A composition for the treatment of periodontitis and regeneration of interdental papilla

Abstract

A composition comprising hyaluronic acid and a mixture of polynucleotides extracted from a natural source, for use as an active substance in the therapeutic and / or cosmetic treatment for regeneration of the interdental papilla or in the therapeutic and / or cosmetic treatment of the recession of the interincisal papilla (black triangle syndrome) or in the therapeutic and / or cosmetic treatment of periodontitis, is described herein.

Description

Hyaluronic acid (HA) is a non-sulphur-containing polymer belonging to the glycosaminoglycan family. It is ubiquitous in mammalian tissues, has an unbranched 15 structure and consists of the orderly repetition of a disaccharide composed of glucuronic acid and N-acetylglucosamine. The size of the HA varies, but exceeds one million Daltons, ranging from 3 to 9 million Daltons in some tissues. Initially, HA was isolated in 1934 by Mayer from the hyaloid substance of the vitreous body, hence the name, and for years HA has been considered a 20 filling and structural substance with extraordinary hydrophilic capacity, with no particular biological role. Only in the last decade, attention has focused on the biological role of this polymer, especially after the discovery of tissue receptors for HA, such as CD44 and RHAMM. The knowledge of the role of HA as an active substance in more complex processes concerning tissue regeneration and repair has therefore broadened. Therefore, HA 25 is no longer considered to be an inert molecule, but a molecule actively involved in important 2020211076   22 Sep 2026 biological processes, such as cell migration and duplication, angiogenesis, and tissue growth and maturation. Within the scope of the present invention, hyaluronic acid can be used as such or be variously salified, for example with sodium. 5 Typically, hyaluronic acid or a sodium salt thereof is used with a molecular weight of between 500 and 3000 kDaltons, preferably between 600 and 1600 kDaltons. Further molecular weights of hyaluronic acid usable within the scope of the present invention are 700 kDaltons, 800 kDaltons, 900 kDaltons, 1000 kDaltons, 1200 kDaltons, 1400 kDaltons, 1600 kDaltons, 1800 kDaltons, 2000 kDaltons, 2200 kDaltons, 2400 kDaltons, 2600 10 kDaltons, 2800 kDaltons. Non-crosslinked hyaluronic acid is preferably used. The term "Polynucleotides" is intended to indicate a fraction of nucleic acid polymer chains, preferably DNA, having a molecular weight distribution preferably in the range between 0.5 kDaltons and 3000 kDaltons, more preferably between 30 kDaltons and 2000 kDaltons, with 15 a numerical average molecular weight, for example, of approximately 250 kDaltons. Said fraction of DNA polymer chains is preferably obtained by extraction from animal or plant natural sources, such as fish sperm or plants, by means of a process which 5 preferably comprises a step of partial fragmentation of the DNA chains, in order to reduce the molecular weights thereof, and a step of partial depurination of the DNA, to eliminate the informational 20 capacity thereof. The preferred percentage of DNA depurination is preferably in the range of from 1% to 5% purine bases removed (i.e. apurinic sites) out of the total purine bases originally present. A preferred depurination percentage is between 2% and 2.5%. Further depurination percentages of polynucleotides usable within the scope of the present invention are 1.5%, 25   1.6%, 1.7%, 1.8%, 1.9%, 2.1%, 2.2%, 2.3%, 2.4%, 2.6%, 2.7%, 2.8%, 2.9%, 3%, 3.1%, 2020211076   22 Sep 2026 3.2%, 3.3%, 3.4%, 3.5%, 3.6%, 3.7%, 3.8%, 3.9%, 4%, 4.1%, 4.2%, 4.3%, 4.4%, 4.5%, 4.6%, 4.7%, 4.8%, 4.9%. From the foregoing, it is obvious that the characteristics of the PNs are significantly different from those of conventional polynucleotides which have not been subjected to: 5    • partial depurination, • sterilisation techniques for viruses and prions, • procedures for purification of the product which, when dry, exceeds 98% purity with quantities of proteins below 0.5% and a molecular weight range varying between 0.2 and 3000 kDaltons. 