WO2011121062A1 - Composition for the treatment of periodontitis and other inflammatory infectious diseases - Google Patents

Abstract

The present invention provides a novel composition comprising chlorhexidin, bisphosphonate, a non steroidal anti - inflammatory drug (NSAID) and an immunomodulator and its use for the treatment or prevention of mucosal and epithelial wounds and for the treatment or prevention of oral, mucosal or dermal infections or inflammations, in particular periodontitis.

Description

COMPOSITION FOR THE TREATMENT OF PERIODONTITIS AND OTHER INFLAMMATORY OR INFECTIOUS DISEASES

The present invention provides a novel composition comprising chlorhexidine, bisphosphonate, a non steroidal anti-inflammatory drug (NSAID) and an immunomodulatory agent for the treatment of mucosal and epithelial wounds and for the treatment or prevention of oral infections and other cutaneous or mucosal inflammations.

Cutis

Cutis is the combined term for the epidermis and the dermis, the two outer layers of the skin. Underneath is the subcutis. The epidermis is the outer layer of the skin, composed of terminally differentiated stratified squamous epithelium, acting as the body's major barrier against an inhospitable environment. The epidermis is avascular, nourished by diffusion from the dermis, keratinocytes are the major constituent. The stratified squamous epithelium is maintained by cell division within the basal layer. Differentiating cells slowly displace outwards through the stratum spinosum to the stratum corneum, where anucleate corneal cells are continually shed from the surface (desquamation).

The dermis is a layer of skin between the epidermis and subcutaneous tissues, and is composed of two layers, the papillary and reticular dermis. Structural components of the dermis are collagen, elastic fibers, and extracellular matrix.

Mucosa and Endothelium:

The mucosal membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line various body cavities that are exposed to the external environment and internal organs. Epithelium is a tissue composed of cells that line the cavities and surfaces of structures throughout the body. It lies on top of connective tissue, and the two layers are separated by a basement membrane. Epithelium is often defined by the expression of the adhesion molecule e-cadherin. Loss of function of e-cadherins contributes to progression in cancer by increasing proliferation, invasion, and/or metastasis. The blood-brain barrier in the central nervous system CNS built of endothelial cells restrict the diffusion of microscopic objects (e.g. bacteria) and large or hydrophilic molecules into the cerebrospinal fluid CSF, while allowing the diffusion of small hydrophobic molecules (0₂, hormones, C0₂). Cells of the barrier actively transport metabolic products such as glucose across the barrier with specific proteins. Endothelial cells forming capillaries in the CNS differ from those in the rest of the body in two respects. First, they are able to form tight junctions, restricting paracellular flux, and, second, they have very few endocytotic vesicles, limiting transcellular solute movement from the blood to the brain interstices (Rubin, R.R, Staddon, J.M. Annu Rev

Neurosci. 1999;22: 11-28. and Staddon JM, Rubin LL., Curr Opin Neurobiol. 1996

Oct;6(5):622-7). As a result, the blood-brain barrier impedes entry of virtually all blood molecules, except those that are small and lipophilic, such as steroids. A dense basement membrane and astrocyte processes, termed end-feet, surround capillary endothelial cells, further contributing to the blood-brain barrier.

Periodontium is the supporting structure of a tooth, helping to attach the tooth to surrounding tissues and to allow sensations of touch and pressure. It consists of the cementum, periodontal ligaments, alveolar bone, and gingiva. Periodontal ligaments connect the alveolar bone to the cementum of the tooth. Alveolar bone surrounds the roots of teeth to provide support and creates what is commonly called an alveolus, or "socket". Lying over the bone is the gingiva or gum, which is readily visible in the mouth.

Cell Adhesion Molecules (CAMs) are proteins located on the cell surface involved with the binding with other cells or with the extracellular matrix (ECM) in the process called cell adhesion. These proteins are typically transmembrane receptors and are composed of three domains: an intracellular domain that interacts with the cytoskeleton, a transmembrane domain, and an extracellular domain that interacts either with other CAMs of the same kind (homophilic binding) or with other CAMs or the extracellular matrix (heterophilic binding). The major types of molecular processes that control cellular differentiation involve cell signalling.

Dedifferentiation is a natural part of the immune response, wound healing and tissue repair.

Cell signalling is part of a complex system of communication that governs basic cellular activities and coordinates cell actions. The ability of cells to perceive and correctly respond to their microenvironment is the basis of development, tissue repair, and immunity as well as normal tissue homeostasis. Complex multi-component signal transduction pathways provide opportunities for feedback, signal amplification, and interactions inside one cell between multiple signals and signalling pathways. Cellular signalling pathways like the mitogen- activated protein kinase (MAPK) pathway couple intracellular responses to the binding of growth factors to cell surface receptors and CAMs. This pathway is very complex and includes many components. Mitogen-activated protein (MAP) kinases are serine/ threonine-specific protein kinases that respond to extracellular stimuli (mitogens, osmotic stress, heat shock and proinflammatory cytokines) and regulate various cellular activities, such as gene expression, mitosis,

differentiation, proliferation, adaptation to drugs and cell survival/apoptosis.

The classical ER MAPK pathway is responsible for cell proliferation and differentiation whereas the JNK and p38 pathways lead to inflammation, dedifferentiation, disjunction and apoptosis (programmed cell death). In many cell types, activation of these pathways promotes cell division. PKC is used by many receptors to regulate the MAP kinase pathway, alone or with other mechanisms and may act at several steps in the cascade. Other sites of action of PKC are likely to be either farther upstream or at the level of MAP kinase inactivation.

In cell biology, microtubule-associated proteins (MAPs) are proteins that interact with the microtubules of the cellular cytoskeleton. They are both stabilizing and destabilizing

microtubules, guiding microtubules towards specific cellular locations, cross-linking

microtubules and mediating the interactions of microtubules with other proteins in the cell.

Keratin refers to a family of fibrous structural proteins. Keratin is an intermediate filament; when assembled in bundles, it is tough and insoluble forming hard, unmineralized structures. Like actin filaments in microtubules, intermediate filaments function in the maintenance of cell- shape by bearing tension. Microtubules resist compression. It may be useful to think of micro- and intermediate filaments as cables, and of microtubules as cellular support beams.

Intermediate filaments organize the internal tridimensional structure of the cell, anchoring organelles and serve as structural components in some cell-cell and cell-matrix junctions.

Wound healing, or wound repair, is an intricate process in which the skin or another organ repairs itself after injury. In normal skin and mucosa, the epithelium, the outermost layer, and the underlying connective tissue exist in steady-state equilibrium, forming a protective barrier against the external environment, the key function of innate immunity. Tight Junctions have an organizing role in epithelial and mucosal polarization and establish an apico-lateral barrier to the diffusion of solutes through the intra- and paracellular space (gate function). They also restrict the movement of lipids and membrane proteins between the apical and the baso lateral membrane (fence function).

Once the protective barrier is broken, the normal physiologic process of wound healing is immediately set in motion. The cellular reaction after injury depends on the tissue type as well as the extent of the wound and level of infection or inflammation.

Ultimately these processes are resolved or dampened leading to a mature wound and macroscopic scar formation. Although inflammation and repair mostly occur along a proscribed course, the sensitivity of the process is underscored by the consequences of disruption of the balance of regulatory cytokines. Consequently, cytokines, which are central to this constellation of events, have become targets for therapeutic intervention to modulate the wound healing process. Depending on the cytokine and its role, it may be appropriate to either enhance

(recombinant cytokine, gene transfer) or inhibit (cytokine or receptor antibodies, soluble receptors, signal transduction inhibitors, antisense) the cytokines to achieve the desired outcome.

It is also possible to influence cytokine profile and cell receptor profile, junctional complexes and differentiation by standard pharmaceuticals, as shown below.

