80                            MISWAK (CHEWING STICK): A CULTURAL AND                                      SCIENTIFIC HERIT...
AL SADHAN AND ALMAS                                                                                            81 Black Am...
82                                                                               MISWAK TYPES AND EFFECTSto the treatment ...
AL SAD HAN AND ALMAS                                                                                         832. Antimyco...
84                                                                             MISWAK TYPES AND EFFECTSStudies showing Rel...
AL SADHAN AND ALMAS                                                                                            85recession...
86                                                                                      MISWAK TYPES AND EFFECTS  The use ...
AL SADHAN AND ALMAS                                                                                               8724. Mo...
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  1. 1. 80 MISWAK (CHEWING STICK): A CULTURAL AND SCIENTIFIC HERITAGE RAED I. AL SADHAN,* BDS KHALID ALMAS,1 BDS, MSC, DDPH.RCS, FRACDS, FDS RCSED, FICD Miswak (chewing stick) was used by the Babylonians some 7000 years ago; it was later used throughout the Greek and Roman empires, and has also been used by ancient Egyptians and Muslims. It is used in different parts of Africa, Asia-especially the Middle East- and South America. Chewing sticks are used for oral hygiene, religious and social purposes. This article presents some of the different types of chewing sticks used around the world with special emphasis on the most commonly used plant in the Middle East, the Arak (Salvadora persica). The Pharmacological and therapeutic aspects of Miswak and its role in plaque control, gingival recession, tooth wear, bleeding gums and periodontal health is discussed with reference to current literature. Finally, this review concludes with how to select and use the Miswak. Introduction chewed on one end until they become frayed into a brush. The brush-end is used to clean the Dental caries and periodontal diseases are the teeth in a manner similar to the use of atwo main afflictions to mankind. Bacterial toothbrush. When used in this manner, they areplaque is solely responsible for the initiation and commonly referred to as chewing sticks orprogression of periodontal diseases. The Miswak.methods available for the maintenance of oral The conventional meaning of Miswak is stickhealth are mainly mechanical and chemical. used on teeth and gums to clean them. ItsToothbrushes and dentifrices are widely used various names are Miswak and Siwak as used infor cleaning teeth. The traditional toothbrush or the Middle East, Mswaki in Tanzania, Mefaka inchewing stick is deeply rooted in Islamic culture. Ethiopia and Datun in India and Pakistan.1This article gives a brief cultural and historical Although Siwak or Miswak is used to describebackground of the subject and review current Arak (Salvadora persica), the stick which theliterature on Miswak. Prophet Muhammad - Peace and Blessings ofDefinitions Allah be upon Him (PBUH) - used to clean his mouth with, miswak is a more general term Pencil-sized sticks of various plants are which includes all types of sticks used as tooth-fashioned from certain plant - parts and are cleaning aids.Received 2.12.98; Accepted 11.20.98•Demonstrator, Division of Oral and Maxillofacial Radiology, Types of MiswakDepartment of Maxillofacial and Diagnostic Sciences, College of Dentistry, King Saud University. In the Middle East, the most common sourceAssistant Professor, Division of Periodontics, Department of of chewing sticks is Arak (Salvadora persica). InPreventive Sciences, King Saud University, College of West Africa, the lime tree (Citrusaurantafolia)Dentistry, P.O. Box 60169, Riyadh 11545, K.S.A. and the orange tree (Citrussinensis) are used.Address reprint requests to: Dr. Khalid Almas The roots of senna (Cassia vinnea) were used by The Saudi Dental Journal, Vol. 11, No. 2, May August 1999
