j indian soc periodontol

7/24/2019 J Indian Soc Periodontol

1/8

J Indian Soc Periodontol. 2012 Jan-Mar; 16(1): 8488.

doi: 10.4103/0972-124X.94611

PMCID: PMC3357041

Clinical effect of miswak as an adjunct totooth brushing on gingivitis

Punit Vaibhav Patel,S. Shruthi,andSheela Kumar

Author information Article notes Copyright and License information This article has beencited byother articles in PMC.

Go to:

Abstract

Background:

The aim of the study was to clinically evaluate the effect of miswak as an adjunct to tooth

brushing on plaque levels and gingival health in subjects diagnosed with mild to moderate

chronic generalized marginal gingivitis in comparison with those of toothbrush users.

Materials and Methods:

The study comprised of 30 systemically healthy subjects, aged 18-35 years diagnosed with mild

to moderate gingivitis. The study was designed as a randomized, single-blind, parallel-armed

study. Subjects were randomly divided into three groups. Group A (toothbrush users), group B(toothbrush and miswak users), and group C (miswak users). Subjects were advised to use

toothbrush, miswak, or both, three times daily depending on their respective allocations.

Gingival index according to Loe and Silness, Plaque index, according to Turesky modified

Quigley-Hein plaque index, and the digital photographs of the total labial surfaces of the teethwere taken for image analysis. Recording of data were done at baseline, 2

nd, 4

th, 6

th, and 8

thweek

time intervals. Obtained data were analyzed using repeated measure ANOVA and student ttest

(independent samples).

Results:

Group B showed statistically significant (P0.05) from 2

nd to 4

thweek. Further at the 6

thand 8

thweek, there was significant difference

(P


2/8

The most common type of chewing stick, miswak, is derived from Salvadora persica, a small

tree or shrub with a spongy stem and root, which is easy to crush between the teeth. Pieces of the

root usually swell and become soft when soaked in water.[5]Miswak is a chewing stick used inmany developing countries as a traditional toothbrush for oral hygiene.[4]

Reports on the oral health of miswak users are contradictory; several studies have claimed thatchewing sticks are effective in reducing plaque and gingival inflammation.[58] When used

properly, the miswak is reported to be as effective as a toothbrush.[5,6] It was found that thechewing stick removed plaque from interproximal sites to virtually the same extent as from other

more accessible sites.[6] The conventional tooth brushing has been reported to be relatively

ineffective for the removal of interproximal plaque.[6]The value of chewing sticks is believed tobe in their mechanical cleansing action. The use of miswak has also been reported to inhibit the

formation of dental plaque chemically and exert antimicrobial effect against many oral

bacteria.[9]

However, some studies[10,11] have reported more plaque formation and gingival bleeding in

individuals who used chewing sticks in comparison with toothbrush users. In few studies,[11]ithas been found that the toothbrush was more efficient as an oral hygiene aid than the miswak.

Surprisingly, despite the widespread use of miswak since ancient times, relatively little scientificattention has been paid to its oral health beneficial effects. In 1987, World Health Organization

encouraged the developing nations to use miswak for oral hygiene because of tradition,

availability, and low cost.[12]Recently, various authors have concluded that chewing sticks orits extract has therapeutic effect on gingival diseases.[4,13]

Thus, a study was designed to clinically evaluate the effect of miswak stick as an adjunct to toothbrushing on plaque levels and gingival health in subjects diagnosed with mild to moderate

chronic generalized marginal gingivitis in comparison with those of toothbrush users.

Go to:

MATERIALS AND METHODS

Thirty subjects diagnosed with mild to moderate chronic generalized marginal gingivitis were

selected randomly from the out patient department (OPD) presenting to JSS Dental College andHospital, Mysore. A prior written informed consent was taken from all included subjects. The

study was approved by ethical committee JSS University Mysore.

Inclusion criteria

The inclusion criteria included subjects to be within the age group of 18-35 years; subjects whowere having full set of teeth; subjects who were diagnosed with mild to moderate chronic

generalized marginal gingivitis; subject having a probing pocket depth less than or equal to 3

mm; and subjects showing gingival index[14] (Loe and Silness) more than 1, and plaqueindex[15,16](Turesky modified Quigley-Hein plaque index) more than 1.

Exclusion criteria

Exclusion criteria were the subjects who were systemically compromised; pregnant and lactating

mothers; subjects having orthodontic appliance; subjects who have grossly decayed teeth, mal-positioned teeth or crowded teeth, overhanging restorations, crowns, and fixed partial dentures;patients who used antibiotics in the previous three months; and patients with xerostomia and on

antihistamines were also excluded.