Healing of both oral mucosal and dermal wounds proceeds through the same stages, including hemo stasis, inflammation, proliferation, reepithelialization, angiogenesis and remodeling of the collagen matrix. Each stage of the wound healing response, i.e., hemostasis, inflammation, repair, angiogenesis, remodeling, is controlled by the onset of several genes, molecular pathways and distinct cytokine profiles, leading to different development stages of adhesive junctional complexes, cell cycle and tissue differentiation.

Impaired wound healing through reduced vascularisation and tissue differentiation is found e.g. in chronic venous ulcerous wounds of diabetics, epidermolysis bullosa EB and bio film infection of periodontal tissues:

Impaired healing results from interruption of the healing process at explicit stages by bacterial infections or poor nutrition of the affected tissue, leading to disjunction, reduced expression of adhesive complexes and extracellular matrix components in addition to the constant

degradation of matrix proteins and growth factors in the wound exudates.

Different cytokine profiles lead to expression of different, i.e. chronical wound forms:

In (diabetic) venous ulcers, different to regular wound repair, Vascular Endothelial Growth Factor VEGF induced Nitric Oxide NO is reduced leading to lower neovascularisation and atrophic state of the wound with low proliferation of cutaneous structures; in periodontal disease NO induces vascularisation resulting in swelling, gum bleeding and dedifferentiation and degradation of the mucosal barrier and supportive structures. Mechanisms of wound healing in healthy people versus people with diabetes:

In healthy individuals, the acute wound healing process is guided and maintained through integration of multiple signals released by keratinocytes, fibroblasts, endothelial cells, macrophages, and platelets and other cells. During wound-induced hypoxia, VEGF released by macrophages, fibroblasts, and epithelial cells induces the activation of NOS in the bone marrow, resulting in an increase in NO levels, which triggers the mobilization of bone marrow

Endothelial Progenitor Cells to the circulation. Released chemicals (SDF-lcc) promote the homing of these EPCs to the site of injury, where they participate in neovasculogenesis.

Gallagher and colleagues show that NOS activation in the bone marrow is impaired, which directly limits EPC mobilization from the bone marrow into the circulation. They also show that SDF-lcc expression is decreased in the diabetic wound, which prevents EPC recruitment to wounds and therefore limits wound healing (Gallagher, K., J Clin Invest. 2007 May 1; 117(5): 1249-1259).

Epidermolysis bullosa EB:

Epidermolysis bullosa (EB) is a rare genetic disorder caused by a mutation in the keratin genes. The disorder is characterized by the expression of defective keratins in the basal cell layer of the epidermis and presence of extremely fragile skin and recurrent blister formation, resulting from minor mechanical friction or trauma. In normal individuals, keratin filaments impart mechanical strength to epithelial tissues in part by anchoring the intermediate filaments at sites of cell-cell contact, called desmosomes, or cell-matrix contact, called hemidesmosomes.

Basement membranes are sheet-like depositions of Extra Cellular Matrix ECM on which various epithelial cells rest.

In people born with EB, the epidermis or two skin layers or junctional complexes to the basement membrane lack the anchors that hold them together, and any action that creates friction between the layers (like rubbing or pressure) will create blisters and painful sores.

Sufferers of EB have compared the sores to second- to third-degree burns. Keratin chains are coexpressed during differentiation of simple and stratified epithelial tissues. Clumping of the tonofilaments occurs in association with early blister formation. The severity of the clinical disease appears to correlate with the degree of disruption of keratin filament or junctional complex formation. These mutations result in poor keratin filament formation or not fully differentiated junctional complexes, thus contributing to cell and tissue fragility. Open wounds on the skin heal slowly or not at all, often scarring extensively, and are particularly susceptible to infection.

Gingivitis and Periodontitis refer to a number of inflammatory diseases affecting the tissues that surround and support the teeth and are caused by microorganisms that adhere to and grow on the tooth's surfaces, form bio film colonies out of which anaerobic species enter the periodontal tissues resulting in partly destructive host immune reactions .

In Gingivitis inflammation along the gumlines leads to swollen and redish mucosa reaction with exsudation and bleeding. A combination of suboptimal doses of chemically modified non- antimicrobial tetracyclines and bisphosphonates were shown to inhibit endotoxin-induced gingival collagenase in rats (Llavaneras A. et al, J. Periodontal, 2001, 72, 8, pp. 1069-1077).

Periodontal infection leads to disjunction of the supportive periodontal ligament, pocket formation and attachment and alveolar bone loss.

Periodontitis is very common, is widely regarded as the second most common disease worldwide, after dental decay, and has prevalence in Europe and the United States of 30-50% of the population aged above 35 years, of which about 15%-20% suffer from severe forms. Various concepts in periodontal therapy have been tried, specifically antimicrobial therapies using compositions based on single active compounds like chlorhexidine, phenolic agents or antiseptics or antimicrobial agents or NSAIDs (Greenwell H. and Bissada, N., Drug, 2002, 62(18) pp. 2681-2687; Norowski P. and Baumgardner J., J. Biomed. Mat. Res., Past B: Applied Biomaterials, 88, 2, 2009, pp. 530-543, Badran Z. et al, Oral Health & Preventive Dentistry, 2009, 7, l, pp. 3-12).

Periimplantitis is caused by Bio film ingrowth on the implant surface, disintegration of the tissue interface, infection of the surrounding tissue and implant loss.

As indicator of periodontal status pocket depth is used according to Treatment Need codes 3 and 4 in Community Periodontal Index - Treatment Needs (CPITN). This code is applied to every treated tooth or implant.

Periodontal pockets: shallow (Code 3: 4-5mrn) and deep (Code 4: 6mm or more). Table 1

Standard therapy for periodontitis as presently recommended for Class 3+4 comprises complex treatment consisting of motivation, bio film control by patient (e.g. CHX 1 wt% brushing for 2 weeks) and in office polishing, ultrasonic scaling of tooth surface and pocket, administration of antibiotics, splinting of mobile teeth, and surgical procedures (bone augmentation, guided bone regeneration, tissue graft, implant therapy). Although this method has proved to be fairly successful in treating individuals, there is still a high recurrence rate.

US2007/0258996A1 describes a synergistic antimicrobial composition comprising at least three active compounds. Various different compounds including complexing agents, carbohydrates, terpenes, terpenoids, peptides, alkaloids, plant oils, coloring agents, sulfonates, phenols, esther, fatty acids or dibenzofuran-derivatives. No NSAIDs are disclosed in US2007/0258996.

US2005/0013836A1 describes antimicrobial solutions comprising at least one alcohol, at least one microbiological agent and at least on chelator and/or anticoagulant.

US2003/0096722A1 describes a disinfectant or hard- surface cleaning reagent which can comprise chlorhexidine. WO2008/152444A2 describes pharmaceutical and cosmetic preparations comprising a plurality of different agents like complexing agents, antibiotics, anti-inflammatory agents,

immunoregulatory agents etc.

Antimicrobial compositions for the treatment of skin or ear tissue infections are disclosed in WO2005/097094. The compositions can comprise a polymeric biguanide or bis(biguanide) compound, a chelating agent and a buffering agent.

JP8268854A describes compositions to prevent discoloration containing an acidic nonsteroidal anti-inflammatory agent, a cationic bacterizide or a tetracycline based antibiotic and an organic acid for the treatment of periodontitis or oral odor.

There is a constant need for an efficient treatment that can support wound healing of the epidermis or the mucosa, specifically to have a composition that can re-establish the healthy tissue condition around the affected tooth and can, as a result, render dental surgery or tissue graft unnecessary.

There is no causative treatment for EB; symptomatic wound care helps to cope with the difficulties for the "butterfly disease" affected.

It is an object of the invention to provide a novel composition that can fulfil the unmet needs. It is a further object of the invention to provide a method for treating epithelial wounds or oral infections or inflammations using such compositions.

The object of the invention is met by providing a topical composition comprising chlorhexidine, bisphosphonate and a non-steroidal anti-inflammatory drug (NSAID) together with an immunomodulatory component. These active ingredients may be combined into a gel, cream, solution, rinse, gauge or other pharmaceutically acceptable carrier which can be applied topically to or onto the wounded sides of inflammation or infection.

