REVIEW ARTICLE

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

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

ABSTRACT: Miswak, as a cultural and scientific heritage 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 being a 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 invitro experiments and clinical trials. Special emphasize is on how to use and when to use miswak for effective cleaning of teeth and mouth. Recent scientific evidence regarding its probiotic role, cell viability and comparative cytotoxicity and 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 oral hygiene measures due to various constraints. The use of miswak on population bases is in line with the theme of primary health care approach (PHCA) and oral health promotion. Miswak has wider acceptance among many communities 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.

INTRODUCTION Miswak (chewing sticks) has its unique role in oral hygiene and maintenance of oral health. healthy mouth leads to a healthy body. Good oral hygiene is the key to good oral and MISWAK IN A HISTORICAL PERSPECTIVE A systemic health. Acceptable level of plaque control, from where periodontal disease cannot be The evolutionary development of the modern day initiated or progressed is the ultimate desire of oral and may be traced to chewing sticks that were dental professionals. The body -mouth relationship is used by the Babylonians. The use of chewing stick was of great interest among health care professionals. With recorded by the Babylonians in 5,000 BC and the fashion the increasing prevalence of oral and dental diseases, rapidly spread throughout the Greek and Roman empires. the international need for preventive and curative The chewing stick was also used by the Egyptians, the methods has been surfaced. Not only are alternate Jews, and among the . References to the preventive and treatment methods being expanded but use of chewing stick can be found in the Talmud, as also safe, effective, economical and culture based the Quesum, the Siwak, Miswak and Arak. Its use as traditional remedies and products are being explored. a chewing stick or Siwak was documented in the Arabian A tooth brush and tooth pastes are commonly used in Muwasha written by Alwashah, in AD 900. It is believed developed and developing countries for cleaning teeth. that the modern day tooth brush was not known in Europe until about 300 years ago, Lewis and Lewis (1). 1. University of Connecticut, College of Liberal Arts and Sciences, Storrs Campus. Medical texts of ancient India, Susruta Samhita and Connecticut. USA 2. Professor of Periodontology Charaka Samhita, have also emphasized on oral hygiene Director Predoctoral Periodontics &Director International Fellowship in Advanced and brushing teeth with herbal sticks (2). Today miswak Periodontics Division of Periodontology, University of Connecticut, School of Dental Medicine Farmington. Connecticut. CT is being used in different parts of the world. Chewing 06030. USA Email: [email protected], [email protected] sticks are known by various names including the word

