Available via license: CC BY 4.0
Content may be subject to copyright.
Vol.2, No.5, 499-503 (2010)
doi:10.4236/health.2010.25074
Co
pyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
Efficacy of Miswak (salvadora persica) in preventing
dental caries
Fatemeh Ezoddini-Ardakani
Department of Oral and maxillofacial radiology, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran;
ezoddini@gmail.com
, afsan40@yahoo.co.uk
Received 1 November 2009; revised 5 December 2009; accepted 7 December 2009.
ABSTRACT
The rate of dental caries and periodontal dis-
eases in the world is still high, regardless of
progress in the oral and dental hygiene. The
natural toothbrush or chewing stick called “Mis-
wak” has been used since ancient history. In
this research the efficacy of Miswak in prevent-
ing dental caries was investigated and com-
pared with the efficacy of toothbrush and tooth-
paste. The analytical and clinical trial method
was applied for this research among high sch-
ool’s students in the city of Yazd, Iran, 2006.
Three hundred eighty second year’s students
(190 cases and 190 controls) were examined
dentally. Then the Miswak was distributed to the
case group and required trainings were given to
both groups. After one year, the examinations
were repeated. For analyzing the data one-way
variance analysis test, Kai square, Paired t-test
and two variable analyses were used. In the be-
ginning of this study, there were no significant
differences between two groups (cases and
controls) regarding their dental situation and
the frequency of brushing their teeth (p-value =
0.162). In addition, there were no significant
differences in DMFT between the two groups.
The data collected at the end of the study
showed a significant increase in DMFT in the
control group (p-value = 0.000). There was 55%
increase in the rate of dental caries in control
group compared to case group (0.89 before the
study and 1.38 after the study). The risk of den-
tal caries for each tooth in control group was
9.35 times more than case group (9.14% and
0.98% respectively). Dental caries rate was de-
tected slightly less in the case group at the end
of this study. This might be as a result of the
antimicrobial effects of Miswak. A longer study
with more cases is needed to prove this sug-
gestion.
Keywords:
Miswak; Dental Caries;
Salvadora Persica; Toothbrush
1. INTRODUCTION
Salvadora Persica (S.P.) is a plant that grows in the de-
serts of the area from west India to Africa. The roots and
sticks of S.P. are used widely for cleaning the teeth in
these areas. The other names for this plant are Arak tree,
Chewing stick, Natural toothbrush and Miswak [1].
Regardless of daily improving dental and oral health
in the world the dental caries and gingivitis is increasing
due to the widely use of sugar in food, fluoride and cal-
cium deficiency and finally ignoring health care [2].
There are nearly seven plants for this meaning but the
most commonly used one is Miswak which is derived
from S.P. plant mostly in Saudi Arabia and parts of the
Middle East [3]. The values of these sticks are due to
their components and cleaning mechanisms. Recently
these sticks were recommended as an effective tool for
oral health by the World Health Organization (WHO).
The sticks have usually 15 cm length and 1 cm di-
ameter (Figure 1). This is why these sticks are called
chewing sticks as well. Their pleasant hot taste made
them easily chewable. Sometimes a small part of the
stick is used as a tooth stick.
Primary analysis showed that S. Persica contains
Tri-Methyamin, Salvadrin, Chloride, Fluoride, Silica,
Sulfur, Mustard, Vitamin C and a small amount of Sapo-
nine Tanin. These components have antibacterial and
antifever effects in addition to be against gingival irrita-
tion [4]. There are many studies showing that Miswak
have strong anti caries effects due to large amounts of
fluoride in it. Many dental studies reported antimicrobial
activity in derivates from Miswak. In addition, the me-
chanical cleaning effects of Miswak were investigated
and it was reported that the value of chewing sticks is
due to their mechanical cleaning [5]. There are many
reports showing Miswak is effective in decreasing gin-
givitis and dental plaques. Elvin-Lewis et al. [6] showed
that the dental loss in adults is very low in the countries
F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
500
Openly accessible at
Figure 1. The shape of some chewing sticks.
that Miswak is used widely. Almas, [7] showed amazing
antibacterial effects of Miswak on Streptococcus Mutant
and Fecalis. Olsson [8] reported that chewing sticks are
more effective in decreasing dental caries than tooth-
brush. Al-lafi and Ababneh [9] investigated antibacterial
effects of Miswak in three ways and showed that deriva-
tives if these sticks have strong effects on the growth of
Streptococcus and staphylococcus aurous. Danielsen, et al.
