Miswak: Scientific oral health benefits and the potential of its application in preventive dentistry
Aim: The aim of this research was to examine scientific oral health benefits, disadvantages and future recommendations in fields of application of chewing stick (Miswak), by reviewing available literature.
Methods: Working data were collected by researching on available literature found on Google scholar’s database. Search was limited to publications in the English language. Keywords used, were: Miswak, oral health, natural toothbrush, miswak vs. Toothbrush, Salvadora Persica, etc.
*Additionally, three authentic religious scriptures, and a link from „eBay“ were used as a working data.
Miswak is a traditional chewing stick prepared from the roots, twigs, and stem of various trees and has been used as a natural method for tooth cleaning in many parts of the world for thousands of years.14 Miswak in Arabic language means “tooth cleaning stick”.1 Synonyms for it are; “misswak,” “miswaki,” “meswak,” “mswaki,” “sewak,” “siwak,” and “siwaki”. It represents a pencil-shaped stick of certain plants, 15-20 cm long with a diameter of 1-1.5 cm, which are chewed on one end till they are formed into a brush (Fig.1).1,20 Miswak is a popular oral hygiene aid used in Pakistan, India, and most of the Arabian countries, as well as certain African countries. It is mostly made of Arak (Salvadora Persica), a tree also known as “toothbrush tree”.(Fig.2)4,29
Fig.1. Pencil – shaped stick made out of Salvadora Persica tree 20
Fig.2. Salvadora persica – “toothbrush tree” 29
- Historical background of Miswak
Miswak was used by the Babylonians 7000 years ago followed by the Greek, Romans, Jews, Egyptians and Islamic empires.2 Its usage is also a pre-Islamic custom which ancient Arabs used in order to get their teeth white and shiny, as white and shiny teeth were associated with beauty and attractiveness.1,14 Japanese called it “Koyoji”, while the Romans used mastic to rub their teeth and as a toothpick.4
- Religious background of Miswak
Persistence of Miswak nowadays is mainly of a religious character and is mostly used in Muslim countries. Islam teaches the importance of cleanliness of the body, and basic oral hygiene is incorporated as a very significant religious practice. The Messenger of Allah, Muhammed (SAW), in several narrations in authentic religious scriptures emphasizes the importance of miswak.
- “Miswak cleanses the mouth and pleases the Lord” 8,
- “ Were it not for the fact that I did not want to make things too hard for my ummah* (the whole community of Muslims bound together by ties of religion), I would have commanded them to use the miswak at every time of prayer” 8,9
- Were it not for the fact that I did not want to make things too hard for my ummah* (the whole community of Muslims bound together by ties of religion), I would have commanded them to use the miswak at every time of making wudoo* (ritual washing to be performed in preparation for prayer and worship)” 8,9
- Aa’ishah, the wife of the Prophet (SAW) said: When he entered his house, the first thing he would do was to use the miswak” 9
- Hudayfahibn al-Yamaan, reported that when the Prophet (SAW) got up during the night, he would clean his mouth thoroughly with the miswak” 10
- Chemical composition of Miswak (SalvadoraPersica)
The beneficial effects of Miswak in respect of oral hygiene and dental health are partly due to its mechanical action and partly due to pharmacological actions.1 Al-Lafi and Ababneh in 1995 reported that the use of miswak inhibits the formation of dental plaque chemically and also exerts antimicrobial effect against many microorganisms.4 Many researchers have studied constituents of miswak and found it to contain more than ten different natural chemical compounds considered essential for good oral and dental hygiene. They are, silica, tannic acid, resins, alkaloids (salvadorine), volatile oils (simgrins), sulfur, vitamin C, sodium bicarbonate, chlorides, calcium, benzylisothoicyanate.4 A study by Chawlareported that some types of chewing sticks such as Neem (Azadirachtaindica), Salvadorapersica and Acacc/aarabica contain a reasonable amount of fluoride.7
- The Effects of Different Components
- The fresh sap released during the chewing of the stick has anticariogenic effect and it acts like a topical fluoride whose effectiveness depends on its ability to wet the tooth enamel and reach caries susceptible sites.1
- Salvadora persica Miswak contains nearly 1.0 μg/g of total fluoride and was found to release significant amounts of calcium and phosphorus.4
- Silica removes stains due its abrasive nature thus promoting whiteness of the teeth.1