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“miswak” or “arak” in , “qesam in Hebrew, until it becomes frayed and looks similar to the head “qisa” in Aramaic, “koyoji” in Japanese, “mastic” in of a toothbrush (9). Latin (3) and “mefaka” in Ethopia (4) and datun in Considering the historical, cultural and religious Pakistan and India (5). importance of S. persica miswak as an oral hygiene In many Middle Eastern, Asian, and African and maintenance tool, this current review is an update American communities, traditional methods of tooth on recent developments in miswak research. Major cleaning are still used due to low cost, affordability, emphasize is on chemical composition, how to use and availability, usage in rituals, and to serve custom, and when to use miswak for effective cleaning of teeth and religious purposes (6). Chewing sticks have various mouth. Recent scientific evidence regarding its probiotic other uses such as: using them as jaw exercisers, role, cell viability and comparative cytotoxicity and inducing a reflex of copious saliva secretion, combating research trends are highlighted. undesirable oral habits including smoking and thumb- sucking, and lastly, they can also be used during the CHEMICAL COMPOSITION teething process (7). In terms of geographical distribution, S. persica usage is widely spread and The advantageous effects of miswak, in terms of ranges from countries such as , Nepal and oral hygiene maintenance and dental health, can be India in the East through Iran, Iraq, Pakistan, Saudi attributed to the mechanical role of brushing and its Arabia, and Egypt to Mauritania in the West, from North pharmacological component (9). Chemical analysis Africa and Central Africa to Southwestern Africa (8). shows that miswak contains numerous, natural In the Middle East, Arak (Salvadora persica) is constituents that are known to benefit oral health. The the most common chewing stick. Additionally, the roots chemical substances present in S. persica are as follows: of African laburnum (C. siberianba) are used in Sierra chloride, fluoride, saponins, salvadorine, silica, sulfur, Leone and Neem (A. indica) is primarily common in sterols, trimethylamine, and vitamin C (7). Another the . Other forms of chewing sticks chemical investigation demonstrates the following can be found in Western Africa, where the lime tree compounds present in the S. persica plant: -sitostrol (C. aurantafolia) and the orange tree (C. sinensis) are and m-anisic acid chlorides, salvadorea, and gypsum; utilized for oral health purposes. Not only are miswak organic compounds, including pyrrolidine, pyrrole, and used for oral hygiene, they are also related to religious piperidine derivatives; glycosides, such as salvadoside rituals and social purposes (9). and salvadoraside; and flavonoids, including karmpferol, One hundred and eighty-two kinds of plants/shrubs querceting rutin, and a quercertin glucoside (13). The have been used as chewing sticks, throughout the main constituent of the Salvadora persica root oil is developing world; the most significant is Arak, Benzyl- isothiocyanate (BITC) (14). This component Salvadora persica (10). The roots, twigs, and stems are of the Salvadora persica root, Benzyl- isothiocyanate, the specific parts of the plant that provide dental hygiene exhibits broad-spectrum bactericidal activity (15) and (11). inhibits the growth and acid production of Streptmutans The miswak is a small, upright evergreen tree or (16). According to Chawla (17) , chewing sticks like shrub with white branches and aromatic roots, rarely Neem (A. indica), S. persica, A. arabica contain a ever more than three meters in height and 30 cm in noticeable amount of fluoride (79). diameter (12). The fresh leaves on the S. persica can Many of Salvadora persica's constituents cited be utilized in traditional medicine for treating cough, above, aid in the prevention of decay and benefits to asthma, scurvy, and other diseases, whereas, the flowers preserve the human dentition if utilized properly. The of the tree are used as a stimulant and are mildly silica present in chewing sticks acts as an abrasive purgative (9). Stems and roots of the S. persica are material to reduce stains and whiten teeth. Both the spongy, thus they can be easily chewed and crushed sulfur compounds and alkaloid (salvadorine) present between the teeth. The chewing stick becomes quite in S. persica have a bactericidal role but, only spongy after it is soaked in water; therefore, it is highly salvadorine exerts a stimulatory action on the gingival unlikely to traumatize the gums, if used properly, while (9). The tannins and resins give protection against caries brushing (7). The stem or root is chewed on one end, by forming a layer over the enamel due to the astringent

256 JPDA Vol. 22 No. 04 Oct-Dec 2013 Miswak (salvadora persica chewing stick) andits Almas AK / Almas K role in oral health; An update effect on the mucous membrane. Chewing sticks the chewing stick is either replaced by a new one or a obtained from plants similar to Aegles marmelosm, fresh end is formed by cutting off the old bristles, and S. persica, A. indica, and Fagara zantholoxoids contain essential oils that exert analgesic, antiseptic, and carminative action. Strong anti-inflammatory action on the gums is provided by substance present in other plants, including Alnus glutinosa, Antidesma venosum, and A. indica (7). Lastly, due to the high concentrations of chloride present in S. persica miswak, calculus formation is inhibited (9). Also, since miswak is used regularly and for a longer period of time, severe calculus buildup does not occur.

THE PREPARATION OF A MISWAK Fig 1. Bristles end of three different shaped chewing sticks.