  2. 2. AL SADHAN AND ALMAS 81 Black Americans, and those of African laburnum Chemical Composition of Miswak (Salvadora {Cassia sieberianba) were used in Sierra Leone. persica) Neem (Azadirachta indica) is widely used in the Indian subcontinent.2 The beneficial effects of Miswak in respect of Arak, a tree used for Miswak, is also known as oral hygiene and dental health are partly due to"tooth brush tree" and "mustard plant". Although its mechanical action and partly due tothe Miswak is usually obtained from the roots of pharmacological actions.the Arak tree, some sticks are made from its Farooqi et al4 isolated benzy-lisothiocyanatebranches and bark.3 from Salvadora persica root, they claimed to Salvadora persica is an upright evergreen have found saponins along with tannins, silica, asmall tree or shrub, seldom more than one foot small amount of resin, trimethylamine and ain diameter reaching maximum height of three fairly large amount of alkaloidal constituents.meters. The leaves are small, oval, thick and Ray et al5 found B-sitosterol, m-anisic acid, andsucculent with a strong smell of cress or salvadourea [1,3-Bis-(3-methoxy-benzyl)-urea].mustard. The fresh leaves are eaten as salad Lewis and Elvin-lewis6 report a high content ofand are used in traditional medicine for cough, minerals in the root: 27.06%.asthma, scurvy, rheumatism, piles and other Ezmirly et al7 also found B-sitosterol, togetherdiseases. The flowers are small and fragrant and with elemental sulfur (S8 a monoclinic form) inare used as a stimulant and are mildly purgative. the root of Salvadora persica. They also foundThe berries are small and barely noticeable; they sulfur-containing mustard oil with the content ofare eaten both fresh and dried.4 sulfur in the ash of the roots as high as 4.73%. Attar8 indicates that plant fibers contain sodiumHistorical and Cultural Background of Miswak bicarbonate. El-Mostehy et al9 reported finding the following chemical substances: Trime- The use of Miswak is a pre-lslamic custom, thylamine, an alkaloid, chlorides, high amountswhich was adhered to by the ancient Arabs to of fluoride, silica (Si02), sulfur, vitamin C, andget their teeth white and shiny. It also small amounts of tannins, saponins, flavenoidscontributed to ritual purity. This custom was and sterols. Akhtar and Ajmal10 mentionedadopted and Islamized by Prophet Muhammad resin and large amounts of salts containing(PBUH) around 543 AD. This kind of chlorine. A study by Chawla11 reported thattoothbrushing has been used by the Arabs, the some types of chewing sticks such as NeemBabylonians some 7000 years ago,2 theJapanese called it Koyoji, while the Romans (Azadirachta indica), Salvadora persica andused mastic to rub their teeth and as a Acacc/a arabica contain a reasonable amount oftoothpick. Ancient Egyptians and the Jews also fluoride.used it.3 It is in use throughout the Islamiccountries. The Effects of Different ComponentsReligious Background The effectiveness of a topical fluoride preparation depends on its ability to wet the Islam introduced basic oral hygiene by tooth enamel and adequately reach cariesincorporating it as a religious practice. Islam susceptible sites such as pits, fissures andteaches the importance of cleanliness of the interproximal areas. The repeated process ofbody as well as of the mind. Several quotations using chewing sticks releases fresh sap, whichare found in the compendium of the Prophet seems to fulfill the above criteria.2Muhammad (PBUH), as to the benefits of Silica in Miswak acts as an abrasive material toMiswak in oral hygiene. For example: Prophet remove stains giving the teeth whiteness.102Muhammad (PBUH), said: "Siwak purifies the Tannins (tannic acid) are a mixture of esters ofmouth and pleases Allahand said: Were it not gallic acid with glucose whose exactto be a hardship on my community, I would composition varies according to its source.have ordered them to use Siwak for every Tannic acid is an astringent that precipitatesablution. albumin. Its topical use is now restrictedThe Saudi Dental Journal, Vol. 11, No. 2, May - August 1999
