Abstract:
Disclosed is a mouthwash composition, and a related use and method, for the treatment or prevention of bacterial and fungal infection in the oral cavity, the mouthwash composition comprising an effective amount of metronidazole and nystatin, together with an orally-acceptable carrier.

Description:
FIELD OF THE INVENTION  
         [0001]    This invention relates to a mouthwash composition and method for treating or preventing bacterial and fungal infection in the oral cavity, which causes conditions such as bad breath, also referred to as halitosis or oral malodour, periodontal disease and gingival inflammation or bleeding.  
         BACKGROUND OF THE INVENTION  
         [0002]    Oral malodour (halitosis), or as it is commonly known, bad breath, is a condition that affects between 40% and 50% of the population. It is widely accepted that most individuals afflicted with oral malodour also experience psychosocial problems related to this condition. In addition to breath odour, individuals may have an unpleasant taste, described as bitter, dry, stale, fecal, metallic, hot or pasty, and they associate this taste with the presence of tainted breath, even when the mouth air has no detectable odour.  
           [0003]    It is generally believed that the cause of this condition is due to the presence of anaerobic bacteria, especially gram-negative anaerobic bacteria, within the oral cavity. These bacteria actively degrade the sulfur-containing amino acids, methionine and cysteine, to generate pungent compounds collectively known as volatile sulfur compounds (VSC). Hydrogen sulfide (H—S—H), methyl mercaptan (CH 3 —S—H) and dimethyl sulfide (CH 2 —S—CH 3 ) are the principal odorous components generated. These substances, especially methyl mercaptan, have an unpleasant odour, even in very low concentrations, and the exhalation of these volatile sulfur compounds is perceived as bad breath.  
           [0004]    It is also recognized that VSC can produce biologic effects such as altering the epithelial barrier within the oral cavity, resulting in bleeding and inflammation. For example, methyl mercaptan enables the penetration of bacterial toxins into the underlying connective tissue through the increased permeability of the oral mucosa. This volatile sulfur compound can alter enzymatic and immunologic activities, delay wound healing and influence gene activity through the alteration cell shape and cytoskelton pattern (Tonzetich,  Bad Breath, A Multidisciplinary Approach.  79-91, 1996).  
           [0005]    It has been established that systemic conditions, including liver and kidney abnormalities, diabetes, oral cancers, chronic sinusitis and tonsillitis, can also contribute to oral malodour. Periodontal diseases are a cluster of widespread inflammatory conditions that have an association with substantial VSC production. Oral microorganisms, predominantly gram negative anaerobic flora, contribute to the initiation and progression of periodontal diseases as well as substantial oral malodour.  
           [0006]    Various oral rinse preparations are known for treating halitosis. U.S. Pat. No. 4,525,342 (Weiss et al.; Jun. 25, 1985) discloses a composition comprising a salt water aqueous phase and an oily phase in a double compartment double squirt bottle that allows an emulsion to be generated in the mouth during rinsing. U.S. Pat. No. 5,401,496 (Fitzig et al.; Mar. 28, 1995) discloses a preparation comprising a synthetic oil of a caprylic/capric triglyceride mixture. U.S. Pat. No. 5,738,840 (Richter; Apr. 14, 1998) discloses an aqueous composition comprising molecular chlorine dioxide and a metal chlorite salt. U.S. Pat. No. 6,071,500 (Thistle; Jun. 6, 2000) discloses a breath cleansing spray that includes xylitol as a sweetener and calcium hydroxide to raise the pH of the saliva. U.S. Pat. No. 6,132,701 (Perez et al.; Oct. 17, 2000) discloses a method for reducing halitosis that includes generating an aqueous solution of calcium hydroxide for rinsing an oral cavity. In general, known anti-halitosis mouthwashes may not remove the often bitter or pasty taste that causes distress to the individual, suggesting that they leave microorganisms in numbers large enough to produce byproducts that continue to affect the taste perceptions of the individual.  