The recommended method for preparing a usable creating new ones by chewing and tapering it. It is chewing stick is discussed by Almas and Al-Lafi (5). recommended that the chewing stick should be kept at A chewing stick is a piece of wood, usually from the a moist place when not in use. It should be washed/rinsed stem of a plant that has an average length of fifteen with water before using it again (7). centimeters and a diameter of one centimeter. Though chewing sticks are sold in several different lengths and TECHNIQUES OF USING A MISWAK diameters, it is important to adjust both the length and the diameter according to the general user. A length of Almas and Al-Lafi (7), gave an account of the twenty centimeters for adult use and fifteen centimeters mechanical techniques employed for removing plaque for children/minors are the size values recommended using a toothbrush and a miswak are analogous. Vertical for convenience and to insure safe and proper use of and horizontal brushing is important, however, the the miswak. They also provided a brief anatomical manual dexterity of individuals, their attitude towards description of the phloem, fibers, and wood of the and knowledge of oral health is the critical basis needed S. persica plant. There is a large amount of phloem in to maintain proper oral cleanliness. The chewing stick the S. persica, as well as, widely spaced, think-walled resembles to the toothbrush as both have bristles and fibers. The spongy wood can be easily crushed by the are utilized to remove biofilm/plaque from the tooth teeth and softened so that the miswak is chewable surfaces mechanically. However, the chewing stick also without any difficulty. have a chemical role and may be chewed or sucked for The first step is to prepare a chewing stick that is many hours daily by some people. freshly cut so that they are supple and still possess all A length of 15 cm for children and 20 cm for adults of their active constituents. The reason being, that a is highly recommended for convenient grip and ease of very dry chewing stick can damage the gums manipulation. A diameter of 1 cm makes for suppleness surrounding the teeth in the oral cavity. It is vital to and sufficient firmness (7). remember that if a stick is originally dry, it should be Two basic holds have been described in order to soaked in fresh water for twenty-four hours. If the stick have a firm, well controlled movement of the brush- is immersed in water for a longer period, it can cause end of the chewing stick in mouth is achieved and that the loss of active ingredients present in the chewing every part of oral cavity is reached with relative stick, and can even diminish the therapeutic properties convenience. They are described below (8); the stick possesses. Next, in order to create bristle-like Five fingers grip (shown in figure 2) structures on the chewing stick, one side of it should The four fingers of one hand are curled lightly be chewed on for few seconds, until the fibers stand found the stick, with the index finger nearest the end out similar to individual bristles of a regular toothbrush to be chewed. (Fig 1.) After having been used for several instances, The pulp of the thumb rests firmly on the opposite

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Fig 2. Five fingers grasp (palm grasp) of chewing stick. Fig 4. Three fingers grasp of chewing stick (being used by a child). side of the stick to the index finger, the thumb is thus the procedure is practiced for three-five minutes. in a higher position than the index finger. The thumb controls the movement of the stick and retains it in a firm grip. All tooth surfaces are accessible if the wrist or arm is moved as needed. Three fingers grip (shown in figures 3 & 4) The chewing stick is placed between the index and third fingers. The operative end of the stick is pointed upwards when the hand is in the supine position. The fourth and fifth fingers are kept clenched on the palm. The thumb rests on the side opposite the index the third fingers, where it assumes the dominant role and position. Fig 5. The application of chewing stick on buccal surfaces (A), on lingual surfaces (B) and on occlusal surfaces (C). Tongue is another part of the oral cavity that needs to be cleaned to maintain proper oral hygiene. The tongue is considered to be the cause of bad breath/halitosis if there is a buildup of a white coating on the dorsum of the tongue. Likewise to cleaning teeth with it, the miswak is very effective against cleaning the surface of the tongue in two ways. The bristle end of the miswak can be used, however, for best possible outcome, the sticks can be broken into a V-shaped manner and the resulting blade can be used to scrape several times across the tongue, posterio-anteriorly. The miswak is not only a natural toothbrush; it can also become a Fig 3. Three fingers grasp of chewing stick. makeshift natural tongue scraper for achieving good The tooth cleaning movement should be directed oral hygiene (7). away from the gingival margin of the teeth on both the buccal/facial and lingual surfaces. An anterior to WHEN TO USE THE MISWAK posterior scrubbing movement is carried out on the occlusal surfaces. Careful movement and effort should Unlike the toothbrush, that is usually allotted a be done to avoid damaging the soft tissues of the oral specific time-morning, afternoon, or night, to be used- cavity (Fig 5). Satisfactory cleaning can be achieved if miswak can be used at various different times throughout

