Periodontics

The relationship hetween chewing sticks (Miswak) and periodontal health. Part I. Review of the literature and profile of the subjects Mohamed A. Eid* / Hassan A. Sehm** / Abdullah R. Al-Shammery***.

For more than 1,000 years. Moslems all over the world have used chewing sticks (Mis- wak) as an aid. In spite of the introduction of modern oral hygiene de- vices, many Mosletns still prefer ta use the natural Miswak. Despite its common use, there is a paucity of data about its effeets on the periodontal structures. This is the ßrst of a three-part series examining the relationship between Miswak and periodontal health. Part I presents a review of the current literature and a demographic profile of the study population. Patients presenting for routine dental appointments were subject- ed to a comprehensive interview regarding ¡heir demographic data, oral hygiene habits, and use of Miswak. Clinical examination included seoring of plaqtte and periodontal health. (Quintessence Int 1990;21:9í3-9l7.)

Introduction age to keep their teeth sufficiently clean by means of such traditional methods. Accordingly, the search for Without plaque, periodontal disease will not devel- supplementary aids, such as antibacterial substances, op.'- Plaque must be removed frequently and routinely to control dental plaque formation has been extensive for the prevention of periodontal disease.^ Periodon- during recent years,*-' The only agent that has so far titis will recur in surgically treated areas if plaque con- been sueeessfully introduced as an antiplaque sub- trol is not maintained.'' The prevention of periodontal stance is chlorhexidinc* ' This potent antiplaque agent disease can only be achieved by a combination of reg- is not, however, available in all parts of the world. ular professional care and daily, meticulous, personal home care.^ Review of the literature Because the correct use of , dental floss, or other cleaning devices removes plaque and Since the dawn of time, numerous oral hygiene aids therefore is directly associated with reduction of dis- have been used. This has been verified by excavations ease, routine use of such aids is the most cost-effective all over the world, in which toothpicks, chewing sticks, and the easiest way for an individual to prevent peri- tree twigs, linen strips, birds" feathers, and animal odontal disease. However, many patients do not man- bone devices have been recovered.'" Those aids that originated from plants represent a transitional step toward the modern oral hygiene devices. About seven plants have been found to be the natural sources of several of these hygiene remedies." The value of chewing sticks is believed to be in their * Assistant Professor. Division of Periodontics. King Sand Uni- versity, College of Dentistry, PO Box 60169, Riyadh, Saudi mechanical cleansing action. Several reports have Arabia 11545, claimed that they are effective in reducing plaque and ** Lecturer, Department of Restorative Dentistry, King Saud gingival inflammation.'-"'"* A survey by Elvin-Lewis et University. al'- indicated that tooth loss is minimal among adults *** Assistant Professor and Vice Dean, Depariment of Restorative in countries in which chewing sticks are used. In an- Dentistry, King Saud University, other survey, Elvin-Lewis'^ examined the dental health Address all correspondence to Dr A. R. Al-Shammcry,

