Efficacy of Miswak (salvadora persica) in preventing dental caries

doi:10.4236/health.2010.25074

Paper Menu >>

Journal Menu >>

Vol.2, No.5, 499-503 (2010)

doi:10.4236/health.2010.25074

Health

Efficacy of Miswak (salvadora persica) in preventing

dental caries

Fatemeh Ezoddini-Ardakani

Department of Oral and maxillofacial radiology, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran;

ezoddini@gmail.com, afsan40@yahoo.co.uk

Received 1 November 2009; revised 5 December 2009; accepted 7 December 2009.

ABSTRACT

The rate of dental caries and periodontal dis-

eases in the world is still high, regardless of

progress in the oral and dental hygiene. The

natural toothbrush or chewing stick called “Mis-

wak” has been used since ancient history. In

this research the efficacy of Miswak in prevent-

ing dental caries was investigated and com-

pared with the efficacy of toothbrush and tooth-

paste. The analytical and clinical trial method

was applied for this research among high sch-

ool’s students in the city of Yazd, Iran, 2006.

Three hundred eighty second year’s students

(190 cases and 190 controls) were examined

dentally. Then the Miswak was distributed to the

case group and required trainings were given to

both groups. After one year, the examinations

were repeated. For analyzing the data one-way

variance analysis test, Kai square, Paired t-test

and two variable analyses were used. In the be-

ginning of this study, there were no significant

differences between two groups (cases and

controls) regarding their dental situation and

the frequency of brushing their teeth (p-value =

0.162). In addition, there were no significant

differences in DMFT between the two groups.

The data collected at the end of the study

showed a significant increase in DMFT in the

control group (p-value = 0.000). There was 55%

increase in the rate of dental caries in control

group compared to case group (0.89 before the

study and 1.38 after the study). The risk of den-

tal caries for each tooth in control group was

9.35 times more than case group (9.14% and

0.98% respectively). Dental caries rate was de-

tected slightly less in the case group at the end

of this study. This might be as a result of the

antimicrobial effects of Miswak. A longer study

with more cases is needed to prove this sug-

gestion.

Keywords: Miswak; Dental Caries;

Salvadora Persica; Toothbrush

1. INTRODUCTION

Salvadora Persica (S.P.) is a plant that grows in the de-

serts of the area from west India to Africa. The roots and

sticks of S.P. are used widely for cleaning the teeth in

these areas. The other names for this plant are Arak tree,

Chewing stick, Natural toothbrush and Miswak [1].

Regardless of daily improving dental and oral health

in the world the dental caries and gingivitis is increasing

due to the widely use of sugar in food, fluoride and cal-

cium deficiency and finally ignoring health care [2].

There are nearly seven plants for this meaning but the

most commonly used one is Miswak which is derived

from S.P. plant mostly in Saudi Arabia and parts of the

Middle East [3]. The values of these sticks are due to

their components and cleaning mechanisms. Recently

these sticks were recommended as an effective tool for

oral health by the World Health Organization (WHO).

The sticks have usually 15 cm length and 1 cm di-

ameter (Figure 1). This is why these sticks are called

chewing sticks as well. Their pleasant hot taste made

them easily chewable. Sometimes a small part of the

stick is used as a tooth stick.

Primary analysis showed that S. Persica contains

Tri-Methyamin, Salvadrin, Chloride, Fluoride, Silica,

Sulfur, Mustard, Vitamin C and a small amount of Sapo-

nine Tanin. These components have antibacterial and

antifever effects in addition to be against gingival irrita-

tion [4]. There are many studies showing that Miswak

have strong anti caries effects due to large amounts of

fluoride in it. Many dental studies reported antimicrobial

activity in derivates from Miswak. In addition, the me-

chanical cleaning effects of Miswak were investigated

and it was reported that the value of chewing sticks is

due to their mechanical cleaning [5]. There are many

reports showing Miswak is effective in decreasing gin-

givitis and dental plaques. Elvin-Lewis et al. [6] showed

that the dental loss in adults is very low in the countries

F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503

500

Openly accessible at

Figure 1. The shape of some chewing sticks.

