MISWAK (SALVADORA PERSICA CHEWING STICK) AND ITS ROLE … · the Quesum, the Siwak, Miswak and Arak. Its use as a chewing stick or Siwak was documented in the Arabian Muwasha written

INTRODUCTION

healthy mouth leads to a healthy body. Goodoral hygiene is the key to good oral andsystemic health. Acceptable level of plaque

control, from where periodontal disease cannot beinitiated or progressed is the ultimate desire of oral anddental professionals. The body -mouth relationship isof great interest among health care professionals. Withthe increasing prevalence of oral and dental diseases,the international need for preventive and curativemethods has been surfaced. Not only are alternatepreventive and treatment methods being expanded butalso safe, effective, economical and culture basedtraditional remedies and products are being explored. A tooth brush and tooth pastes are commonly used indeveloped and developing countries for cleaning teeth.

Miswak (chewing sticks) has its unique role in oralhygiene and maintenance of oral health.

MISWAK IN A HISTORICAL PERSPECTIVE

The evolutionary development of the modern daytoothbrush may be traced to chewing sticks that wereused by the Babylonians. The use of chewing stick wasrecorded by the Babylonians in 5,000 BC and the fashionrapidly spread throughout the Greek and Roman empires.The chewing stick was also used by the Egyptians, theJews, and among the Muslim world. References to theuse of chewing stick can be found in the Talmud, asthe Quesum, the Siwak, Miswak and Arak. Its use asa chewing stick or Siwak was documented in the ArabianMuwasha written by Alwashah, in AD 900. It is believedthat the modern day tooth brush was not known inEurope until about 300 years ago, Lewis and Lewis (1).Medical texts of ancient India, Susruta Samhita andCharaka Samhita, have also emphasized on oral hygieneand brushing teeth with herbal sticks (2). Today miswakis being used in different parts of the world. Chewingsticks are known by various names including the word

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MISWAK (SALVADORA PERSICA CHEWING STICK) ANDITS ROLE IN ORAL HEALTH; AN UPDATE

Areej K Almas1 BSKhalid Almas2 BDS, MSc, FDSRCS, FRACDS, MSc, DDPH.RCS, FICD

ABSTRACT: Miswak, as a cultural and scientific heritage oral hygiene tool, it is now being evaluated on evidence-based criteria. Through comparing the naturally-occurring and scientific evolution of Salvadora persica's usage,we will be able to better understand the uniqueness of miswak, relative to that of other oral hygiene tools as beinga solo oral hygiene tool of a significant part of the World population. The review is an update on chemical composition,antimicrobial, anticariogenic, anti plaque, and antigingivtis effects of miswak on oral health in the context of invitroexperiments and clinical trials. Special emphasize is on how to use and when to use miswak for effective cleaningof teeth and mouth. Recent scientific evidence regarding its probiotic role, cell viability and comparative cytotoxicityand research trends will be highlighted.It is hoped that the review will help health care professionals to have better knowledge and awareness about miswak,to improve the quality of life of their culturally diverse patients population who are uninitiated for regular oralhygiene measures due to various constraints. The use of miswak on population bases is in line with the theme ofprimary health care approach (PHCA) and oral health promotion. Miswak has wider acceptance among manycommunities and populations around the world.KEY WORDS: Miswak, Chewing stick, Salvadora persica, natural tooth brush, oral hygiene.HOW TO CITE: Almas AK, Almas K. Miswak (Salvadora Persica Chewing Stick) And Its Role In Oral Health;An Update. J Pak Dent Assoc 2013; 22: 000-000.

A

1. University of Connecticut, College of Liberal Arts and Sciences, Storrs Campus.Connecticut. USA2. Professor of PeriodontologyDirector Predoctoral Periodontics &Director International Fellowship in AdvancedPeriodontics Division of Periodontology,University of Connecticut, School of Dental Medicine Farmington. Connecticut. CT06030. USAEmail: [email protected], [email protected]

REVIEW ARTICLE

“miswak” or “arak” in Arabic, “qesam in Hebrew,“qisa” in Aramaic, “koyoji” in Japanese, “mastic” inLatin (3) and “mefaka” in Ethopia (4) and datun inPakistan and India (5).