10 It is known and documented that PNs have the ability to induce mitosis in fibroblasts, endothelial cells and other cells. They have been used to stimulate tissue repair and in many experimental models have shown a remarkable ability to promote ex novo synthesis of extracellular matrix molecules. In all wound-healing processes, the scientific literature confirmed that PNs have a positive 15 effect on damage repair. PNs also have a remarkable ability to modulate the action of many inflammatory factors and interact with physiological growth factors, which makes these molecules very important and biologically very active in the growth of different cell lines and the secretory activity thereof. The polynucleotides used in the present invention have a molecular weight distribution 20 preferably in the range between 0.2 kDaltons and 3000 kDaltons, more preferably between 30 kDaltons and 2000 kDaltons, with a numerical average molecular weight of approximately 250 kDaltons, for example. The molecular weight distribution of the polynucleotides used in the scope of the present invention can also be included within the following ranges: 5-2500 kDaltons; 50-1500 kDaltons; 100-1000 kDaltons. 25 The composition according to the invention comprises: - hyaluronic acid as described above 2020211076   22 Sep 2026 - polynucleotides (PNs) as described above. For liquid formulations (for example formulations suitable for injection or topical application), for example, polyols are used in order to obtain a suitable osmolarity. A preferred polyol is mannitol in concentrations from 0 mg / ml to 50 mg / ml. To ensure an 5 approximately neutral pH (7.0 + / - 1.0) a buffer system is used, preferably phosphate buffer. The mannitol used can be sterile, pyrogen-free, pharmaceutical grade, for injectable use according to the European Pharmacopoeia. The phosphate buffer used can be pharmaceutical grade, injectable, sterile, pyrogen-free. In addition to liquid formulations, the PN + HA combination for use according to the present 10 invention can also be used in the form of gel formulations known per se and commercially available, for example, as Nucliaskin® Oral care from Mastelli S.r.l. Compositions used typically comprise: - polynucleotides from 1 mg / ml to 20 mg / ml, preferably from 5 mg / ml to 12 mg / ml, - hyaluronic acid from 1 mg / ml to 20 mg / ml, preferably from 5 mg / ml to 12 mg / ml, 15 with polynucleotide / hyaluronic acid weight ratios within the range from 0.2:1 to 2:1. EXAMPLES Example 1 Mannitol:          40 mg / ml phosphate buffer:    1.3 mg / ml 20   hyaluronic acid:     7.5 mg / ml PNs:               7.5 mg / ml Water:             943.7 mg / ml Example 2 25   Mannitol:          40 mg / ml phosphate buffer:    1.3 mg / ml 2020211076   22 Sep 2026 hyaluronic acid: 10 mg / ml PNs 10 mg / ml Water: 938.7 mg / ml 5 Example 3 Mannitol: 40 mg / ml phosphate buffer: 1.3 mg / ml hyaluronic acid: 3.5 mg / ml PNs 3.5 mg / ml 10 Water: 951.7 mg / ml Example 4 Mannitol: 40 mg / ml phosphate buffer: 1.3 mg / ml 15 hyaluronic acid: 5 mg / ml polynucleotides: 15 mg / ml Water: 938.7 mg / ml Example 5 20 Mannitol:          40 mg / ml phosphate buffer:    1.3 mg / ml hyaluronic acid:     3 mg / ml PNs (respectively): 7.5, 11, 16 mg / ml Water:              948.2; 944.7; 939.7 mg / ml Example 6 2020211076   22 Sep 2026 Mannitol:          40 mg / ml Phosphate buffer:    1.3 mg / ml Hyaluronic acid:     17 mg / ml Polynucleotides:     3 mg / ml 5 Water:             938.7 mg / ml The effectiveness of the compositions described above in the treatment of periodontitis has been determined by clinical trials on patients suffering from acute or chronic periodontitis. In these clinical trials, which are described in detail in the following experimental section, a commercial composition falling within the scope of the present invention (20 mg / ml Newest 10   - class III medical device - CE 0373) was administered to the patients into the periodontal pockets and through local infiltration into the vestibule. The results obtained show that the administered composition was able to reduce the depth of the periodontal pocket in 94% of treated cases. A significant improvement was also observed in subjective parameters, such as burning, pain, discomfort, bleeding, swelling and redness. 