The toothbrush, ideally in combination with a fluoride toothpaste, is the most commonly used device to control dental plaque. In comparison the miswak or chewing stick is a low-cost oral hygiene device that is also effective at controlling dental plaque. Miswak can be obtained from several different plant species such as lime tree (Citrus medica L.), orange tree citrus (Citrus sinensis (L) Osbeck) and Neem (Azadirachta indica A.Juss.) but most often harvested from the Arak tree (Salvadora persica L.). Bark can be easily removed when the end of the stick is crushed between teeth to produce a brush-like instrument for toothbrushing. Miswak has also been shown to contain various bioactive components that promote oral health.
The aim of this review was to assess the effectiveness of the miswak in reducing plaque and gingivitis in adults.
A review protocol was registered in PROSPERO and searches conducted in the PubMed, EBSCOHOST (Dentistry & Oral Sciences), Scopus, and Database for Systematic Review and ClinicalTrials.gov databases. Randomised controlled trials (RCTs) comparing miswak with toothbrushes in adults published in English were considered. The primary outcomes were clinical effect on periodontal health measured as plaque or gingival scores. Two reviewers independently searched for and selected studies with data being extracted by a single review and cross-checked by a second reviewer. Two reviewers assessed risk of bias independently using the Cochrane RoB 2 tool. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess overall quality.
- 9 RCTs (5 cross-over, 4 parallel) reported in 10 papers were included
- 6 RCTs recruited patients with health periodontium, 3 RCTs investigated patients with gingivitis.
- Study durations ranged from 1-2 months with wash out periods of 1 week in all cross-over studies.
- 5 RCTs were considered to be at low risk of bias, 3 at high risk of bias and one at unclear risk.
- There was no significant difference in the plaque score reduction between miswak and toothbrush (see table).
|Miswak versus toothbrush||No. of studies||Standard Mean Difference (95%CI)|
|Overall||6||0.39 (− 0.05 to 0.83)|
|Gingivitis patients||2||0.31 (− 0.68 to 1.30)|
|Health periodontium patients||4||0.41 (- 0.12 to 0.94)|
|Brushing twice daily||5||0.52 (− 0.03 to 1.06)|
|Brushing more than twice daily||2||0.04 (− 0.52 to 0.59)|
- No significant difference was seen between miswak and toothbrush users for plaque reduction on the labial surface of anterior teeth, SMD = 0.02 (95%CI: − 0.57 to 0.60) [3 studies].
- There was no significant difference in the mean gingivitis score reduction SMD = 0.13 (95% CI: − 0.16 to 0.43) between miswak and toothbrush users [5 studies].
- Adjunctive use of miswak and toothbrush led to a
- significantly higher mean plaque score reduction compared to toothbrush usage alone SMD = 0.68 (95% CI: 0.14 to 1.22). [ 3 studies].
- significant difference in the mean of gingivitis score reduction SMD = 0.66(95% CI: 0.03 to 1.29) [3 studies].
- The GRADE certainty of evidence is shown in the table below
|Outcomes||No. of participants (studies)||GRADE certainty|
|Miswak on mean plaque reduction
assessed with: Plaque index
|Miswak on mean plaque reduction on labial surface of anterior teeth assessed with: Photographic stained plaque||80
|Miswak on mean gingivitis reduction
assessed with: Gingival index
|Adjunctive miswak on mean plaque reduction
assessed with: Plaque index
|Adjunctive miswak on mean gingivitis reduction
assessed with: Gingival index
The authors concluded: –
Miswak effectively reduced plaque and gingivitis scores to a level comparable to toothbrush when used exclusively. Adjunctive miswak use was particularly effective in improving periodontal health. However, the included studies inadequately reported on the method of toothbrushing using miswak and the frequency of miswak use. Therefore, further clinical studies are recommended to explore on the advantages and proper method of miswak practice for optima outcome and safety.
While a range of databases were searched restricting the inclusion criteria to the English language may have excluded some relevant studies. Nine RCTs were identified all published since 2003 and while a majority are of a cross-over design they are generally small in size with only 3 studies involving 50 or more patients. The findings suggest that the miswak has a similar effect to a toothbrush in relation to reducing plaque levels and gingivitis and that this is seen in both patients with gingivitis or a health periodontium. Perhaps not unsurprisingly using a miswak in combination with a toothbrush had a larger effect. As noted earlier these studies are short term so more studies on longer term use would be beneficial as would data on any potential adverse effects. Toothbrushing with fluoridated toothpaste is recommended particularly to reduce caries and some studies have been conducted with fluoridated miswak ( e.g. Zawawi & Birkhed 2017 , Raina et al.,2017) suggest this may provide additional benefit so larger well-conducted longer term studies are needed.
Ramli H, Nor Aripin KN, Mohd Said S, Mohamad Hanafiah R, Mohd Dom TN. The effectiveness of miswak (Salvadora persica L. and Azadirachta indica A.Juss.) practices in reducing plaque and gingivitis among adults: A systematic review and meta-analysis. J Ethnopharmacol. 2022 Aug 6;298:115598. doi: 10.1016/j.jep.2022.115598. Epub ahead of print. PMID: 35944735.
Zawawi KH, Birkhed D. Comparison of Fluoridated Miswak and Toothbrushing with Fluoridated Toothpaste on Plaque Removal and Fluoride Release. J Contemp Dent Pract. 2017 Apr 1;18(4):300-306. doi: 10.5005/jp-journals-10024-2035. PMID: 28349908.
Raina R, Kumar V, Krishna M, Raina S, Jaiswal A, Selvan A, Patil C, Kalgotra S. A Comparison of Antibacterial Efficacy of 0.5% Sodium Fluoride Impregnated Miswak and Plain Miswak Sticks on Streprococcus mutans – A Randomized Controlled Trial. J Clin Diagn Res. 2017 Feb;11(2):ZC01-ZC04. doi: 10.7860/JCDR/2017/21250.9165. Epub 2017 Feb 1. PMID: 28384969; PMCID: PMC5376902.
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