258 JPDA Vol. 22 No. 04 Oct-Dec 2013 Miswak (salvadora persica chewing stick) andits Almas AK / Almas K role in oral health; An update the day. For instance, many people use miswak in public any antimicrobial activity. Once again, the microbes places, while conversing, before breakfast, before going included were; Strept faecalis, Strept pyogenis, to bed, before praying, and so on (7). Ideally, the Strept mutans, C albicans, Staph aureus, and Staph chewing stick should be used before meals or epidermis. Mean growth inhibition of the various immediately after meals so that the bacteria that convert microbes was recorded (in mm). It was demonstrated sugar into acid can be removed. However, it was found that a 50% extract of S. persica miswak was effective that the use of miswak after meals is not practical, since against both Strep. mutans and Staph. faecalis. the drop in pH and the associated damage takes place The experiment resulted that there was a seven mm within a few minutes, and after twenty minutes, the inhibition zone for Strep. faecalis and a three millimeter saliva executes the buffering role. In general, the use inhibition zone for Strep. mutans. However, there of miswak, five times a day, is recommended for all was no microbial inhibition for the remaining benefits of the naturally occurring effects to take place. microorganisms. To the Muslim, the use of chewing stick is an important From the two studies, Almas (18) and Almas et al. part of ablutions before worship which takes place five (19), it can be concluded that utilizing miswak does times daily. The regular use of chewing stick conforms in fact, have antimicrobial effects against two types with the theme of primary health care and has long been of microorganisms. There is stronger action presented established practice with certain cultural and religious against Streptococcus faecalis as compared to beliefs and norms (7). Streptococcus mutans. In the examination of the antimicrobial activity of chewing extracts against EFFECTS OF MISWAK ON ORAL HEALTH different human pathogens, much effort has been expended (6). Though not all dental hygiene tools Antimicrobial effects are helpful in thoroughly inhibiting all pathogens, the Some invitro studies exemplified that S. persica reduction of harmful microbial organisms that exist extracts inhibited the growth of various oral aerobic in the oral cavity is still a significant achievement. and anaerobic bacteria (6). In an invitro study by Almas Various studies have shown that S. persica contains (15), the antimicrobial effects of the aqueous extract substances that possess plaque inhibition and belonging to seven different types of chewing sticks antibacterial properties against several types of were compared. The several varying types of chewing cariogenic bacteria which are commonly found stick that were examined included Azadirechta indica, in the oral cavity. The growth and acid production Olea europaea, Acacia Arabica, S. Persica (common properties of these bacteria are thus inhibited name: Peelu and Arak), Gycosmic pentaphylla, and (20, 21, 22, 23). Capparis aphylla. The four microorganisms that were AL-Lafi and Ababneh (24) evaluated the tested consisted of Strept faecalis, Strept mutans, Staph antibacterial properties of S. persica against a few oral aureus, and C albicans. The aim of the experiment aerobic and anaerobic bacteria and reported that the was to find out which microbe was affected by one or extract of these sticks had a drastic effect on the growth more of the chewing sticks and if so, by how much (in of Staph aureus, and a variable effect on other bacterial mm) was their growth inhibited. It was concluded that species. They informed that the chewing sticks used there was no effect of any chewing stick on Stept mutans, were harvested one month earlier, and suggested that Staph aureus, and C albicans microorganisms. using more fresh sticks will give better and improved However, the results also concluded that S. persica results. Almas et al. (23) compared fresh vs. one- month- (Arak) and Acacia Arabica had significant antimicrobial old miswak extracts for antibacterial activity and found activity against Strept faecalis at 50% concentration of no difference. A comparison of alcohol and aqueous the miswak extract. The inhibition zone was up to two extract of miswak was also evaluated. It was reported millimeters for the two chewing sticks. that miswak alcoholic extract is more effective than Another invitro experimental study performed by aqueous extract for antibacterial activity (25). A recent Almas et al. (19), focused on comparing miswak extract study by Almas et al. (26) reported that, the S. persica with commercially available mouth rinses. Similarly, extract, at a 50% concentration, delayed the growth of there was an experiment to check if there was Actinomyces naeslundii, Lactobacillus casei, Staph