15 The effectiveness of the compositions described above in the regeneration of the interdental papilla was determined by clinical trials on patients who exhibited at least one site with papilla loss in the aesthetic area, a papillary defect commonly referred to as the "black triangle syndrome". In these clinical trials, which are described in detail in the 25 following experimental section, a commercial composition falling within the scope of the present 20 invention (20 mg / ml Newest - class III medical device - CE 0373) was administered to the patients through infiltration into the papilla and the surrounding area (vestibule). The results obtained show that the administered composition was able to induce an improvement in the clinical picture of the papilla in 100% of treated cases. Furthermore, as shown by an extended clinical study, administration by infiltration of the aforementioned commercial composition 25 did not cause the side or adverse effects described in the state of the art (in particular in Bertl K. et al., Clin Oral Implants Res. 2017 Sep;28(9):1054-1061(a) and Bertl K et al., Clin Oral 2020211076   22 Sep 2026 Implants Res. 2017 Jul;28(7):871-876)(b)), presumably thanks to the combination of hyaluronic acid with polynucleotides. The synergistic effect of the compositions comprising PNs and HA was determined by in vitro tests, described in detail in the following experimental section, aimed at determining 5 the effect on the growth of human gingival fibroblast cells and on protein matrix deposition. The results obtained show that, while the effect of HA alone is modest, its combination with PNs results in increased effectiveness of the latter. It can therefore be concluded that by combining HA and PNs a synergistic effect is obtained at the gingival fibroblasts in terms of both cell regeneration and protein matrix deposition. This, in particular, may explain the 10 special effectiveness of the HA and PN combination in the treatment of the black triangle syndrome and in periodontal therapies. Lastly, studies were carried out for assessing local inflammation and the presence of metalloproteinases at periodontal pockets (assessed through the harvesting of crevicular fluid and measurement of alpha-2-macroglobulin and MMP-9 markers analysed by the 15 ELISA method), in order to verify the modulation action of the product on inflammatory cytokines, as well as the local tolerability of a composition comprising the combination of PNs and HA. In the study, 25 patients suffering from periodontal disease with at least 2 periodontal pockets were evaluated. All patients were treated with a normal hygiene and prophylaxis 20 standard therapy, and in addition, the test MD was used in one of the two pockets, in a randomized way, through a single application in the periodontal pocket. The results show that, in the case of alpha-2-macroglobulin, 100% of periodontal pockets treated with the test MD exhibited an improvement, that is a 68% improvement, whereas, in the untreated group, 1 pocket worsened, and the average improvement was 63%. 25 As for the MMP-9 parameter, the results show that periodontal pockets treated with the test MD exhibited a 69% improvement, whereas 6 untreated pockets worsened (24%) and the 2020211076   22 Sep 2026 average improvement in the untreated pockets was significantly lower, that is 49%. These results are particularly significant also because each patient serves as a self-control, i.e., the patient has both a treated pocket and an untreated pocket, thus eliminating any possibility of interference due to individual variability. 5   In the laboratory, therefore with objective and blind parameters, it also appears that treatment with polynucleotides + hyaluronic acid brings about an improvement compared to the standard hygiene and prophylaxis therapy, in particular by modulating and reducing parameters related to inflammation and by reducing MMP9 activity. Also underlining the high tolerability and biocompatibility of the device. 10 Experimental Section 1. Periodontal Therapy - Clinical Study 15 patients aged between 30 and 83 were treated in the study, including 2 men and 13 women suffering from acute periodontitis (3 patients) or chronic periodontitis (12 patients). Periodontitis is defined as periodontal tissue inflammation, which causes loss of attachment 15 of the teeth to the alveoli, which results in formation of periodontal pockets, loose teeth, bleeding gums, abscesses and suppurations, ending in the loss of one or more 20 teeth. 