In many Middle Eastern, Asian, and AfricanAmerican communities, traditional methods of toothcleaning are still used due to low cost, affordability,availability, usage in rituals, and to serve custom, andreligious purposes (6). Chewing sticks have variousother uses such as: using them as jaw exercisers,inducing a reflex of copious saliva secretion, combatingundesirable oral habits including smoking and thumb-sucking, and lastly, they can also be used during theteething process (7). In terms of geographicaldistribution, S. persica usage is widely spread andranges from countries such as Malaysia, Nepal andIndia in the East through Iran, Iraq, Pakistan, SaudiArabia, and Egypt to Mauritania in the West, from NorthAfricaand Central Africa to Southwestern Africa (8).

In the Middle East, Arak (Salvadora persica) isthe most common chewing stick. Additionally, the rootsof African laburnum (C. siberianba) are used in SierraLeone and Neem (A. indica) is primarily common inthe Indian subcontinent. Other forms of chewing stickscan be found in Western Africa, where the lime tree(C. aurantafolia) and the orange tree (C. sinensis) areutilized for oral health purposes. Not only are miswakused for oral hygiene, they are also related to religiousrituals and social purposes (9).

One hundred and eighty-two kinds of plants/shrubshave been used as chewing sticks, throughout thedeveloping world; the most significant is Arak,Salvadora persica (10). The roots, twigs, and stems arethe specific parts of the plant that provide dental hygiene(11).

The miswak is a small, upright evergreen tree orshrub with white branches and aromatic roots, rarelyever more than three meters in height and 30 cm indiameter (12). The fresh leaves on the S. persica canbe utilized in traditional medicine for treating cough,asthma, scurvy, and other diseases, whereas, the flowersof the tree are used as a stimulant and are mildlypurgative (9). Stems and roots of the S. persica arespongy, thus they can be easily chewed and crushedbetween the teeth. The chewing stick becomes quitespongy after it is soaked in water; therefore, it is highlyunlikely to traumatize the gums, if used properly, while

brushing (7). The stem or root is chewed on one end,until it becomes frayed and looks similar to the headof a toothbrush (9).

Considering the historical, cultural and religiousimportance of S. persica miswak as an oral hygieneand maintenance tool, this current review is an updateon recent developments in miswak research. Majoremphasize is on chemical composition, how to use andwhen to use miswak for effective cleaning of teeth andmouth. Recent scientific evidence regarding its probioticrole, cell viability and comparative cytotoxicity andresearch trends are highlighted.

CHEMICAL COMPOSITION

The advantageous effects of miswak, in terms oforal hygiene maintenance and dental health, can beattributed to the mechanical role of brushing and itspharmacological component (9). Chemical analysisshows that miswak contains numerous, naturalconstituents that are known to benefit oral health. Thechemical substances present in S. persica are as follows:chloride, fluoride, saponins, salvadorine, silica, sulfur,sterols, trimethylamine, and vitamin C (7). Anotherchemical investigation demonstrates the followingcompounds present in the S. persica plant: b-sitostroland m-anisic acid chlorides, salvadorea, and gypsum;organic compounds, including pyrrolidine, pyrrole, andpiperidine derivatives; glycosides, such as salvadosideand salvadoraside; and flavonoids, including karmpferol,querceting rutin, and a quercertin glucoside (13). Themain constituent of the Salvadora persica root oil isBenzyl- isothiocyanate (BITC) (14). This componentof the Salvadora persica root, Benzyl- isothiocyanate,exhibits broad-spectrum bactericidal activity (15) andinhibits the growth and acid production of Streptmutans(16). According to Chawla (17) , chewing sticks likeNeem (A. indica), S. persica, A. arabica contain anoticeable amount of fluoride (79).