JPDA Vol. 22 No. 04 Oct-Dec 2013 259 Miswak (salvadora persica chewing stick) andits Almas AK / Almas K role in oral health; An update aureus, Strept gordonii, Strept mutans, Strept oralis, inhibitory effect on the streptococci bacteria and addition Strept sanguinis, Veillonella sp. PK1910, F nucleatum of Lactobacillus strains significantly reduced the viable and C albicans compared to controls where the extract counts of S. mutans. Almas et al. (26) reported that was replaced by dPBS. 25% extract had a bacteriostatic S. persica extract had moderate bactericidal properties effect in subset of these species, while 10% extract against a wide range of oral microorganisms. had no effect. On the contrary, the S. persica extract Interestingly, it did not affect in any way Lactobacillus did not affect the planktonic growth of Lactobacillus fermentum, a commonly used probiotic bacterium. The fermentum. Killing assays showed that the extract finding has not been observed in any previous studies. had a partial bactericidal effect on most of the strains The quest in the probiotic role of miswak is in progress tested. The S. persica extract did not affect the viability and hopefully soon further developments would be part of C. albicans, S. aureus and L. fermentum. Sofrata et of scientific literature. al., (27), reported that the inhibitory effect was most obvious on P. gingivalis, A. actinomycetemcomitans, ANTIOXIDANT CAPACITY OF MISWAK and H. influenza, comparatively less on S. mutans, and least on L.acidophilus. Suspended miswak pieces There is growing interest in bioactive compounds had comparable or even stronger effects than the miswak of S. persica miswak especially antioxidant compounds embedded in agar medium. (31). By definition, antioxidants are substances that when present in foods or body at low concentrations ANTIFUNGAL ACTIVITY compared with that of an oxidizable substrate markedly delay or prevent the oxidation of that substrate. Various Al- Bagieh et al. (28) concluded that aqueous antioxidants included enzymatic antioxidants (e.g., extracts of miswak could be used to reduce growth of superoxide dismutase, peroxidase, polyphenoloxidase C. albicans. Such inhibition lasts for up to 36 hours at and catalase) and nonenzymatic antioxidants (e.g., concentrations of 15% and higher. A recent study by ascorbic acid (vitamin C), -tocopherol (vitamin E), Almas et al. (26) reported that Salvadora persica glutathione, carotenoids, and flavonoids) (32). extract did not affect the viability of C.albicans. Antioxidants have been considered to help the body to Al-Bayati and Sulaiman (29) compared the aqueous protect itself against various types of oxidative damage and methanol extracts of S. persica chewing stick for caused by reactive oxygen species, which are linked antimicrobial activities against seven isolated oral to a variety of diseases including cardiovascular diseases, pathogens (S. aureus, Strept mutans, Strept pyogenes, cancers (33) neurodegenerative diseases, Alzheimer’s E. faecalis, L acidophilus, P aeruginosa, and C albicans) disease (34) and inflammatory diseases (35) and some using two different methods. Both antimicrobial assays other ailments. The supplement of the diet (or other resulted that the aqueous extract inhibited all isolate uses) with antioxidant compounds is one of solutions microorganisms and was more efficient than the of this problem that are preserved in natural plant methanol extract, which was resisted by L. acidophilus sources (36). These natural plant antioxidants sources and P. aeruginosa. The most pronounced and strongest can therefore serve their role as a type of preventive antibacterial activity was shown by the aqueous extract medicine. Some investigators suggested that two thirds against E. faecalis. Turbidity tests exhibited that both of the world’s plant species have medicinal value; in extracts had equal antifungal activity against C. albicans. particular its considered that many medicinal plants Further research is needed in antimycotic/antifungal have great antioxidant potential (32). effects of miswak. Mohamed and Khan (31) reported that furan derivatives containing hydroxyl groups could possess PROBIOTIC AND PREVENTIVE ROLE OF antioxidant activities. The antioxidant enzymes were also S. PERSICA MISWAK detected in the chewing stick extract with high level of peroxidase and low level of catalase and polyphenoloxidase. Mehanna and Reid (30), studied the effect of The synergistic actions of antioxidant compounds and miswak extract on oral pathogens and its potential for antioxidant enzymes make chewing stick as a good tool probiotic use concluded that, miswak had a marked for cleaning teeth, oral hygiene, oral health and food