12 / 15 patients had disease familiarity when they entered the study, 6 / 15 were smokers. Each patient underwent hygiene and prophylaxis as per guidelines and was then treated with a polynucleotide and hyaluronic acid gel (20 mg / ml Newest - class III medical device - CE 20   0373). Table 1. Patients: general data Total number of patients 15 Age min 30-max 83 M / F 2 M / 13 F acute periodontitis 3 (out of 15) chronic periodontitis 12 (out of 15) 2020211076   22 Sep 2026 smokers 6 (out of 15) familiarity 12 (out of 15) Materials and Methods: Each patient underwent a specific therapeutic program consisting of 3 main phases. One visit was scheduled for each phase, for a total of 3 visits. The program is described in detail below: 5       1) Pre-Treatment Phase: hygiene and prophylaxis sessions are scheduled and performed (for example, manual and ultrasonic therapy, aimed at decreasing the presence of plaque, tartar and therefore bacteria). An average of 2-3 20-30-minute sessions of hygiene and prophylaxis were carried out for each patient on a monthly basis. Each patient underwent the first visit (V1) during this phase. 10 At V1, patients were clinically evaluated to record subjective parameters (symptoms reported by the patient) and objective parameters (signs detected by the physician). 2) Treatment phase with the test medical device: once clean, the patients were 15 administered via the topical and infiltration routes with the polynucleotide and hyaluronic acid gel (20 mg / ml Newest); this phase was divided into several sessions: - The first session involved topical application into the periodontal pockets and local infiltrations into the vestibule. - The subsequent sessions, carried out on a monthly basis, only involved local infiltrations 20 into the vestibule. Each patient underwent the second visit (V2) during this phase. At V2, subjective and objective parameters were evaluated again. 2020211076   22 Sep 2026 3) Maintenance phase: a session of hygiene and local infiltrations into the vestibule with the polynucleotide and hyaluronic acid gel (20 mg / ml Newest) is carried out every 3-6 months. Each patient underwent the last visit (V3) of the study during this phase. At V3, 5 subjective and objective parameters were evaluated again, in order to evaluate the clinical course of the disease compared to the initial (basal) situation. Application into the periodontal pockets was carried out by using a blunt tip applicator. Local infiltrations into the vestibule were carried out with a 30G needle, at a distance of 0.5 -1 cm, after appropriate local disinfection. 10 Results: At the end of the study, 27% of treated cases exhibited a pocket depth reduction of 2 mm, whereas 67% of cases exhibited a reduction of 1 mm. Only in 6% of cases the pocket depth remained unchanged. Burning, pain, discomfort, bleeding, swelling and redness were the subjective parameters 15 assessed during the study at V1 (pre-treatment phase), V2 (treatment phase) and V3 (maintenance phase). All the tested parameters showed an improvement in the starting conditions. In detail: Pain reduction, assessed by using a VAS scale with a score of 0-10, averaged 67.3%. In fact, the average value ranged from 3.7 at V1 to 1.2 at V3, with an average reduction of 2.5 points. 20 The graph in Figure 1 shows the reduction in the sensation of pain perceived by each patient from visit V1 to visit V3. The reduction in burning, assessed by using a VAS scale with a score of 0-10, averaged 64.4%. In fact, the average value ranged from 3.9 at V1 to 1.4 at V3, with an average reduction of 2.5 points. 25 The graph in Figure 2 shows the reduction in the sensation of burning perceived by each patient from visit V1 to visit V3. 2020211076   22 Sep 2026 The reduction in discomfort, assessed by using a VAS scale with a score of 0-10, averaged 63.6%. In fact, the average value ranged from 3.7 at V1 to 1.3 at V3, with an average reduction of 2.3 points. The graph in Figure 3 shows the reduction in the sensation of discomfort perceived by each 5 patient from visit V1 to visit V3. The reduction in bleeding, assessed on a scale with a score from 0-3, where 0 indicated no bleeding and 3 heavy bleeding, was on average 64.7%, in fact, the average value ranged from 2.3 at V1 to 0.8 at V3, with an average reduction of 1.5 points. The graph in Figure 4 shows the reduction in bleeding obtained for each patient from visit 10 V1 to visit V3. In conclusion, the treatment of chronic and generalized periodontal diseases (11 / 15 cases treated) with the gel containing the PN + HA combination gave excellent results in terms of disappearance of swelling and redness. There was also an improvement of over 60% in signs such as bleeding and symptoms such as burning, pain and discomfort. There was also an 15 objective improvement in terms of reduction of the pocket depth. Therefore, in the dental field, treatment with the gel containing the PN + HA combination represents a valuable and innovative therapeutic choice associated with hygiene and prophylaxis sessions, to improve and enhance the response to the classic hygiene and prophylaxis therapy. 