Many of Salvadora persica's constituents citedabove, aid in the prevention of decay and benefits topreserve the human dentition if utilized properly. Thesilica present in chewing sticks acts as an abrasivematerial to reduce stains and whiten teeth. Both thesulfur compounds and alkaloid (salvadorine) presentin S. persica have a bactericidal role but, onlysalvadorine exerts a stimulatory action on the gingival(9). The tannins and resins give protection against caries

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Miswak (salvadora persica chewing stick) anditsrole in oral health; An updateAlmas AK / Almas K

by forming a layer over the enamel due to the astringenteffect on the mucous membrane. Chewing sticksobtained from plants similar to Aegles marmelosm,S. persica, A. indica, and Fagara zantholoxoids containessential oils that exert analgesic, antiseptic, andcarminative action. Strong anti-inflammatory action onthe gums is provided by substance present in otherplants, including Alnus glutinosa, Antidesma venosum,and A. indica (7). Lastly, due to the high concentrationsof chloride present in S. persica miswak, calculusformation is inhibited (9). Also, since miswak is usedregularly and for a longer period of time, severe calculusbuildup does not occur.

THE PREPARATION OF A MISWAK

The recommended method for preparing a usablechewing stick is discussed by Almas and Al-Lafi (5).A chewing stick is a piece of wood, usually from thestem of a plant that has an average length of fifteencentimeters and a diameter of one centimeter. Thoughchewing sticks are sold in several different lengths anddiameters, it is important to adjust both the length andthe diameter according to the general user. A length oftwenty centimeters for adult use and fifteen centimetersfor children/minors are the size values recommendedfor convenience and to insure safe and proper use ofthe miswak. They also provided a brief anatomicaldescription of the phloem, fibers, and wood of theS. persica plant. There is a large amount of phloem inthe S. persica, as well as, widely spaced, think-walledfibers. The spongy wood can be easily crushed by theteeth and softened so that the miswak is chewablewithout any difficulty.

The first step is to prepare a chewing stick that isfreshly cut so that they are supple and still possess allof their active constituents. The reason being, that avery dry chewing stick can damage the gumssurrounding the teeth in the oral cavity. It is vital toremember that if a stick is originally dry, it should besoaked in fresh water for twenty-four hours. If the stickis immersed in water for a longer period, it can causethe loss of active ingredients present in the chewingstick, and can even diminish the therapeutic propertiesthe stick possesses. Next, in order to create bristle-likestructures on the chewing stick, one side of it shouldbe chewed on for few seconds, until the fibers standout similar to individual bristles of a regular toothbrush

(Fig 1.) After having been used for several instances,the chewing stick is either replaced by a new one or a

fresh end is formed by cutting off the old bristles, andcreating new ones by chewing and tapering it. It isrecommended that the chewing stick should be kept ata moist place when not in use. It should be washed/rinsedwith water before using it again (7).

TECHNIQUES OF USING A MISWAK

Almas and Al-Lafi (7), gave an account of themechanical techniques employed for removing plaqueusing a toothbrush and a miswak are analogous. Verticaland horizontal brushing is important, however, themanual dexterity of individuals, their attitude towardsand knowledge of oral health is the critical basis neededto maintain proper oral cleanliness. The chewing stickresembles to the toothbrush as both have bristles andare utilized to remove biofilm/plaque from the toothsurfaces mechanically. However, the chewing stick alsohave a chemical role and may be chewed or sucked formany hours daily by some people.

A length of 15 cm for children and 20 cm for adultsis highly recommended for convenient grip and ease ofmanipulation. A diameter of 1 cm makes for supplenessand sufficient firmness (7).