Although the single components as used for the inventive composition are known in the field of anti-inflammatory and antibiotic treatments, it was surprisingly shown by the inventor that the present composition comprising specifically selected compounds or groups of compounds show a highly therapeutic effect especially in the treatment and prevention of epithelial wounds, oral infections or inflammations and show tissue regenerative capacity. The invention is also directed to a method for treating epithelial or mucosal infections or inflammations employing the above described topical preparation.

Systemic application of the composition could provide help to treat inflammation in body compartments difficult to reach as the CNS being protected by a dense blood-brain barrier consisting of junctional complexes.

Because NO production via inducible NO synthase in articular chondrocytes plays a central role in the pathophysiology of arthritis by causing inflammation, apoptosis, dedifferentiation, and the activation of matrix metalloproteinases, the inventor^'s results suggest that NSAIDs have protective effects on cartilage damage, not only by alleviating inflammation but also by inhibiting NO-induced apoptosis and dedifferentiation of articular chondrocytes (Yoon, K. 2003, The Journal of Biological Chemistry, 278, 15319-15325) and immunomodulatory agents restore the chronic inflammatory response and barrier function into a normal tissue homeostasis and repair when combining these agents.

The term "nitrosative stress" is put aside the oxidative stress within the last years (Hausladen, Privalle et al. 1996, Nat. Struct. Biol, 5, 247-249, Stamler & Hausladen 1998, Cell, 86, 719- 729). It was shown that many expressions of cell pathology which were until now explained as reactions to oxidative stress could be at least partly explained as a result of increased production of Nitric Oxide NO.

The Dualistic Nature of the Immune System:

"Jin- Yang" Cross- Regulation - Balance of Thl/Th2 immunity

IL2 - IFN-γ - TNFp - IL-12 - TH1 - cellular cytotoxic, (peripheral IGG)

TH0→

IL-6 - IL-5 - IL-10 - 11-4 - TGFpi - TH2: humoral (mucosal IGA)

Microenvironmental factors stimulate T-cells to express either T-helper l(Thl) or T-helper 2 (Th2) cytokines which are associated with "cellular" and "humoral" immunity, respectively. Other alignments of cytokines may contribute to cross-regulation of immune responses associated with parenteral or mucosal immunization. The cytokines IL-12 and TGF beta 1 are predominant influences in "peripheral" and "mucosal" lymphatic tissues. Thus expression of these cytokines affect T cells and B cells in such a way that proliferating B cells become committed to secrete "peripheral" IgG or "mucosal" IgA, respectively. The mucosal immune system is a complex and redundant system that generates large amounts S-IgA as well as cell-mediated immunity at mucosal surfaces to prevent pathogen infiltration and inflammation. Limited Cytotoxic T-Lymphocyte CTL activity at mucosal surfaces is a built-in mechanism to protect the mucosal epithelium from damage. Antigenic exposure at mucosal sites activates mucosal B and T-lymphocytes to emigrate from the inductive site and home to various mucosal effector sites. Antigen-specific CTL responses at mucosal surfaces are dictated by induction of CTL locally. CTLs in immunologically privileged sites fail to differentiate into fully functional CTL, unless exposed to antigen (Ksander BR, 1990, J Immunol. 1990 Oct l;145(7):2057-63).

Regulatory T -cells (T_reg) regulate both acquired and innate immunity through multiple modes of suppression. Immunomodulation by CD25- CD4 T cells in which T_reg activity is contextual along a continuum of dendritic cell DC maturation and TLR-induced activation, and

mechanisms contributing to the reversal of T_reg suppression and anergy are separable, and independently modulated by proinflammatory cytokines produced by DCs (Kubo Takekazu 2004, The Journal of Immunology, 2004, 173: 7249-7258/

Selective targeting of T_reg-cell trafficking and compartmentalization is therapeutically beneficial:

Effects of antibiotics on phagocytosis and bacterial killing

There are many ways in which antibiotics may affect the responses of cells of the immune system. First, these drugs enhance the phagocytosis of bacteria. Sub-inhibitory concentrations of a variety of beta-lactam antibiotics have been shown to augment the process of opsonisation. Antibiotics such as clindamycin enhance the phagocytosis of Baeteroides fragilis,

Staphylococcus aureus and Streptococcus pyogenes related to the ability of clindamycin to suppress the production of capsular formation, protein A and M-protein on their surfaces.

Antibiotics also enhance the microbicidal activity of polymorphonuclear leucocytes and macrophages demonstrated with penicillin when used against S. aureus, and with cefaclor and cefetamet when used against Escherichia coli, Klebsiella, Enterobacter, Pseudomonas and Proteus. Similar effects have been demonstrated with cefodizime against a variety of

Gramnegative organisms. Mechanisms of altered phagocytic and intracellular killing of microbes induced by antibiotics

Enhancement of the polymorphonuclear leukocyte killing of microbes by antibiotics occurs through a variety of mechanisms. Inhibitory and sub-inhibitory concentrations may render micro-organisms more susceptible to the intrinsic mechanisms of phagocyte killing (Arduino, R.C., Rakita, R.M. 1994, Infect. Immun. 62, 5587-5594).

Clindamycin promotes phagocytosis and intracellular killing of periodontopathic bacteria by crevicular granulocytes (Eick,S. 2000, J Antimicrob Chemother. 2000 Oct;46(4):583-8).

Both antibiotics and oxygen radicals produced by phagocytes have the ability to inactivate critical penicillin-binding microbial proteins leading to an inability to replicate normally.

Certain antibiotics enhance the generation of oxidative intermediates ROS. Cefaclor and cefetamet increase the production of oxygen radicals by neutrophils. Ras, G.J. (1992, Antimicrob Agents Chemother. 1992; 36: 1236-1240) demonstrated that clindamycin, erythromycin and roxithromycin reduced the generation of oxygen radicals by neutrophils. Some antibiotics interfere with the expression of virulence factors by bacteria, which improves the ability of phagocytes to ingest and kill the pathogen. Clindamycin inhibits the synthesis of streptolysin 0 and M protein by S. pyogenes, phospholipase C (alpha toxin) by Clostridium perfringens, protein A by S, aureus, and capsule formation by B. fragilis. Clindamycin increased the phagocytic killing of Klebsiella and E. coli, although clindamycin had no activity against either microbe when measured by standard antibiotic susceptibility assays.

Because these virulence factors either inhibit ingestion or are cytotoxic to phagocytes, antibiotic-induced inhibition of their synthesis favors successful phagocytosis and killing and they therefore have a positive immunomodulating effect.

Effects of antibiotics on cytokine production

Stevens, D.L. (1995, Clin Infect Dis. 1995;20 (Suppl. 2): 154-157) demonstrated that clindamycin suppressed TNF-a production by peripheral blood mononuclear cells stimulated by LPS. Tetracycline hydrochloride also suppressed TNF-a production. Similarly, Kloppenburg, M. (1994, Arthritis Rheum. 37:629-636, 1995, J. Rheumatol. 22:611-616, 1995 Clin. Exp. Immunol. 102:635-641) demonstrated that minocycline suppressed IFN-γ synthesis by cloned synovial T-cells. Finally, erythromycin treatment reduced microvascular injury to the lung in a rat model of LPS-induced lung injury. In contrast, Witkin, S.S. (1993, Infectious Diseases in Clinical Practice. 2(3): 182- 185, May/June 1993) demonstrated that doxycycline but not erythromycin or clindamycin suppressed LPS-induced monocyte production of TNF-a and IL-6.

Many of these agents demonstrate an in- vivo efficacy that is unrelated to antimicrobial activity, but is related instead to the modulation of the host immune response (Stevens, D. 1996, Infect Dis Clin North Am 1996, 10: 727-746).