[10] studied two groups of students in Kenya. One group
used chewing sticks plus toothpaste and the other group
used only chewing sticks. There were no extra effects in
removing dental plaques in the group that used tooth-
paste in addition to chewing sticks.
The aims of this study were to investigate the effects
of Miswak in preventing tooth caries comparing with
toothbrush.
2. MATERIALS AND METHODS
This study was a clinical trial with before and after de-
sign. It was done in 190 cases and 190 controls (95 girls
and 95 boys) in the second year students of Yazd high
schools. Cluster sampling was used to choose 6 boys and
6 girls high schools in Yazd. Then these high schools
were randomly divided into two groups of three high
schools each using as case and control groups.
The investigators were chosen among final year dental
students. Required training regarding filling question-
naires and dental examination were given to them. The
author supervised all the investigation’s steps. The mate-
rials used by the investigators were explorer, mirror,
light, gloves, upper and lower teeth models, Oral-B
toothbrush and Miswak. Dentists examined all of the
students teeth at the beginning of the study and the
number and degree of DMF teeth were recorded in the
questionnaires. The degrees of caries were measured by
explorer and persons complaints. Even small insertion of
the explorer in the teeth recorded as a caries. The de-
grees of the caries were divided to class I to class VI.
After recording the primary data Miswak were given to
the case group and the way to use it were trained to the
group and ask them to use it two to three times per day.
The Miswaks were controlled every three months and
the new Miswaks were given to them if it was neces-
sary. While, the toothbrushes were given to control
group, and the training was given to them to brush their
teeth two to three times per day exactly as it done for
the case group.
After one year, the teeth examinations were done the
same as the beginning of the study and the data were
recorded in the questionnaire. Our data showed the car-
ies rate in the beginning and at the end of the study and
because DMFT have no improvement so the differences
were considered to be as the results of disease develop-
ment in the study year.
The data were imported in the EPI 6 software and
were analyzed by SPSS 13 version software. For com-
paring the data one way variance analysis test, Chi-
Square, Paired t-test and two variable analyses were
used. For comparing the relative risk of disease devel-
opment in two groups the Relative risk index was used.
3. RESULTS
In this research, from the initial 380 students that started
this study, 330 students continued it until the end. In case
group there were 174 students which used Miswak for one
year and 156 students were in the control group which
used toothbrush for one year. The trainings and number of
brushing teeth per day were the same for two groups. At
the beginning of the study the numbers of case and control
students were the same (190). This means that 16 students
in the case group (8.4%) but 34 students in the control
group (17.9%) did not continue the experiments until the
end. The difference is significant (p-value = 0.006). This
means that the cases which used Miswak have more in-
terest in brushing their teeth than the controls. The odds
ratio to discontinue brushing was 2.37 times in control
group than this ratio in case group with the confidence
interval of 1.21 to 3.72 which is different from number
one significantly (p-value < 0.05).
F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
501
501
The same numbers of male and female were chosen at
the beginning of this study, but after one year 159 male
and 171 female continue the study. This means that the
number of cases which abandon the study was more in
the male group but this difference is not significant
(p-value = 0.068) and the sex ratio in two groups is
nearly the same. In addition, the age of all the cases and
controls were nearly the same with maximum 6 months
difference from the median.