Two basic holds have been described in order tohave a firm, well controlled movement of the brush-end of the chewing stick in mouth is achieved and thatevery part of oral cavity is reached with relativeconvenience. They are described below (8);4 Five fingers grip (shown in figure 2)q The four fingers of one hand are curled lightlyfound the stick, with the index finger nearest the endto be chewed.


Miswak (salvadora persica chewing stick) anditsrole in oral health; An update

Fig 1. Bristles end of three different shaped chewing sticks.

Almas AK / Almas K

q The pulp of the thumb rests firmly on the oppositeside of the stick to the index finger, the thumb is thusin a higher position than the index finger. The thumbcontrols the movement of the stick and retains it in afirm grip. All tooth surfaces are accessible if the wristor arm is moved as needed.4 Three fingers grip (shown in figures 3 & 4)q The chewing stick is placed between the index andthird fingers. The operative end of the stick is pointedupwards when the hand is in the supine position.q The fourth and fifth fingers are kept clenched onthe palm.q The thumb rests on the side opposite the index thethird fingers, where it assumes the dominant role and

position.The tooth cleaning movement should be directed

away from the gingival margin of the teeth on both thebuccal/facial and lingual surfaces. An anterior toposterior scrubbing movement is carried out on theocclusal surfaces. Careful movement and effort shouldbe done to avoid damaging the soft tissues of the oral

cavity (Fig 5). Satisfactory cleaning can be achieved if

the procedure is practiced for three-five minutes.Tongue is another part of the oral cavity that needs

to be cleaned to maintain proper oral hygiene. Thetongue is considered to be the cause of badbreath/halitosis if there is a buildup of a white coatingon the dorsum of the tongue. Likewise to cleaning teethwith it, the miswak is very effective against cleaningthe surface of the tongue in two ways. The bristle endof the miswak can be used, however, for best possibleoutcome, the sticks can be broken into a V-shapedmanner and the resulting blade can be used to scrapeseveral times across the tongue, posterio-anteriorly.The miswak is not only a natural toothbrush; it can alsobecome a makeshift natural tongue scraper for achievinggood oral hygiene (7).

WHEN TO USE THE MISWAK

Unlike the toothbrush, that is usually allotted aspecific time-morning, afternoon, or night, to be used-


Miswak (salvadora persica chewing stick) anditsrole in oral health; An update

Fig 2. Five fingers grasp (palm grasp) of chewing stick.

Fig 3. Three fingers grasp of chewing stick.

Fig 4. Three fingers grasp of chewing stick (being used by a child).

Fig 5. The application of chewing stick on buccal surfaces (A),on lingual surfaces (B) and on occlusal surfaces (C).

Almas AK / Almas K

miswak can be used at various different times throughoutthe day. For instance, many people use miswak in publicplaces, while conversing, before breakfast, before goingto bed, before praying, and so on (7). Ideally, thechewing stick should be used before meals orimmediately after meals so that the bacteria that convertsugar into acid can be removed. However, it was foundthat the use of miswak after meals is not practical, sincethe drop in pH and the associated damage takes placewithin a few minutes, and after twenty minutes, thesaliva executes the buffering role. In general, the useof miswak, five times a day, is recommended for allbenefits of the naturally occurring effects to take place. To the Muslim, the use of chewing stick is an importantpart of ablutions before worship which takes place fivetimes daily. The regular use of chewing stick conformswith the theme of primary health care and has long beenestablished practice with certain cultural and religiousbeliefs and norms (7).

EFFECTS OF MISWAK ON ORAL HEALTH

Antimicrobial effectsSome invitro studies exemplified that S. persica

extracts inhibited the growth of various oral aerobicand anaerobic bacteria (6). In an invitro study by Almas(15), the antimicrobial effects of the aqueous extractbelonging to seven different types of chewing stickswere compared. The several varying types of chewingstick that were examined included Azadirechta indica,Olea europaea, Acacia Arabica, S. Persica (commonname: Peelu and Arak), Gycosmic pentaphylla, andCapparis aphylla. The four microorganisms that weretested consisted of Strept faecalis, Strept mutans, Staphaureus, and C albicans. The aim of the experimentwas to find out which microbe was affected by one ormore of the chewing sticks and if so, by how much (inmm) was their growth inhibited. It was concluded thatthere was no effect of any chewing stick on Stept mutans,Staph aureus, and C albicans microorganisms.However, the results also concluded that S. persica(Arak) and Acacia Arabica had significant antimicrobialactivity against Strept faecalis at 50% concentration ofthe miswak extract. The inhibition zone was up to twomillimeters for the two chewing sticks.