Quintesse International- •lumt 11/1990 913 Periodontics among S87 chewing stick users in southern Ghana and cently there has been considerable inicrest in the chem- ' found that 83,7% of the study population had no ical contents of Miswak and their effects on plaque * discernible loss of teeth. Olsson,''' in a more controlled and gingival inflammation." Chemically it has been clinical investigation, studied the efficiency of an Ethi- reported to contain trimethyl amine, an alkaloid sal- opian chewing stick (Mefaka) in oral hygiene pro- vadorine, chlorides, high amounts of fluoride and sil- grams among schoolchildren. It was found that the ica, sulfur, vitamin C, small amounts of tannins, sa- - chewing stick is as effective as the in re- ponins, flavenoids, and sterols."^^" It is hypothesized moving oral deposits. Olsson'"* concluded that the Me- that these chemotherapeutic agents specifically inhibit faka should be used in preventive denta! programs in plaque formation.'^" Ben20phenathridine, the alka- Ethiopia, because it is effective, inexpensive, and fa- loid component of an African chewing stick, has been miliar to the population. included in a variety of medications for the treatment One of the most widely used chewing sticks since of coughs, asthma, scurvy, and rheumatism." A sub- early limes is the Miswak. It is obtained from a plant stance pharmacologically similar to benzophenathri- called Salvadora pérsica that grows mainly in Saudi dine, known as sanguinarine. is thought to be com- Arabia but also in other parts of the Middle East. It parable to gluconate in its plaque re- has been used by Moslems for more than 1.000 years. duction capacity'' and in its inhibitory effect on aero- since the prophet realized its value as an bic and anaerobic bacteria.-" Sanguinarine is currently oral hygiene device. The Miswak has become a tra- being included in mouthwashes and . Mis- dition and a spiritual habit.""" wak extracts are also being used in the manufacture . of toothpastes."-' One , known commer- Salvadora pérsica is a small tree or shrub with a cially as Sarkan toothpaste (Sarkan Ltd) (from Sal- crooked trunk. It is usually 1 ft in diameter The stem vadora pérsica), has been produced. and the roots are spongy and easy to crush between the teeth. Pieces of the root usually swell and become Despite the wide use of the Miswak in various coun- soft when soaked in water" tries, few studies have examined its beneficial and/or Although several reports have been pubhshed on its possible unintended side-effects on the periodon- different types of chewing sticks, there is a paucity of tium. It is generally agreed, for example, that damage data in the hterature on Miswak and its relationship to the gingiva as well as abrasions of the teeth may to periodontal health. To our knowledge, only one result from aggressive or improper toothbrushing : experimental study has examined the effect of Miswak techniques." -" It is therefore possible that the Mis- ' on piaque reduction and gingivitis."' That study was wak, in addition to some beneficial effects, may also principally initiated because the author felt that the lead to unfavorable side-effects, especially when im- great quality of oral cleanliness in the population un- properly used. der study was due to the use of the Miswak. Eighty Becau.se there is a paucity of data in the literature individuals who participated in that study were in- describing the effects of Miswak on the periodontal cluded in one of four groups: Miswak. powdered Mis- tissues, and because the majority of people in the Arab wak, starch, or commercial toothpowder. The Miswak Gulf countries are using Miswak as an oral hygiene group was instructed to use the Miswak in their own device, the objective of this three-part investigation is way, while the powdered Miswak group used crushed tc study the relationship between Miswak and peri- Miswak as a powder on toothbrushes. The starch and odontai health. The purpose of part I is to review the the commercial toothpowder groups were given 50 g current literature and to collect information on the of starch and toothpowder, respectively, and they were oral hygiene habits and attitude toward use of Miswak instructed to use an intrasulcular method of brushing. from the study population. All groups were examined weekly for 5 weeks, and the degree of plaque and gingivitis were scored. The re- sults of that study showed that the Miswak and the Method and materials powdered Miswak are more effective in reducing plaque and gingivitis than are starch and toothpow- The incisors, canines, and premolars were examined der." It should be noted, however, that the statistical in 236 patients presenting for routine examination at analysis of the data was only based on calculated the College of Dentistry screening clinic of King Saud means and standard deviations. University. All patients were subjected to a compre- hensive interview regarding their demographic data, In addition to its claimed mechanical effects, re- oral hygiene habits, and use of Miswak, Clinical mea-

914 Quintessence International Volume 21. Numbpr 11/199Q Pehodontios surements included plaque score, pocket depths, bleeding sites, loss of attachment, and gingival reces- sion. Test of exatniner reproducibility for clinical measurements were eonducted prior to and following completion of the study. For more details on chnical measurements, data analysis, and méthodologie error, refer to Eid et al.-^ All examinations throughout the study were performed by two examiners. The patients were interviewed and demographic data were first col- lected by one examiner (HS). The participants then moved to another chair for scoring of the periodontal situation. All clinical measurements were carried out by a second examiner (ME). All scores were dictated to the chairside assistant who recorded the scores on Fig 1 Age distribution of the study popuiafion special forms. Patients were then divided into three groups: a Miswak group, a toothbrush group, and a Miswak/toothbrush group.

Results strate how he or she used it. The majority (66.7%) of the Miswak group used a vertical (up-and-down) tech- The results of test of reproducibility and méthodologie nique, and only 16.7% used a rotating method. error are presented elsewhere.'^ The demographic in- fonnation obtained from each patient included age, Tooth type and surface sex. and oral hygiene habits. The majority (83.3%) of the population examined used the Miswak on both anterior and posterior teeth. Age and se.\ distribution It was used on the facial surfaces alone hy 50.4%, The mean age for the study population was 29.6 ± while 48.6% used it on both facial and lingual sur- 0.6 years (range of 17 to 51 years) (Fig 1 ). The majority faces. None of the subjects used the Miswak on the of the subjects were in the younger age groups. Almost lingual surfaces exclusively. 80% of the subjects were younger than 35 years. The majority (61.7%) of the subjects were male. Type and size of Miswak Most of the subjects (86.1%) reported using the soft Oral hygiene aid Miswak instead of the hard type (13.9%); 91.5% used Of the study group, 29.2% were classified as Miswak the thin type and only 8.5% used the thick Miswak. users, 40% used the toothbrush alone, and 30.8% used both Miswak and a toothbrush. Gra.sp of Miswak The Miswak was used with a "pen grasp'" by 55.6Vo Frequency of use of subjects, while the "thumb grasp" was used by Thirty-eight percent of the subjects used the Miswak 41.7%. Only 2.8% of the subjects used both pen and regularly, one to three times per day, 25.4% used it thumb grasps interchangeably five times a day or more, and 36.6% used it weekly or irregularly. Discussion The purpose of this study was to collect information Method of application regarding the use of Miswak in a dental clinic popu- The technique of use of Miswak and/or the tooth- lation to provide baseline information on the study brush was determined after each patient was given a population and to describe the patients' attitude to- Miswak and/or a toothbrush and asked to demon- ward use of Miswak. The results indicated that the