that Miswak is used widely. Almas, [7] showed amazing

antibacterial effects of Miswak on Streptococcus Mutant

and Fecalis. Olsson [8] reported that chewing sticks are

more effective in decreasing dental caries than tooth-

brush. Al-lafi and Ababneh [9] investigated antibacterial

effects of Miswak in three ways and showed that deriva-

tives if these sticks have strong effects on the growth of

Streptococcus and staphylococcus aurous. Danielsen, et al.

[10] studied two groups of students in Kenya. One group

used chewing sticks plus toothpaste and the other group

used only chewing sticks. There were no extra effects in

removing dental plaques in the group that used tooth-

paste in addition to chewing sticks.

The aims of this study were to investigate the effects

of Miswak in preventing tooth caries comparing with

toothbrush.

2. MATERIALS AND METHODS

This study was a clinical trial with before and after de-

sign. It was done in 190 cases and 190 controls (95 girls

and 95 boys) in the second year students of Yazd high

schools. Cluster sampling was used to choose 6 boys and

6 girls high schools in Yazd. Then these high schools

were randomly divided into two groups of three high

schools each using as case and control groups.

The investigators were chosen among final year dental

students. Required training regarding filling question-

naires and dental examination were given to them. The

author supervised all the investigation’s steps. The mate-

rials used by the investigators were explorer, mirror,

light, gloves, upper and lower teeth models, Oral-B

toothbrush and Miswak. Dentists examined all of the

students teeth at the beginning of the study and the

number and degree of DMF teeth were recorded in the

questionnaires. The degrees of caries were measured by

explorer and persons complaints. Even small insertion of

the explorer in the teeth recorded as a caries. The de-

grees of the caries were divided to class I to class VI.

After recording the primary data Miswak were given to

the case group and the way to use it were trained to the

group and ask them to use it two to three times per day.

The Miswaks were controlled every three months and

the new Miswaks were given to them if it was neces-

sary. While, the toothbrushes were given to control

group, and the training was given to them to brush their

teeth two to three times per day exactly as it done for

the case group.

After one year, the teeth examinations were done the

same as the beginning of the study and the data were

recorded in the questionnaire. Our data showed the car-

ies rate in the beginning and at the end of the study and

because DMFT have no improvement so the differences

were considered to be as the results of disease develop-

ment in the study year.

The data were imported in the EPI 6 software and

were analyzed by SPSS 13 version software. For com-

paring the data one way variance analysis test, Chi-

Square, Paired t-test and two variable analyses were

used. For comparing the relative risk of disease devel-

opment in two groups the Relative risk index was used.

3. RESULTS

In this research, from the initial 380 students that started

this study, 330 students continued it until the end. In case

group there were 174 students which used Miswak for one

year and 156 students were in the control group which

used toothbrush for one year. The trainings and number of

brushing teeth per day were the same for two groups. At

the beginning of the study the numbers of case and control

students were the same (190). This means that 16 students

in the case group (8.4%) but 34 students in the control

group (17.9%) did not continue the experiments until the

end. The difference is significant (p-value = 0.006). This

means that the cases which used Miswak have more in-

terest in brushing their teeth than the controls. The odds

ratio to discontinue brushing was 2.37 times in control

group than this ratio in case group with the confidence

interval of 1.21 to 3.72 which is different from number

one significantly (p-value < 0.05).

F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503

501

The same numbers of male and female were chosen at

the beginning of this study, but after one year 159 male

and 171 female continue the study. This means that the

number of cases which abandon the study was more in

the male group but this difference is not significant

(p-value = 0.068) and the sex ratio in two groups is

nearly the same. In addition, the age of all the cases and

controls were nearly the same with maximum 6 months

difference from the median.