20   2. Clinical study of papilla regeneration (black triangle syndrome) 10 patients with an average age of 52 years, including 7 men and 3 women, were treated in the study. Two of the patients at the start of the study were smokers. In all cases, the patients exhibited at least one site with papilla loss in the aesthetic area, a papillary defect commonly referred to as the "black triangle syndrome". 2020211076   22 Sep 2026 Table 2. Patients: general data Total number of patients 10 average age 52 M / F 7 M / 3 F Smokers 2 (out of 10) Materials and Methods: Each patient underwent a specific therapeutic program consisting of 2 main phases. One visit 5 was scheduled for each phase during the study and one follow-up visit was scheduled after the treatment phase, for a total of 3 visits. The program is described in detail below: 1) Pre-Treatment Phase: The phase in which hygiene and prophylaxis sessions were scheduled and performed (for example, manual and ultrasonic therapy, aimed at decreasing the presence of plaque, tartar and therefore bacteria). All patients were instructed to perform 10 mechanical cleaning at home by using an ultra-soft toothbrush and a brushing technique with movements in the apical-coronal direction. An average of 2-3 20-30-minute sessions of hygiene and prophylaxis were carried out for each patient on a monthly basis. Each patient underwent the first visit (V1) during this phase. Photographs were taken at V1 and the physician's clinical evaluation and patient satisfaction 15 were recorded. 2) Treatment phase with the test medical device: At least one month after stabilization of the clinical picture following the hygiene and prophylaxis sessions, the patients were administered with the polynucleotide and hyaluronic acid gel (20 mg / ml Newest). After disinfection with mouth rinses and local disinfectant at the infiltration site, the affected 20 area was treated by infiltrating the papilla and the surrounding area (vestibule) with small doses of product, generally less than 0.1-0.2 ml. Local infiltrations into the vestibule were carried out with a 30G needle, at a distance of 0.5 -1 cm. 2020211076   22 Sep 2026 The treatment was repeated three to six weeks apart for a total of 3-10 infiltrations. Each patient underwent the second visit (V2) during this phase. At V2, the effects were documented with photographs, compared with those taken before treatment and by filling in a data collection form with recording of the physician's clinical evaluation and patient 5 satisfaction. Results: Patients’ subjective evaluations were very positive both from the point of view of pain and compliance with the treatment and of satisfaction with said treatment, with the following results. 10 The clinical results were very encouraging. Evaluation based on a quartile scale showed improvement in 100% of patients. All cases showed a clinical improvement of the papilla, although not all of them showed complete healing. On average, regrowth started to appear after the second or third session, although in some cases regrowth began after the seventh or eighth session. 15 As regards the objective evaluation of the papillae, all patients showed improvement in the papillary structure, such as to change their classification: • in three cases, class III papilla became class I papilla • in six cases, class II papilla became class I papilla • in one case, class I papilla became a Normal papilla (the papilla fills the interdental space 20 again up to the point of contact). In particular, it should be underlined that the improvement of the papilla occurred very quickly: all patients already exhibited an initial regeneration of the papilla after one week and this regenerative process continued over time. In fact, the sites were checked in a followup and the improvement that took place after the applications, one month after the last 25 treatment, was still present. In no case was there a recurrence. 