Thalidomide and its analogues (e.g. lenalidomide) with more potency and less toxicity are potent TNF-a inhibitors (Reddy, N. 2008, British Journal of Haematology, 140:36-45).

Statins where shown to reduce the expression of IL1 / IL6 proinflammatory cytokines (van der Most PJ 2009, Prog. Neurobiol. 88(1), 64-75).

Vitamin D (15-30 microgram/d) affects periodontal disease in an anti- inflammatory way via immune system (induction of bone mineralisation (ID 150), contribution to normal cell division (ID 153), normal function of the immune system and inflammatory response (ID 154,159): European Food Safety Authority efsa scientific opinion EFSA Journal 2009;7(9): 1227ff, 2010:8(2): 1468ff.

Oligomeric polycyclic cyanids (OPC cyanidin bioflavonoids) inhibit platelet function (Murphy, K. 2003, Am J Clin Nutr. 2003 Jun; 77(6): 1466-73. Putter, M. 1999, Am J Clin Nutr. 2003 Jun; 77(6): 1466-73) and selectively bind to collagen and elastin and aid in the production of endothelial NO (Nishioka, K. 2007, Hypertension Research. 30(9):775-80).

Detailed description of the invention:

A composition is provided that comprises chlorhexidine, bisphosphonate and a non steroidal anti-inflammatory drug (NSAID) together with an immunomodulatory component.

Specifically, the inventive composition is formulated as a pharmaceutical composition. The specific concentrations of each active component as comprised in the inventive composition may be determined by the skilled person.

According to an embodiment of the invention, the composition may also comprise combinations of different bisphosphonates, NSAIDs and/or immunomodulatory agents, specifically two, specifically three, specifically four, more specifically at least five different compounds selected from bisphosphonates, NSAIDs and immunomodulatory agents or any combinations thereof. Specifically, NSAID in said composition is present, in the range of 0,001 to 10%, specifically in the range of 0,001 to 2%, more specifically in the range of 0,001 to 1,5%, more specifically in the range of 0.001 to 0.75%>, even more specifically in the range of 0.01 to 0,6 % by weight of the composition.

It has been shown by the inventors that due to the low concentration of NSAID the therapeutic effect of the composition is received without the negative side effects that usually occur due to higher NSAID concentrations as it is well known that NSAID blocks inflammatory MAPK pathways (p38) and stimulates the ER pathway as well as junctional complex and apicobasal cell differentiation regulating the PAR genes via PKC.

According to the embodiment of the invention NSAID can be selected from, but is not limited to, the group consisting of salicylic acid, acetylsalicylic acid (aspirin), bis-salicylate, benzyl- benzoic acid, diflunisal, fendosal, indomethacin, acemetacin, cinmetacin, sulindac, tolmetin, zomepirac, diclofenac, fenclofenac, isoxepac, ibuprofen, flurbiprofen, naproxen, ketoprofen, fenoprofen, benoxaprofen, indoprofen, pirprofen, carprofen, mefenamic acid, flufenamic acid, meclofenamate, niflumic acid, tolfenamic acid, flunixin, clonixin, phenylbutazone, feprazone, apazone, trimethazone, mofebutazone, kebuzone, suxibuzone, piroxicam, isoxicam, tenoxicam. nabumetone, choline magnesium trisalicylate, sodium salicylate, meloxicam, oxaprozin and COX-2 inhibitors such as rofecoxib, celecoxib, valdecoxib, or lumiracoxib.

More specifically, the inventive composition comprises mefenamic acid.

As an alternative, two, specifically three, more specifically four, more specifically at least five different NSAIDs may be comprised in the composition.

According to a specific embodiment of the invention, chlorhexidine may be present in the inventive composition in the range of 0.01 to 10wt%, preferably in the range of 0.01 to 5 wt%, preferably in the range of 0.1 to 2 wt%.

According to a specific embodiment of the invention, bisphosphonate may be present in the range of 0.0001 to 5%, preferably in the range of 0.005 to 1%, preferably in the range of 0.01 to 0.7%) by weight of the composition.

According to the embodiment of the invention, bisphosponates may generally have a P-C-P molecular structure. The bisphonsphonates may comprise, for example, alkyl side chains, amino-bisphosphonates with an amino -terminal side chain or they have a cyclic side chain. Specifically, bisphosphonate can be selected from, but is not limited to, the group consisting of aminobisphosphonate, alendronic acid, clodronate, etidronate, ibandronate, pamidronate, risedronate, tiludronate, olpadronate, icadronate and zoledronate. According to a specific embodiment, clodronate is the most preferred bisphosphonate for the inventive composition.

Alternatively, two, specifically three, more specifically four, more specifically at least five different bisphosphonates may be comprised in the composition.

According to the invention immunomodulatory agents can be any agents which have an effect on the immune system. Thus, according to the specific immunomodulatory agent the amount of said agent can be exemplified by the skilled person and may be in the range of 0,00001-10% per weight of the composition.

There are two types of effects - immunostimulation and immunosuppression. Immunosuppressants primarily have the suppressant effect and can be for example glycocorticoids, cytostatics, antibodies, drugs acting on immunophilins or other drugs like interferons, opoids, TNF binding proteins or small biological agents. Immunostimulants primarily have the stimulant effect and can be for example endogenous immunostimulants, synthetic

immunostimulants or herbal immunostimulants.

Most agents however do not have effects on only one receptor, so an immunomodulator may be at the same time an immunosuppressant and an immunostimulant, on different targets within the immune system.

Immunmodulatory agents can also be from the group of disease modifying antirheumatic drugs (DMARDs).

The term "DMARD" refers to a therapeutic agent that is used for the treatment of an inflammatory disease. A DMARD can be used treat, prevent, or reduce one or more of the symptoms of or the progression of an inflammatory disease in a patient when administered in a therapeutically effective amount. Examples of DMARDs known in the art include auranofin, aurothioglucose, azathioprine, chlorambucil, cyclophosphamide, cyclosporine, D-penicillamine, gold sodium thiomalate (injectable gold), hydroxychloroquine, leflunomide, methotrexate, minocycline, mycophenolate mofetil, or sulfasalazine. According to a specific embodiment of the invention, the immunomodulatory agent is selected from the group of antibiotics, thalidomide and its analogues, statins, Vitamin D or oligomeric proanthocyanids (OPC) or DMARDs or combinations thereof.

Antibiotics can be but are not limited to the tetracycline group antibiotics selected from the group of e.g. tetracycline, doxycycline, minocycline, tigecycline; aminoglycosides (e.g.

gentamycin, neomycintobramycin), ansamycins (e.g. geldanamycin, herbimycin),

carbacephems, carbapenems, cephalosporins, glycopeptides, lincosamides (e.g. clindamycin, lincomycin), lipopeptides, macro lides (e.g. erythromycin), quinolones, monobactrams, nitrofurans, polypeptides, sulfonamides, arsphenamine, chloramphenicol, fosfomycin, fusidic acid, linezolid, metronidazole.

Antibiotics can also be selected from β-lactam antibiotics, for example, but not limited to cefaclor, cefetamet, cefodicime or from penicillin and derivates like penams, ampicillin.

According to a specific embodiment, tetracycline and clindamycin are preferred antibiotics.

The immunomodulatory agent may also be selected from the group of statins, which have been shown to increase the concentration of T_regs, recruit macrophages, induce differentiation (pleiotropic effects) besides their cholesterol synthesis lowering activity.

Statins can be fermentation-derived or synthetic statins. For example, statins can be selected from Atorvastatin, Cerivastatin, Fluvastatin, Lovastatin, Mevastatin, Pitavastatin, Pravastatin, Rosuvastatin, Simvastatin.

Specifically, lovastatin may be present in said composition in the range of 0.001 to 5%, preferably in the range of 0.1 to 0.6%, preferably in the range of 0.01 to 0.1% by weight of the composition.

