteal region, prior wound infection within the operation field, different lateralization distances of the flaps from the midline, post-operative wound care, immunosuppression, underreporting and a short follow-up period may play role in the outcomes after surgical treatment. A drawing template which was recommended by Yuksel et al. in 2019 may help to standardize modified Limberg flap procedure in order to facilitate the comparison of end results accurately. Keywords: Flap, Limberg, Modified, Pilonidal, Recurrence
This chapter describes the eruption and spread of the SARS-COV-2 virus throughout Brazil. We also describe the governmental measures used to combat the virus, the regional influences impacting viral spreading, and the prevalence of the disease in different Brazilian subpopulations. It is hoped that such information will contribute to the control of the virus and help to prepare the region for future pandemics.
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Recent investigations are seeking a novel treatment to control the new pandemic of coronavirus 19 (COVID-19). The aim of this systematic review was to study the effect of ozone therapy on COVID-19 patients and the available supporting evidence. Electronic databases including MEDLINE (via PubMed), EMBASE, Cochrane Library (CENTRAL), and TRIP, clinical trial registries, and preprint sources were searched for published evidence-based articles. In addition, manual searching was conducted for articles published up to April 6, 2020, using MeSH and free text keywords with no language limitation. Articles were screened, categorized, and extracted for relative data. Data were reported in a descriptive manner. Among 234 articles, 9 were selected for review of the inclusion criteria. No published original articles were found regarding the efficacy of ozone therapy on COVID-19. Five review studies were found in which the potential role of systemic ozone therapy was concluded to be effective in controlling COVID-19 because of its antiviral, oxygenation, anti-inflammatory, oxidation balancing, and immunomodulation effects. Three ongoing clinical trials were registered in China. A preliminary report of an ongoing study in Italy on 46 patients (11 intubated and 35 non-intubated) showed that in 39 (84%) of the patients, an improvement was seen. In spite of the promising background data, as well as the expert opinions and a preliminary report indicating the effectiveness of ozone, there is still not enough evidence to confirm this as a viable treatment option for COVID-19.
Since December 2019, a novel coronavirus known as Severe Acute Respiratory Virus 2 (SARS-CoV-2) has caused an outbreak of a respiratory illness worldwide. Even though SARS-CoV-2 primarily affects the respiratory system, other organs such as the heart and kidneys are implicated. The pathophysiology of Acute Kidney Injury (AKI) in coronavirus 2019 (COVID-19) patients is not clearly defined. Direct kidney injury results from virus entry through angiotensin-converting enzyme-2 (ACE2) receptors which are highly expressed by the podocytes and proximal convoluted tubules, as suggested by "viral-like" particles on electron microscopy. However, the link between the presence of viral particles in kidney tissue and kidney injury has not been fully explained. Furthermore, it is also hypothesized that collapsing focal segmental glomerulosclerosis (FSGS), myoglobin toxicity, sepsis-linked, and glomeruli fibrin thrombi is part of the mechanism for AKI. Reported cases link FSGS and high-risk apolipoprotein 1 (APOL1) alleles in patients of African ancestry. Typically, these patients present with AKI and nephrotic-range proteinuria. The rate of AKI in hospitalized patients is high and associated with a higher mortality rate in older patients with comorbidities. Even higher mortality is now being reported in patients with chronic kidney disease and kidney transplant recipients due to immune system dysfunction. Herein, we review the current literature on kidney disease and pathogenesis in COVID-19 patients.