- Tannins (Tannic acid) acts as an astringent that precipitates albumin and it shows anti-tumor effects on animals in vitro.1 They reduce plaque and gingivitis by inhibiting the action of glucosyltransferase.It also acts antimycotic when applied to base of the denture, showing a decrease in Candida Albicans colonies.1
- Resins are hard, transparent, complex mixtures of resin acids, resin alcohols, phenols, esters and chemically inert compounds, which form a layer over the enamel and protect it from caries.1,2,3,4
- Alkaloids are nitrogenous organic compounds. The alkaloid present in Salvadora persica is Salvadorine which has a bactericidal effect and stimulatory action on the gingiva.(1)
- Characteristic aroma and mildly bitter taste comes from essential (volatile) oils, which stimulate the flow of saliva.1,2,3,4
- High Sulfur compounds (4.73%) in Miswak have bactericidal effects.1,4
- Vitamin C assists in repairing and healing of the tissues.1,2,3,4
- Sodium bicarbonate (baking soda) NaHCOB works as a dentifrice due to its mild abrasive properties, while having a mild germicidal action.1,2,4
- High concentration of chloride helps in removing stains from the teeth by inhibiting calculus formation.1,2,3,4
- Calcium saturation promotes remineralization of tooth enamel.1,2,3,4
- Benzylisothiocyanate (BIT) is a chemo-preventive agent which prevents carcinogenic and other genotoxic compounds from reaching or reacting with the target sites on the treated tissue.1 Al Dosari et al studied the effect of BIT on epithelial changes induced by trauma and Dimethylbenzanthracin (DMBA) in the hamster tongue. Results showed that BIT reduced the development of neoplastic changes.1 Al-Bagieh et al reported that BIT inhibits the growth and acid production of streptococcus mutans. It was also reported that BIT, at a concentration of 133.3 μg/m,l has a virucidal activity against HSV-1.1 BIT also exhibited rapid and strong bactericidal effect against oral pathogens involved in periodontal disease as well as against other Gram-negative bacteria.1,4
- Concentrated liquor (Decoction) of S. persica has been used by alternative medical practitioners for the treatment of spleenomegaly, rheumatism, tumors, and renal stones in humans. It was also shown to possess hypoglycemic effects and an incremented oral-glucose tolerance in normal rats and to enhance plasma immunoreactive insulin level.1,9
- Extracts from the root and stems of Salvadore Persica were successfully used in treatment of oral infections in humans.1,9
- Almas, 2001; Lafi and Ababneh, 1995, showed the ability of aqueous and ethanol extracts of S. Persicain removing the smear layer from dentin surfaces and occlude dentine tubules.1,9
- Pharmacological properties
- Antimicrobial properties
The oral cavity harbors a diverse and abundant number of complex oral pathogens causing different oral diseases. The development of dental caries and periodontal diseases has been found to be closely associated with various gram positive and gram negative microrganisms.17 Studies have shown that S. Persica contains substances which possess plaque inhibiting and antibacterial properties against several types of frequently found cariogenic bacteria in oral cavity.1,4
Almas in (1999) showed that S. Persica extracts had antimicrobial effects on Streptoccusmutans and E. feacalis, potentially due to interaction with bacteria which prevents their attachment to the tooth surface.4 AlLafi and Ababneh (1995) demonstrated strong antimicrobial effects of S. Persica, on the growth of Streptoccus sp. and Staphylococcus aureus.13 In according to its high sulfate content, Al Baqieh et al. (1994) showed that the aqueous extract of S. Persica had an inhibitory effect on the growth of Candida albicans.4 Darout et al. (2000; 2002) had identified several anionic antimicrobial components which had potent promoter effects on salivary peroxidase thiocyonate and hydrogen peroxidase antimicrobial systems. In randomized study of 15 Saudi Arabian volunteers, Al-Otaibi et al. (2004) showed that the level of A. Actynomicetemcomitans in subgingival plaque was significantly more reduced by using miswak than toothbrush.16 Pourselami et al. (2007) based on their remarkable antimicrobial effects experimental results, recommended the use of S. Persica extract in mouthrinses and toothpastes.1 Sofrata et al. (2008) showed strong antibacterial effects against oral microorganisms associated with periodontitis and dental caries.1 Farooqi and Srivastava (1968) showed the BIT component of S. Persica as a bacterial growth inhibitor.20 Al-Bayati and Sulaiman (2008) showed the antimicrobial activity of aqueous and methanol extracts of S. Persica against seven isolated oral pathogens (S.aureus, Streptococcus mutans, Streptococcus pyogenes, E. faecalis, Lactobacillus acidophilus, Pseudomonas aeruginosa, and Candida albicans).1