Design

The study was performed according to a randomized, single-blind (clinical investigator),parallel-armed design. Before the start of the study, during the first visit, intraoral examination

was performed. Oral hygiene habits were recorded by a structured interview based on a prepared

questionnaire. The questionnaire included education level, smoking habit, dental visit, usage ofchewing stick and/or toothbrush and its frequency.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref9http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref9http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref9http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref12http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref12http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref12http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref12http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref9http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5


3/8

The subjects were randomly assigned to one of the three groups consisting of 10 subjects in each

group.

1. Group A- Subjects were asked to brush with the provided toothbrush without toothpaste

during morning, mid day, and evening.

2.

Group B- Subjects were asked to brush with the provided toothbrush without toothpastethrice daily, and in addition, miswak sticks were given to use during morning, mid day,

and evening.3. Group C- Subjects were asked to use miswak sticks during morning, mid day, and

evening.

Subjects were trained and instructed on a model to use miswak or toothbrush (without

toothpaste) or both, depending on the respective assigned group.

Sufficient numbers of commercially available standard sized (20 cm in length and 1 cm in

diameter) miswak branch-lets/twigs (Miswak Haleemi, Haleemi Natural Products, Karachi,

Pakistan, 75700) [Figure 1]were purchased from local market of Mysore, India, and were storedin the refrigerator until implemented into the study.

Figure 1

Demonstrating a miswak stick and a toothbrush used in the study

Subjects falling under group C were given fresh sticks of standard sized miswak sticks. Subjectsfalling under group A were given a new straight handled, medium soft toothbrush without

toothpaste (Ajay QuestToothbrush, Raghav Lifestyle Products, New Delhi, India) [Figure 1].

Subjects falling under group B were given both miswak sticks and tooth brushes withouttoothpaste. Subjects using miswak (group B and C) were advised to use freshly prepared miswak

stick at each indicated time interval and store in refrigerator packed in provided paper when not

in use.

Clinical examination and image analysis

Recording of clinical indices and photographs were taken at baseline, 2nd

4th

, 6th

, and 8th

weektime intervals. The clinical parameters measured were: a) gingival index, according to Loe and

Silness[14] and b) plaque index, according to Turesky modified Quigley-Hein plaque

index.[15,16] Both gingival inflammation and plaque were registered at four sites per tooth(buccal, mesial, distal, and lingual) for all teeth, except the third molar, and were analyzed

according to respective indexing system. Plaque was stained with erythrosine before scoring.

Photograph of stained plaque on anterior dentition was taken by using a digital camera (Kodak

C713, Eastman Kodak Company, Rochester, NY 14650), keeping the camera approximatelyperpendicular (90) and at a distance of 25 cm from the labial surface of upper central incisor.

Photographic images were analyzed by computer software (UTH SCSA Image Tool [IT version

2]) for the percentage of plaque coverage. The total labial teeth surfaces and the area covered by

plaque were directly counted in pixels. The plaque area was then calculated in percentage of thetotal labial teeth surfaces. All images were coded and the analysis of the images was done in a

blinded way. Ten images of each interval were analyzed and average was considered for each

subject. The analysis of the images was done at baseline, 2nd

4th

, 6th

, and 8th

week time intervals.

Statistical analysis

Recorded data were analyzed using software program (Statistical package version 17, Statistical

Package for the Social Sciences (SPSS), Chicago, IL). All parametric variables were analyzedusing repeated measures of analysis of variance (ANOVA) for examining the mean differences

from baseline to 8th

week and Student's t test (independent samples) for comparison of meandifferences between groups at specific time intervals. Differences were considered significant if

P


4/8

Go to:

RESULTS

None of the participants complained of discomfort or showed any signs of adverse reactions with

use of prescribed chewing sticks.

Comparison of plaque scores

Data analyzed by repeated measure of ANOVA for time and cleaning method interactions

showed a significant reduction in plaque score (F=20.612; P


5/8

DISCUSSION

Current study was designed to investigate the clinical therapeutic effect of miswak as an adjunctto tooth brushing method in the treatment of chronic gingivitis. The selection of miswak from the

Salvadora persicatree for the present study was based on number of factors. The use of miswak

is most common in the Middle East region and in the Indian subcontinent, its taste isacceptable,[5]it is inexpensive, and has been reported to have anti-plaque and many therapeutic

pharmacological properties.[58]

There are studies[48] on the comparison of toothbrushes and miswak for plaque removal.