  3. 3. 82 MISWAK TYPES AND EFFECTSto the treatment of bedsores, minor ulcerations Calcium saturation of saliva inhibits deminer-and the likes.13 Tannic acid shows anti-tumor alizalion and promotes remineralization of tootheffect on animals and in vitro.u When denture enamel.16bases were treated with tannic acid there were The root of Salvadora persica contains areduced Candida <3/Mv?/75attachments to these steam-distillable oil composed of 10% benzylsurfaces.15 It exerts an astringent effect on the nitrate and 90% Benzylisothiocyanate (BIT).24mucous membrane, thus reducing the clinically BIT is classified as one of the chemo-preventivedetectable gingivitis.12 Tannins also inhibit the agents that are thought to prevent carcinogenicaction of glucosyl transferase thus reducing and other genotoxic compounds from reachingplaque and gingivitis.16 or reacting with the target sites on the treated Resins are amorphous products with a tissue.25 Al Dosari et al26 studied the effect ofcomplex chemical composition. They are end BIT on epithelial changes induced by traumaproducts of metabolism. Physically, they are and Dimethylbenzanthracin (DMBA) in theusually hard, transparent, or translucent and, hamster tongue. Their results indicate that BITwhen heated, soften and finally melt. retarded the development of neoplastic changesChemically, they are complex mixtures of resin induced by trauma or trauma plus DMBA. BIT isacids, resin alcohols (resinols), resin phenols reported to have a virucidal activity against(resinotannols), esters, and chemically inert herpes simplex virus 1 (HSV-1) at acompounds.1317 Resin forms a layer over the concentration of 133.3 mg/ml.27 In addition, it isenamel and thus protects against caries.12 reported to have a broad-spectrum bacteriocidal Alkaloids are one of a large group of basic activity.28 Al-Bagieh et al reported that BITnitrogenous organic compounds found in inhibits the growth and acid production ofplants, usually having strong physiological or streptococcus mutans.29toxic effects on the animal body. They areusually derivatives of Nitrogen ring compounds, Pharmacological Propertiespresenting colorless crystals that are bitter intaste, soluble in alcohol, and slightly soluble in 1. Antibacterial propertieswater, their names end in - ines. Examples are Studies have indicated that Salvadora persicaatropine, caffeine, coniine, morphine, nicotine, contain substances that possess plaquequinine, and strychine. The term is also applied inhibiting and antibacterial properties againstto synthetic substances such as procaine.1819The alkaloid present in Salvadora persica is several types of cariogenic bacteria which areSalvadorine, which yields trimethylamine on frequently found in the oral cavity. The growthhyrolytical cleavage.20 It exerts a bacteriocidal and acid production of these bacteria is thuseffect and stimulatory action on the gingiva.1 inhibited.7-23-2930 Essential (volatile) oils possess characteristic Al Lafi and Ababneh31 tested the antibacterialaroma and exert carminative, antiseptic action.10 activity of Salvadora persica against some oralThe mild bitter taste stimulates the flow of aerobic and anaerobic bacteria and reportedsaliva, which is antiseptic.21 that the extract of these sticks had a drastic The sulfur compounds present in Miswak as effect on the growth of Staphylococcus aureus,shown by their pungent taste and smell have a and a variable effect on other bacterial species.bactericidal effect.22 They commented that the chewing sticks they Vitamin C helps in the healing and repair of used were harvested one month earlier, andtissues. suggested that using more fresh sticks will give Sodium bicarbonate (baking soda) NaHCOB better result. Almas et al32 tested fresh vs. one-has mild abrasive properties and is, thus, used month-old Miswak extracts for antibacterialas a dentifrice.18 In addition to having a mild activity and found no difference. A comparisongermicidal action.23 of alcohol and aqueous extract of Miswak was High concentrations of chloride inhibit also made. It was found that alcoholic extract iscalculus formation4 and help in removing stains more effective than aqueous extract forfrom the teeth.1 antibacterial activity.33 The Saudi Dental Journal, Vol. 11, No. 2, May - August 1999