- Release of calcium and chloride – Gazi et al reported that Miswak produced significant changes on the composition of mixed saliva by increasing levels of calcium and chloride.1
- Analgesic effect – Mansour et al. found that decotion of Miswak had analgesic effect against thermal stimuli when injected to mice. Ra’ed I. Al Sadhan et al. have stated that if analgesic effect of Miswak gets confirmed in clinical dental pain, usage of Miswak would be of practical value.1
- Other pharmacological properties – Beside the astringent and detergent effect, it has been reported that Miswak possess anti-inflammatory and hypoglycemic activities.1,2,
- Effects on dental plaque, gingival health and periodontal status
Gazi et. al reported significantly reduced dental plaque and gingivitis when Miswak was used five times a day comparing to commercial toothbrush.4 Another study suggested that the frequent use of the Miswak was associated with a reduced need for periodontal care among Saudi Arabian adults.1 Danielson et al. proved a reduction of plaque on frontal teeth and recommended Miswak as a tool for oral hygiene.1 Danielseh et al (1989) in a study conducted among of two groups of students in Kenya reported that no additional method was required to remove dental plaque in the group that used toothpaste in combination with chewing sticks.21 In a randomized crossover study among 15 Saudi Arabian male volunteers, Al-Otaibi et al. (2003) found that miswak use significantly reduced plaque and gingival indices and was more effective than toothbrushing when preceded by professional instruction regarding its correct application.4 Rinsing with a slurry of toothpaste containing S. Persica Miswak has been shown to reduce gingival inflammation and bleeding on probing.4 Elwin-Lewis et al (1980) found low levels of tooth loss in adults in countries where Miswak is widely used.3 Low periodontal treatment needs among Saudi Arabian adults who used Miswak was reported by Al-Khateeb et al (1991) and Guille (1992). Darout IA et al. conducted a study on 213 males, aged 20 to 65 years, to evaluate the periodontal status of miswak and toothbrush users. They reported that periodontal status of miswak users in Sudanese population is better than that of toothbrush.19
- Anticariogenic effects and comparative oral health status of Miswak and Toothbrush users
Bristle toothbrush, which is the most common and widely used aid for oral hygiene, was first time patented in America in 1887 and has since then undergone little change.2 The American Dental Association has described the range of dimensions of acceptable brushes: a brushing surface 1 to 1.25 inches (25.4 to 31.8mm long) and 5/10 to 3/8 inch (7.9 to 9.8 mm) wide, 2 to 4 rows of bristles, and 5 to 12 tufts per row.2 The diameter of commonly used bristles ranges from 0.0071 inches (0.2 mm) for soft brushes to 0.012 inches (0.3 mm) for medium brushes and 0.014 inches (0.4 mm) for hard brushes.2 These tooth brushes are usually used with dentifrices which aid in cleaning and polishing the tooth surfaces.2
Most of the studies discussing the efficacy of miswak and modern tooth brush have shown a superior or comparable effect of miswak over the use of tooth brushes.1,2,3,4
Many epidemiological studies revealed that S. persica miswak had strong anti-decay effects.4 Emslie (1966) conducted a survey in Sudan in which he reported a lower caries prevalence among miswak users than among tootbrush users.1 Baghdady and Ghose, (1979); Sathananthan et al., (1996) ; Younes and El-Angbawi, (1982) found lower caries incidence among school children using Miswak.23 Elvin – Lewis et al (1980); Olsson (1978) Despite the carbohydrate – rich diet traditionally consumed in Ghana, they proved that Miswak reduced dental caries more effectively than commercial tootbrushes.1 Decreased rate of caries and Miswak users in comparison to non-users was reported in a cross-sectional pilot study among adults in West Africa (Norton and Addy, 1989).4,24 Hattab (1997) showed that chewing effects and pungent taste of Miswak increased saliva secretion and thereby increased its buffering capacity.25 Sofrata et al (2007) in an in vivo study, showed that rinsing with S. Persica extract raised the plaques pH by stimulating parotid gland secretion, therefore directly contributing in prevention of dental caries.1,2,3,4 Petersen and Mzee (1998) found that the caries prevalence rate, in Zanzibar, was significantly lower in rural areas, where Miswak was used, than in urban areas.26 Darmani et al (2006) found that the aqueous extract of Miswak was able to significantly inhibit the growth of cariogenic bacteria.27 Carl and Zambon (1993) reported that dental caries was relatively rare among Kenyan primary school children who were using only miswak as an oral hygiene tool.28