           [0007]    Metronidazole is used for the treatment of several types of anaerobic infections including periodontal disease. Short-term, systemic use of metronidazole administered orally in humans caused a sustained reduction of anaerobic gram-negative microorganisms, including  spirochetes, Bacteroides  sp.,  Fusobacterium  sp., and the anaerobic  cocci, Peptostreptococcus  sp., for weeks to months, with improved periodontal health ( J. Clin Periodontol.  8:29-44, 1981). Although it is well absorbed within 1 to 2 hours after ingestion, between 60 to 80% of the drug is excreted. U.S. Pat. No. 4,997,830 (van Winkelhoff et al.; Mar. 5, 1991) discloses a pharmaceutical composition comprising metronidazole and amoxicillin for the treatment of periodontitis.  
           [0008]    However, systemic use of metronidazole can have undesirable side effects such as nausea, headaches and gastrointestinal discomfort. U.S. Pat. No. 4,568,535 (Loesche; Feb. 4, 1986) discloses a slow release film for placement in the oral cavity in a periodontal pocket, the film including metronidazole. However, such a film requires a dental professional to fit it and may be uncomfortable.  
           [0009]    Microfungal infections of the oral cavity are a problem often associated with oral lesions and dryness. Many individuals who complain about bad breath and bad taste have substantial numbers of yeast organisms, in addition to the gram-negative anaerobic bacteria. Gingival bleeding is often also present in these individuals. The  Candida  species are aerobic yeasts that can also grow anaerobically.  C. albicans  is the species most often responsible for infections in the oral cavity and may cause a variety of disorders including gingival bleeding and denture stomatitis. Oral candidiasis is an extremely virulent and uncomfortable condition, especially prevalent in the aged and those with chronic debilitating ailments.  
           [0010]    The establishment of a mycotic infection in the oral cavity presents a serious health problem to the individual. Thus, it is desirable to treat and contain this infection through both mechanical methods such as proper oral cleansing as well as chemical therapy in the form of antifungal drugs. However, systemic administration of antimycotics, in doses high enough to control oral infections, can induce undesirable side effects.  
           [0011]    Nystatin is a polyene antifungal, antibiotic complex that is used for the treatment of fungal infections. Nystatin binds to the covering membrane of fungi altering the cell membrane thus leading to cell death. It is both fungicidal and fungistatic against a variety of yeasts and fungi. Nystatin is applied topically in most cases.  
           [0012]    Canadian Patent Application 2,008,772 (Friedman; published Jul. 31, 1990) discloses a sustained-release oral antifungal varnish, that includes nystatin in a sustained-release polymer, and states that mouth rinses that include antifungal drugs do not maintain the drugs at efficacious levels in the oral cavity. U.S. Pat. No. 4,725,440 (Ridgway et al.; Feb. 16, 1988) discloses an antifungal pastille formulation for treating oral candidiasis by a relatively slow release of the antimicrobial agent, including nystatin, and indicates that use of nystatin in an oral suspension is not considered an effective way to treat oral candidiasis. PCT publication WO 99/61491 (Kolias et al.; published Dec. 2, 1999) discloses an antimicrobial denture adhesive, for the treatment of denture stomatitis, that includes nystatin as the active ingredient.  
           [0013]    None of the above references relate to use of metronidazole and nystatin together in an oral rinse composition.  
         SUMMARY OF THE INVENTION  
         [0014]    It has not been appreciated until now that a mouthwash-based combination therapy comprising metronidazole and nystatin, as set out below, can alleviate oral conditions such as halitosis, periodontal disease and gingival inflammation or bleeding.  
           [0015]    Therefore, the present invention provides a mouthwash composition for the treatment or prevention of bacterial and fungal infection in the oral cavity, the mouthwash composition comprising an effective amount of metronidazole and nystatin, together with an orally-acceptable carrier, such as water.  
           [0016]    The present invention also provides a method for the treatment or prevention of bacterial and fungal infection in the oral cavity, the method comprising the step of rinsing an oral cavity with a composition comprising an effective amount of metronidazole and nystatin, together with an orally-acceptable carrier, such as water.  
           [0017]    The present invention also provides use of an effective amount of metronidazole and nystatin for the manufacture of a product for the treatment or prevention of bacterial and fungal infection in the oral cavity.  
           [0018]    The composition, use and/or method described herein can be used for the treatment or prevention of halitosis, a periodontal disease, or gingival inflammation or bleeding.  