Reports on the oral health of miswak users are contradictory and published literatures suggest

that its therapeutic role in oral health needs to be verified before implementing into generalpractice of dentistry.

Current dental literature[1416] describes several clinical indices and methods for measuringplaque and gingival inflammation, both quantitatively and qualitatively. The indices used to

measure the accumulation of dental plaque and gingival inflammation are usually based onsubjective estimations of the plaque-covered areas of the tooth surface and inflammatory changesof gingiva.[16]However, these indices on an ordinal scale are visual determinations resulting in

data of less sensitivity. Photogrammetric techniques giving measurements in an interval scale

have therefore been used to obtain more accurate measurements of the plaque area.[17]

The results of the present study showed that there was a significant reduction in plaque score and

improvement in gingival health after the use of miswak as an adjunct to tooth brushing method.The miswak stick when not used as adjunct to tooth brush was not effective as the conventional

toothbrush in reducing plaque until 4th

week. Later at the 6th

and 8th

week, there was significant

difference in plaque score in toothbrush user compared to miswak user. This initial reduction in

the plaque score among the miswak users could be due to Hawthorne effect.[18]The Hawthorneeffect is a form of reactivity, whereby subjects improve or modify an aspect of their behavior

being experimentally measured simply in response to the fact that they are being studied, but not

in response to any particular experimental manipulation.[18]The effect might have resulted fromsubject's initial excitement of using a new product (miswak) and trying to get a good result out of

their use. After some time, as the weeks progressed, there could be a probability that the subjects

lost their interest in using the miswak effectively. On the other hand, toothbrush is a part ofroutine oral hygiene procedure and is being practiced by individuals since the eruption of first

dentition in the oral cavity. The subjects under toothbrush group used it effectively until the

completion of the study.

Various controversial reports on the mechanical cleansing efficacy of the miswak have beenpublished. Previous studies have revealed that higher plaque and gingival bleeding in chewing

stick users as compared with toothbrush users.[10] Studies have also revealed that poor oral

hygiene with those using chewing sticks may be a reflection of poor techniques. [10,11]

Furthermore, the difference in topographic design of handles and bristles of miswak stick mightbe other reason of poor plaque control in miswak users. Studies have revealed that miswak

bristles are not similar to the toothbrush bristles that are used to remove plaque from the tooth

surfaces mechanically.[19]Unlike a conventional toothbrush, the bristles of the miswak lie in thesame long axis as its handle.[10,11,19]The angulations in the toothbrush enable it to adapt more

easily to the distal tooth surfaces, particularly on the posterior teeth. However, the techniques

employed for removing plaque mechanically from outer surface and interproximal sites are

similar with the toothbrush and the chewing stick, e.g., vertical and horizontal brushing.[20,21]These techniques primarily depend upon the people's attitudes, knowledge, and manual

dexterity.[20]These mechanical differences were evident in our result also, and miswak bristleswere not as effective as tooth brush bristles on outer surface area as well as interproximal area.

These findings suggest that mechanically, miswak when not used in conjunctions to tooth

brushes is not as effective as toothbrushes in cleaning the tooth surfaces.

In the present study, a standardized design was developed to minimize the effects of other

variables, which could affect plaque control, including type of toothbrush and/or chewing stick(miswak), frequency of tooth brushing and/or miswak, and the technique of tooth brushing

and/or miswak. The study condition was standardized by instructing all subjects on how to use

the identical conventional toothbrushes and chewing sticks under direct supervision of
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref17http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref17http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref17http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref18http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref17http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref5


6/8

investigator. Furthermore, all participants were issued with identical conventional toothbrushes

and fresh chewing sticks of fairly uniform length.

Digital image analysis of plaque coverage was done for anterior region of dentition. Studies have

revealed that in anterior region, the strokes and bristle angulations remain the same in both

toothbrush and miswak stick and differ to great extent in posterior dentition.[20] Thus, anattempt was made to measure the covered plaque area from matched mechanical cleansing

procedure in anterior dentition, which was not possible in posterior dentition.