- Disadvantages of Miswak
Although S. persica miswak is considered to be an essential aid in maintaining oral hygiene, certain disadvantages are associated with its use.4 Its bristles lie in the long axis of the stick, whereas those of a toothbrush are placed perpendicular to the handle. Thus, it is difficult to reach the lingual surfaces of the dentition with a miswak.4 Hollist (1981) and Khoory (1983) reported another disadvantage related to habitual use of Miswak for a prolonged period.1,4 They showed that chewing sticks users may excessively scrub the anterior teeth, which are located in the area of primary concern, while ignoring the posterior teeth.1,4 In Tanzania a relatively high prevalence of gingival recession has been reported among adults using miswak, however the severity of the recession was significantly more pronounced in the miswak users than in the toothbrush users.3 These disadvantages may be overcome with a dentist’s provision of precise instructions on the acceptable methods and duration of miswak use.
- Current therapeutic applications of Miswak
- Toothpaste – Some of the known commercial toothpaste produced from Salvadorapersica plant are: Sarkan toothpaste®, UK, Quali-Meswak tooth- paste®, Switzerland, Epident toothpaste®, Egypt, SiwakF®toothpaste, Indonesia. Fluoroswak,®Miswak,® Pakistan. DentacareMiswak Plus,® Saudi Arabia.1
- Mouthwashes – Mostafa et al found a reduction in plaque formation by Miswak-based mouthwash. But no such preparation presently exists in the market.1
- Endodontic irrigation solution – Abo Al Samh, et al evaluated, in vitro, the effect of different concentrations of Miswak extract on L929 cell-line in tissue culture and compared the results with sodium hypochlorite (NaOCI). They found a concentration-dependent morphological change of L929 cell-line when exposed to Miswak extract and NaOCI. They suspect recovery of the cells after a 4-hour exposure period to different Miswak extract concentrations.1
- Recommendations for application in preventive dentistry
Based on all of the above mentioned, evidentially scientifically proven facts, regarding the oral health benefits of the Miswak, most authors, and myself, recommend that it should be more frequent, and globally used in preventive dentistry. Not only that Miswak contains an incredible amount of significantly useful compounds in its composition, but it also shows very little or no disadvantages, if used properly and with the right technique. Strong evidence from the available descriptive and experimental studies support the view that Salvadora persica (Miswak) can be a potent oral hygiene tool, not only due to its excellent mechanical plaque-removing efficiency but for its broad range of biological properties. Not to mention that is very economic,(a Miswak stick can be purchased in under 0.5$), convenient and practical in every day, and everyplace use. It does not need expertise or any extra resources to manufacture it. World Health Organization has recommended and encouraged the use of these sticks as a tool for oral hygiene in areas where their use is effective and customary.31 This recommendation is also consistent with the principles of the Primary Health Care Approach that focus on prevention, community participation, and the use of appropriate technology.31 Chewing sticks may play a role in the promotion of oral hygiene, and further evaluation of their effectiveness is warranted, as stated in the World Health Organization (WHO) Consensus Report on Oral Hygiene.1 To obtain optimum oral health and hygiene, miswak (Salvadora persica) can be used alone or as an adjunct to a traditional toothbrush.31 Hence, miswak use should be encouraged and promoted based on scientific knowledge of its numerous therapeutic effects on oral health, easy availability, popularity, and low cost. However, achieving the optimum effects of miswak (Salvadora persica) depends on its regular use with proper, and effective techniques.31
- How to use Miswak
Miswak is available in various diameters and lengths and can be further adjusted and modified by cutting it into suitable lengths by the user.1 Recommended length for the convenience of grip and ease of manipulation in a confined space is 20 cm for adults and 15 cm for children, with a diameter of about 1cm.1,41 An excessively long stick may result in a traumatic injury, from the intra-oral end. This usually happens as a result of carrying out oral hygiene whilst operating other domestic duties, therefore not paying enough attention to technique of brushing.1