The number of brushing the teeth in two group were

the same at the beginning of the study (p-value = 0.162)

(Table 1). There were no significant differences regard-

ing DMFT rate between two groups of cases and con-

trols at the beginning of the study (Table 2).

In this study DMFT was used as a dependent vari-

able to investigate the effectiveness of Miswak. The

mean DMFT in two groups at the beginning of the

study was 3.691 ± 2.797 (mean ± S.D.) with the confid-

ence interval of 95% from 3.39 to 3.99. These data

shows the efficacy of Miswak in preventing tooth de-

cay (Table 3).

Table 4 shows that the rate of increased DMF in the

case group was nearly 10 times this rate in the control

group.

Our data showed that at the beginning of the study the

incidence of DMF in the case group was more than this

in the control group, but after one year (at the end of the

study) this incidence in the case group became less than

this in the control group (Table 5). The prevalence ratio

of decayed teeth in control group compare with case

group was 0.89 before the study, but this was 1.38 after

the study. These data shows a 55% increase in the rate of

decay in control group compare with the case group. In

addition, the relative risk of decay incidence in the con-

trol group was 9.35 times this in the case group.

4. DISCUSSIONS

The importance of chewing sticks or Miswak was inves-

tigated in several studies (11, 12, 13 and 14). Almas, [7]

showed that Miswak has antimicrobial effects against

Streptococcus Mutants and Fecalis. In addition, Al-Lafi

and Ababnch [9] and Almas, et al. [15] studies showed

that Streptococcus Fecalis is the most sensitive microor-

ganism affected by Miswak. Our results showed that the

rate of carries decreases after using Miswak and this can

be due to these antimicrobial effects. Almas and Al-Zeid

[16] in a study investigated the antimicrobial effects of

Miswak and it’s extract specially on Streptococus Mutan

and Lacto Basilus. These effects were compares with the

effects of toothbrush and normal saline. Their results

showed that in Miswak users there was a significant de-

creases in streptococcus (p = 0.013) but not in Lacto

Basilus (p = 0.147).

Table 1. The number of brushing per day in the two groups at

the beginning of the study.

Cases Controls Total

Group

Brushing/day No% No % No %

3 times 2 1.1 2 1.3 4 1.2

2 times 12 6.9 18 11.5 30 9.1

1 time 84 48.371 45.5 15547

Rarely 62 35.643 27.6 10531.8

Never 14 8 22 14.1 36 10.9

Total 174100 156 100 330100

P-value = 0.162.

Table 2. The teeth situation in the students at the beginning of

the study.

Cases (No = 174) Controls (No = 156)

Group

No MeanS.D. Mean S.D.

p-value

Filled teeth

One side 0.79 1.81 0.54 1.47 0.176

Two sides 0.1 0.52 0.08 0.32 0.767

Three sides 0.06 0.375 0 0 0.036

Decay teeth

Class I 2.36 2.18 2.41 2.14 0.366

Class II 0.16 0.47 0.16 0.461 0.99

Class III 0.02 0.13 0.05 0.3 0.17

Class IV 0 0 0.02 0.18 0.156

Class V 0.01 0.08 0.02 0.18 0.364

Class VI 0.01 0.11 0 0 0.18

Missing teeth0.13 0.44 0.17 0.41 0.39

Table 3. Comparison of the differences between DMF in two

groups before and after the study.

Case No = 174 Control No = 156

Group

Time XS.D.MinMax X S.D. Min Maxp-value

Before 3.92.890 143.46 2.68 0 130.147

After 4.143.050 175.7 3 0 160.000

p-value0.000 0.000

Table 4. The difference between DMF in each group.

Group NoMean of increase

during 1 year S.D. p-value

Case 1740.2356 0.523 0.000

Control 1562.2436 1.188 0.000

F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503

502

Table 5. Prevalence and incidence of decay in two groups.