The immunomodulatory agent can also be Thalidomide or an analogue thereof. The analogues can be, but are not limited to lenalidomide (Revlimid, CC-5013, 3-(4'aminoisoindoline- -one)- l-piperidine-2, 6-dione); pomalidomide (CC-4047, ACTIMID), CC-5103, IMiD3, EM12, ENMD-0995.

The analogs can also be selected from the non-fluoro-substituted phthalimides comprising N-(3-Chlorophenyl)-phthalimide, N-(2-Chlorophenyl)-phthalimide, N-(3,4-Dichlorophenyl)- phthalimide, N-(4-Methylphenyl)-phthalimide, N-(3-Methylphenyl)-phthalimide, N-(2-Methyl- phenyl)-phthalimide, N-(4-Methoxyphenyl)-phthalimide, N-Phenyl-tetrafluorophthalimide, N-(4-Chlorophenyl)-tetrafluorophthalimide, 2-Indan-l-yl-isoindole-l,3-dione, 2-(l, 2,3,4- Tetrahydronaphthalen- 1 -yl)-isoindole- 1 ,3-dione, 2-(6,7,8,9-Tetrahydro-5H-benzocyclohepten- 5-yl)-iso indole- 1 ,3-dione, 6,7,8,9-Tetrahydrobenzocyclohepten-5-oneoxime.

Alternatively, the analogs can also be selected from tetrafiuorophthalimides like for example N-(3-Chlorophenyl)-tetrafluorophthalimide, N-(2-Chlorophenyl)-tetrafluorophthalimide, N-(3,4-Dichlorophenyl)-tetrafluorophthalimide, N-(4-Methylphenyl)-tetrafiuorophthalimide, N-(3-Methylphenyl)-tetrafiuorophthalimide, N-(2-Methylphenyl)-tetrafiuorophthalimide, N-(4-Methoxyphenyl)-tetrafiuorophthalimide, N-Benzyltetrafluorophthalimide, 4,5 ,6,7-Tetra- fluoro-2-indan-l-yl-isoindole-l,3-dione, 4,5, 6,7-Tetrafiuoro-2-( 1,2,3, 4-tetrahydronaphtha-len- l-yl)-isoindole-l,3-dione, 4,5,6,7-Tetrafiuoro-2-(6,7,8,9-tetrahydro-5H-ben- zocyclohepten-5- yl)-isoindole- 1 ,3-dione, 6,7,8,9-Tetrahydro-5H-benzocyclohepten-5-yl-amine-hydrochloride.

According to the present invention the term "analogues" includes also derivatives and analogues of said substances The terms "analogue" or "derivative" relate to a chemical molecule that is similar to another chemical substance in structure and function, often differing structurally by a single element or group, which may differ by modification of more than one group (e.g., 2, 3, or 4 groups) if it retains the same function as the parental chemical. Such modifications are routine to skilled persons, and include, for example, additional or substituted chemical moieties, such as esters or amides of an acid, protecting groups such as a benzyl group for an alcohol or thiol, and tert-butoxylcarbonyl groups for an amine. Derivatives can also include conjugates, such as biotin or avidin moieties, enzymes such as horseradish peroxidase and the like, and radio-labeled, bio luminescent, chemo luminescent, or fluorescent moieties. Further, moieties can be added to the agents described herein to alter their pharmacokinetic properties, such as to increase half-life in vivo or ex vivo, or to increase their cell penetration properties, among other desirable properties. Also included are prodrugs, which are known to enhance numerous desirable qualities of pharmaceuticals (e.g., solubility, bioavailability, manufacturing, etc.).

The term "derivative" also includes within its scope alterations that have been made to a parent sequence including additions, deletions, and/or substitutions that provide for functionally equivalent or functionally improved molecules.

The immunomodulatory agent can also be Vitamin D, e.g. D2 or preferred D3 (cholecalciferol) which, when binding to Vitamin D receptor, has been shown to increase the activity of natural killer cells, enhance the phagocytotic activity of macrophages, inhibit inflammatory cytokine production, reduce the inflammatory response of THl-cells, increase antimicrobial peptides (e.g. cathelicidin (LL-37), and has positive effects on bone formation and preservation.

Specifically, vitamin D3 may be present in said composition in the range of 0.00001 to 1%, preferably in the range of 0.00005 to 0.01%, preferably in the range of 0.0001 to 0.05% by weight of the composition.

The immunomodulatory agent can also be a flavonoid polyphenol, like for example oligomeric polycyclic cyanidins - OPC, katechins, tannins, leukocyanidin, leukoanthocyanin, proantho- cyanidin, procyanidin, found in peanut skin, pine bare, quercus heartwood, grape and wine seeds and skins, chokeberry, bilberry, blackberry, black currant, tea or preferred as standardized cowberry / Imgonberry extract. OPC shows anti- inflammatory properties and reduces edema, selectively binds to collagen and elastin and aids in the production of endothelial nitric oxide (NO) facilitating normal blood flow.

Specifically, OPC is present in said composition in the form of a standardized cowberry / lingonberry extract in the range of 0.01-50%, preferably in the range of 0.1 to 20% by weight of the composition.

The immunomodulatory agent may alternatively also be an interferon or a peptide or protein thereof having at least 70% sequence identity with the full length interferon protein and having at least 50% activity of human IFN-P-la in the ability to suppress EAE in a mouse model or a small molecule (e.g., BG12 (fumarate), fingolimod (FTY-720), laquinimod, teriflunomide, or atorvastatin, or a molecule that demonstrates the same or substantially the same biological activity to an interferon or a peptide. This immunomodulatory agent encompasses both naturally occurring interferons as well as recombinantly produced interferons.

According to a specific embodiment, two, specifically three, more specifically four, more specifically at least five different immunomodulatory agents may be comprised in the composition.

Specifically, Vitamin D3 and OPC may be combined in the inventive formulation. According to a specific embodiment of the invention the immunomodulatory agent, specifically tetracycline, is present in the range of 0.001 to 10 wt%, preferably in the range of 0.01 to 5 wt%, preferably in the range of 0.01 to 1 wt%.

According to further embodiments, Statin may be present in an amount between 0,001 and 5%, preferably between 0,01 and 0,6%; clindamycin may be present in an amount between 0,01 and 5%, preferably between 0,5 and 2% by weight of composition, vitamin D3 may be present in an amount between 0,00001 and 1%>, preferably between 0,0001 and 0,001%) and OPC may be present in amount between 0,01 and 50%>, preferably between 1 and 20%> by weight of composition.

The minimally inhibitory concentration MIC for tetracycline against important periodontal pathogens is estimated to be about 2 - 3μg per ml (0,002-0,003 wt%>).

Certain antimicrobials exhibit pleiotropic effects both reducing the numbers of bacteria and suppressing the host's inflammatory response e.g. by reducing matrix metalloproteinase MMP synthesis. These pleiotropic properties have led to the widespread use of tetracyclines for the treatment of chronic inflammatory diseases like periodontitis, rosacea, acne, multiple sclerosis, epidermolysis bullosa.

At low or subantimicrobial doses, tetracyclines reduce inflammation via chemotaxis inhibition, anticoUageno lytic, antimatrix-degrading metalloproteinase, and complement pathways as well as inflammatory cytokine down-regulating properties including the inhibition of matrix metallo- proteinases (MMPs), tumor necrosis factor (TNF), and inducible nitric oxide synthase (iNOS) production. Subantimicrobial dose (SD) doxycycline (Periostat 20 mg) has clinical utility in periodontitis and has been investigated in a double -blind, placebo-controlled trial in the treatment of moderate facial acne as well as in an open label study in the treatment of rosacea.

Semisynthetic tetracyclines used in the adjunctive treatment of inflammatory periodontal disease enhance collagen expression in induced periodontal lesions of rats.