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Background and objectives: Low back pain is a prevalent disease in the adult population, whose quality of life is considerably affected. In order to solve this problem, several therapies have been developed, of which ozone therapy is an example. Our objective in this study was to determine the effectiveness of ozone therapy for lumbar pain relief in adult patients compared to other therapies (steroid and placebo). Method: We used randomized clinical trials to compare the effectiveness of ozone and other therapies for lumbar pain relief in adults (Prospero: CRD42018090807). Two independent reviewers searched the Medline (1966–April/2018), Scopus (2011–May/2018), Lilacs (1982–May/2018), and EMBASE (1974–March/2018) databases. We use the terms ozone and pain as descriptors. The primary variable was pain relief and the secondary ones were complication, degree of satisfaction, quality of life and recurrence of pain. Results: Of the 779 identified articles, six selected clinical trials show that ozone therapy is more effective for lumbar pain relief; however, they were mostly classified as having a high or uncertain risk of bias (Cochrane Handbook). The meta-analysis regarding the effectiveness of pain relief did not show a significant difference between groups in the three-month period (RR = 1.98, 95% CI: 0.46–8.42, p= 0.36; 366 participants). It also showed greater effectiveness of the ozone therapy at six months compared to other therapies (steroid and placebo) (RR = 2.2, 95% CI: 1.87–2.60, p< 0.00001; 717 participants). Conclusions: The systematic review has shown that ozone therapy used for six months for lumbar pain relief is more effective than other therapies; however, this result is not definitive as data from studies with moderate to high risk of bias were used.
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Ozone therapy has been widely used in everyday clinical practice over the last few years, leading to significant clinical results in the treatment of herniated discs and pain management. Nevertheless, further studies have demonstrated its potential efficacy and safety under other clinical and experimental conditions. However, some of these studies showed controversial results regarding the safety and efficacy of ozone therapy, thus mining its potential use in an everyday clinical practice. To this regard, it should be considered that extensive literature review reported the use of ozone in a significant different dose range and with different delivery systems. The aim of the present review is to describe the various pharmacological effects of ozone in different organs and clinical conditions and to provide possible biochemical and molecular insights for ozone biological properties, thus providing a possible explanation for various controversial clinical outcomes described in the scientific literature.
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In this study, the effects of ozonetherapy on secondary wound healing were evaluated histologically and immuno-histochemically. Material and Methods: 8 healthy pigs were used in this study. Six wounds with 10 mm in diameter were created through the punch technique on the palatinal gingiva of each pig. Ozone gas was applied on only 3 wounds (test group) and the remaining 3 were left to natural healing (control group). Biopsy samples were taken from one of the wounds in each group on the third day, from another wound of each group on the seventh day, and from another one on the tenth day. Routine histological analysis and immuno-histochemical staining were performed to investigate transforming growth factor-beta (TGF-β) and (VEGF) expressions. Results: No statistical difference was found between the test and control groups in terms of collagen fibers, epithelial formation and inflammation scores. A VEGF expression found in the test group was statistically higher than control group samples taken on the 3rd and 7th day. There was no statistical difference between the test and control groups in terms of TGF-β expression on any of the sampling days. Conclusion: The topical application of ozone gas could be effective in the early stages of wound healing by increasing the amount of VEGF expression. Clinical Relevance: Topical application of ozone gas may be effective in the early stages of oral wound healing.