Quintessenz 11/1990 915 Periodontics majority (approxitiiateiy 60%) of the population ex- occur if an excessively hard-fiber chewing stick is used amined used the Miswak alone or in conjunction with or if it is apphed too aggressively.'- This finding is in other oral hygiene aids. A significant percentage of accord with that of Younes and El-Engebawi,-' who the population (29%) used the Miswak as the only reported that the high incidence of gingival recession method for cleaning teeth. This finding is in contrast observed in a younger Saudi age group, mostly school- to a recent survey-'' of 600 Sudanese schoolchildren children, probably resulted from the common use of that revealed that 16% used the Miswak alone and Miswak. It is possible, therefore, that in addition to only 2% used both the toothbrush and the Miswak- its claimed beneficial effects, the Miswak tnay also The cultiiral difference and the younger age of that lead to unfavorable side-effects. Additional research is study population is likely an explanation for such dif- needed to determine any possible association between ferences. The results of the present investigation, how- Miswak atid gingival recession- Controlled clinical ever, indicated that the Miswak is still used by many studies should be initiated to investigate its effects on individuals, despite the use of the modern oral hygiene the gingiva and the surrounding structures. aids. The Miswak is carefully selected for such properties Conclusion as size, hardness, and taste. It is usually washed with water and chewed on one end to macerate it until it Within the limitations of this study, the data con- becomes softer and brushlike. Most users preferred the firmed what has generally been conceded regarding soft Miswak to the hard type, and the tnajority used the use of Miswak as an oral hygiene deviee. More the thin Miswak more than they did the thick one. significantly, the population examined seemed to be The Miswak is generally used for a longer period well suited for further investigation on the relationship of time than is the toothbrush- Most users applied the between Miswak and periodontal health. Miswak one to ftve times a day. The tnajority (57.6%) Part II of this investigation will study the effects of used it more than once every day. Miswak on plaque accumulation and gingival inflam- It has been reported that chewing stick users are mation and the relationship of Miswak to pocket mainly concerned abont their front teeth and may depth and attachtnent loss. Part III will examine the scrub them excessively while neglecting the posterior association between the use of Miswak and gingival teeth,'^"^ In the present study, tnost subjects (83,3%) recession. reported using the Miswak on both anterior and pos- terior teeth. Only 15.3% used it on the anterior teeth alone. It appears, therefore, that use of Miswak is not Acknowledgment limited to the anterior teeth. The authors would like to express their gratitude tc More than 50% of the subjects reported using the Professor Tryggve Lie of the University of Bergen, Miswak only on the facial surfaces, whereas 48.6% Norway, and to Professor Axel Bergenholtz of the Uni- applied it on both facial and lingual surfaces. This is versity of Umeâ, Sweden, for their valuable contri- a major drawback in the use of Miswak and is prob- butions and assistance in this project- ably a result of its straight shape, which makes it dif- This project was funded by King Saud University, ficult to reach all tooth surfaces. Additional research College of Dentistry Research Center (CDRC) Grant is needed to determine the ability of Miswak to reach No. 1023- all tooth surfaces. The results of this study indicated that there are two methods for using the Miswak to clean the teeth. One References method resembles the up-and-down technique, while the other assumes a rotating or circulating action. It 1. Loe H. Theiiade E, Jensen SB: Experimental gingivitis in man, is generally agreed that damage to the gingiva may J PerwdiinUil I965;36:I77-187. 2. Saxe SR. Greene JC, Bohannan HM, et ai: Oral debris, catctllus result from aggressive or improper toothbrushing and periodontal disease in ttie beagle dog. / Periodontol techniques,""-'' and because tnany (66.7%) of the 1967:38:217-225. study subjects used the up-and-duwn technique, this 3. Theiiade E, Wright WH, Jensen SB, et al: Experimental gingiv- could be an important factor contributing to gingival itis in man. II. A longitudinal ciinical and bacteriological in- recession, especially on facial surfaces, on which the vestigation, / Periodont Res 1966:1:1-13. 4. Nyman S, Lindhe J, Rosling B: Periodonta! surgery in plaque- Miswak is used most. Such effects are also likely to infeeted dentitions. J Clin Feriodomol 1977:4:240-249.