Another invitro experimental study performed byAlmas et al. (19), focused on comparing miswak extractwith commercially available mouth rinses. Similarly,

there was an experiment to check if there wasany antimicrobial activity. Once again, the microbesincluded were; Strept faecalis, Strept pyogenis,Strept mutans, C albicans, Staph aureus, and Staphepidermis. Mean growth inhibition of the variousmicrobes was recorded (in mm). It was demonstratedthat a 50% extract of S. persica miswak was effectiveagainst both Strep. mutans and Staph. faecalis.The experiment resulted that there was a seven mminhibition zone for Strep. faecalis and a three millimeterinhibition zone for Strep. mutans. However, therewas no microbial inhibition for the remainingmicroorganisms. From the two studies, Almas (18) and Almas et al.(19), it can be concluded that utilizing miswak doesin fact, have antimicrobial effects against two typesof microorganisms. There is stronger action presentedagainst Streptococcus faecalis as compared toStreptococcus mutans. In the examination of theantimicrobial activity of chewing extracts againstdifferent human pathogens, much effort has beenexpended (6). Though not all dental hygiene toolsare helpful in thoroughly inhibiting all pathogens, thereduction of harmful microbial organisms that existin the oral cavity is still a significant achievement.

Various studies have shown that S. persica containssubstances that possess plaque inhibition andantibacterial properties against several types ofcariogenic bacteria which are commonly foundin the oral cavity. The growth and acid productionproperties of these bacteria are thus inhibited(20, 21, 22, 23).

AL-Lafi and Ababneh (24) evaluated theantibacterial properties of S. persica against a few oralaerobic and anaerobic bacteria and reported that theextract of these sticks had a drastic effect on the growthof Staph aureus, and a variable effect on other bacterialspecies. They informed that the chewing sticks usedwere harvested one month earlier, and suggested thatusing more fresh sticks will give better and improvedresults. Almas et al. (23) compared fresh vs. one- month-old miswak extracts for antibacterial activity and foundno difference. A comparison of alcohol and aqueousextract of miswak was also evaluated. It was reportedthat miswak alcoholic extract is more effective thanaqueous extract for antibacterial activity (25). A recentstudy by Almas et al. (26) reported that, the S. persicaextract, at a 50% concentration, delayed the growth of



Actinomyces naeslundii, Lactobacillus casei, Staphaureus, Strept gordonii, Strept mutans, Strept oralis,Strept sanguinis, Veillonella sp. PK1910, F nucleatumand C albicans compared to controls where the extractwas replaced by dPBS. 25% extract had a bacteriostaticeffect in subset of these species, while 10% extracthad no effect. On the contrary, the S. persica extractdid not affect the planktonic growth of Lactobacillusfermentum. Killing assays showed that the extracthad a partial bactericidal effect on most of the strainstested. The S. persica extract did not affect the viabilityof C. albicans, S. aureus and L. fermentum. Sofrata etal., (27), reported that the inhibitory effect was mostobvious on P. gingivalis, A. actinomycetemcomitans,and H. influenza, comparatively less on S. mutans, andleast on L.acidophilus. Suspended miswak pieceshad comparable or even stronger effects than the miswakembedded in agar medium.