Teeth No in Case group Teeth No in Control group

Prevalence

Total Decayed % Total Decayed %

p-value

Before 4872 679 13.94 4368 539 12.340.059

After 4872 720 14.78 4368 889 20.350.00

One year

incidence 4193 41 0.98 3829 350 9.140.00

Wolinsky et al. [17] showed that S.P. decreases the

ability of some Streptococcus to colonize on teeth sur-

faces. Bearing in mind that the cause of tooth decay is

acid secretion by microorganisms, the decreases in the

rate of caries in this study and also low rate of DMF in

the countries which use Miswak can be due to this abil-

ity of S.P.

Elvin-lewis et al. [6] and Almas [7] suggested that the

antibiotic effects detected in S.P. may have interaction

with bacteria and prevent their attachment. The other

component of Miswak with possible interaction with

bacterial glycolytic enzyme and their acids or intracellu-

lar polysaccharides products is Fluoride. Furthermore,

Benzylisothiocyanate (BIT) that is naturally a compo-

nent of S.P. acts as inhibitor of bacterial growth and their

acidic products [18]. Chawla [19] showed that some

kinds of chewing sticks such as Neem, S.P. and Acaccia

Arabica have reasonable amounts of fluoride. They

showed that Miswak sticks from S.P. tree have signifi-

cant antimicrobial effects on streptococcus mutants,

streptococcus mitis and staphylococcus. Darout et al. [20]

studied the caries and periodontal situation of adults

Sudanese using either habitual Miswak or Toothbrush.

They suggested using Miswak in developing world be-

cause of its availability and cheap price. In our study as

well the effects of Miswak were significant and every

three months that we were going to the schools to deliver

new Miswak sticks to the students their excitement in

requesting Miswak was interesting.

At the end of our study, the Miswak has been used

more frequently in the Miswak users than toothbrush in

the other group. This difference cannot be due to the

training, because both groups have the same trainings. In

addition our study showed that the rate of DMF which

was the same in both groups increased significantly in

the toothbrush users compared with Miswak users. This

difference can be because of two reasons; 1/Miswak

users used Miswak more frequently and 2/Miswak has

antimicrobial effects plus fluoride and calcium.

Faiez [21] reviewed the effects of Miswak. Many re-

searchers believed that the efficacy of S.P. is because of

its mechanical action while the others believe that Mis-

wak is a natural source for topical fluoride.

About half of the people in Saudi Arabia use Miswak.

Magbool [22] showed that only 12.5% of students are

Caries free in Saudi Arabia and the rate of tooth decay is

48% in 6 and 7 years old age group but this rate de-

creases and is only 1.03% in 16 and 17 years old age

group. We showed that the prevalence of caries in case

group is less than this rate in control group and this can

be as a result of using Miswak.

Norton and Addy [23] did a pilot and cross sectional

study among adults in Ghana. They showed that the rate

of plaque and carries in Miswak users was less than this

rate among non users.

In the other studies among Ethiopian and Nigerian

students and Saudi Arabian dental students, using Mis-

wak and toothbrush was compared. These comparisons

showed that Miswak was more effective than toothbrush

in removing plaque [6,23,24]. These differences can be

related to the frequency and duration of brushing, ex-

periences in using Miswak, motivation and supervision.

One of the specifications of Miswak is its straight

shape that is a disadvantage because it cannot clean lin-

guinal sides of the teeth.

Miswak contains nearly 1.02 μg/g total fluoride.

Chawla showed that the chewing sticks of S.P., Neem-

kikar, Walnut and Pekujebu have 2.8, 1.0, 0.5 and 0.2

μg/ml fluorides respectively [19]. Miswak releases a

significant amount of calcium and phosphor in water and

these elements are necessary for remineralization. Crys-

tallographic studies with fluorescence and x-ray micro-

analysis showed that S.P. sticks have more calcium and

phosphor [24].

