Ozonized water used as complementary therapy for stomatitis in Salvator merianae – case report

The Argentine black and white tegu (Salvator merianae) is a reptile belonging to the family Teiidae. Compared with other families, teiids are morphologically similar. However, their sizes vary considerably, with S. merianae being the largest endemic lizard in South America. The characteristics, habitat, and habits of S. merianae need to be investigated, to provide adequate ex situ adaptation opportunities and avoid accidents in the pet industry. One advancing complementary therapy is the use of ozone, which has potent antimicrobial action when applied topically, due to the oxidizing and healing effects resulting from the stimulation of tissue cell proliferation and remodeling. To generate information concerning ozone therapy, the treatment of stomatitis caused by Portland cement in an Argentine black and white tegu using ozonized water as a complementary therapy is reported. Fluid and antibiotic therapies (enrofloxacin, butorphanol, meloxicam, and sucralfate) were introduced, along with the daily rinsing of the oral cavity with freshly prepared ozonized water. No toxic effects relating to ozone use were observed, and its topical use as a complementary therapy proved to be low cost and highly efficient. These findings demonstrate the need to obtain knowledge concerning this therapy and promote its use in wild animals. Research, Society and Development, v. 10, n. 11, e280101119550, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i11.19550 2


Introduction
The Argentine black and white tegu (Salvator merianae) is a reptile belonging to the order Squamata and family Teiidae. Compared with other families, teiids are highly morphologically similar to each other. Almost all species have an elongated slender body, with whip-shaped tails, and heads ending in narrow snouts. However, size within the family varies considerably (Vitt et al, 2000), with the Argentine black and white tegu being the largest endemic lizard in South America, reaching 160 cm in total length and weighing up to 5 kg (Cechin et al, 2011). They are omnivorous and opportunistic foragers with daytime habits that feed on vegetables, fruits, insects, small vertebrates, and even carcasses (Vieira, 2016).
The inflammatory process of the oral cavity, known as stomatitis, in reptiles is characterized by having several predisposing factors as primary sources, including nutritional deficiencies, unhealthy management, poorly executed physical containment, and preexisting viral infections. All of these predispose the animals to opportunistic infections, which is a worrisome factor when treating reptiles (Draper et al, 1981;Hedley, 2016;Pereira et al, 2017;Martins et al, 2021). However, stomatitis can also be caused by the ingestion of irritants, such as Portland cement, because of its alkaline, hygroscopic, and abrasive properties are often associated with occupational dermatitis (Bedoya-Marrugo et al, 2017;Leon-Kabamba et al, 2018).
Portland cement is a fine powder with binding properties due to its chemical composition, resulting from the combination of raw materials (limestone and clay) calcined inside furnaces. This mainly generates silicates, aluminates, iron, and calcium aluminates. Portland cement hardens under the action of water, reaching a pH greater than 12, which is a highly alkaline pH, making the cement more irritating to the skin due to its hygroscopic and abrasive properties. When Portland Research, Society andDevelopment, v. 10, n. 11, e280101119550, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i11.19550 3 cement remains under pressure, friction, or occlusion for a long time and is in contact with the skin, this can cause anything from mild to severe irritant contact dermatitis (Alchorne et al, 2010;Pugliesi, 2018;Leon-Kabamba et al, 2018) This oral inflammation, either caused by microorganisms or by irritants, requires special attention concerning the treatment of choice, as systemic topical drugs and complementary therapies need to be combined to achieve the complete recovery of the patient. One of the complementary therapies that has been growing in human and veterinary medicine, is the use of ozone, which when applied topically has potent antimicrobial action due to the oxidizing and healing effects resulting from the stimulation of the proliferation and remodeling of tissue cells. Given its low cost and minimal side effects, it is a viable option in most clinical situations (Bocci, 2005;Smith et al, 2017, Zeng & Lu, 2018Suh et al, 2019).
As the Argentine black and white tegu has been introduced into the pet industry, their characteristics, habitat, and habits need to be investigated, seeking to provide adequate ex situ adaptation opportunities, thus avoiding the occurrence of accidents. An animal that is not adapted to the enclosure where it lives can become agitated and look for ways to escape from the environment, potentially putting the animal in a situation where it can get hurt or come into contact with toxic substances, putting its health at risk.
To generate information concerning the use of ozone therapy in these animals, this study reports on the treatment of stomatitis caused by Portland cement in an Argentine black and white tegu (Salvator merianae) using ozonized water as a complementary therapy. At the physical examination, the animal was slightly apathetic, with a good body score. Remnants of Portland cement, sialorrhea, gingivitis, ulcerative lesions, and plaques with caseous material in the lateral commissures and palate were observed while evaluating its oral cavity ( Figure 1A), characterizing a severe picture of stomatitis. Radiographic examinations and ultrasounds were requested for a complete evaluation of the gastrointestinal tract, looking for solid aggregates or mucosal lesions due to substance ingestion. However, no relevant changes were observed in either examination.