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Background: Digital ulcers (DUs) in Systemic sclerosis (SSc) result from recurrent Raynaud's phenomenon (RP) and microtrauma with high impact on quality of life. Medical use of ozone (triatomic oxygen) was initiated in the 19th century. Ozone has multiple therapeutic effects in wound healing due to the property of releasing nascent oxygen, which has been shown to stimulate antioxidant enzymes. We aimed to assess the effects of ozone therapy on the healing of scleroderma DUs and determine levels of expression of vascular endothelial growth factor (VEGF), and endothelin-1 type A receptor (ETAR) autoantibodies in the wounds after treatment. Subjects and methods: Fifty SSc female patients with DUs, were randomized into ozone group (I) (n=25) treated by calcium channel blockers plus oxygen-ozone treatment and control group (II) (n=25) treated by calcium channel blockers only. Ozone group received noninvasive oxygen-ozone treatments for 30 minutes per day for 20 days using the ozone generator device. Therapeutic effects were graded into 4 levels according to Zhang and other researchers. The wounds sizes were measured at baseline and day 20, respectively. Expressions of VEGF and ETAR autoantibodies proteins were determined by immune-histochemical examination. Results: Demographics and clinical characteristics of the 2 groups showed no significant differences. At day 20, the effective healing rate was significantly higher in group (I) than in group (II), where it represented 96% (24/25) in ozone group versus 44% (11/25) in control group, and (𝑃 = 0.007). After treatment, the wound sizes in both groups were significantly smaller than before treatment. In group (I), the wound size reduction was significantly more than in group (II) (0.75 ± 0.30 versus 2.44 ± 0.80 mm), (𝑃 = 0.00). At day 20, VEGF was significantly higher in ozone group (I), than in control group (II), (83.96±9.68) versus (67.92±6.55), (𝑃 = 0.00) while, ETAR was significantly lower in ozone group (I), than in control group (II), (3.14±1.12 versus 4.59±1.24), (𝑃 = 0.00). Conclusion: Ozone therapy may be beneficial tool in the treatment of DUs in SSc patients, where it promotes the wound healing through a potential induction of VEGF and down-regulation of ETAR at sites of the ulcers.
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BACKGROUND AND OBJECTIVES: Osteoarthrosis affects 85% of the population over 75 years of age. It is divided into primary and secondary, however despite the knowledge at the molecular level the treatments are not yet fully effective. However, ozone therapy emerges as an alternative therapy, which is low cost and seems effective in the treatment of chronic pain. The objective of this study was to evaluate the current evidence to support or to refute the use of ozone therapy in the treatment of patients with osteoarthritis. CONTENTS: Systematic review using the keywords “ozone therapy”, “ozone”, “osteoarthritis”, “arthritis”, “randomized”, “controlled” and “meta-analysis”. The selection of publications was based on inclusion and exclusion criteria. In total, 9 articles were used. Among the 9 articles found regarding ozone therapy in osteoarthritis, 7 of them clearly show the benefits of ozone. The concentrations of ozone used in the studies ranged from 20µg/mL to 15g/mL. The route of administration was intra-articular and rectal insufflation. The frequency of use was, on average, 1 to 3 times a week and the treatment time was between 3 to 4 months in most of the studies. CONCLUSION: The use of ozone produces clinically relevant benefits in patients with osteoarthrosis. Therefore, ozone therapy in osteoarthrosis represents a low-cost, efficient therapeutic alternative that should be implemented in the country’s Public Health, considering the prevalence of the disease.
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Background This study aimed to investigate the therapeutic effect of low, medium, and high concentrations of medical ozone on trauma-induced lumbar disc herniation. Material/Methods A total of 80 patients were included and were grouped into a control group, a low medical ozone (20 μg/ml) group, a medium medical ozone (40 μg/ml) group, and a high medical ozone (60 μg/ml) group. The CT scan and enzyme-linked immunosorbent assay (ELISA) were used to detect IL-6 level, SOD activity, IgM, and IgG levels upon admission and at 6 and 12 months after follow-up. The area under the ROC curve (AUC) was calculated for visual analogue scale (VAS) and efficiency rate. Results All patients showed disc retraction at 6- and 12-month follow-up; while patients in the medium medical ozone (40 μg/ml) group showed the greatest disc retraction rate. The IL-6, IgM, IgG, and VAS levels significantly decreased while SOD activity increased among all groups over time (p<0.05). The AUCIL-6, AUCIgG, AUCIgM, and AUCSOD was closest to 1 in the medium medical ozone (40 μg/ml) group compared with other groups (p<0.01), with the highest efficacy at 6 (35%) and 12 (85%) months during follow-up. Conclusions Low concentrations of medical ozone (20 μg/ml and 40 μg/ml) reduced the serum IL-6, IgG, and IgM expression, presenting as analgesic and anti-inflammatory effects, while high concentrations of medical ozone (60 μg/ml) increased the serum IL-6, IgG, IgM expression, presenting as pain and pro-inflammatory effects. The medical ozone concentration of 40 μg/ml showed the optimal treatment efficacy.