           [0019]    Metronidazole, and hence the composition, use and/or method described herein, can be used to treat bacterial infections, such as those caused by a bacterial pathogen selected from the group consisting of obligate anaerobic gram-negative  bacilli  such as  Bacteroides  sp (e.g.  B. fragalis ),  Fusobacterium, Clostridium  sp and certain anaerobic protozoal parasites such as  Trichomonas, Giardia  and  Entamoeba . It also has bactericidal activity against the obligate anaerobic  cocci  isolated from infections in the oral cavity,  Peptococcus  sp and  Peptostreptococcus  sp. It is also effective in the treatment of mixed bacteria infections, that is a combination of anaerobes and aerobes.  
           [0020]    In the oral cavity, bacterial infection is typically caused by a bacterial pathogen selected from the group consisting of  Bacteroides  sp,  Fusobacterium  sp,  Spirochetes, Clostridium  sp,  Peptococcus  sp and  Peptostreptococcus  sp.  
           [0021]    Nystatin, and hence the composition, use and/or method described herein, can be used to treat fungal infections, including those caused by a  Candida  fungal pathogen, such as  Candida albicans  which can be found in oral cavity infections.  
           [0022]    The advantages provided by the present invention include ease of use of a mouth rinse, with none of the side effects found in systemic use of both metronidazole and nystatin, and none of the inconvenience of topical formulations. Also, metronidazole and nystatin appear to act in synergy to produce positive results in patients that had not found relief from halitosis using conventional treatments. Furthermore, the composition of the present invention removes sufficient anaerobes and yeasts that an individual no longer has a perception of a bad taste.  
           [0023]    The addition of the nystatin prevents the formation of yeast during the process of removing the anaerobes as well as eliminating yeast in those subjects where it is already present. It was observed that gingival and palatal tissue response is improved with the inclusion of nystatin in the composition, relative to metronidazole alone. Patients also reported a greater decrease in oral dryness with the inclusion of nystatin in the composition relative to metronidazole alone.  
           [0024]    Other aspects and advantages of embodiments of the invention will be readily apparent to a person of ordinarily skilled in the art upon review of the following description. 
       
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS  
       [0025]    The present invention relates to a vehicle that can effectively eliminate oral malodour and reduce the extent of periodontal diseases, especially the inflammatory process. The combination of metronidazole and nystatin in an aqueous suspension, when applied to the oral cavity for no less than 30 seconds several times a day, can decrease anaerobic bacteria and oral yeast within a two week period, with a noticeable difference in breath malodour and tissue status within in 24 to 48 hours.  
         [0026]    In the composition, use and/or method of the invention, nystatin is preferably present at a concentration of about 20,000 to about 600,000 I.U. per ml (based on 100,000 I.U. per gram, this equates to a range of about 200 to about 6000 mg per ml), and is typically present at a concentration of about 100,000 I.U. per ml. Metronidazole is preferably present at a concentration of about 5 to about 200 mg per ml, more preferably between about 20 to about 50 mg per ml. One embodiment is contemplated in which, when nystatin is present at 100,000 I.U. per gram, metronidazole is not present at 50 mg per ml. Another embodiment is contemplated in which, when metronidazole is present at 50 mg per ml, nystatin is not present at 100,000 I.U. per gram.  
         [0027]    Metronidazole (Apo-Metronidazole, Apotex Research Inc.) was prepared by grinding tablets into a powder form and water is added to make a paste. The paste was added to a suitable quantity of nystatin, which was obtained as an aqueous solution from Alimed or PMS PharmaScience (Nilstat™). Metronidazole does not dissolve in water but forms a paste that, when added to nystatin, forms a suspension. A typical 190 ml batch of oral rinse comprises 40 ml of metronidazole paste added to 150 ml nystatin solution. The mouth rinse has a slightly sticky consistency that provides effective contact with the tissues.  
         [0028]    The composition, use and/or method of the invention can also include additives such as a corticosteroid, for example hydrocortizone at about 0.5 to about 2% per ml, which acts to promote healing of oral tissues. Pain relief agents, such as lidocaine, can also be added. In addition, a self-sterilizing agent, a flavouring agent, a colouring agent, and the like, may optionally be included as appropriate.  
         [0029]    Preferably, a volume of about 3 to about 5 ml of the above formulation is used three times a day. If necessary, the volume and rinse frequency can be varied as appropriate. A treatment period of 14 days was found to be suitable, but this period can be varied as necessary.  