  4. 4. AL SAD HAN AND ALMAS 832. Antimycotic activity Uses of Miswak for Therapeutic Purposes Results of the investigation carried by Al-Bagieh et al14 suggest that aqueous extracts of Whenever Miswak is used, both the teeth andMiswak could be used to reduce growth of the tongue are cleaned. It has also been usedCandida albicans. Such inhibition lasts for up to to treat toothache. Miswak has various36/h at concentrations of 15% and above. therapeutic uses, such as reputed benefits from the juice of the stick extracted on chewing3. Release of calcium and chloride into saliva (antibacterial extracts) and its functional aspects Gazi et al16 investigated the immediate and of chewing as a jaw exerciser followingmedium-term effect of Miswak on the traumatic injuries to the jaw andcomposition of mixed saliva. They reported that temporomandibular joint, as well as aMiswak produced significant increases in Sialogogue - a reflex induction of copious salivacalcium (22-fold) and chloride (6-fold), and - which is beneficial to the oral hygiene andsignificant decreases in phosphate and pH. general health. Miswak is often used to preventCalcium saturation of saliva inhibits deminera- oral habits such as smoking in adults and thumblization and promotes remineralization of tooth sucking in children. It can also be used in theenamel whereas high concentrations of chloride development of dentition during eruption.1 Itinhibit calculus formation.4 may improve appetite and regulate peristaltic movements of the gastro-intestinal trad.124. Analgesic effect Mansour et al35 studied the analgesic effect of Therapeutic applications of MiswakMiswak decoction when injected to mice. Theyfound that Miswak was more effective against 1. Toothpastethermal stimuli than against chemical stimuli. Some of the known commercial toothpasteShould the analgesic effect of Miswak be produced from Salvadora persica plant are:confirmed in clinical dental pain, e.g. superficial Sarkan toothpaste®, UK, Quali-Meswak tooth-pain due to dental hypersensitivity to thermal, paste®, Switzerland, Epident toothpaste®, Egypt,tactile, or to chemical stimuli, Miswak will be of Siwak-F®toothpaste, Indonesia. Fluoroswak,®practical value. Miswak,® Pakistan.1 Dentacare Miswak Plus,® Saudi Arabia.5. Cytotoxicity Mohammad et al23 investigated the cytotoxic 2. Mouthwashespotential of Salvadora persica on gingiva and Mostafa et al36 found a reduction in plaqueother periodontal structures using the agar formation by Miswak-based mouthwash. But nooverlay method. Results showed no cytotoxic such preparation presently exists in the market.effect by a freshly cut and freshly used Miswak.However, the same plant used for after 24 hours 3. Endodontic irrigation solutiondoes contain harmful components. Based on Although the antimicrobial activity of Miswakthese findings they recommend cutting the used has been reported,72223-293134 its toxicity mustportion of the Miswak after it has been used for be considered. In addition, no report has beenone day and preparing a fresh part. The yet made on the utilization of the extract as ancytotoxicity in this study became evident only irrigant solution in endodontic practice. Abo Alafter 24 hours because the agar overlay method Samh, et al37 evaluated, in vitro, the effect ofdepends on the diffusion of the medicament different concentrations of Miswak extract onthrough the agar material. In addition, it did not L929 cell-line in tissue culture and compared theprovide direct contact between the cells and the results with sodium hypochlorite (NaOCI). Theytested solution.23 found a concentration dependent morphological change of L929 cell-line when6. Other pharmacological properties exposed to Miswak extract and NaOCI. They Miswak was reported to have anti-inflam- suspect recovery of the cells after a 4-hourmatory, hypoglycemic activities723 beside the exposure period to different Miswak extractastringent and detergent effect.9 concentrations.The Saudi Dental Journal, Vol. 11. No. 2, May-August 1999
  5. 5. 84 MISWAK TYPES AND EFFECTSStudies showing Relationship ofMiswak to Oral reduction.47 It was found that streptococcusHygiene mutans were eliminated in the Miswak group and were less in CHX. 1. Plaque reduction Gazi et al41 reported that plaque and gingivitis Few studies have reported on the cleaning were significantly reduced when Miswak waseffectiveness of chewing sticks. Cross-sectional used 5 times a day compared with conventionalstudies show conflicting results. A cross- toothbrush. Another study suggested that thesectional study in Ghana38 among adults frequent use of the Miswak was associated withrevealed higher plaque and gingival bleeding in a reduced