ANTIFUNGAL ACTIVITY

Al- Bagieh et al. (28) concluded that aqueousextracts of miswak could be used to reduce growth ofC. albicans. Such inhibition lasts for up to 36 hours atconcentrations of 15% and higher. A recent study byAlmas et al. (26) reported that Salvadora persicaextract did not affect the viability of C.albicans.

Al-Bayati and Sulaiman (29) compared the aqueousand methanol extracts of S. persica chewing stick forantimicrobial activities against seven isolated oralpathogens (S. aureus, Strept mutans, Strept pyogenes,E. faecalis, L acidophilus, P aeruginosa, and C albicans)using two different methods. Both antimicrobial assaysresulted that the aqueous extract inhibited all isolatemicroorganisms and was more efficient than themethanol extract, which was resisted by L. acidophilusand P. aeruginosa. The most pronounced and strongestantibacterial activity was shown by the aqueous extractagainst E. faecalis. Turbidity tests exhibited that bothextracts had equal antifungal activity against C. albicans.Further research is needed in antimycotic/antifungaleffects of miswak.

PROBIOTIC AND PREVENTIVE ROLE OFS. PERSICA MISWAK

Mehanna and Reid (30), studied the effect ofmiswak extract on oral pathogens and its potential for

probiotic use concluded that, miswak had a markedinhibitory effect on the streptococci bacteria and additionof Lactobacillus strains significantly reduced the viablecounts of S. mutans. Almas et al. (26) reported thatS. persica extract had moderate bactericidal propertiesagainst a wide range of oral microorganisms.Interestingly, it did not affect in any way Lactobacillusfermentum, a commonly used probiotic bacterium. Thefinding has not been observed in any previous studies.The quest in the probiotic role of miswak is in progressand hopefully soon further developments would be partof scientific literature.

ANTIOXIDANT CAPACITY OF MISWAK

There is growing interest in bioactive compoundsof S. persica miswak especially antioxidant compounds(31). By definition, antioxidants are substances thatwhen present in foods or body at low concentrationscompared with that of an oxidizable substrate markedlydelay or prevent the oxidation of that substrate. Variousantioxidants included enzymatic antioxidants (e.g.,superoxide dismutase, peroxidase, polyphenoloxidaseand catalase) and nonenzymatic antioxidants (e.g.,ascorbic acid (vitamin C), a-tocopherol (vitamin E),glutathione, carotenoids, and flavonoids) (32).Antioxidants have been considered to help the body toprotect itself against various types of oxidative damagecaused by reactive oxygen species, which are linkedto a variety of diseases including cardiovascular diseases,cancers (33) neurodegenerative diseases, Alzheimer’sdisease (34) and inflammatory diseases (35) and someother ailments. The supplement of the diet (or otheruses) with antioxidant compounds is one of solutionsof this problem that are preserved in natural plantsources (36). These natural plant antioxidants sourcescan therefore serve their role as a type of preventivemedicine. Some investigators suggested that two thirdsof the world’s plant species have medicinal value; inparticular its considered that many medicinal plantshave great antioxidant potential (32).

Mohamed and Khan (31) reported that furanderivatives containing hydroxyl groups could possessantioxidant activities. The antioxidant enzymes were alsodetected in the chewing stick extract with high level ofperoxidase and low level of catalase and polyphenoloxidase.The synergistic actions of antioxidant compounds andantioxidant enzymes make chewing stick as a good tool



for cleaning teeth, oral hygiene, oral health and foodpurposes.

ANTIPLAQUE, GINGIVAL AND PERIODONTALHEALTH EFFECTS OF MISWAK

It has been observed, both clinically andexperimentally, that S. persica chewing stick was aseffective and useful as a toothbrush for reducing plaqueon buccal tooth surfaces (37). While assessing plaqueremoval in children from Ethiopia, it was confirmedthat the chewing stick appeared to be as effective asthe toothbrush, if not more (4). In addition, practicing the proper use of chewing stick as an oral hygieneaid, significantly lower plaque scores in comparisonwith the use of commonly used toothbrushes (38).