2020211076   22 Sep 2026 In conclusion, a trophic / regenerative effect of polynucleotides, which were only locally infiltrated, was shown for the first time in the treatment of the black triangle syndrome, a disease hitherto treated with invasive methods such as orthodontic, restorative and surgical 5 interventions, which however yielded poor clinical results. 5   3. In vitro study on gingival fibroblasts Human gingival fibroblasts were cultured on growth medium (Dulbecco’s Modified Eagle 10 Medium) supplemented with 10% bovine foetal serum (BFS). Cells were seeded at a density of 10,000 / cm2. 24 hours after seeding the cells were incubated under the conditions shown in Table 3, again prepared in DMEM + 10% BFS. 10 Cells were counted and proteins were quantified after 3 days of treatment. The number of cells was measured with a particle counter. Proteins were quantified by spectrophotometric reading of stained protein lysates by using a modification of Lowry’s method. Table 3 shows the concentrations of the tested compositions and the values relating to cell 15 growth and protein content, expressed as % of the control. The control is the fibroblast cell culture not subjected to any treatment, measured at the same time point. Table 3 Product % gingival fibroblasts vs control.cell growth % gingival fibroblasts vs control:proteins pn 50 ug ml 123 124 pn 100 ug ml 127 129 pn 300 ug ml 128 129 ha 50 ug ml 102 103 ha 100 ug ml 105 104 ha 300 ug ml 106 104 pn+ha 50 ug ml 127 130 2020211076   22 Sep 2026 pn+ha 100 ug ml 131 130 pn+ha 300 ug ml 132 133 control 100 100 Cell growth and protein quantification results are also shown in figures 5 and 6. The results show that hyaluronic acid does not change its action as its concentration increases, constantly maintaining a mild effect both in terms of protein expression and cell 5 growth. Instead, it is clear that polynucleotides increase their effect as the dose increases. Compared to the individual components, the effect obtained with the mixture - which, for each total concentration, consisted of 50% hyaluronic acid and 50% polynucleotides - was consistently superior to the effect of the PNs used alone and the HA used alone. Accordingly, bearing in mind the low effect of hyaluronic acid alone, it is obvious that the 10 presence of the latter is important for increasing the effect of the PNs, which are the most active component in cell growth and protein expression. It can be concluded that by combining HA and PNs a synergistic effect is obtained at the gingival fibroblasts in terms 15 of both cell regeneration and protein matrix deposition. This, in particular, may explain the special effectiveness of the HA and PN combination in the treatment of the black triangle 15 syndrome and in periodontal therapies. 4. In vivo study of the crevicular fluid Treatment of periodontitis first of all involves controlling bacteria and inflammation, and immediately afterwards, the subsequent step of regenerating the lost, hard and soft periodontal tissues becomes essential, in order to restore tooth attachment and eliminate 20 gingival and bone pockets. ODONTO-PNHA is a class III Medical Device manufactured by Mastelli Srl - Sanremo (IM). It is an original combination of polynucleotides and hyaluronic acid for application in periodontal pockets. 2020211076   22 Sep 2026 The main purpose of the clinical study with Odonto -PNHA is to evaluate the efficacy and safety of a medical device in non-surgical periodontal therapy. The experimental hypothesis is that the addition of ODONTO-PNHA can help obtain periodontal attachment 5 gain in the periodontal pockets, in order to avoid a surgical procedure. 5 To evaluate this, a total of 50 patients were recruited: each patient provided a test site (treated with ODONTO-PNHA) and a control site (untreated). Patients will be followed up for 12 months after treatment. The study is performed in a single clinical centre, at the 10 Department of Periodontology, Universita La Sapienza. Primary objective: evaluation of ODONTO-PNHA's performance on Probing Pocket Depth 10 (PPD), Marginal Bleeding Index (MB), Modified Plaque Index (mPLI), pain, Investigator Global Satisfaction with the usability of the device and Patient Global Satisfaction with the performance 15 of the device (5-point Likert scale). Tolerability and safety assessment. Objective of the biochemical analysis: Evaluation of the effects of ODONTO-PNHA on the inflammatory state of the tissues around the tooth in 25 subjects. This was assessed through 15 harvesting the crevicular fluid and assessing alpha 2 macroglobulin (a2M) and metalloprotease-9 (MMP-9) in the fluid at baseline and at week 6. The crevicular fluid samples, adsorbed on methylcellulose strips, were processed and assayed with the ELISA method. Matrix metalloproteinases are an important group of proteinases related to collagen 20 degradation during the destructive process of periodontal disease, which can be measured in the gingival crevicular fluid. Alpha 2 macroglobulins are plasma proteins that participate in the regulation of blood clotting and immune response and increase in the presence of a chronic infection. 