need for periodontal care amongchewing stick users as compared with Saudi Arabian adults.48 It has demonstrated thattoothbrush users. Another retrospective study Miswak may be of potential value in reducingshowed that Miswak users had deeper pockets plaque and gingival inflammation.49and more prevalence of periodontal diseases.39 In a controlled study,9 it was reported that In contrast, no differences in plaque and powdered Miswak if used with a mechanically proper device i.e. toothbrush, will give bettergingival bleeding were found between results than Miswak sticks alone or commercialtoothbrush and chewing stick users among 7-15 toothpowder in term of plaque percentage.years old children in Tanzania.40 It is reported Guile et al50 concluded from a survey of Saudithat patients using Miswak regularly show school children that the low incidence ofdecreased gingival bleeding on probing periodontal disease was attributable to thecompared with non-Miswak users.41 Thus, poor practice of using Miswak for teeth cleaning.oral hygiene with those using chewing sticks Similar results and conclusions were reported inmay be a reflection of poor techniques.42 another study regarding dental caries in Saudi On the other hand, controlled longitudinal children.51studies were more consistent. A clinical trial In general, it is concluded from the above-study on Ethiopian schoolchildren comparing mentioned studies that reduction in plaquemefaka (Miswak) with conventional toothbrush, leads to a decrease in gingivitis and ultimately afound Miswak to be as effective as the reduction in bleeding gums.toothbrush in removing oral deposits. The studyalso found instruction and supervision to be 2. Gingival recessionimportant since the children in the sample were A relatively high prevalence of gingivalfound not to be familiar with Miswak techniques. recession among adults in Tanzania has beenThe study further concluded that Miswak should reported.52 Gingival recession on buccal sur-be used in preventive dental programs, as it was faces has been ascribed to brushing habits.53 54economical and familiar to the older people.43 Since the lingual surfaces in the TanzanianIn a clinical trial among adolescents in Nigeria, population exhibits gingival recession to thethe results showed that the Massularia same extent as the buccal surfaces, as has beenacuminata chewing stick was as effective in reported,52 then it is doubtful that the Miswak iscontrolling and removing dental plaque as the the cause of high prevalence of gingivaltoothbrush and paste.42 recession.55 Al-Lafi44 reports reduction in plaque in Miswak Younes and El-Angbawi56 reported that aboutusers. Danielsons, et al-showed that there was a 22% of the Saudi schoolchildren with gingivalreduction of plaque on the front teeth more than recession used Miswak. The low percentage ofthe posterior teeth and recommended Miswak calculus deposits found in the group affected byas a tool for oral hygiene.45 Mustafa et al36 gingival recession may be due to the commonfound 75 per cent plaque reduction after eight use of Miswak.days of Miswak use. It has been reported that Miswak users had significantly more sites of gingival recession Rinsing with a slurry of Miswak toothpaste than did the toothbrush users. Furthermore, thereduces gingival inflammation and bleeding on severity of the recession was significantly moreprobing.46 Chlorhexidine and Miswak were pronounced in the Miswak users than that incompared and Chlorhexidine (CHX) was found the toothbrush users.57 However, the gingivalto be more effective than, Miswak in plaque The Saud! Dental Journal, Vol. 11, No. 2, May - August 1999
  6. 6. AL SADHAN AND ALMAS 85recession reported in Miswak users may be a action and may be chewed or sucked for severalreflection of poor techniques. hours daily by some people.2 But unlike a conventional toothbrush, the bristles of the3. Occlusal wear Miswak lie in the same long axis as its handle. A study by Johansson et al58 analyzed the The angulation in the toothbrush enables it topossible factors influencing the occurrence of adapt more easily to the distal tooth surfacesocclusal tooth wear in a young Saudi population, particularly on the posterior teeth.42factors found to correlate significantly with The techniques employed for