A recent statement on oral hygiene measures (39)concluded that bacterial plaque plays an important rolein the etiology of dental caries, gingivitis andperiodontitis and effective removal of dental plaquecan result in the prevention and or reduction of theabove mentioned diseases and conditions (6). As aconsequence of plaque reduction, the usage of chewingsticks can also assist in the reduction of gingivalinflammation. However, chewing sticks can causeocclusal tooth wear and a small degree of gingivalinflammation if used improperly or excessively.Moreover, if a miswak stick is chewed upon in the samearea of the mouth, and over a long period of time, itcan end up proving to be detrimental instead of beneficial(7). Gingival indices were found significantly lowerfollowing the use of S. persica chewing sticks incomparison with the use of a commonly usedconventional toothbrush without toothpaste (38).

Relatively low number of tooth loss in adults havebeen reported in countries where miswak is commonlyused (10). Epidemiological studies (40,41) emphasized that chewing stick use had beneficial effects on theprevalence and prevention of periodontal diseases andcaries. Some other studies reported low periodontaltreatment needs among Saudi adults who were regular miswak users (40, 42). An epidemiological study ofnomadic population of the Kaisut Desert region ofKenya reported that dental caries and advancedperiodontal disease were rare among miswak usersunder the age of 50 years (43). A retrospective studyfrom Saudi Arabia reported conflicting results aboutmiswak users. They observed deeper periodontal pockets

and a higher prevalence of periodontal diseases amongmiswak users (44) than did non-users. In an institutionalstudy from Sudan (45), showed that the periodontalstatus of regular miswak users was similar to or slightlybetter than that of toothbrush users. The above mentionedstudies reflect the beneficial use of miswak for thegingival and periodontal health.

CYTOTOXICITY OF MISWAK EXTRACT

The effective role of an ideal antimicrobial agentdepends on its ability to kill microbes while causingminimal toxicity to host cells (minimal collateraldamage). Rajabalian et al. (46) compared pesicamouthwash and Chlorhexidine mouthwashes on culturedhuman and mouse cell lines. The cytotoxic effects offour dilutions of Persica and Chlorhexidine mouthwasheson KB, Soas-2, J744 A1, and gingival fibroblast cellswere evaluated using MTT assay. The effect of fetalcalf serum (FCS) components on the cytotoxicity ofthese mouthwashes was also evaluated. They found thatboth Persica and Chlorhexidine mouthwasheswere toxic to epithelial, fibroblast, macrophages, andosteoblast cells in concentration-dependent manner.

A recent comparative study by Almas et al.(47),on cytotoxicity of S. persica aqueous extract andChlorhixidine gluconate on L929 mouse fibroblastsobtained from American Type Culture Collection(Manassas, VA, USA). They concluded that the cellviability of miswak extract was 88%, 90%, 97%, 95%in original strength (50%) and 1/2 , 1/4, 1/8, 1/16, 1/32dilutions, while the cell viability of CHX is 3% , 47%,87%, 93%, 92% and 95% in the correspondingconcentrations. Miswak extract had significantly lesscytotoxicity than CHX in the original and 1/2, 1/4dilutions (p=0.05).

Mohammad and Turner (48) tested the cytotoxicpotential of the S. persica miswak and its diffusiblecomponents on oral tissues using the tissue culture agaroverlay method. They reported no cytotoxic effect offreshly cut S. persica chewing stick, but observed thatthe same plants contained harmful components if usedafter 24 hours. A recent study evaluated the role ofdirect administration of high doses of S. persica miswakextract to mice, reported minor side effects on maleand female reproductive systems and fertility (49). Anearlier study concluded that neither aqueous norethanolic S. persica miswak extract was toxic to mice,




reported minor side effects on male and femalereproductive systems and fertility (49). An earlier studyconcluded that neither aqueous nor ethanolic S. persicamiswak extract was toxic to mice at doses of up to1200 mg/kg (50).