The number of brushing the teeth in two group were
the same at the beginning of the study (p-value = 0.162)
(Table 1). There were no significant differences regard-
ing DMFT rate between two groups of cases and con-
trols at the beginning of the study (Table 2).
In this study DMFT was used as a dependent vari-
able to investigate the effectiveness of Miswak. The
mean DMFT in two groups at the beginning of the
study was 3.691 ± 2.797 (mean ± S.D.) with the confid-
ence interval of 95% from 3.39 to 3.99. These data
shows the efficacy of Miswak in preventing tooth de-
cay (Table 3 ).
Table 4 shows that the rate of increased DMF in the
case group was nearly 10 times this rate in the control
group.
Our data showed that at the beginning of the study the
incidence of DMF in the case group was more than this
in the control group, but after one year (at the end of the
study) this incidence in the case group became less than
this in the control group (Ta ble 5 ). The prevalence ratio
of decayed teeth in control group compare with case
group was 0.89 before the study, but this was 1.38 after
the study. These data shows a 55% increase in the rate of
decay in control group compare with the case group. In
addition, the relative risk of decay incidence in the con-
trol group was 9.35 times this in the case group.
4. DISCUSSIONS
The importance of chewing sticks or Miswak was inves-
tigated in several studies (11, 12, 13 and 14). Almas, [7]
showed that Miswak has antimicrobial effects against
Streptococcus Mutants and Fecalis. In addition, Al-Lafi
and Ababnch [9] and Almas, et al. [15] studies showed
that Streptococcus Fecalis is the most sensitive microor-
ganism affected by Miswak. Our results showed that the
rate of carries decreases after using Miswak and this can
be due to these antimicrobial effects. Almas and Al-Zeid
[16] in a study investigated the antimicrobial effects of
Miswak and it’s extract specially on Streptococus Mutan
and Lacto Basilus. These effects were compares with the
effects of toothbrush and normal saline. Their results
showed that in Miswak users there was a significant de-
creases in streptococcus (p = 0.013) but not in Lacto
Basilus (p = 0.147).
Table 1. The number of brushing per day in the two groups at
the beginning of the study.
Cases Controls Total
Group
Brushing/day
No % No % No %
3 times 2 1.1 2 1.3 4 1.2
2 times 12 6.9 18 11.5 30 9.1
1 time 84 48.3 71 45.5 155 47
Rarely 62 35.6 43 27.6 105 31.8
Never 14 8 22 14.1 36 10.9
Total 174 100 156 100 330 100
P-value = 0.162.
Tab le 2. The teeth situation in the students at the beginning of
the study.
Cases (No = 174) Controls (No = 156)
Group
No
Mean S.D. Mean S.D.
p-value
Filled teeth
One side 0.79 1.81 0.54 1.47 0.176
Two sides 0.1 0.52 0.08 0.32 0.767
Three sides 0.06 0.375 0 0 0.036
Decay teeth
Class I 2.36 2.18 2.41 2.14 0.366
Class II 0.16 0.47 0.16 0.461 0.99
Class III 0.02 0.13 0.05 0.3 0.17
Class IV 0 0 0.02 0.18 0.156
Class V 0.01 0.08 0.02 0.18 0.364
Class VI 0.01 0.11 0 0 0.18
Missing teeth 0.13 0.44 0.17 0.41 0.39
Tab le 3. Comparison of the differences between DMF in two
groups before and after the study.
Case No = 174 Control No = 156
Group
Time
X S.D. Min Max X S.D. Min Max p-value
Before 3.9 2.89 0 14 3.46 2.68 0 13 0.147
After 4.14 3.05 0 17 5.7 3 0 16 0.000
p-value 0.000 0.000
Tab le 4. The difference between DMF in each group.
Group No
Mean of increase
during 1 year
S.D. p-value
Case 174 0.2356 0.523 0.000
Control 156 2.2436 1.188 0.000
F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
502
Tab le 5. Prevalence and incidence of decay in two groups.