         [0030]    Procedures  
         [0031]    Oral hygiene procedures, including tongue cleaning, were generally performed prior to using a formulation, which was used by all adult subjects, the formulation comprising metronidazole at 50 mg per ml (25 mg per ml for children) and nystatin at 100,000 I.U. per ml.  
         [0032]    The mouth was cleared of debris and cleansing materials by rinsing well with water. A dose of about 3 to 5 ml of the metronidazole/nystatin suspension was taken 3 times a day for a period of 14 days. The suspension was swished and gargled in the mouth for a period of 30 seconds and then expectorated. There was no rinsing or eating for at least 30 minutes after the procedure, to let the medication take affect. Normal flossing was carried out after the morning and evening rinse. With more persistent cases of interproximal bleeding or odour, after a 14 day treatment course, floss was dipped into a capful of the above-noted formulation and wet flossing carried out and the results subsequently monitored.  
         [0033]    Clinical Results  
         [0034]    The following tables are clinical data showing the efficacy of the nystatin-metronidazole rinse. Fifty four subjects received treatment with this medication.  
         [0035]    Twelve of the subjects were treated with 0.2% chlorhexidine prior and evaluated for response prior to treatment with nystatin-metronidazole. These subjects used chlorhexidine twice a day rinsing for 60 seconds each time for a period of 14 days. Chlorhexidine was brushed into the tongue and carried into the gingival sulcus using an appropriate vehicle, such as floss, superfloss or proxabrush, soaked in the chlorhexidine. After the two weeks, subjects were evaluated for changes. These subjects still had some oral odours and in some cases had slightly more than the original measurements.  
         [0036]    Subjects were instructed to refrain from food, drink and oral hygiene for two hours prior to each appointment. All subjects were instructed to refrain from garlic, onions, alcohol, spices, mouthwashes, and scented cosmetics for at least 24 hours.  
         [0037]    The extent of the malodour for each subject has been established by taking volatile sulfur measurements in concentrations of parts per billion with a Halimeter™, a portable sulfur monitor adapted for oral use by Interscan Corporation, Chatsworth, Calif. It is relatively accurate instrument for the measurement of hydrogen sulfide but measures methyl mercaptan to about a 50% accuracy and dimethyl sulfide to an even lesser degree. When the predominant odour is methyl mercaptan, there is usually a low reading on the Halimeter when compared to the organoleptic rating.  
         [0038]    Organoleptic ratings of mouth air, nasal air, tongue base, tongue dorsum and floss were established by three trained, experienced judges. Two criteria, bleeding on probing and measurement of periodontal pockets, were used to determine the extent of gingival bleeding and periodontal status. A calibrated probe was used to assess the probing depth of a sulcus or periodontal pocket. The rod-shaped working end of the probe is marked in millimeter units and is similar to a ruler. The probe was inserted into the sulcus or pocket and the depth measured from the junction of the tooth and gum tissue (epithelial attachment) to the top of the gum or gingival margin. Healthy gums or gingiva have pockets that range from 0.5 to 3.0 mm in depth. A depth greater than 3.0 mm is called a periodontal pocket. To measure the depth of the sulcus or pocket, the probe was held lightly and the working end of the instrument placed against the enamel and gently inserted beneath the gum until there was a soft but resilient resistance. The probe was walked around the entire circumference of the tooth and measurements of 4 mm and greater were recorded. There are six areas at which measurements were taken, 3 on the surface next to the cheek and 3 on the surface next to the tongue. These evaluations were performed just before treatment and fourteen days after treatment for all subjects except where stated otherwise.  
         [0039]    Some subjects were evaluated 24 to 48 hours after taking the nystatin-metronidazole rinse because they travelled a significant distance (e.g. South America) and could not stay for the 14 day term. However, they were required to complete the nystatin-metronidazole rinse and report by telephone or email as to further progress.  
         [0040]    Tables 1A, 1B and 1C show the pretreatment and post-treatment levels of odours, periodontal involvement and microbiology of subjects who were treated with a commercially available aqueous 0.2% chlorhexidine solution (PerioWorks, Vernon, B C). Table 1D shows the measurements of these same subjects following treatment with the nystatin-metronidazole formulation detailed above.  