removingincreased occlusal wear were bruxism, and the plaque mechanically are similar with theuse of Miswak. toothbrush and the chewing stick, e.g., vertical and horizontal brushing. However, theseHow to use Miswak techniques are less important than peoples attitudes, knowledge and manual dexterity.2 Miswak is available in various diameters and There are two basic holds, Pen-grip (three-lengths and can be further cut into suitable finger grip) or palm-grip (five-finger grip).2 Inlengths by the user. A length of 20 cm for adults each case the aim is to ensure:and 15 cm for children is recommended forconvenience of grip and ease of manipulation in a) Firm but controlled movement of the brusha confined space.2 An excessively long stick end of the Miswak within the oral cavity.may result in serious traumatic injuries, from the b) That every area of the mouth is reached withintra-oral end. This is possible because most relative ease and convenience.59people habitually carry out their oral hygiene The cleaning movement should always bewhilst continuing with other domestic duties.59 directed away from the gingival margin of theThe diameter is normally 1 centimeter. This teeth on both the buccal and lingual surfaces.gives a supple stick which is firm enough to An anterior-to-posterior scrubbing movement istransmit the pressure of the cleansing action to used on the occlusal surfaces. Care should bethe teeth without breaking off.59 The thicker taken to avoid damaging the soft tissues of thesticks tend to be older and difficult to chew.60 mouth. Satisfactory cleaning can be achieved if Miswak should be freshly cut so that it is this procedure is followed for five minutes.2supple, easily chewed, and still rich in active The tongue is commonly cleaned by users ofconstituents.2 The root should be whitish-brown chewing sticks, the objective being to controlin color; a dark brown color indicates that the bad breath and remove the white coating thatMiswak is no longer fresh.23 A very dry Miswak develops on the dorsum of the tongue. Thiscan be expected to damage the gums and other surface is usually cleaned by means of the brushoral tissues. If a stick is dry, the end for chewing end of the chewing stick, but better results areshould initially be soaked in fresh water for 24 obtained by breaking the stick into a V-shapehours. It should be noted that soaking for unduly and scraping the resulting blade several timeslong periods causes loss of active constituents across the tongue.2-12and diminishes the therapeutic properties,although the mechanical effects on the teeth When to Use Miswakcan still be expected to occur.2 Before Miswak isused, the end should be washed with water. It Ideally, Miswak should be used before mealsis then chewed repeatedly until the fibers stand to remove the bacteria that convert sugar intoout like the bristles of a toothbrush. These fibers acid, or immediately after meals. However, theshould be clipped of every 24 hours. If possible latter is impractical, since the fall in pH and thethe Miswak should be kept in a moist place associated damage occur within a few minutes,when not in use.2 and 20 minutes later the saliva performs the Miswak is very similar to the toothbrush in that buffering action itself. It does not seem that theboth have bristles and are used to remove use of Miswak occurs regularly after meals. Inplaque from the tooth surfaces mechanically. general it is recommended to use Miswak fiveHowever, Miswak may also have a chemical times a day.2The Saudi Dental Journal, Vol. 11, No. 2, May - August 1999
  7. 7. 86 MISWAK TYPES AND EFFECTS The use of the Miswak alone can be satisfying 5. Farooqi MIH and Srivastava JG. The toothbrushif enough time is devoted to its application tree (Salvadora persica), Quart. J. Crude Drug Res.during the period it is kept in the mouth. A 1968; 8: 1297-99. 6. Ray AB, Lai Chand and Dutta SC. Chemistrycommon fault is the habit of keeping it in the and Industry. 1975;15 : 517.mouth while domestic duties are carried on, with 7. Lewis WH and Elvin-Lewis MPF. Oral Hygiene,the complete neglect of the stick. A definite Medical Botany, John Wiley & Sons, New York,time should be set aside for the use of the 1977:226-270.chewing stick; five minutes of complete devotion 8. Ezmirly ST, Cheng JC and Wilson SR. Saudito this function is deemed sufficient to ensure Arabian Medicinal plants: Salvadora persica.good cleansing. The resulting smooth feel of Planta Medica. 