Teeth No in Case group Teeth No in Control group
Prevalence
Total Decayed % Total Decayed %
p-value
Before 4872 679 13.94 4368 539 12.34 0.059
After 4872 720 14.78 4368 889 20.35 0.00
One year
incidence
4193 41 0.98 3829 350 9.14 0.00
Wolinsky et al. [17] showed that S.P. decreases the
ability of some Streptococcus to colonize on teeth sur-
faces. Bearing in mind that the cause of tooth decay is
acid secretion by microorganisms, the decreases in the
rate of caries in this study and also low rate of DMF in
the countries which use Miswak can be due to this abil-
ity of S.P.
Elvin-lewis et al. [6] and Almas [7] suggested that the
antibiotic effects detected in S.P. may have interaction
with bacteria and prevent their attachment. The other
component of Miswak with possible interaction with
bacterial glycolytic enzyme and their acids or intracellu-
lar polysaccharides products is Fluoride. Furthermore,
Benzylisothiocyanate (BIT) that is naturally a compo-
nent of S.P. acts as inhibitor of bacterial growth and their
acidic products [18]. Chawla [19] showed that some
kinds of chewing sticks such as Neem, S.P. and Acaccia
Arabica have reasonable amounts of fluoride. They
showed that Miswak sticks from S.P. tree have signifi-
cant antimicrobial effects on streptococcus mutants,
streptococcus mitis and staphylococcus. Darout et al. [20]
studied the caries and periodontal situation of adults
Sudanese using either habitual Miswak or Toothbrush.
They suggested using Miswak in developing world be-
cause of its availability and cheap price. In our study as
well the effects of Miswak were significant and every
three months that we were going to the schools to deliver
new Miswak sticks to the students their excitement in
requesting Miswak was interesting.
At the end of our study, the Miswak has been used
more frequently in the Miswak users than toothbrush in
the other group. This difference cannot be due to the
training, because both groups have the same trainings. In
addition our study showed that the rate of DMF which
was the same in both groups increased significantly in
the toothbrush users compared with Miswak users. This
difference can be because of two reasons; 1/Miswak
users used Miswak more frequently and 2/Miswak has
antimicrobial effects plus fluoride and calcium.
Faiez [21] reviewed the effects of Miswak. Many re-
searchers believed that the efficacy of S.P. is because of
its mechanical action while the others believe that Mis-
wak is a natural source for topical fluoride.
About half of the people in Saudi Arabia use Miswak.
Magbool [22] showed that only 12.5% of students are
Caries free in Saudi Arabia and the rate of tooth decay is
48% in 6 and 7 years old age group but this rate de-
creases and is only 1.03% in 16 and 17 years old age
group. We showed that the prevalence of caries in case
group is less than this rate in control group and this can
be as a result of using Miswak.
Norton and Addy [23] did a pilot and cross sectional
study among adults in Ghana. They showed that the rate
of plaque and carries in Miswak users was less than this
rate among non users.
In the other studies among Ethiopian and Nigerian
students and Saudi Arabian dental students, using Mis-
wak and toothbrush was compared. These comparisons
showed that Miswak was more effective than toothbrush
in removing plaque [6,23,24]. These differences can be
related to the frequency and duration of brushing, ex-
periences in using Miswak, motivation and supervision.
One of the specifications of Miswak is its straight
shape that is a disadvantage because it cannot clean lin-
guinal sides of the teeth.
Miswak contains nearly 1.02 μg/g total fluoride.
Chawla showed that the chewing sticks of S.P., Neem-
kikar, Walnut and Pekujebu have 2.8, 1.0, 0.5 and 0.2
μg/ml fluorides respectively [19]. Miswak releases a
significant amount of calcium and phosphor in water and
these elements are necessary for remineralization. Crys-
tallographic studies with fluorescence and x-ray micro-
analysis showed that S.P. sticks have more calcium and
phosphor [24].