260 JPDA Vol. 22 No. 04 Oct-Dec 2013 Miswak (salvadora persica chewing stick) andits Almas AK / Almas K role in oral health; An update purposes. miswak users (44) than did non-users. In an institutional study from Sudan (45), showed that the periodontal ANTIPLAQUE, GINGIVAL AND PERIODONTAL status of regular miswak users was similar to or slightly HEALTH EFFECTS OF MISWAK better than that of toothbrush users. The above mentioned studies reflect the beneficial use of miswak for the It has been observed, both clinically and gingival and periodontal health. experimentally, that S. persica chewing stick was as effective and useful as a toothbrush for reducing plaque CYTOTOXICITY OF MISWAK EXTRACT on buccal tooth surfaces (37). While assessing plaque removal in children from Ethiopia, it was confirmed The effective role of an ideal antimicrobial agent that the chewing stick appeared to be as effective as depends on its ability to kill microbes while causing the toothbrush, if not more (4). In addition, practicing minimal toxicity to host cells (minimal collateral the proper use of chewing stick as an oral hygiene damage). Rajabalian et al. (46) compared pesica aid, significantly lower plaque scores in comparison mouthwash and mouthwashes on cultured with the use of commonly used (38). human and mouse cell lines. The cytotoxic effects of A recent statement on oral hygiene measures (39) four dilutions of Persica and Chlorhexidine mouthwashes concluded that bacterial plaque plays an important role on KB, Soas-2, J744 A1, and gingival fibroblast cells in the etiology of dental caries, gingivitis and were evaluated using MTT assay. The effect of fetal periodontitis and effective removal of dental plaque calf serum (FCS) components on the cytotoxicity of can result in the prevention and or reduction of the these mouthwashes was also evaluated. They found that above mentioned diseases and conditions (6). As a both Persica and Chlorhexidine mouthwashes consequence of plaque reduction, the usage of chewing were toxic to epithelial, fibroblast, macrophages, and sticks can also assist in the reduction of gingival osteoblast cells in concentration-dependent manner. inflammation. However, chewing sticks can cause A recent comparative study by Almas et al.(47), occlusal tooth wear and a small degree of gingival on cytotoxicity of S. persica aqueous extract and inflammation if used improperly or excessively. Chlorhixidine gluconate on L929 mouse fibroblasts Moreover, if a miswak stick is chewed upon in the same obtained from American Type Culture Collection area of the mouth, and over a long period of time, it (Manassas, VA, USA). They concluded that the cell can end up proving to be detrimental instead of beneficial viability of miswak extract was 88%, 90%, 97%, 95% (7). Gingival indices were found significantly lower in original strength (50%) and 1/2 , 1/4, 1/8, 1/16, 1/32 following the use of S. persica chewing sticks in dilutions, while the cell viability of CHX is 3% , 47%, comparison with the use of a commonly used 87%, 93%, 92% and 95% in the corresponding conventional toothbrush without (38). concentrations. Miswak extract had significantly less Relatively low number of tooth loss in adults have cytotoxicity than CHX in the original and 1/2, 1/4 been reported in countries where miswak is commonly dilutions (p=0.05). used (10). Epidemiological studies (40,41) emphasized Mohammad and Turner (48) tested the cytotoxic that chewing stick use had beneficial effects on the potential of the S. persica miswak and its diffusible prevalence and prevention of periodontal diseases and components on oral tissues using the tissue culture agar caries. Some other studies reported low periodontal overlay method. They reported no cytotoxic effect of treatment needs among Saudi adults who were regular freshly cut S. persica chewing stick, but observed that miswak users (40, 42). An epidemiological study of the same plants contained harmful components if used nomadic population of the Kaisut Desert region of after 24 hours. A recent study evaluated the role of Kenya reported that dental caries and advanced direct administration of high doses of S. persica miswak periodontal disease were rare among miswak users extract to mice, reported minor side effects on male under the age of 50 years (43). A retrospective study and female reproductive systems and fertility (49). An from Saudi Arabia reported conflicting results about earlier study concluded that neither aqueous nor miswak users. They observed deeper periodontal pockets ethanolic S. persica miswak extract was toxic to mice, and a higher prevalence of periodontal diseases among at doses of up to 1200 mg/kg (50).