         [0041]    Tables 2A, 2B and 2C show the pretreatment and post-treatment levels of odours, periodontal involvement and microbiology of subjects immediately following measurements on the first appointment, and then following two weeks of treatment with the nystatin-metronidazole formulation detailed above.  
         [0042]    Abbreviations Used in Tables  
         [0043]    Org.m—organoleptic assessment of mouth air.  
         [0044]    Org.tb—organoleptic assessment of the base of the tongue.  
         [0045]    Org.td—organoleptic assessment of tongue dorsum.  
         [0046]    Org.f—organoleptic assessment of floss odours.  
         [0047]    nr—not recorded.  
         [0048]    spiro— Spirochetes    
         [0049]    fuso— Fusobacterium    
         [0050]    gr— bacilli —Gram negative  bacilli    
         [0051]    gr— cocci —Gram negative  cocci    
         [0052]    gr— coccobacilli —Gram negative  coccobacilli    
         [0053]    Organoleptic measurements use the scale 0-5, with the following meanings: 0— no odour; 1—slightly perceivable and fleeting odour; 2—mild but definite; 3—moderate; 4—strong; 5—very strong. The pocket depth (in mm) is stated, followed by the number of pockets in brackets.  
                                                                                                           TABLE 1A                           VSC and organoleptic assessments of individuals with       oral malodour prior to treatment with chlorhexidine.            Patient   Sex   Age   VSC   Org.m   Org.tb   Org.td   Org.f   Taste   Bleeding   Pockets (mm)                    AY2596   F   29   53   2   3   1   5   bitter   no   no       SB2400   M   29   62   3   3   0   2   dry   no   no       HE2046   M   57   51   4   5   4   5   none   no   no       KT2016   F   25   82   4   4   4   2   bad   no   6(3)       ZT2557   M   40   36   1   0   1   0   none   no   4(1)       JM2142   F   35   47   2   1   3   0   bitter   no   no       KN2036   M   39   41   4   nr   2   5   dry   no   no       CD2416   F   33   79   3   4   2   0   sour   no   no       EC2010   F   54   93   4   5   3   5   bad   no   4(1)       VC2399   M   37   134   3   3   2   2   none   yes   no       JA2021   F   47   45   3   4   3   2   none   no   4(1)       TB2425   M   18   39   3   2   0   0   manure   no   no                  
 
         [0054]    [0054]                                                                                           TABLE 1B                           Microbiology of the tongue and interproximal plaque of individuals       in Table 1A, assessed by a commercial laboratory prior to treatment       with 0.2% chlorhexidine.            Patient   Sex   Age   spiro   fuso   gr- bacilli     gr- cocci     gr- coccobacilli     yeast                    AY2596   F   29   yes   no   yes   yes   yes   no       SB2400   M   29   no   no   yes   yes   no   no       HE2046   M   57   yes   yes   yes   yes   no   no       KT2016   F   25   yes   no   yes   yes   no   yes       ZT2557   M   36   yes   no   yes   no   no   yes       JM2142   F   35   yes   yes   yes   yes   no   yes       KN2036   M   39   yes   yes   yes   yes   no   yes       CD2416   F   33   yes   no   yes   yes   no   no       EC2010   F   54   yes   yes   yes   yes   no   yes       VC2399   M   37   yes   no   yes   yes   yes   no       JA2021   F   47   yes   yes   yes   yes   no   yes       TB2425   M   18   no   no   yes   no   no   no                    
         [0055]    [0055]                                                                                                           TABLE 1C                           VSC and organoleptic assessments of individuals from Table 1A       post treatment with a 0.2% chlorhexidine rinse for two weeks.            Patient   Sex   Age   VSC   Org.m   Org.tb   Org.td   Org.f   Taste   Bleeding   Pockets (mm)                    AY2596   F   29   42   2   nr   2   0   bitter   no   no       SB2400   M   29   53   0   3   0   0   none   no   no       HE2046   M   57   26   4   nr   4   4   none   no   no       KT2016   F   25   37   0   0   2   2   nr   no   nr       JM2142   F   35   116   0   nr   2   0   nr   no   no       KN2036   M   39   43   0   nr   0   5   none   no   no       CD2416   F   33   112   3   3   2   0   nr   no   no       EC2010   F   54   149   3   nr   3   3   improved   no   nr       VC2399   M   37   50   2   3   2   0   none   no   no       JA2021   F   47   31   3   nr   1   3   none   no   nr       TB2425   M   18   89   3   nr   3   2   dry   no   no                    