Recently S.P. extract was used in some toothpastes
like Ouali Meswak, Pharba, Sarakan, Backenham UK,
Basaraj and Epident [25]. Miswak extract and 0.8 %
monoflourophosphate sodium) compared with Oral-B
toothpaste (containing only 0.8 % monoflourophosphate
sodium) in dental students. Their results showed that the
toothpaste containing Miswak extract significantly was
more effective in removing dental plaques compare with
Oral-B toothpaste. It was also showed that Miswak has
antidecay effects because of its fluoride contents. In ad-
dition, the hot taste of Miswak plus the chewing effects
of the stick can increase the salvia secretion in the mouth
and therefore increase its buffering capacity [21]. In our
study these factors can be effective as well.
Sofrata reported that the chewing stick (Miswak) is
used for oral hygiene in many parts of the world. In ad-
dition to the mechanical removal of plaque, an antibac-
terial effect has been postulated. Miswak embedded in
agar
or suspended above the agar plate had strong anti-
bacterial effects against all bacteria tested. The antibac-
terial effect of suspended Miswak pieces suggests the
presence of volatile active antibacterial compounds [26].
Almas concluded that toothbrushes and Miswak (che-
wing sticks) are widely used for the mechanical removal
of plaque [27].
F. Ezoddini-Ardakani / HEALTH 2 (2010) 499-503
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
503
503
Sofrata reported that the difference in plaque pH be-
tween Miswak extract and water rinse was statistically
significant at 30 min (p < 0.001) [28]. Rinsing with
Miswak extract stimulated parotid gland secretion (p <
0.01). Miswak extract raised the plaque pH, suggesting a
potential role in caries prevention
Openly accessible at
5. CONCLUSIONS
Our study showed that Miswak effectively prevented
dental caries in high school students. Conducting some
studies on antimicrobial and silicate effects of Miswak
are suggested.
REFERENCES
[1] Galati, E.M., Monforte, M.T., Forestieri, A.M., Miceli,
N., Bade, A. and Trovato, A. (1999) Salvadora persica L:
Hypolipidemic activity on experimental hypercholes-
terolemia in rat. Phytomedicine, 6(3), 181-185.
[2] Kimery, M.J. and Stallard, R.E. (1992) The evolutionary
development and contemporary utilization of various oral
hygiene procedures. Periodontal Abstracts, 16, 90-97.
[3] Abderahim, M. and Jurner, J.E. (1983) In vitro evaluation
of Saudi Arabian tooth tree (Salvadoran Persica). Odon-
tostomatological Tropicale, 613, 145-148.
[4] Wolinsky, L.E. and Sote, E.O. (1984) Isolation of natural
plaque inhibiting substances from Nigerian chewing sticks.
Caries Research, 18(3), 216-225.
[5] Akpata, E.S. and Akinrimisi, E. (1977) Antibacterial
activity of extracts from some African Chewing sticks.
Oral Surgery, 44(5), 717-722.
[6] Elvin-Lewis, M., Hall, J.B. and Adu-uta, M. (1980) The
dental health of chewing stick users of southern Ghana,
preliminary finding. Journal of Preventive Dentistry, 6,
151-154.
[7] Almas, K. (1999) The antimicrobial effects of extracts of
Azadirachta Indica (NEEM) and Salvadora Persica (Arak)
chewing sticks. Indian Journal of Dental Research, 10(1),
23-26.
[8] Olsson, B. (1978) Efficiency of traditional chewing
sticks in oral hygiene programs among Ethiopian School-
children. Community Dentistry and Oral Epidemiology, 6,
105-109.
[9] Al-lafi, T. and Ababneh, H. (1995) The effect of the ex-
tract of the Miswak (chewing sticks) used injordan and
the middle east on oral bacteria. International Dental
Journal, 45(3), 218-222.
[10] Danielsen, B.O., Vibeke, B., Manji, F. and Fejerskov, O.
(1989) Chewing sticks, tooth paste and plaque removal.