1978; 35:191-192. 9. Attar ZA. The Miswak, Natures toothbrush.the teeth with the tongue gives a critical Bull. History of Dentistry 1979; 27: 39- 40.measure of the efficiency and effectiveness of 10. El Mostehy MR, Al-Jassem AA, Al-Yassin IA, etthe chewing stick.59 al. Miswak as an oral health device. Preliminary chemical and clinical evaluation. Conclusions and Recommendations Hamdard 1983; 26:41-50. 11. Akhtar M and AJmal M. Significance of chewing• The use of Miswak might have evolved in sticks (Miswak) in oral hygiene from a pharmacological viewpoint. J. Pak. Med.Assoc. various cultures independent of each other. 1981; 4:89-95.11 Chawla HS. A new natural The influence of Islam on the use and spread source for topical fluoride. J Indian Dent Assoc of it in the world is significant. The concept of 1983;55:419-422. Miswak in Islam includes all oral hygiene aids 12. Chawla Hs. A new natural source for topical and is not restricted to the use of Arak fluoride. J Indian Dent Assoc 1983; 55: 419-422. "Salvadora persica* sticks. 13. Khoory T. The use of chewing sticks in preventive oral hygiene. Clinical Preventive Dentistry. 1983; 5:11-14.• A traditional practice so common in large 14. Tyler VE, Bradly LR Robebers JE. "Pharma- percentage of our population should be cognosy" 9th Ed. Lea & Febiger 1988; 80-106. further thoroughly investigated on modern 15. Gali HU, Perchellet EM and Perchellet JP. scientific lines. "Inhabition of turner promoter-induced ornithine decar-boxylase activity by tannic• Miswak can be a good alternative to the acid and other poly-phenols in mouse epi- toothbrush since it is inexpensive, and readily dermis in vivo". Cancer-Res. 1991; 51 : 2820-5. available. Miswak contains many medicinal 16. Kubota K, Tanaka T, Murata Y and Hirasawa M. Effect of tannic acid on adherence of Candida to properties, and is available in most rural areas denture base. J of Dental Research 1988; 67: of the poor countries. It does not need abstract 183. expertise or any extra resources to 17. Gazi Ml, Davies TJ, Al-Bagieh N and Cox SW. The manufacture it. Thus it is recommended as an immediate and medium- term effects of Meswak important and effective tool for oral hygiene. on the composition of mixed saliva. J Clin Perio- dontol 1992; 19: 113-117.• Dentists who practice in areas where chewing 18. George ET and William CE Pharmacognosy. 12th ed. Bailliere Tindall 1985; 95. sticks are commonly used should realize that 19. Jablonski S. Illustrated Dictionary of Dentistry. their patients might need specific instructions Philadelphia: W. B. Saunders Comp., 1982. on proper ways to use the chewing sticks. 20. Dorland W. A. Newman. Dorlands Illustrated Medical Dictionary. 27th ed. Philadelphia: W. B. References Saunders Co., 1988. 21. Dorner WG. Active substances from African and1. Almas K. Miswak (chewing stick) and its role in oral Asian natural toothbrushes Chemische Run- health. Postgraduate Dentist 1993; 3: 214-18. dschau 1981; 34: 19-23.2. Almas K and Al - Lafi T. The natural toothbrush. 22. Grant J. Miswak- toothbrushes that grow on World Health Forum 1995; 16:206-10. trees. Todays - FDA. 1990; 2: 60.3. Gerrit Bos. The Miswak, an aspect of dental care in 23. Abo Al-Samh D. and Al-Bagieh N. A study of Islam. Medical History 1993; 37:68-79. antibacterial activity of the miswak extract in4. Farooqi MIH and Srivastava JG. The toothbrush vitro. Biomedical Letters. 1996; 53: 225-238. tree (Salvadora perslca). Quart. J. Crude Drug Res. 1968;8:1297-99. The Saudi Dental Journal, Vol. 11, No. 2, May - August 1999