Our result showed a beneficial effect of miswak on gingival health when used as an adjunct to

tooth brushing method. This change could be attributed to the effect of different therapeuticcomponents reported in the extract of miswak. Mentioned therapeutic components have been

shown to beneficially influence the gingival health and plaque inhibition in various in vitroand

in vivostudies.[7,2228]

Silica in miswak acts as an abrasive material to remove plaques and stains.[7]Tannins (tannic

acid) exert an astringent effect on the mucous membrane, thus reducing the clinically detectablegingivitis.[7,21,22] Alkaloids exert a bactericidal effect and stimulatory action on the

gingiva.[23] Essential (volatile) oils possess characteristic aroma and exert carminative,

antiseptic action.[7,21,24]The sulphur compounds have a bactericidal effect.[7,25,26]Vitamin Chelps in the healing and repair of tissues.[7]Sodium bicarbonate (baking soda), NaHCO3, has

mild abrasive properties and has a mild germicidal action.[2527] High concentrations of

chloride inhibit calculus formation.[28]These therapeutic findings of previous studies could bethe reason for improved gingival health in the present study.

In the present study, subjects were advised to use freshly prepared miswak stick at indicated timeinterval. Previous studies have revealed that freshly prepared miswak sticks have no cytotoxic

effect on periodontal tissue.[29]However, the same plant used even after 24 hours does containharmful cytotoxic components and has potential to damage periodontal cells.[29]Based on thesefindings, we recommended cutting the used portion of the miswak after it has been used for one

day and preparing a fresh part for the next use.

In the present study, miswak stick was used instead of miswak extract in mouthwash or

toothpaste form assuming that miswak stick will provide both the mechanical and chemical

effect supported by previous published literatures.[1928] Our results showed beneficialchemical therapeutic action of miswak stick juice on gingival health, which was extracted on

chewing miswak stick. No mechanical beneficial effect was observed when compared with

toothbrush. Our results are in agreement with a controlled study,[30]where it was reported thatpowdered miswak if used with a mechanically proper device i.e. toothbrush, will give better

results than miswak sticks alone or commercial toothpowder on gingival health. Presently, many

commercial preparations are available in market as toothpaste, but no preparation presentlyexists in the form of mouthwash or in-office therapeutic medicament in the market. Thus, in

future, well-controlled studies are required to evaluate miswak based therapeutic medicament,

which can be used in treatment of mild to moderate gingival diseases.

Go to:

CONCLUSION

Our results showed significant improvement in plaque score and gingival health when miswakwas used as an adjunct to tooth brushing. Our findings clearly indicate that miswak cannotreplace the toothbrush, but can be used an adjunct to toothbrush, utilizing the mechanical

efficacy of toothbrush and chemical effects of miswak. Henceforth, in future, a well-designed

study is required to ascertain the efficacy of miswak or miswak extract in the treatment ofgingival diseases.

Go to:

Footnotes

Source of Support:Nil,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref23http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref23http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref23http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref24http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref24http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref24http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref26http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref26http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref26http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref27http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref27http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref30http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref30http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref30http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref30http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref19http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref29http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref27http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref26http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref24http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref23http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref21http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref28http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ref20


7/8

Conflict of Interest:None declared.

Go to:

REFERENCES

1. Page RC, Kornman KS. The pathogenesis of human periodontitis.An introduction.

Periodontol. 2000;1997(14):911. [PubMed]2. Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol. 1965;36:17787. [PubMed]

3. Fischman S. The history of oral hygiene products: How far have we come in 6000 years?

Periodontol. 2000;1997(15):714. [PubMed]4. Wu CD, Darout IA, Skaug N. Chewing sticks: Timeless natural toothbrushes for oral

cleansing. J Periodontal Res. 2001;36:27584. [PubMed]

5. Almas K. Miswak (chewing stick) and its role in oral health. Postgraduate Dentist.1993;3:2148.

6. Khoory T. The use of chewing sticks in preventive oral hygiene. Clin Prev Dent. 1983;5:114.[PubMed]7. Akhtar M, Ajmal M. Significance of chewing sticks (Miswak) in oral hygiene from a

pharmacological viewpoint. J Pak Med Assoc. 1981;4:8995. [PubMed]

8. Farooqi MIH, Srivastava JG. The toothbrush tree (Salvadora persica) Quart J Crude Drug

Res. 1968;8:12979.9. El-Mostehy MR, Al-Jassem AA, Al-Yassin IA, El-Gindy AR, Shoukry E. Miswak as an oral

health device. Preliminary chemical and clinical evaluation. Hamdard. 1983;26:4150.

10. Norman S, Mosha HJ. Relationship between habits and dental health among rural Tanzanianchildren. Comm Dent Oral Epidemiol. 1989;17:31721. [PubMed]

11. Gazi M, Saini T, Ashri N, Lambourne A. Meswak chewing stick versus conventional tooth-

brush as an oral hygiene aid. Clin Prev Dent. 1990;12:1923. [PubMed]12. Oral health surveys. Basic methods. Geneva: WHO; 1997. World Health Organization.