         [0056]    [0056]                                                             TABLE 1D                           VSC and organoleptic assessments of individuals from       Table 1A post treatment with the nystatin-metronidazole       rinse following the two week 0.2% chlorhexidine rinsing.            Patient   Sex   Age   VSC   Org.m   Org.tb   Org td   Org.f   Taste   Bleeding   Pockets (mm)               AY2596   F   29   52   0   nr   0   0   none   no   no       SB2400   M   29   31   0   0   0   0   none   no   no       HE2046   M   57   34   0   nr   0   0   none   no   no       KT2016   F   25   30   0   0   0   0   none   no   nr       ZT2557   M   36   30   0   0   0   0   none   no   nr       JM2142   F   35   55   0   0   0   0   nr   no   no       KN2036   M   39   41   0   nr   0   0   none   no   no       CD2416   F   33   39       2 1     nr   0   0   none   no   no       EC2010   F   54   39   0   nr   0   0   none   no   nr       VC2399   M   37   36       2 1     nr   0   0   none   no   no       JA2021   F   47   27   0   0   0   0   none   no   nr       TB2425   M   18   44   0   0   0   0   none   no   no                            
         [0057]    [0057]                                                                                                           TABLE 2A                           VSC and organoleptic assessments of individuals with oral malodour,       prior to treatment with the nystatin-metronidazole formulation.            Patient   Sex   Age   VSC   Org.m   Org.tb   Orgtd   Org.f   Taste   Bleeding   Pockets (mm)                    CW2714   F   24   362   5   5   5   4   dry   no   no       FA2221   M   45   127   5   4   4   3   metallic   no   4       RN1464   F   52   59   5   4   4   0   nr   no   no       DM2413   M   44   61   3   3   3   0   bitter   no   4 (1)       MG2105   F   58   67   5   2   5   5   sour   no   no       GK2809   F   53   78   2   2   2   3   thick   yes   5 (6)       RL2646   M   35   212   4   4   4   2   metallic   no   no       SL2510   F   52   49   4   5   4   3   none   nr   nr       JP2600   M   24   64   5   5   5   2   acrid   yes   no       EP2799   M   50   198   3   4   3   2   none   no   no       AR2620   F   34   115   3   4   1   3   metallic   yes   4 (many)       GW2158   F   36   81   4   3   4   3   strong   no   no       GB2808   F   21   283   4   4   2   0   sour   yes   4 (6)       MC2648   M   35   65   5   5   3   2   metallic   no   5 (2)       LP2546   F   52   84   3   3   1   1   pasty   no   4 (2)       GK2712   F   68   394   4   5   5   5   bitter   yes   no       SB2679   F   33   70   4   4   1   4   foul   no   no       CG2304   F   54   135   3   4   3   5   foul   no   no       RJ2386   M   39   55   1   4   0   2   none   yes   4 (2)       CB2564   F   36   308   5   5   2   2   bitter   no   no       MH2009   M   8   55   3   3   2   0   none   no   no       NG2411   M   50   142   4   5   3   2   acid   no   5 (3), 7 (1)       HT2384   M   81   38   3   4   1   5   bad   yes   4 (3), 5 (3)       PB2914   M   36   60   1   3   1   1   dry   yes   4 (4)       RK2950   F   51   56   2   3   1   2   stale   yes   4 (2), 5 (4)       BB2747   F   43   62   4   nr   0   5   burning   yes   5 (4), 4 (2)       FB2429   F   41   144   4   4   3   5   stale   yes   no       MA2826   F   55   30   0   3   0   3   metallic   yes   5 (2), 4 (1)       PE2195   M   62   129   4   3   3   0   none   no   5 (1)       SDR2579   M   45   568   5   5   3   4   acid   no   no       EE2314   F   50   210   5   4   4   5   metallic   yes   many       CF2689   M   39   900   5   5   5   3   none   yes   many       MS2784   F   27   208   4   5   4   0   bitter   yes   4 (2)       PS2762   M   31   101   4   4   3   2   none   yes   4 (6), 5 (4)       DL2390   F   25   66   0   4   3   2   metallic   no   4 (8)       SN2835   F   27   08   4   5   3   2   metallic   yes   no       LM2862   F   26   139   3   4   3   0   bitter   yes   no       RM2452   M   44   85   4   2   3   1   metallic   yes   5 (2)       MF2665   M   44   75   4   4   2   3   metallic   no   no       BF2812   M   32   145   3   4   3   0   sulfuric   yes   5 (4), 4 (2)       JF2887   M   41   243   4   3   3   0   none   no   4 (3)       MG2890   M   38   260   4   4   3   3   tinny   yes   no       EG2701   M   26   220   3   4   2   2   sulfuric   no   no       LG2367   F   26   86   4   4   4   3   stale   yes   5 (2)       AG2558   F   46   66   3   3   1   5   none   yes   no       MG2793   F   34   152   3   4   3   3   bitter   yes   no       MG2709   F   25   198   5   4   5   5   stale   yes   4 (1), 5 (5)       AG2338   M   40   223   5   5   4   5   bitter   no   4 (2), 5 (2)       MH2361   M   43   82   5   5   5   3   stale   no   4 (3)       SM2954   M   27   110   3   3   3   3   dry   yes   no       GL2952   F   3781   3   3   3   3   2   bitter   no   no                    
         [0058]    [0058]                                                                                           TABLE 2B                           VSC and organoleptic assessments of individuals with oral malodour       prior to treatment with the nystatin-metronidazole formulation.            Patient   Sex   Age   Spiro   fuso   gr- bacilli   gr- cocci   gr- coccobacilli   yeast                    CW2714   F   24   no   no   yes   no   no   no       FA2221   M   45   yes   yes   yes   yes   yes   yes       RN1464   F   52   yes   yes   yes   yes   no   yes       DM2413   M   44   no   no   yes   yes   no   no       MG2105   F   58   yes   yes   yes   yes   no   yes       GK2809   F   53   yes   yes   yes   no   no   no       RL2646   M   35   yes   yes   yes   yes   no   yes       SL2510   F   52   yes   no   yes   yes   no   yes       JP2600   M   24   no   no   yes   yes   no   yes       EP2799   M   50   yes   yes   yes   no   no   no       AR2620   F   34   yes   no   yes   yes   no   no       GW2158   F   36   yes   yes   yes   yes   no   yes       GB2808   F   21   no   yes   yes   no   yes   no       MC2648   M   35   yes   no   yes   yes   no   yes       LP2546   F   52   no   no   yes   yes   no   yes       GK2712   F   68   yes   no   yes   yes   yes   no       SB2679   F   33   yes   no   yes   yes   no   no       CG2304   F   54   yes   no   yes   yes   no   no       RJ2386   M   39   yes   no   yes   yes   no   no       CB2564   F   36   no   no   yes   yes   no   no       MH2009   M   8   no   no   yes   no   yes   no       NG2411   M   50   yes   no   yes   yes   no   no       HT2384   M   81   yes   no   yes   yes   no   no       PB2914   M   36   no   yes   yes   no   yes   yes       RK2950   F   51   no   yes   yes   no   yes   no       BB2747   F   43   yes   no   yes   yes   no   no       FB2429   F   41   yes   no   yes   yes   no   no       MA2826   F   55   yes   yes   yes   no   no   no       PE2195   M   62   yes   yes   yes   yes   no   yes       SDR2579   M   45   yes   no   yes   yes   no   yes       EE2314   F   50   yes   yes   yes   yes   yes   yes       CF2689   M   39   yes   no   yes   yes   no   no       MS2784   F   27   no   yes   yes   no   no   no       PS2762   M   31   no   no   yes   yes   no   no       DL2390   F   25   no   no   yes   yes   yes   no       SN2835   F   27   yes   yes   yes   no   no   no       LM2862   F   26   yes   yes   yes   no   no   no       RM2452   M   44   yes   no   yes   no   yes   no       MF2665   M   44   yes   no   yes   yes   no   yes       BF2812   M   32   no   yes   yes   no   no   no       JF2887   M   41   yes   yes   yes   no   no   no       MG2890   M   38   no   yes   yes   no   no   no       EG2701   M   26   yes   no   yes   no   no   no       LG2367   F   26   yes   yes   yes   yes   no   no       AG2558   F   46   no   no   yes   yes   no   yes       MG2793   F   34   yes   yes   yes   no   no   yes       MG2709   F   25   yes   no   yes   yes   no   no       AG2338   M   40   yes   no   yes   no   no   no       MH2361   M   43   yes   no   yes   no   no   no       SM2954   M   27   yes   yes   yes   no   no   no       GL2952   F   37   no   yes   yes   no   yes   no                    