Recently S.P. extract was used in some toothpastes

like Ouali Meswak, Pharba, Sarakan, Backenham UK,

Basaraj and Epident [25]. Miswak extract and 0.8 %

monoflourophosphate sodium) compared with Oral-B

toothpaste (containing only 0.8 % monoflourophosphate

sodium) in dental students. Their results showed that the

toothpaste containing Miswak extract significantly was

more effective in removing dental plaques compare with

Oral-B toothpaste. It was also showed that Miswak has

antidecay effects because of its fluoride contents. In ad-

dition, the hot taste of Miswak plus the chewing effects

of the stick can increase the salvia secretion in the mouth

and therefore increase its buffering capacity [21]. In our

study these factors can be effective as well.

Sofrata reported that the chewing stick (Miswak) is

used for oral hygiene in many parts of the world. In ad-

dition to the mechanical removal of plaque, an antibac-

terial effect has been postulated. Miswak embedded in

agar or suspended above the agar plate had strong anti-

bacterial effects against all bacteria tested. The antibac-

terial effect of suspended Miswak pieces suggests the

presence of volatile active antibacterial compounds [26].

Almas concluded that toothbrushes and Miswak (che-

wing sticks) are widely used for the mechanical removal

of plaque [27].

F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503

503

Sofrata reported that the difference in plaque pH be-

tween Miswak extract and water rinse was statistically

significant at 30 min (p < 0.001) [28]. Rinsing with

Miswak extract stimulated parotid gland secretion (p <

0.01). Miswak extract raised the plaque pH, suggesting a

potential role in caries prevention

Openly accessible at

5. CONCLUSIONS

Our study showed that Miswak effectively prevented

dental caries in high school students. Conducting some

studies on antimicrobial and silicate effects of Miswak

are suggested.

REFERENCES

[1] Galati, E.M., Monforte, M.T., Forestieri, A.M., Miceli,

N., Bade, A. and Trovato, A. (1999) Salvadora persica L:

Hypolipidemic activity on experimental hypercholes-

terolemia in rat. Phytomedicine, 6(3), 181-185.

[2] Kimery, M.J. and Stallard, R.E. (1992) The evolutionary

development and contemporary utilization of various oral

hygiene procedures. Periodontal Abstracts, 16, 90-97.

[3] Abderahim, M. and Jurner, J.E. (1983) In vitro evaluation

of Saudi Arabian tooth tree (Salvadoran Persica). Odon-

tostomatological Tropicale, 613, 145-148.

[4] Wolinsky, L.E. and Sote, E.O. (1984) Isolation of natural

plaque inhibiting substances from Nigerian chewing sticks.

Caries Research, 18(3), 216-225.

[5] Akpata, E.S. and Akinrimisi, E. (1977) Antibacterial

activity of extracts from some African Chewing sticks.

Oral Surgery, 44(5), 717-722.

[6] Elvin-Lewis, M., Hall, J.B. and Adu-uta, M. (1980) The

dental health of chewing stick users of southern Ghana,

preliminary finding. Journal of Preventive Dentistry, 6,

151-154.

[7] Almas, K. (1999) The antimicrobial effects of extracts of

Azadirachta Indica (NEEM) and Salvadora Persica (Arak)

chewing sticks. Indian Journal of Dental Research, 10(1),

23-26.

[8] Olsson, B. (1978) Efficiency of traditional chewing

sticks in oral hygiene programs among Ethiopian School-

children. Community Dentistry and Oral Epidemiology, 6,

105-109.

[9] Al-lafi, T. and Ababneh, H. (1995) The effect of the ex-

tract of the Miswak (chewing sticks) used injordan and

the middle east on oral bacteria. International Dental

Journal, 45(3), 218-222.

[10] Danielsen, B.O., Vibeke, B., Manji, F. and Fejerskov, O.

(1989) Chewing sticks, tooth paste and plaque removal.