13. Al-Obaida MI, Al-Essa MA, Asiri AA, Al-Rahla AA. Effectiveness of a 20% Miswak extract

against a mixture of Candida albicans and Enterococcus faecalis. Saudi Med J. 2010;31:6403.[PubMed]

14. Loe H. The gingival index, the plaque index and the retention index systems. J Periodontol.

1907;38:6106. [PubMed]15. Quigiey G, Hein J. Comparative cleansing efficiency of manual and power brushing. J Am

Dent Assoc. 1962;65:269. [PubMed]

16. Turesky S, Giimore ND, Glickman L. Reduced plaque formation by the chloromethylanalogue of vitamin C. J Periodontol. 1970;41:413. [PubMed]

17. Gazi M. Photographic plaque assessment of the antiplaque properties of Sanguinarine andchlor-hexidine. J Clin Periodontol. 1988;15:1069. [PubMed]

18. Wickstrom G, Bendix T. The Hawthorne effectwhat did the original Hawthorne studiesactually show.? Scand J Work Environ Health. 2000;26:3637. [PubMed]

19. Norton MR, Addy M. Chewing sticks versus toothbrushes in west Africa.A pilot study. Clin

Prev Dent. 1989;11:113. [PubMed]20. Almas K, Al-Lafi T. The natural toothbrush. World Health Forum. 1995;16:20610.

[PubMed]

21. Dorner WG. Active substances from African and Asian natural toothbrushes. ChemischeRundschau. 1981;34:1923.

22. Almas K, Al-Bagieh N, Akpata ES. In vitroantibacterial effect of freshly cut and 1-month-

old Miswak extracts. Biomedical Lett. 1997;56:1459.23. Raed I, Al Sadhan, Khalid Alma. Miswak (chewing Stick): A cultural and scientific heritage.

Saudi Dental J. 1999;11:808.

24. Gazi Ml, Davies TJ, Al-Bagieh N, Cox SW. The immediate and medium-term effects of

Meswak on the composition of mixed saliva. J Clin Periodontol. 1992;19:1137. [PubMed]25. Grant J. Miswak-toothbrushes that grow on trees. Todays FDA. 1990;2:6D. [PubMed]

26. Abo Al-Samh D, Al-Bagieh N. A study of antibacterial activity of the miswak extract in

vitro. Biomedical Lett. 1996;53:22538.27. AI-Lafi T, Ababneh H. The effect of the extract of the Miswak (chewing sticks) used in

Jordan and the Middle East on oral bacteria. Int Dent J. 1995;45:21822. [PubMed]