         [0059]    [0059]                                                                                                           TABLE 2C                           VSC and organoleptic assessments of individuals from Table 2A       post treatment with the nystatin-metronidazole formulation.            Patient   Sex   Age   VSC   Org.m   Org.tb   Org td   Org.f   Taste   Bleeding   Pockets (mm)                    CW2714   F   24   28   0   0   0   0   none   no   no       FA2221   M   45   37   0   0   0   0   none   no   no       RN1464   F   52   40   0   0   0   0   none   no   no       DM2413   M   44   30   0   nr   0   0   none   no   no       MG2105   F   58   34   0   nr   0   0   none   no   no       GK2809   F   53   19   0   0   0   0   none   improved   nr       RL2646   M   35   50   0   0   1   0   none   no   no       SL2510   F   52   13   0   0   0   4   none   improved   nr       JP2600   M   24   43   0   0   0   0   none   no   no       EP2799   M   50   28   0   3   0   0   none   no   no       AR2620   F   34   38   0   0   0   0   none   improved   improved       GW2158   F   36   42   0   0   0   0   none   no   no       GB2808   F   21   22   0   1   0   1   none   improved   improved       MC2648   M   35   55   0   0   0   0   none   no   nr       LP2546   F   52   42   0   0   0   0   none   no   nr       GK2712   F   68   20   0   1   0   3   none   improved   no       SB2679   F   33   45   0   0   0   2   none   no   no       CG2304   F   54   12   0   0   0   0   none   no   no       RJ2386   M   39   34   0   0   0   0   yes   improved   improved       CB2564   F   36   35   0   0   0   0   none   no   no       MH2009   M   8   25   1   1   0   0   none   no   no       NG2411 1     M   50   41   0   0   0   4   none   improved   nr       HT2384   M   81   38   0   0   0   4   none   improved   improved       PB2914   M   36   50   0   1   1   0   dry   no   4 (2)       RK2950   F   51   10   0   0   0   0   none   improved   nr       BB2747   F   43   24   0   0   0   0   none   improved   nr       FB2429   F   41   28   0   nr   0   2   none   improved   no       MA2826   F   55   26   0   nr   0   0   none   improved   nr       PE2195   M   62   32   0   nr   0   0   none   no   improved       SDR2579   M   45   41   0   0   0   0   none   no   no       EE2314   F   50   19   0   0   0   2   none   no   improved       CF2689   M   39   14   0   nr   0   0   none   improved   nr       MS2784   F   27   21   0   nr   0   0   none   improved   nr       PS2762   M   31   21   0   nr   0   0   none   no   nr       DL2390   F   25   41   0   0   0   0   none   no   improved       SN2835   F   27   30   0   0   0   0   none   improved   no       LM2862   F   26   16   0   1   0   0   none   improved   no       RM2452   M   44   37   1   1   0   0   none   improved   nr       MF2665   M   44   45   1   1   0   0   none   no   no       BF2812   M   32   28   0   nr   0   2   none   improved   nr       JF2887   M   41   16   0   1   0   0   none   no   improved       MG2890   M   38   36   0   0   0   1   none   no   no       EG2701   M   26   34   0   0   0   0   none   no   no       LG2367   F   26   42   1   1   0   0   none   no   nr       AG2558   F   46   46   0   1   0   0   none   no   no       MG2793   F   34   32   0   0   0   0   none   improved   no       MG2709   F   25   20   0   1   0   5   none   improved   improved       AG2338   M   40   28   0   0   0   0   none   no   nr       MH2361   M   43   28   0   0   0   0   none   no   improved       SM2954   M   27   21   0   0   0   0   none   no   no       GL2952   F   37   14   1   0   0   0   none   no   no                            
         [0060]    Many modifications and variations are possible and would be apparent to a person skilled in the art in light of the above teachings. It is therefore to be understood that the invention can be practiced otherwise than as specifically described herein and still will be within the spirit and scope of the appended claims.