916 Quintessence International Volume 2t, Numter 11/1990 Periodontics

5. Axelsson P, Lindhe J: Ttie signilicance of maintenance care in 18. Odebiyi OO. Sofowara EA: Antimicrobial alkaloids from Ni- the treatment of periodontal disease. J Clin Periodontol gérian chewing stick {Fagara zanghoxyloides]. Plama Med 19Sl;8:281-294. t979;36:2O4~2O7. 6. Ainamo 3: Control of ptaque by chemical agents. J Clin Peri- t9. Southard GL, Boulware RT, Walborn DL, et al: Sanguinarine, odontot 1977;4(special issue):23-35 a new antiplaque agent: retention and plaque specificity. / Am 7. Huit PS: Chemical inhibition of plaque. J Ciin Periodontoi Dent Assoc 1984;tÜ8;338-341. 1980:7:431-442. 20. Dzink JL. Socransky SS: Comparütive in vitro activity of san- 8. Lñe H, Rindom Schiott C: Ttie effect of tnouth rinses and top- guinarine against oral microbial isolates. Aniimicrob Agents ical application of chlorhexidine on the devetopment of dental Chemolher t9S5;27:663-665. plaque and gingivitis in man. J Periodom Res 1970:5:79-83. 2t. Gazi M: Photographic plaque assessment of the antiplaque 9. Lie T, Enersen M: Effects of ctitorhexidine gel in a group of properties of sanguinadne and chlorhexidine. J Clin Perioduntol rnaintenance-care patients with poor oral hygiene. / Periodontot 1988;15:t06-t09. t9S6:57:364-359. 22. Sangnes G: Traumatization of teeth and gingiva related to ha- 10. Kepros SG: Chron Omega District Dent Section 1959;23:235. bitual tooth cleaning procedures. J Clin Feriodontol 1975;3:94- 103. tt. Biimery MJ, Stallard RE: The evolutionary development and contemporary utilization of various oral hygiene procedures. 23. Radentz WII, Barnes GP, Ctitright DE: A survey of factors Periodant Abstr t968; 16:90-97. possibly associated witb cervical abrasion of lootJi surfaces. J Periodontoi t976;7.148-154. 12. Elvin-Lewis M, Kendell K, Lewis WH, et al: The anticariogenic 24. Pattisson GL: Self-inflicted gingival injuries: literature review potential of African chewing sticks. / Dent Res 1974; 53:(abstr and case report. J Periodontol 1983; 54:299-304. No. 277). t3. Etvin-Lewis M: Ptants and dental health. / Pre-v Dent Í98O;6:59- 25. Eid M, A]-Sbatnmery A, Sehm H: The relationship between chewing sticks and periodontal health. Part II. Relationship to 60. plaque, gingivitis, pocket depth, and attachment loss. Quintes- t4. Olsson B: Efficiency of traditional chewing sticks in orat hygiene sence Int (in press). programs among Ethiopian schoolchildren. Communilv Denl Oral Epidemioi t978;6:t05-!O9. 26. Ghandour IA, Ibrahim FA, Shetiata AH: Tbe prevaletice of t5. Khoory T: The use of chewing sticks in preventive orat hygiene. dental caries, fluorosis, and dental attitudes among primary school-children in Omdurman, Sudan. Trop Denl J 1988;3:tO3- Ciin Prev Dent t983;5(4):1t-l4. 106. 15. El-Mostehy MR, Al-Jassem AA, Al-Yassin IA, et al: Miswak 27. Younes SA, Bl-Engebawi MF: Gingival recession in mandibular as an orat health device. Preliminary chetnicat and clinical eval- central incisor region of Saudi schoolctiildren aged 10-t5 years. uation. Hamdard t983;26:41-50. Community Denl Oral Epidemiol 1983;tt:246-249. Ü 17. Akhtar M, Ajmal M: Significance of chewing sticks (Miswaks) in oral hygiene from a pharmacological view-point. JPMA 198I;4:89-95.

Articulating Paper HANEL-GHM-DENTAL GMBH • D-7440 NÜRTINGEN TEL.07022/463 73TX 17-702215- FAX 07022/43599

11/1990 917 Quintessei>eB inWrnatiwial