Results and Discussion
In the present case, a management error allowed the escape of an animal that eventually came into contact with a caustic material, causing the emergence of ulcerative stomatitis, which reinforces the importance of ensuring adequate nutrition and enclosure for reptiles bred in captivity. Improper enclosures are one of the common causes for the occurrence of diseases (Divers & Stahl, 2018). Moreover, adaptation is necessary to avoid accidents, as previously mentioned.
Throughout the treatment, the patient recovered rapidly with a visible regression of the lesions from the third day, with complete healing after 10 days. Faster results were obtained here when compared to Arruda (2012), in which a green iguana (Iguana iguana) with mild stomatitis was treated with a similar protocol, but without ozonized water, and achieved complete healing after 15 days of treatment.
The oral microbiota of lizards is composed mainly of Gram-negative bacteria, such as Pseudomonas, Proteus and Aeromonas (Hedley, 2016;Tian et al, 2020). According to Oliveira and Dias (2012), among the main causes of delayed healing are local bacterial infections, perfusion, and deficient oxygenation (Sanchez, 2008;Gantwerker & Hom, 2012). The bactericidal action attributed to ozone (Penido et al, 2010;Chagas & Mira, 2015;Santana et al, 2018) and its proven action on blood fluidity, decreasing its viscosity by decreasing macromolecules and clot formation (Van Der Zee & De Monte, 2001), contributed to the control and reduction of these conditions and consequently to the improved recovery of the animal.
Ozone is widely recognized as one of the best antibacterial, antiviral, and antifungal agents, and therefore is an important alternative when it comes to multi-resistant bacterial infections, such as those commonly associated with reptile stomatitis (Valacchi et al, 2005;Martins et al, 2021). It is commonly used topically to treat anaerobic infections, abscesses, gingivitis, fistulas, decubitus ulcers, and burns (Valacchi et al, 2005;Zang & Lu, 2018). Although ozone use in reptiles is scarcely documented, the use of ozone to treat spondylitis caused by Salmonella sp. has been reported in Boa constrictor, obtaining significant results (Hardt et al, 2017).
In a recent experimental study, which was the first to evaluate ozone therapy in the healing of dermal lesions in reptiles, ozonized sunflower oil was shown to be effective in increasing the inflammatory response and formation of granulation tissue in experimentally induced wounds in Trachemys scripta elegans (Ginel et al, 2021). The results showed an increase in the presence of leukocyte cells, fibroblast proliferation, and early collagen fibre remodeling compared to the control group. Although the testudines do not have an effective capacity to contract wounds in centripetal motion, due to the absence of cutaneous muscles, wounds treated with ozone had a statistically greater decrease in diameter than those not treated (Ginel et al, 2021). Similar studies and case reports involving humans and other mammals are recurrent; however, in reptiles, they are still scarce (Fitzpatrick et al, 2018;Sciorsci et al, 2020;Ginel et al, 2021).
No toxic effects relating to the use of ozone were observed during therapy. As these effects are usually associated with the volume, concentration, and inadequate routes of administration. Ozone should only be applied by trained professionals to avoid risks to the patient and the loss of therapy credibility (Bocci, 2005).

Conclusion
The topical use of ozonized water as complementary therapy proved to be a low-cost alternative for the treatment of stomatitis in reptiles. Although there is only one study involving this class and few case reports, the findings of this work demonstrated that ozonized water was effective as a complementary therapy for stomatitis in a Salvator merianae, and although researchers are interested in the subject, and potentiality of this therapy, it is still necessary to carry out more research and, consequently, the promotion of its use in reptiles.