Acta Odontol Scand, 47, 121-125.

[11] Akhtar, M. and Ajmal, M. (1981) Significance of chew-

ing sticks (Miswak) in oral hygiene from a pharmacol-

ogical viewpoint. Journal of Pakistan Medical Associa-

tion, 31(4), 89-95.

[12] Farooqi, M.I.H. and Srivastava, J. (1983) The tooth tree

(Salvadora persica). Quarterly Journal of Crude Drug

Research, 81(4), 1297-1299.

[13] El-Mostehy, M.R., Al-Jassem, A.A., Al-Yassin, I.A., et al.

(1983) Miswak as an oral health device preliminary

chemical and clinical evaluation. Hamdard, 26, 41-50.

[14] Khoory, T. (1999) The use of chewing sticks in preven-

tive oral hygiene. Clinic Preventive Dentistry, 5, 11-14.

[15] Almas, K., Al-Bagieh, N. and Akpata, E.S. (1997) In

vitro antimicrobial effects of freshly cut and 1-month old

miswac (chewing stick). Biomedical Letters, 56, 145-149.

[16] Almas, K. and Al-Zeid, Z. (2004) The immediate antim-

icrobial effect of a toothbrush and Miswak on cariogenic

bacteria: A clinical study. Journal of Contemporary Dental

Practice, 5(1), 105-114.

[17] Wolinsky, L.E., Mania, S., Nachnani, S., et al. (1996)

The inhibiting effect of aqueous Azadirechta indica (Neem)

extract upon bacterial properties influencing in vitro

plaque formation. Journal of Dental Research, 75(2), 816-

822.

[18] Al-Bagieh, N.H. and Weinberg, E. (1989) Benzylisothi-

cyanate: A possible agent for controlling dental caries.

Microbios, 39, 143-151.

[19] Chawla, H.S. (1983) A new natural source for topical

fluoride. Journal of the Indian Dental Association, 55

(10), 419-422.

[20] Darout, I.A., Albandar, J.A. and Nils, S. (2000) Perio-

dontal status of adult Sudanese habitual users of Miswac

chewing sticks or toothbrushes. Acta Odontol Scand. 58,

31-37.

[21] Faiez, N.H. (1995) Miswac: The natural toothbrush. The

Journal of clinical Dentistry, 8(5), 125-129.

[22] Magbool, G. (1992) Prevalence of dental caries in school

children in Al-Khobar Saudi Arabia. Journal of Dentistry

for Children, 59(5), 384-386.

[23] Norton, M.R. and Addy, M. (1989) Chewing sticks ver-

sus toothbrushes in West Africa. A pilot study. Clinical

Preventive Dentistry, 11(3), 11-13.

[24] Char, D.C.N., Dogao, A.U. and Dogan, M.M. (1987)

SEM, XRF. and EMPA evaluation of Middle Eastern

toothbrush “Salvadora persica”. Journal of Electron Mi-

croscopy Technology, 5, 145.

[25] Guile, E.E., Al-Shammery, A.R. and El-Backly, M.N.

(1996) Oral health survey of Saudi Arabia: Oral health

knowledge attitudes and practice among adults. Journal

of Dental Research, 75, 1276.

[26] Sofrata, A.H., Claesson, R.L., Lingström, P.K. and Gus-

tafsson, A.K. (2008) Strong antibacterial effect of Mis-

wak against oral microorganisms associated with perio-

dontitis and caries. Journal of Periodontology, 79(8),

1474-1479.

[27] Almas, K. (2002) The effect of Salvadora persica extract

(Miswak) and chlorhexidine gluconate on human dentin:

A SEM study. The Journal of Contemporary Dental

Practice, 3(3), 27-35.

[28] Sofrata, A., Lingström, P., Baljoon, M. and Gustafsson, A.

(2007) The effect of Miswak extract on plaque pH. An in

vivo study. Caries Research, 41(6), 451-454.