Acta Odontol Scand, 47, 121-125.
[11] Akhtar
, M. and Ajmal, M. (1981) Significance of chew-
ing sticks (Miswak) in oral hygiene from a pharmacol-
ogical viewpoint. Journal of Pakistan Medical Associa-
tion, 31(4), 89-95.
[12] Farooqi, M.I.H. and Srivastava, J. (1983) The tooth tree
(Salvadora persica). Quarterly Journal of Crude Drug
Research, 81(4), 1297-1299.
[13] El-Mostehy, M.R., Al-Jassem, A.A., Al-Yassin, I.A., et al.
(1983) Miswak as an oral health device preliminary
chemical and clinical evaluation. Hamdard, 26, 41-50.
[14] Khoory, T. (1999) The use of chewing sticks in preven-
tive oral hygiene. Clinic Preventive Dentistry, 5, 11-14.
[15] Almas, K., Al-Bagieh, N. and Akpata, E.S. (1997) In
vitro antimicrobial effects of freshly cut and 1-month old
miswac (chewing stick). Biomedical Letters, 56, 145-149.
[16] Almas, K. and Al-Zeid, Z. (2004) The immediate antim-
icrobial effect of a toothbrush and Miswak on cariogenic
bacteria: A clinical study. Journal of Contemporary Dental
Practice, 5(1), 105-114.
[17] Wolinsky, L.E., Mania, S., Nachnani, S., et al. (1996)
The inhibiting effect of aqueous Azadirechta indica (Neem)
extract upon bacterial properties influencing in vitro
plaque formation. Journal of Dental Research, 75(2), 816-
822.
[18] Al-Bagieh
, N.H. and Weinberg, E. (1989) Benzylisothi-
cyanate: A possible agent for controlling dental caries.
Microbios, 39, 143-151.
[19] Chawla, H.S. (1983) A new natural source for topical
fluoride. Journal of the Indian Dental Association, 55
(10), 419-422.
[20] Darout, I.A., Albandar, J.A. and Nils, S. (2000) Perio-
dontal status of adult Sudanese habitual users of Miswac
chewing sticks or toothbrushes. Acta Odontol Scand. 58,
31-37.
[21] Faiez,
N.H. (1995) Miswac: The natural toothbrush. The
Journal of clinical Dentistry, 8(5), 125-129.
[22] Magbool, G. (1992) Prevalence of dental caries in school
children in Al-Khobar Saudi Arabia. Journal of Dentistry
for Children, 59(5), 384-386.
[23] Norton, M.R. and Addy, M. (1989) Chewing sticks ver-
sus toothbrushes in West Africa. A pilot study. Clinical
Preventive Dentistry, 11(3), 11-13.
[24] Char, D.C.N., Dogao, A.U. and Dogan, M.M. (1987)
SEM, XRF. and EMPA evaluation of Middle Eastern
toothbrush “Salvadora persica”. Journal of Electron Mi-
croscopy Technology, 5, 145.
[25] Guile, E.E., Al-Shammery, A.R. and El-Backly, M.N.
(1996) Oral health survey of Saudi Arabia: Oral health
knowledge attitudes and practice among adults. Journal
of Dental Research, 75, 1276.
[26] Sofrata, A.H., Claesson, R.L., Lingström, P.K. and Gus-
tafsson, A.K. (2008) Strong antibacterial effect of Mis-
wak against oral microorganisms associated with perio-
dontitis and caries. Journal of Periodontology, 79(8),
1474-1479.
[27] Almas, K. (2002) The effect of Salvadora persica extract
(Miswak) and chlorhexidine gluconate on human dentin:
A SEM study. The Journal of Contemporary Dental
Practice, 3(3), 27-35.
[28] Sofrata, A., Lingström, P., Baljoon, M. and Gustafsson, A.
(2007) The effect of Miswak extract on plaque pH. An in
vivo study. Caries Research, 41(6), 451-454.