Low-dose long-term erythromycin treatment has recently been reported to be very effective in patients with chronic respiratory infection and inflammation. This effect of erythromycin was thought to be not antibacterial but anti- inflammatory. The aims of this study were to investigate the effects of erythromycin on cytokine production and its mechanisms of actions in rat alveolar macrophages. Erythromycin reduced cytokine production and secretion when cytokines where induced by lipopolysaccharide treatment.

At doses ranging from 10^~7 to 10^~4 M, ampicillin decreased IL-6 release from Wistar Institute Susan Hayflick cells. A dose-dependent effect of gentamicin is the reduced MMP-2 protein expression and transcription after mesh coating with 8 μg/mg gentamicin together with the improved collagen type I/III hint on advanced tissue integration even in the long-term.

According to an embodiment of the invention, the composition may comprise chlorhexidine, bisphosphonate, NSAID and tetracycline. Alternatively, the composition may also comprise chlorhexidine, bisphosphonate, NSAID and Vitamin D3. According to a further alternative, the composition may comprise chlorhexidine, bisphosphonate, NSAID and OPC and yet a further alternative may comprise chlorhexidine, bisphosphonate, NSAID and OPC and Vitamin D3.

More specifically the inventive composition can comprise

NSAID, specifically in an amount between 0.001 and 10 wt%

Chlorhexidine, specifically in an amount between 0.01 and 10 wt%

Bisphosphonate, specifically in an amount between 0.005 and 1 wt% and

Tetracycline, specifically in an amount between 0.001 and 5 wt%

Alternatively, the inventive composition may comprise

NSAID, specifically in an amount between 0.001 and 10 wt%

Chlorhexidine, specifically in an amount between 0.01 and 10 wt%

Bisphosphonate, specifically in an amount between 0.005 and 1 wt% and

Vitamin D3, specifically in an amount between 0,0001 - 0,001 wt%

According to a further alternative, the composition may comprise

NSAID, specifically in an amount between 0.001 and 210 wt%

Chlorhexidine, specifically in an amount between 0.01 and 10 wt%

Bisphosphonate, specifically in an amount between 0.005 and 1 wt% and

OPC, specifically in an amount between 0.01 and 50 wt%.

The specific dose of compounds administered according to this invention to obtain therapeutic or prophylactic effects will, of course, be determined by the particular circumstances surrounding the case, including, for example, the specific route of administration and response of the individual patient, the condition being treated and the severity of the patient's symptoms. In general, the compounds of the invention are most desirably administered at a concentration that will generally afford effective results without causing any serious side effects. The composition according to the embodiment is a solid or liquid composition. The active ingredients of the composition can be combined into a gel, hydrogel, polymer, cream, solution, rinse or other pharmaceutically acceptable carrier which can be applied topically to the sides of epithelial wounds, mucosal inflammation or infection. Systemic application of parts of the composition is possible.

More specifically a gel, polymer or hydrogel is the most preferred administration form of the inventive composition, specifically if the composition is administered to a periodontal pocket or a wound of an individual.

The addition of suspending or scaffolding agents to the carrier like, for example, xanthan gum, methylcellulose, hydroxymethylcellulose or hydroxypropylcellulose, or covering agents like PEG-hydrogels can be advantageous when compounding the carrier. In some cases, depending on the carrier, the active agents are first solubilised and then incorporated into the carrier.

Scaffolds capable of supporting three-dimensional tissue formation are critical to recapitulating the in vivo milieu and allowing cells to influence their own microenvironments. Scaffolds usually serve to allow cell attachment and migration, deliver and retain cells and biochemical factors, enable diffusion of vital cell nutrients and expressed products and exert certain mechanical and biological influences to modify the behaviour of the cell phase. Examples of these materials are processed cellular and acellular ECM, proteins like collagen, elastin, fibronectin, laminin, glycosaminoglycans (GAGs), fibrin, soybean proteins, natural polymers and polysaccharidic materials, like chitosan, alginate, dextran, cellulose, starch, hyaluronan, silk fibroin, and some polyesters, polylactic acid (PLA), polyglycolic acid (PGA), polycapro lactone (PCL) and polyhydroxyalkanoates.

In addition to mimicking extracellular matrix characteristics, as well as covering, moist keeping characteristics, these bio-functionalized scaffold and covering ingredients can be applied to every wound related site.

The inventive composition can be used for the treatment of epithelial wounds as well as for the prevention or treatment infections or inflammations of the mucosa, specifically of oral infections or inflammations, more specifically for the treatment of periodontitis and other related diseases, for example oral mucositis, gingivitis or periodontitis, periimplantitis and postoperative or chronic dermal and mucosal wound healing. The inventive composition can be used for the prevention or treatment of any chronic inflammation which may lead to dedifferentiation of the tissues, in case of mucosal and periodontal sites, inflamed tooth extraction sites used for immediate implant placement to a loss of barrier function and to chronic infection of the underlying connective tissue. Swelling, redness, edema and pain with pocket formation along the tooth root or implant surface, attachment loss, bone resorption and delayed wound healing result in tissue destruction, tooth loss and in dermal wound sites in scar formation instead of regular tissue differentiation and regeneration can be treated or prevented as well with the present composition.

Furthermore the inventive composition can be used for prevention or treatment of any acute or chronic mucosal or dermal atraumatic or traumatic inflammation or infection as well as chronic inflammatory tissue destruction or diabetical or other wound healing disturbances.

The present invention further provides ready to use of devices for delivering the composition according to the invention into a periodontal pocket, to an implant placement, mucosal or wound surface or inflammatory area.

Said devices are well known in the art specifically for oral and dermal treatments and can be in the form of a syringe, gel, cream or naturally derived or synthetic matrices,

Hydrogels, polymers in any shape or configuration, gauze, sheets or filler material as known in the art can also be useful for administration of the composition.

By increasing moisture content, hydrogels consisting of cross-linked, wound secretion absorbing bio- or synthetic polymers have the ability to help cleanse and debride necrotic tissue. A moist wound dressing method for example as hydrogel matrix prevents wound contraction. Using this wound dressing, the suitability of e.g. PEG-hydrogels for the application in wound healing was demonstrated. Synthetic materials promote epidermal healing even better than naturally derived fibrin matrices, since the degree of reepithelialization was more than 4-fold increased in PEG hydrogels.

The treatment of the oral infections and inflammations can be performed for example together with treatment procedures stage I+II instruction for self administration by the patient of the gelous composition into the diseased pockets (Code 3+4 CPITN) out of a syringe is

administered for several weeks (2-8) depending on resulting pocket depth and repeated if necessary.

As periodontal disease develops on anaerobically modified bio film level, it is necessary to reestablish a healthy microbial community on the tooth surface. High and frequent sugar intake allows excessive plaque development and anaerobic shift at the gumline, facilitated by attachment loss and exposure of dentine bone protein structure allowing anaerobic receptor - adhesin coadhesion of red complex anaerobic pathogens.

As periodontitis is a multifactorial disease resulting from bio film infection of the periodontal structures, affecting immune defense and tissue differentiation, cytokine signalling and resulting in chronic inflammation and destruction, the combined composition can simultaneously act on different levels:

Degradation of late colonizer dominated dental bio film (anaerobic shift to Aggregatibacter actmomycetemcomitans A.a., Porphyromonas gingivalis P.g., Treponema denticola T.d. content = Red Complex according to Prof. Socransky, J Clin Periodontol 1998; 25: 134-44) by Chlor- hexidine. Frustrated phagocytosis of a biofilm leads to overstimulation of inflammatory cytokines and shift of TH1 mediated immune defense (acute lesion) to TH2 dominated cytotoxic defense (chronic disease). The subgingival biofilm degradation and disturbance of regrowth can be achieved by the composition^'s chlorhexidine component through disinfection and disturbance of the microbial cell wall synthesis.

Inhibition of microbial and immune system proteases (e.g. gingipains from P. g. and MMPs) which lead to disjunction and downregulation of cellular adhesive structures via E-Cadherin, opening paracellular spaces to infection and resulting in LPS induced inflammation in deeper connective tissue.