JPDA Vol. 22 No. 04 Oct-Dec 2013 261 Miswak (salvadora persica chewing stick) andits Almas AK / Almas K role in oral health; An update reported minor side effects on male and female aid and should be introduced and promoted to general reproductive systems and fertility (49). An earlier study population based on scientific rationale. In addition, concluded that neither aqueous nor ethanolic S. persica the use of the miswak conforms to the theme of primary miswak extract was toxic to mice at doses of up to healthcare approach, as well as certain cultural, 1200 mg/kg (50). traditional, social, and religious beliefs and rituals. Further research is needed to assess the comparative Incorporating the utilization of miswak into the cytotoxic effects of miswak extract and Chlorhexidine healthcare system of many developing countries will to human macrophages, epithelial cells, fibroblasts and greatly facilitate the masses with financial constraints, osteoblasts. That would help to precisely use of miswak as well as limited oral health care facilities. extract or chlorhexidine after periodontal or oral surgery Miswak is available in rural areas of developing procedures. countries, it does not require special technology to produce. Health care resources are limited in many MISWAK AS A CULTURAL HERITAGE AND countries, and there is a growing concern to scientifically ORAL HEALTH PROMOTION TOOL research, and test freely available and relativel low cost traditional preventive tools in order to improve the In the early Islamic period, the use of miswak healthcare conditions of the world population. became a part of a cultivated and elegant mode of life Despite the high initial cost of further investigating and as a prominent feature of Islamic hygienic the properties of S. persica miswak, it will prove to be jurisprudence. Today, cross-cultural knowledge can economically and financially profitable once the help motivate public health dentists and dental hygienists consorted efforts are made. The advantageous effects to recognize culturally accepted behaviors for the of miswak usage are undeniable, and it is indisputable purpose of strengthening patient-provider that there is a plethora of benefits of utilizing the relationships and optimizing public health outcomes. miswak. Now, the responsibility of healthcare Such recommendations can offer ways to mix or merge professionals including, medical and dental doctors, western healthcare with Islamic practices and precepts hygienists across the globe is to revisit miswak for surrounding the use of miswak and dental hygiene better oral and systemic health of their respective practices considering that healthcare providers and populations. Certainly that would improve the quality professionals live and work in a global village or of life of those populations and societies and reduce society. (51). The French philosopher Auguste Comte the oral diseases and financial burden. Countries like (1798-1857) stated, “demography is destiny”. With Pakistan, could benefit from the culture and religion- world populations becoming more culturally diverse, based oral hygiene use of miswak both at rural and healthcare providers must practice cultural awareness urban levels. Healthcare professionals should learn and sensitivities to achieve trust, and to direct the more about the recent advances in scientifically proven patient-provider relationship toward the desired goal role of miswak for their respective clientele. of quality oral health care for all populations. Further research should be conducted to explore Unfortunately, ignorance of customs can undermine the probiotic and antioxidant role of miswak. Double establishment of trusting relationship. As in the case of blinded, randomized clinical trials (RCTs) comparing the miswak chewing stick; oral health care professionals clinical parameters of periodontal health and diseases should review miswak use with their patients to ensure would add into evidence-based scientific credibility proper and effective use and angulation to achieve and practices of miswak. maximum bacterial plaque removal. (51-53). Miswak being a cultural and scientific heritage has a lot ACKNOWLEDGMENTS more to offer to present day oral hygiene needs of many communities around the world. Authors would like to thank and appreciate the dedicated researchers for their continuous interest in CONCLUSION AND RECOMMENDATIONS miswak research. I am (KA) pleased to share my twenty years of scientific progress and contributions to miswak Miswak has been proven effective as an oral hygiene (Salvadora persica chewings sticks) literature

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