Chewing stick should be freshly cut so that it is supple, easily chewed, and still rich in active constituents.1 The color of the root should be whitish-brown, while a dark brown color indicates that the Miswak is no longer fresh.4 It is important to make sure that the Miswak is not very dry, which can lead to damaging of the gums and other oral tissues.1,4,3 If a stick is dry, the end for chewing should initially be soaked in fresh water for 24 hours. It should be noted that soaking for unduly long periods causes loss of active constituents and diminishes the therapeutic properties, although the mechanical effects on the teeth can still be expected to occur.1 The end of a chewing stick should be washed with water prior to its usage. It is the chewed repeatedly until the fibers become soft and stand out like the bristles of a toothbrush.1 These fibers should be clipped every 24 hours and should be kept in a moist place when not in use.1
The techniques employed for removing plaque mechanically are similar with the toothbrush and the chewing stick, e.g., vertical and horizontal brushing. However, these techniques are less important than people’s attitudes, knowledge and manual dexterity.1
There are two basic holds, Pen-grip (three finger grip) or palm-grip (five finger grip). In each case the aim is to ensure:
a) Firm but controlled movement of the brush end of the Miswak within the oral cavity.
b) That every area of the mouth is reached with relative ease and convenience.1
The cleaning movement should always be directed away from the gingival margin of the teeth on both the buccal and lingual surfaces. An anterior to posterior scrubbing movement is used on the occlusal surfaces. Care should be taken to avoid damaging the soft tissues of the mouth.1
The tongue is commonly cleaned by users of chewing sticks, the objective being to control bad breath and remove white coating that develops on the dorsum of the tongue. This surface is usually cleaned by means of the brush end of the chewing stick, but better results are obtained by breaking the stick into a V-shape and scraping the resulting blade several times across the tongue.1
- When to use Miswak
Ideally, Miswak should be used before meals to remove the bacteria that convert sugar into acid, or immediately after meals.1 However, the latter is impractical, since the fall in pH and the associated damage occur within a few minutes, and 20 minutes later the saliva performs the buffering action itself. In general, it is recommended to use Miswak five times a day.1
The use of the Miswak alone can be satisfying if enough time is devoted to its application during the period it is kept in the mouth. A common fault is the habit of keeping it in the mouth while domestic duties are carried on, with the complete neglect of the stick.1 A definite time should be set aside for the use of the chewing stick; five minutes of complete devotion to this function is deemed sufficient to ensure good cleansing. The resulting smooth feel of the teeth with the tongue gives a critical measure of the efficiency and effectiveness of the chewing stick.1
This present review clearly highlights the many beneficial effects of Salvadora persica (Miswak) on oral disease prevention and health promotion. The majority of authors have concluded a superior, or at least comparable effect of Miswak over the use of toothbrushes, thus recommending it as a future indispensable oral hygiene tool.
- Miswak (chewing Stick): A Cultural And Scientific Heritage – Ra’ed I. Al Sadhan, BDS , Khalid Almas, BDS, MSC, DDPH.RCS, FRACDS, FDS RCSED, FICD College of Dentistry, King Saud University,P.O. Box 60169, Riyadh 11545, K.S.A. Saudi Dental Journal 1999/Volume 11 Number 2; 80-88
- Miswak: A Periodontist’s Perspective – ParveenDahiyam, Reet Kamal, R.P. Luthra, Rahuh Mishra and GuaravSaini. Journal of Ayuverda and Integrative Medicine – Oct-Dec 2012
- Miswak in oral cavity – An update – AkhilanandChaurasia, RanjitPatil and Amit Nagar. Journal of Oral Biology and Craniofacial Research – May –Aug 2013
- A review on Miswak (Salvadorapersica) and its effect on various aspects of oral health – Hassan SulimanHalawany, Department of Periodontics and Community dentistry, Dental Caries Research Chair, College of Kind Saud Universitiy, Saudi Arabia – The Saudi Dental Journal, Volume 24, Issue 2, April 2012, Pages 63-69
- Microbiology of Dental Decay and Periodontal Disease – Walter J. Loesche, Medical Microbiology, 4th edition.