  8. 8. AL SADHAN AND ALMAS 8724. Mohammad A and Turner JE. In vitro evaluation of 40. Olsson B. Efficiency of traditional chewing Saudi Arabian toothbrush tree (Salvadora persica). sticks in oral hygiene programs among Ethiopian Odontostomatol Trop 1983; 3:145-148. school children. Comm Dent Oral Epidemiol24. Ezmirly ST and El-Nasr MS. Isolation of gluco- 1978; 6:105-9. tropaeolin from Salvadora persica. J Chem Soc 41. Al-Lafi T. Effectiveness of Miswak as a tool for oral Pak 1981; 3: 9-12. hygiene. M Sc. Thesis 1988. University of25. Wattenberg LW. Inhibition of carcinogenic effects London. of polycyclic hydrocarbons by benzylisothio- 42. Danielsons B, Baelum V, Manji F and Fejerskov O. cyanate and related compounds. J Natl Cancer Chewing stick, toothpaste and plaque removal. Inst. 1977;58:395-8. Acta Odontol Scand 1989; 47:121-25.26. Al-Bagieh NH and Weinberg ED. Benzylisothiocya- 43. Gazi M, Lambourne A and Chagla A. The anti- nate: a possible agent for controlling dental caries. plaque effect of toothpaste containing Salvadora Microbios. 1988; 39: 143-151. persica compared with chlorhexidine gluconate.27. Brown JM and Jacobs JW. An investigation into Clin Preventive Dent 1987;9:3-8. antibacterial activity in chewing sticks against oral 44. Gazi M. Photographic plaque assessment of the streptococci. Odontostomatol Trop. 1979; 2 :25-30. antiplaque properties of Sanguinarine and chlor-28. AI-LafiTand Ababneh H. The effect of the extract hexidine. J Clin Periodontol 1988; 15:106-9. of the Miswak ( chewing sticks ) used in Jordan 45. Al - Khateeb TL, OMullane DM, Whelton H and and the Middle East on oral bacteria. Int Dent J. Sulaiman Ml. Periodontal treatment needs 1995;45:218-22. among Saudi Arabian adults and their relation-29. Almas K, Al-Bagieh N, and Akpata ES. In Vitro ship to the use of the Miswak. Comm Dent antibacterial effect of freshly cut and 1-month-old Health 1991;8:323-28. Miswak extracts. Biomedical letters. 1997;56:145- 46. Eid MA, Al - Shammery AR and Selim HA. The 149. relation-ship between chewing sticks (Miswak)30. Al - Bagieh N. and Almas K. In-vitro antibacterial and periodontal health. II. Relationship to plaque, effects of aqueous and alcohol extracts of Miswak gingivitis, pocket depth, and attachment loss. (chewing sticks). Cairo Dental Journal. 1997; Quint Int 1990;21:1019-22. 13:221-24. 47. Guile E, Al-Shammery A, Backly M and Lambourne31. Al-Bagieh NH, Idowu A and Salako O. Effect of A. Periodontal status of school attenders in aqueous extract of Miswak on the in vitro growth Saudi Arabia. J of Dent Res 1988; 67: Abstr no. of Candida albicans Microbios 1994; 80:107-113. 1456.32. Mansour Ml, Al-Khateeb TL and Al -Mazraoo AA. 48. Younes SA and El - Angbawi MF. Dental caries The analgesic effect of Miswak. SDJ 1996; 8: 87-91. prevalence in intermediate Saudi schoolchildren33. Mustafa MH, Abd-el Al MM and Abo-el Fadl-KM. in Riyadh. Community Dent Oral Epidemiol 1982; Reduced plaque formation by Miswak - based 10:74-76. mouthwash. Egypt Dent J 1987; 33: 375-84. 49. Baelum V. Pattern of periodontal breakdown in34. Abo Al-Samh D., and Al-Nazhan S. In vitro study adult Tanzanians. Scand J Dent Res 1987; of the cytotoxicity of the miswak ethanolic 95:221-28. extract. Saudi Dental Journal. 1997; 9 :125-30. 50. OLeary TJ, Drake RB, Jividen GF and Allen MF. The incidence of recession in young males;35. Norton MR and Addy M. Chewing sticks versus Relationship to gingival and plaque scores. tooth brushes in West Africa. Clin Preventive Dent Periodontics 1968; 6:109-11. Sangnes G and 1989; 11:11-13. Gjermo P. Prevalence of oral soft and hard tissue36. Eid MA and Selim HA. Retrospective study on the lesions related to mechanical tooth cleaning relationship between Miswak chewing stick and procedures. Community Dent Oral Epidemiol periodontal health. Egyptian Dent J 1994; 40:589- 1976;4:77-83. 92. 51. Van Palenstein Helderman WH, Munck L,37. Norman S and Mosha HJ. Relationship between Mushendwa S and Mrema FG. Cleaning habits and dental health among rural Tanzanian effectiveness of chewing sticks among Tanzanian children. Comm Dent Oral Epidemiol 1989; schoolchildren. J Cli Periodontol 1992; 19:460-63. 17:317-21. 52. Younes SA and El Engebawi MF. Gingival38. Gazi M, Saini T, Ashri N and Lambourne A. recession in mandibular central incisor region Meswak chewing stick versus conventional tooth- of Saudi schoolchildren aged 10-15 years. brush as an oral hygiene aid. Clin Preventive Dent Community Dent Oral Epidemiol 1983; 4:246-49. 1990; 12: 19-23. 53. Eid MA, Selim HA and Al-Shammery AR. The39. Sote EO. The relative effectiveness of chewing relationship between chewing sticks (Miswak) sticks and toothbrush on plaque removal. African and periodontal health. III. Relationship to Dent J 1987; 1:48-53. gingival recession. Quint Int 1991; 22:61-4.The Saudi Dental Journal, Vol. 11, No. 2, May-August 1999