Further research is needed to assess the comparativecytotoxic effects of miswak extract and Chlorhexidineto human macrophages, epithelial cells, fibroblasts andosteoblasts. That would help to precisely use of miswakextract or chlorhexidine after periodontal or oral surgeryprocedures.

MISWAK AS A CULTURAL HERITAGE ANDORAL HEALTH PROMOTION TOOL

In the early Islamic period, the use of miswakbecame a part of a cultivated and elegant mode of lifeand as a prominent feature of Islamic hygienicjurisprudence. Today, cross-cultural knowledge canhelp motivate public health dentists and dental hygieniststo recognize culturally accepted behaviors for thepu rpose o f s t r eng then ing pa t i en t -p rov ide rrelationships and optimizing public health outcomes.Such recommendations can offer ways to mix or mergewestern healthcare with Islamic practices and preceptssurrounding the use of miswak and dental hygienepractices considering that healthcare providers andprofessionals live and work in a global village orsociety. (51). The French philosopher Auguste Comte(1798-1857) stated, “demography is destiny”. Withworld populations becoming more culturally diverse,healthcare providers must practice cultural awarenessand sensitivities to achieve trust, and to direct thepatient-provider relationship toward the desired goalof quality oral health care for all populations.Unfortunately, ignorance of customs can undermine theestablishment of trusting relationship. As in the case ofthe miswak chewing stick; oral health care professionalsshould review miswak use with their patients to ensureproper and effective use and angulation to achievemaximum bacterial plaque removal. (51-53). Miswakbeing a cultural and scientific heritage has a lotmore to offer to present day oral hygiene needs of manycommunities around the world.

CONCLUSION AND RECOMMENDATIONS

Miswak has been proven effective as an oral hygiene

aid and should be introduced and promoted to generalpopulation based on scientific rationale. In addition,the use of the miswak conforms to the theme of primaryhealthcare approach, as well as certain cultural,traditional, social, and religious beliefs and rituals.Incorporating the utilization of miswak into thehealthcare system of many developing countries willgreatly facilitate the masses with financial constraints,as well as limited oral health care facilities.

Miswak is available in rural areas of developingcountries, it does not require special technology toproduce. Health care resources are limited in manycountries, and there is a growing concern to scientificallyresearch, and test freely available and relativel low costtraditional preventive tools in order to improve thehealthcare conditions of the world population.

Despite the high initial cost of further investigatingthe properties of S. persica miswak, it will prove to beeconomically and financially profitable once theconsorted efforts are made. The advantageous effectsof miswak usage are undeniable, and it is indisputablethat there is a plethora of benefits of utilizing themiswak. Now, the responsibility of healthcareprofessionals including, medical and dental doctors,hygienists across the globe is to revisit miswak forbetter oral and systemic health of their respectivepopulations. Certainly that would improve the qualityof life of those populations and societies and reducethe oral diseases and financial burden. Countries likePakistan, could benefit from the culture and religion-based oral hygiene use of miswak both at rural andurban levels. Healthcare professionals should learnmore about the recent advances in scientifically provenrole of miswak for their respective clientele.

Further research should be conducted to exploreprobiotic and antioxidant role of miswak. Doubleblinded, randomized clinical trials (RCTs) comparingclinical parameters of periodontal health and diseaseswould add into evidence-based scientific credibilityand practices of miswak.

ACKNOWLEDGMENTS

Authors would like to thank and appreciate thededicated researchers for their continuous interest inmiswak research. I am (KA) pleased to share my twentyyears of scientific progress and contributions to miswak(Salvadora persica chewings sticks) literature



(Appendix; A). It is hoped the review would attractand invite new researchers in the scientific journeyof miswak.

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MISWAK (SALVADORA PERSICA CHEWING STICK) AND ITS ROLE … · the Quesum, the Siwak, Miswak and Arak. Its use as a chewing stick or Siwak was documented in the Arabian Muwasha written