The composition is designed to restore a non-inflammatory state immune function and redifferentiate cellular adhesive structures to restore barrier function, the main component of innate immunity.

Immune modulation of the chronically shifted TH2 cytotoxic reaction due to cytokine over- expression (TNF-alpha, NO) as result of failed phagocytosis of biofilm protected anaerobic bacteria releasing LPS, blockade of MMP protease and osteoclast activation is essential to reduce the inflammatory response and tissue destruction in deeper connective tissues and bone. Sub- or low dose antimicrobiotical doses of immunomodulators like tetracycline are able to block MMP activation and macrophage / monocyte overstimulation. Bisphosphonate is able to block cholesterol synthesis and down regulate osteoclast stimulation and synthesis of inflammatory mediators. Cholesterol synthesis is regulated via mevalonate-dependent (MAD) route or isoprenoid pathway, which is an important cellular metabolic pathway that serves as the basis for the biosynthesis of molecules used in processes as diverse as terpenoid synthesis, protein prenylation, cell membrane maintenance, hormones, protein anchoring, and N- glycosylation. It is also a part of steroid biosynthesis.

To shift the TH2 driven immune response with resulting tissue destruction (periodontal ligament, alveolar bone, dermis, mucosa) back to a healthy, non- inflammatory state it is necessary to redirect overstimulated inflammatory pathways, allow tissue clearance of inflammatory mediators and modulate immune response to stop chronic inflammation and destruction in deeper connective tissue and restore barrier function of the epithelial or endothelial structure.

Adhesive cellular complex rejunction and reestablishment of barrier function and closure of paracellular infective or immune system driven pathways into deeper tissues can be reached by inhibition of inflammatory and infective dedifferentiation (NFkB, MAPK, p38, p53, COX/PGE, caspase) and rejunction and differentiation in the tissues (ERK, PKC stimulation) by down regulation of cytokine overexpression via non-steroidal and anti-inflammatory as well as immunomodulatory drug.

Surprisingly it has been shown according to the invention that the specific selection and combination of the components of the composition results in a highly effective treatment regimen. A composition reduced of bisphosphonate and tetracycline containing only Chlorhexidine and NSAID or a composition containing only CHX and statin or a composition containing

Chlorhexidine and vitamin D3 is able to stop inflammation, but tissue regeneration and differentiation to a non-inflammatory state can only be reached partly (Data shown in case 1 and 4 for NSAID, case 15 for statin and D3).

An alternative CHX gel formulation containing vitamin D3 and OPC as immunomodulatory / regenerative components could achieve comparable results to the composition containing CHX, NSAID, tetracycline and bisphosphonate.

The foregoing description will be more fully understood with reference to the following examples. Such examples are, however, merely representative of methods of practicing one or more embodiments of the present invention and should not be read as limiting the scope of invention. Examples:

Examples to show efficiency and efficacy of the composition:

Initial motivation and cleaning instruction, supragingival bio film reduction by trimestrially repeated brushing in CHX solution 1 wt% for two weeks by the patient and tooth and pocket cleaning by ultrasonic scaling as well as covering exposed root dentine by adhesive fillings to hide protein coaggregational binding sites for anaerobic microbial species (A.a., P.g., T.d.) was administered.

Cases were treated with standard composition comprising bisphosphonate (0,01 wt%), chlorhexidine (1 wt%), NSAID 0,5 wt%) and tetracycline (0,75 wt%) for 4-8 weeks 3-6 times daily depending on pocket depth with repeated treatment periods after 4-12 months and follow up measurement up to 17 months. In cases 1 and 4 a reduced formulation lacking bisphosphonate and tetracycline was used for one prolonged treatment cycle.

Table 2

Total Nr. of CPITN % Code 4: % Treatment time sites Code severe

measured 3+4 Nr.

(6 per tooth)

/teeth

case 2 B.S. Periodontal due to Tooth preservation despite pocket cracked crack for 15 months tooth

Before 6/1 3 50 3 50

treatment

After treatment 1 16,6 0 6 weeks

Follow up 1 16,6 0 15 months stable

Extraction 18 months after reinfection: crack in tooth found case 3 F.U. Periodontitis

Before 42/7 12 28,5 0

treatment

After treatment 0 0 8 weeks

Follow up 0 0 Stable after 12 months case 4 W.G. Periodontitis

Before 150/25 78 52 36 24

treatment

^reduced 53 35,3 7 4,6 16 weeks formulation

Standard 0 0 6 weeks formulation

Follow up 0 0 Stable after 15 months case 5 H.H. Periodontitis

Before 6/1 2 33 2 33

treatment

After treatment 2 33 0 6 weeks

Follow up 2 33 0 18 months case 6 J.T. Periodontitis

Before 168/28 76 45,2 24 14,3

treatment

1^st treatment 53 35,3 7 4,6 8 weeks

2^nd treatment 4 2,4 0 8 weeks

Follow up 4 2,4 0 18 months case 7 R.J. Periimplantitis

25 Total Nr. of CPITN % Code 4: % Treatment time sites Code severe

measured 3+4 Nr.

(6 per tooth)

/teeth

Before 6/1 6 100 6 100

treatment

After treatment 0 0 6 weeks

* reduced formulation is composed of CHX (1 wt%), double dose NSAID (1 wt%) without bisphosphonate and without tetracycline. As shown in data case 1 + 4 even prolonged use could not restore periodontal status in the way standard formulation did. As shown below all components of the composition and repeated administration in combination with establishment of good oral hygiene are essential for better outcome.

Table 3

d-data:

After initial findings taken, first treatment with standard composition on diseased pockets for 4 weeks showed slightly deepened pockets (3,1% pocket measured sites code 3+4 CPITN deeper than 4 mm and 1,2% code 4 deeper than 6 mm (3 sites buccally mesial, median and distal edge of tooth and 3 similar sites lingually) due to progression of disease.

In the beginning the patient had strong sensitivity resulting from exposed root surface and could not establish proper cleaning because of these sensitivity problems during brushing. After reducing this standard composition of tetracycline and bisphosphonate and doubling the content of NSAID and prolonged administration for 16 weeks of the reduced formulation improvement of 7,4% code 3+4 sites (> 4 mm) and 17,9% code 4 sites (> 6 mm) was measured. After another treatment period with standard gel administered for 8 weeks only 16% of the measured sites were code 3+4 (> 4 mm), a significant reduction of 42% of pockets deeper than 4 mm, and only 2,5% of the sites were categorised code 4 (> 6mm), a significant improvement of 23,4%) on pocket sites deeper than 6 mm.

After 17 months periodontal situation was stable, motivation, bio film reduction and

professional tooth cleaning was administered trimestrially.

Table 4

After initial findings taken, treatment with reduced composition on diseased pockets showed shallower pockets.

After administration of reduced composition (no tetracycline and bisphosphonate and doubling the content of NSAID) and prolonged administration for 16 weeks improvement on 25% code 3+4 sites (> 4 mm) and 19,4% code 4 sites (> 6 mm) was measured.

After another treatment period with standard gel administered for 6 weeks none of the measured sites were code 3+4 (> 4 mm), a treatment success of 100% on diseased pockets.

After 15 months periodontal situation was stable, motivation, bio film reduction and

professional tooth cleaning was administered trimestrially. Results of standard and reduced formulation in periodontitis and periimplantitis:

Case 1 : Statistically significant improvement on 42% of all diseased sites in comparison to initial findings and on 23,4% of severely diseased pocket measuring sites could be shown with repeated administration of the standard formulation containing all components (including tetracycline, bisphosphonate), whereas reduced formulation could improve only 7,4% of all diseased sites and 17,4% of severely deep pockets despite prolonged administration and doubled NSAID content.

Case 4: Complete disappearance of pockets deeper than 4 mm was observed after 6 weeks of standard gel application accompanied by bio film reduction and ultrasonic pocket scaling and cleaning, whereas the reduced composition could improve 25% of all diseased sites and 29% of severely diseased measure points.