25 patients suffering from periodontal disease and recruited in the ODONTO-PNHA-01 clinical study underwent two takings of crevicular fluid, one taking 25 from the periodontal pocket treated with the test MD and one from an untreated pocket. 2020211076   22 Sep 2026 The takings were performed at baseline (Visit 1) and at week 6 (Visit 2). The total 4 samples were assessed for the presence and concentration of inflammation markers. Results After 6 weeks, the concentrations of the markers, both in the pocket treated with the 5   polynucleotide and hyaluronic acid MD and in the untreated pocket, were significantly lower compared to week 0, showing a general improvement in periodontal disease, thanks to the standard hygiene and prophylaxis therapy. Analysis of data from the test MD-treated and untreated periodontal pockets showed a further difference, described below, to the advantage of patients who had received treatment 10 with the test MD. In the treated pockets, the average alpha 2 macroglobulin value was 1898.71 at time 0 and 15 605.90 after 6 weeks, with an average reduction of 1292.81 corresponding to 68.09%. Out of 25 treated pockets, 19 (76%) showed an improvement of more than 50% (Table 4). In the untreated pockets, the average alpha 2 macroglobulin value was 1665 at time 0 and 15   601 after 6 weeks, with an average reduction of 1064 corresponding to 63.91%. Out of 25 treated pockets, 17 (68%) showed an improvement of more than 50% (Table 4). Table 4: TREATED CONTROLS Total numberBof patients 25 25 Start of the study 1898.7 1665.3 6 weeks 605.9 601.1 Delta 1292.8 1064.3 % Improvement compared to baseline 68.1% 63.9% No. improved patients> 50% 19 17 An even greater difference between treated and controls was found in the MMP-9 parameter. 20   In the treated pockets, the average MMP-9 value was 234.9 at time 0 and 72.9 after 6 weeks, 2020211076   22 Sep 2026 with an average reduction of 162.00 corresponding to 68.96%. Out of 25 treated pockets, 18 (72%) showed an improvement of more than 50% (Table 5). In the untreated pockets, the average MMP-9 value was 173.4 at time 0 and 87.4 after 6 5 weeks, with an average reduction of 86 corresponding to 49.58%. Out of 25 treated pockets, 5 only 9 (36%) showed an improvement of more than 50% (Table 5). Table 5: TREATED CONTROLS Total number of patients 25 25 Start of the study 234.9 173.4 6 weeks 72.9 87.4 Delta 162.0 86.0 % Improvement compared to baseline 68.96% 49.58% No. improved patients> 50% 18 out of 25 (72%) 9 out of 25 (36%) No. worsened patients 2 (8%) 6 (24%) The results show that, in the case of alpha 2 macroglobulin, all treated patients showed an improvement, whereas in the untreated group, 1 patient worsened; in the case of the MMP- 10   9 parameter, all patients except 1 showed an improvement, whereas in the untreated group, 6 patients showed a worsening. In general, improvement was greater in the test MD-treated patients and this improvement was particularly clear for the MMP-9 parameter. These results are particularly significant also because each patient serves as a self-control, 15   i.e., the patient has both a treated pocket and an untreated pocket, thus eliminating any possibility of interference due to individual variability. Conclusion In the laboratory, therefore with objective and blind parameters, it also appears that treatment with polynucleotides + hyaluronic acid brings about an improvement compared to the 2020211076   22 Sep 2026 standard hygiene and prophylaxis therapy, in particular by modulating and reducing parameters related to inflammation and by reducing MMP9 activity. Therefore, the preliminary laboratory results illustrated above support the experimental hypothesis that the PN + HA combination can help obtain periodontal attachment gain in 5 periodontal pockets, in order to avoid surgical procedure.