28. Mustafa MH, Abd-el Al MM, Abo-el Fadl-KM. Reduced plaque formation by Miswak -

based mouthwash. Egypt Dent J. 1987;33:37584. [PubMed]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2http://www.ncbi.nlm.nih.gov/pubmed/9567963http://www.ncbi.nlm.nih.gov/pubmed/9567963http://www.ncbi.nlm.nih.gov/pubmed/9567963http://www.ncbi.nlm.nih.gov/pubmed/14296927http://www.ncbi.nlm.nih.gov/pubmed/14296927http://www.ncbi.nlm.nih.gov/pubmed/14296927http://www.ncbi.nlm.nih.gov/pubmed/9643227http://www.ncbi.nlm.nih.gov/pubmed/9643227http://www.ncbi.nlm.nih.gov/pubmed/9643227http://www.ncbi.nlm.nih.gov/pubmed/11585114http://www.ncbi.nlm.nih.gov/pubmed/11585114http://www.ncbi.nlm.nih.gov/pubmed/11585114http://www.ncbi.nlm.nih.gov/pubmed/6607809http://www.ncbi.nlm.nih.gov/pubmed/6607809http://www.ncbi.nlm.nih.gov/pubmed/6607809http://www.ncbi.nlm.nih.gov/pubmed/6785501http://www.ncbi.nlm.nih.gov/pubmed/6785501http://www.ncbi.nlm.nih.gov/pubmed/6785501http://www.ncbi.nlm.nih.gov/pubmed/2591186http://www.ncbi.nlm.nih.gov/pubmed/2591186http://www.ncbi.nlm.nih.gov/pubmed/2591186http://www.ncbi.nlm.nih.gov/pubmed/2088630http://www.ncbi.nlm.nih.gov/pubmed/2088630http://www.ncbi.nlm.nih.gov/pubmed/2088630http://www.ncbi.nlm.nih.gov/pubmed/20563361http://www.ncbi.nlm.nih.gov/pubmed/20563361http://www.ncbi.nlm.nih.gov/pubmed/20563361http://www.ncbi.nlm.nih.gov/pubmed/5237684http://www.ncbi.nlm.nih.gov/pubmed/5237684http://www.ncbi.nlm.nih.gov/pubmed/5237684http://www.ncbi.nlm.nih.gov/pubmed/14489483http://www.ncbi.nlm.nih.gov/pubmed/14489483http://www.ncbi.nlm.nih.gov/pubmed/14489483http://www.ncbi.nlm.nih.gov/pubmed/5264376http://www.ncbi.nlm.nih.gov/pubmed/5264376http://www.ncbi.nlm.nih.gov/pubmed/5264376http://www.ncbi.nlm.nih.gov/pubmed/2831250http://www.ncbi.nlm.nih.gov/pubmed/2831250http://www.ncbi.nlm.nih.gov/pubmed/2831250http://www.ncbi.nlm.nih.gov/pubmed/10994804http://www.ncbi.nlm.nih.gov/pubmed/10994804http://www.ncbi.nlm.nih.gov/pubmed/10994804http://www.ncbi.nlm.nih.gov/pubmed/2605858http://www.ncbi.nlm.nih.gov/pubmed/2605858http://www.ncbi.nlm.nih.gov/pubmed/2605858http://www.ncbi.nlm.nih.gov/pubmed/7794468http://www.ncbi.nlm.nih.gov/pubmed/7794468http://www.ncbi.nlm.nih.gov/pubmed/7794468http://www.ncbi.nlm.nih.gov/pubmed/1602035http://www.ncbi.nlm.nih.gov/pubmed/1602035http://www.ncbi.nlm.nih.gov/pubmed/1602035http://www.ncbi.nlm.nih.gov/pubmed/2282247http://www.ncbi.nlm.nih.gov/pubmed/2282247http://www.ncbi.nlm.nih.gov/pubmed/2282247http://www.ncbi.nlm.nih.gov/pubmed/7558361http://www.ncbi.nlm.nih.gov/pubmed/7558361http://www.ncbi.nlm.nih.gov/pubmed/7558361http://www.ncbi.nlm.nih.gov/pubmed/3503729http://www.ncbi.nlm.nih.gov/pubmed/3503729http://www.ncbi.nlm.nih.gov/pubmed/3503729http://www.ncbi.nlm.nih.gov/pubmed/3503729http://www.ncbi.nlm.nih.gov/pubmed/7558361http://www.ncbi.nlm.nih.gov/pubmed/2282247http://www.ncbi.nlm.nih.gov/pubmed/1602035http://www.ncbi.nlm.nih.gov/pubmed/7794468http://www.ncbi.nlm.nih.gov/pubmed/2605858http://www.ncbi.nlm.nih.gov/pubmed/10994804http://www.ncbi.nlm.nih.gov/pubmed/2831250http://www.ncbi.nlm.nih.gov/pubmed/5264376http://www.ncbi.nlm.nih.gov/pubmed/14489483http://www.ncbi.nlm.nih.gov/pubmed/5237684http://www.ncbi.nlm.nih.gov/pubmed/20563361http://www.ncbi.nlm.nih.gov/pubmed/2088630http://www.ncbi.nlm.nih.gov/pubmed/2591186http://www.ncbi.nlm.nih.gov/pubmed/6785501http://www.ncbi.nlm.nih.gov/pubmed/6607809http://www.ncbi.nlm.nih.gov/pubmed/11585114http://www.ncbi.nlm.nih.gov/pubmed/9643227http://www.ncbi.nlm.nih.gov/pubmed/14296927http://www.ncbi.nlm.nih.gov/pubmed/9567963http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357041/#ui-ncbiinpagenav-2


8/8

29. Abo Al-Samh D, Al-Nazhan S. In vitro study of the cytotoxicity of the miswak ethanolic

extract. Saudi Dental J. 1997;9:12530.

30. Attar ZA. The miswak - natures toothbrush. Bull Hist Dent. 1979;27:3940. [PubMed]
http://www.ncbi.nlm.nih.gov/pubmed/295678http://www.ncbi.nlm.nih.gov/pubmed/295678http://www.ncbi.nlm.nih.gov/pubmed/295678http://www.ncbi.nlm.nih.gov/pubmed/295678

j indian soc periodontol

Documents