Reduced gel was able to extinct almost all severe sites except 4,6%, but left shallower pockets at 35,3%), whereas standard formulation could heal all diseased sites after 6 weeks of administration.

In two periimplantitis cases (7+8) inflammation and entrance of the periodontal probe between gingival and implant surface could be reduced after administration of standard gel for 5-6 weeks.

Table 5

Results of standard formulation in periimplantitis, implant healing, wound healing and chronic wounds:

Total Nr. of CPITN % Code 4: % Treatment time sites Code Severe

measured 3+4 Nr. Nr.

(6 per tooth)

/teeth

Case 11 V.W. Implant into Mucosal wound inflamed covered after 3 socket weeks, bone 2mm over cover screw after 3 months

Case 12 S.T. Burned wound class 2 big

blister

Full epithelial coverage of 2 weeks

site

Case 13 I.S. chronic plantar bleeding,

dermal fissure infection

Full epithelial coverage of 2 weeks

site

Implant and wound healing cases:

In two postoperative sites (cases 9 + 10, implant placement, diameter of wound 6 mm) full epithelial coverage was achieved after 2 weeks of standard gel administration. When implants are placed transgingivally healing is impaired by bio film development on the implant head and results in inflammation and often fistulation of the mucosal wound.

In case 11 (V.W.) an implant was placed into an inflamed root extraction socket and after application of standard gel formulation for 3 weeks onto the placement site mucosa covered the wound without any fistulation. When reopened after 3 months the implant cover screw was covered by 2 mm of new bone and the implant was well osseointegrated.

A big blister resulting from a class two burn wound injury on a finger (case 12) did heal without pain after 2 weeks of continuous standard gel application, full epithelial coverage was reestablished. Second-degree burns manifest as erythema with superficial blistering of the skin, and can involve more or less pain depending on the level of nerve involvement. Second-degree burns involve the superficial (papillary) dermis and may also involve the deep (reticular) dermis layer. Infection, scar built-up and pain are major complications of burns. In the management second degree burns little quality evidence exists to determine which type of dressing should be used, biosynthetic dressings and Hydrogels may speed healing. A second or third degree blister could serve as model for uncomplicated blisters in e.g. epidermolysis bullosa simplex, as the tissue disruption happens at the junction of epidermis and dermis eventually involving deeper layers.

A chronically inflamed and hurting fissure on the planta pedis (case 13) resulting from badly administered pedicure gone too deep into the dermal parts of the highly keratinized plantar skin was closed after 2 weeks of continued administration and did heal painlessly under full epidermal reconstruction.

Other formulations with different immunomodulatory components instead of tetracycline were investigated:

Clindamycin, statin, D3, and OPC (Oligomeric Proanthocyanids from standardized cowberry / lingonberry extracts):

The minimal inhibitory concentration (MIC) of clindamycin is 0,15 mg/1 for P. gingivalis and 0,16 mg/1 for A. actinomycetemcomitans.

A standard gel composition where 1 weight % clindamycin replaces tetracycline as

immunomodulatory agent is able to produce similar results as the gel comprising tetracycline:

Table 6:

formulation

The alternative immunomodulatory and regenerative capacity of formulations containing bisphosphonate (lodronate 0,01 wt%), NSAID (mefenamic acid 0,5 wt%) and CHX 1 wt% in combination with either or clindamycin (1 wt%).

Case 13 and 14 (second treatment protocol 20 days upper jaw) demonstrates an immunomodulatory effectiveness of clindamycin (1 wt%), which is slightly reduced but effective in comparison to tetracycline. Similar results were obtained for statin in case 14 treatment protocol 1st week.

The immunomodulatory capacity of a formulation containing vitamin D3 (0,0005 wt%) was shown in cases 14 and 15, where no regeneration (14) was observed, but a complete disappearance of Mc Calls girlande representing the edema in gingivitis could be demonstrated.

Claims

Claims

1. Composition comprising chlorhexidine, bisphosphonate, a non steroidal antiinflammatory drug (NSAID) and an immunomodulatory agent.

2. Composition according to claim 1 wherein NSAID in said composition is present in the range of in the range of 0,001 to 10%, 0,001 to 2%, preferably in the range of 0,001 to 1,5%, preferably in the range of 0.001 to 0.75% by weight of the composition, preferably in the range of 0.01 to 0,6%> by weight of the composition.

3. Composition according to any one of claims 1 or 2 wherein the immunomodulatory agent is an antibiotic, thalidomide or its analogue, a statin, OPC, Vitamin D or DMARD or combinations thereof.

4. Composition according to any one of claims 1 to 3 wherein the antibiotic is selected from the group of tetracycline group antibiotics, clindamycin, aminoglycosides, erythromycin, β-lactam antibiotics.

5. Composition according to any one of claims 1 to 4 wherein the statin is selected from the group of atorvastatin, cerivastatin, fluvastatin, lovastatin, mevastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin.

6. Composition according to any one of claims 1 to 5 wherein chlorhexidine is present in the range of 0.01 to 10%, preferably in the range of 0.01 to 5%, preferably in the range of 0.1 to 2%> by weight of the composition

7. Composition according to any one of claims 1 to 6 wherein bisphosphonate is present in the range of 0.0001 to 5%, preferably in the range of 0.005 to 1%, preferably in the range of 0.01 to 0.7%) by weight of the composition.

8. Composition according to any one of claims 1 to 7 wherein the tetracycline present in the range of 0.001 to 10 wt%, preferably in the range of 0.01 to 5%, preferably in the range of 0.01 to 1%), by weight of the composition.

9. Composition according to any one of claims 1 to 8 wherein NSAID is selected from the group consisting of salicylic acid, acetylsalicylic acid (aspirin), bis-salicylate, benzyl- benzoic acid, diflunisal, fendosal, indomethacin, acemetacin, cinmetacin, sulindac, tolmetin, zomepirac, diclofenac, fenclofenac, isoxepac, ibuprofen, flurbiprofen, naproxen, ketoprofen, fenoprofen, benoxaprofen, indoprofen, pirprofen, carprofen, mefenamic acid, flufenamic acid, meclofenamate, niflumic acid, tolfenamic acid, flunixin, clonixin, phenylbutazone, feprazone, apazone, trimethazone, mofebutazone, kebuzone, suxibuzone, piroxicam, isoxicam and tenoxicam.

10. Composition according to any one of claims 1 to 9 wherein bisphosphonate is selected from the group consisting of aminobisphosphonate, alendronic acid, clodronate, etidronate, ibandronate, pamidronate, risedronate, tiludronate, and zoledronate.

11. Composition according to any one of claims 1 to 10 comprising NSAID, chlorhexidine, bisphosphonate and an antibiotic, selected from tetracycline or clindamycin.

12. Composition according to any one of claims 1 to 11 comprising NSAID, chlorhexidine, bisphosphonate and Vitamin D3.

13. Composition according to any one of claims 1 to 12 comprising NSAID, chlorhexidine, bisphosphonate and OPC.

14. Composition according to any one of claims 1 to 13 comprising NSAID, chlorhexidine, bisphosphonate and a statin.

15. Composition according to any one of claims 1 to 14 wherein said composition is a solid or liquid composition, preferably being a gel.

16. Composition according to any one of claims 1 to 15 which is a pharmaceutical composition.

17. Use of a composition according to any one of claims 1 to 16 for the preparation of a medicament.

18. Composition according to any one of claims 1 to 16 for use in the treatment or prevention of an oral infection or oral inflammation, preferably of oral mucositis, gingivitis or periodontitis, periimplantitis and postoperative, post injury or chronically impaired wound healing.

19. Composition according to any one of claims 1 to 16 for use in the treatment of epithelial or mucosal wounds.

20. Use of a ready to use device for delivering the composition according to any one of claims 1 to 16 into a periodontal pocket using a syringe, hydrogel, polymeric carrier, ointment or scaffold.