- Case Report – The Use of Miswak as Toothbrush for Orthodontic Patient – Khoirulzariah Ismail, Case reports in Dentistry – Craniofacial and Biomaterial Sciences Cluster, Advanced Medical and Dental Institute, UniversitiSains Malaysia, Bertam, 13200 Kepala Batas, Pulau Pinang, Malaysia
- Study of the Effects of Natural Toothbrush (Salvadorapersica) in Prevention of Dental Caries and Plaque index.FatemehEzoddini-Ardakani et al. Scientific Research, Health, Vol.4 No.9
- The Natural Toothbrush “Miswak” and The Oral Health – Ismail A Darout, International Journal of Life Sciences Biotechnology and Pharma Research 2014
- Saheeh Al – Bukhari 2/274, 2/299, 1/98*
- Saheeh Muslim 1/151, 1/220*
- Saheeh Ahmad 6/47*
- The effect of the extract of the miswak (chewing sticks) used in Jordan and the Middle East on oral bacteria – Al Lafi T
- A review of the therapeutic effects of using miswak ( Salvadora Persica) on Oral Health – Mohammad M. Haque – Saudi Medical Journal
- The Immediate Antimicrobial Effect of a Toothbrush and Miswak on Cariogenic Bacteria : A Clinical Study – K. Almas et al, J Contemp Dent Pract 5 (1)
- Subgingival Plaque microbiota in Saudi Arabians after use of Miswak chewing stick and tootbrush – Al – Otaibi M, Al-harthy M, Gustafsson A, Johansson A, Claesson R, Angmar-Mansson B.
- Efficacy of Miswak on Oral Pathogens – Adnan Sukkarwalla, SalimaMehboob Ali, PraneeLunberg and FarzeenTanwir – Dental Research Journal
- Effectivness of Salvadorapersica extracts against common oral pathogens – HananBalto, Ibrahim Al-Sanie, Sultan Al-Beshri and Abdullah Aldrees.
- Periodontal treatment needs among Saudi Arabian adults and their relationship to the use of the Miswak – Al Khateeb, O’Mullane DM, Whelton H., Sulaiman MI.
- The Tooth – Brush tree (Salvadorapersica) – I.H. Farooqi and J.G. Srivastava
- Chewing sticks, toothpaste, and plaque removal – Bo Danielsen, VibekeBaelum, FirozeManji and Ole Fejerskov
- Significance of chewing-sticks (Miswaks) in oral hygiene from a pharmacological view-point – Muhammad Ajmal (Dept. of Microbiology, University of Agriculture, Faisalabad)
- Comparison of the severity of caries attack in permanent first molars in Iraqi and Sudanese schoolchildren – Baghdady VS, Ghose LJ.
- Chewing sticks versus toothbrushes in West Africa, a pilot study – Norton MR, Addy M.
- Meswak: The natural toothbrush – Hattab FN
- Oral Health profile of schoolchildren, mothers, and schoolteachers in Zanzibar – Petersen Poul Erik; Mzee, M.O.
- Effects of extracts of Miswak and derum on proliferation of Balb/C 3T3 fibroblasts and viability of cariogenic bacteria
- Dental health of the Rendille and Samburu of the northern frontier district of Kenya – Carl W, Zambon JJ.
- SalvadoraPersica – M Khatak, S Khatak, A.A. Siddiqui, N. Nasudeva, A. Aggarwal and P. Aggarwal
- Significance of chewing sticks (Miswak) in oral hygiene from a pharmacological viewpoint. J. Pak. Med.Assoc. 1981; 4:89-95.11 Chawla HS. A new natural source for topical fluoride. J Indian Dent Assoc 1983;55:419-422.
- A review of the therapeutic effects of using miswak (Salvadora Persica) on oral health – Mohammad M. Haque BDS, MPH, and Saeed A. Alsareii, Saudi Medical Journal