Claims

1. A composition comprising hyaluronic acid and a mixture of polynucleotides extracted from a natural source, wherein said mixture of polynucleotides has a depurination ratio ranging from 1% to 5% purine bases removed out of the total purine bases originally present5 and it is a fraction of nucleic acid polymer chains having a molecular weight distribution ranging from 0.5 kDaltons to 3,000 kDaltons when used as an active substance in the therapeutic and / or cosmetic treatment for regeneration of the interdental papilla or in the therapeutic and / or cosmetic treatment of the recession of the interdental papilla (black triangle syndrome) or in the therapeutic and / or cosmetic treatment of periodontitis.10   2. The composition when used according to claim 1, wherein said periodontitis is acuteperiodontitis or chronic periodontitis.

3. The composition when used according to claim 1 or 2, wherein said therapeutic and / or cosmetic treatment results in reduction in the depth of the periodontal pockets and / or in pain reduction and / or in stinging reduction and / or in discomfort reduction and / or in bleeding 15 reduction.

4. The composition when used according to any one of claims 1 to 3, wherein said therapeutic and / or cosmetic treatment causes the regeneration of the papilla.

5. The composition when used according to any one of claims 1 to 4, wherein said 20 therapeutic and / or cosmetic treatment results in increased proliferation of gingival 20 fibroblasts and increased deposition of a protein matrix.

6. The composition when used according to any one of claims 1 to 5, wherein the treatment is carried out by topical application and / or local infiltration.

7. The composition when used according to any one of claims 1 to 6, wherein the treatment is carried out by topical application in the periodontal pockets.25   8. The composition when used according to any one of claims 1 to 7, wherein the treatment30 is carried out by local gingival infiltration in the papilla and / or in the vestibule.2020211076   22 Sep 20269. The composition when used according to any one of claims 1 to 8, comprising from 1 mg / ml to 20 mg / ml of hyaluronic acid and from 1 mg / ml to 20 mg / ml of said mixture of polynucleotides.

10. The composition when used according to claim 9, comprising from 5 mg / ml to 12 mg / ml 5 of hyaluronic acid and from 5 mg / ml to 12 mg / ml of said mixture of polynucleotides.

11. The composition when used according to claims 9 or 10, comprising the polynucleotides and the hyaluronic acid in a weight ratio of from 0.2:1 to 2:1.

12. The composition when used according to any one of claims 1 to 11, wherein said mixture of polynucleotides is a fraction of nucleic acid polymer chains having a molecular weight 10 distribution ranging from 30 kDaltons to 2,000 kDaltons, for example with an average molecular weight of approximately 250 kDaltons.

13. The composition when used according to any one of claims 1 to 12, wherein said mixture of polynucleotides is obtainable by extraction from a natural, animal or plant source, by a process comprising a step of partial fragmentation of the polynucleotide nucleic acid chains 15 and a step of partial depurination of the nucleic acid.

14. The composition when used according to any one of claims 1 to 13, wherein the hyaluronic acid is not cross-linked.

15. The composition when used according to any one of claims 1 to 14, comprising hyaluronic acid with a molecular weight of between 500 kDaltons and 3,000 kDaltons.20   16. The composition when used according to any one of claims 1 to 15 in the liquid form,free of physiological saline solution, in an aqueous solvent comprising a pharmaceutically acceptable polyol, preferably mannitol.

17. The composition when used according to claim 16, having an osmolarity between 10 m.o.s. / l and 500 m.o.s. / l, preferably between 250 m.o.s. / l and 350 m.o.s. / l.25   18. The composition when used according to any one of claims 1 to 17, in a dosage formsuitable for topical application or local infiltration.2020211076   22 Sep 202619. A method of therapeutic and / or cosmetic treatment for regeneration of the interdental papilla or in the therapeutic and / or cosmetic treatment of the recession of the interdental papilla (black triangle syndrome) or in the therapeutic and / or cosmetic treatment of periodontitis in a patient in need thereof, comprising administering to said patient a 5 therapeutically or cosmetically effective amount of a composition comprising hyaluronic acid and a mixture of polynucleotides extracted from a natural source, wherein said mixture of polynucleotides has a depurination ratio ranging from 1% to 5% purine bases removed out of the total purine bases originally present and it is a fraction of nucleic acid polymer chains having a molecular weight distribution ranging from 0.5 kDaltons to 3,000 kDaltons.10   20. A use of a composition comprising hyaluronic acid and a mixture of polynucleotidesextracted from a natural source, wherein said mixture of polynucleotides has a depurination ratio ranging from 1% to 5% purine bases removed out of the total purine bases originally present and it is a fraction of nucleic acid polymer chains having a molecular weight distribution ranging from 0.5 kDaltons to 3,000 kDaltons, in the manufacture of a15 medicament for the therapeutic and / or cosmetic treatment for regeneration of the interdental papilla or in the therapeutic and / or cosmetic treatment of the recession of the interdental papilla (black triangle syndrome) or in the therapeutic and / or cosmetic treatment of periodontitis in a patient in need thereof.

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