Fibroblast growth factor 2 (FGF2) regulates the wound repair process and it is secreted by inflammatory and endothelial cells, and by myofibroblasts. This study aimed to establish the expression patterns of FGF2 and myofibroblastic differentiation during wound healing in rats treated with subcutaneous ozone injection. We created full-thickness excisional wounds in rats, and the healing process was analyzed through morphometric analyses and digital quantification of immunoreactivity of smooth muscle actin and FGF2. Ozone therapy-treated wounds presented granulation tissue with a reduced number of inflammatory cells and greater dermal cellularity, and intense collagen deposition. FGF2 immunoreactivity, microvessel density, and amount of myofibroblasts were significantly higher in treated wounds compared to controls. In conclusion, it was demonstrated that subcutaneous injections of ozone accelerate and ameliorate wound repairing process. Moreover, injectable ozone therapy’s action mechanism may be associated with FGF2 overexpression.
Background Diabetic foot ulcer is one of the common complications of diabetes disease that is costly and difficult to treat. This problem can lead to morbidity and even mortality. Ozone is a gas that can optimize cellular metabolism and, because of its antioxidant and antibacterial effects, can help the better healing of diabetic foot ulcer. Method Two hundred patients, aged 18–85 with diabetic foot ulcers ranging from grade 1 to 4 according to Wagner classification in two groups were studied. Group 1 was treated by full ozone therapy besides the standard regular DFU treatment while group two just was received routine diabetic foot care. Wound size, wound grade, healing time, Fasting blood sugar and inflammatory biomarker before and after treatment were checked. Results All patients have had complete wound closure in the ozone group. The mean age of the patients included in the results was 59.03 ± 12.593 and 53.5 ± 10.212 for ozone group and control group. The baseline average surface area of ulcers was 13.41 ± 14.092 cm² (range 1–70 cm²) in ozone group and 12.72 ± 0.911 (range 1_64 cm²) in the control group. Average healing time was 69.44 ± 36.055 days (range 15–180 days), which is significantly lower than the median healing time measured in the control group and some previous studies. Conclusion Our study results support the efficacy of ozone therapy especially in its comprehensive use in DFU healing and reduction in the chances of infection and amputation.
Osteoarthritis (OA) is a chronic multifactorial disease characterized by progressive joint degeneration. The purpose of this study was to compare the effects of ultrasound-guided corticosteroid injection with oxygen–ozone injection in patients with knee OA. This double-blind randomized clinical trial was performed on 62 patients with knee OA. The patients were randomly divided into two groups. In the first group 40 mg triamcinolone (1 cc) and in the second group 10 cc (15 μg/ml) oxygen–ozone (O2–O3) were injected into the knee joint under ultrasound guidance. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis (WOMAC), knee flexion range of motion (ROM), effusion in ultrasound images of the suprapatellar recess, and visual analog scale (VAS), which were evaluated before injection, 1 week, 1 month, and 3 months after the treatment. Sixty-two patients (10 men and 52 women) were enrolled with mean age of 57.9 years. VAS improved in both groups (steroid P value = 0.001, oxygen–ozone P value > 0.001). The improvements seen in VAS and WOMAC scores 3 months after treatment were in favor of the oxygen–ozone group when compared to the steroid group (P = 0.041 vs P = 0.19). There was no significant difference between the two groups in ROM and joint effusion seen under ultrasound (ROM p = 0.880, effusion p = 0.362). However, in the oxygen–ozone-receiving group, joint effusion was decreased significantly (p < 0.001). Both steroid and oxygen–ozone injections are effective in patients with knee osteoarthritis. Our study showed that the effects of oxygen–ozone injection last longer than those of steroid injection to the knee joint.