Short term clinical effect of active and inactive Salvadora persica miswak on dental plaque and gingivitis.

ETHNOPHARMACOLOGICAL RELEVANCE: Salvadora persica shrub has been used traditionally in folk medicine for different medical condition treatments. The habitual use of Salvadora persica roots (chewing sticks) for dental hygiene is still wildly spread throughout parts of Asia, Africa, and Middle. It is one of the most important species with its reported strong antibacterial, antifungal, and antiviral effects. Mechanical removal of dental plaque is regarded as an effective mean of controlling progression of periodontal disease. AIM OF THE STUDY: To evaluate the effect of active and inactive miswak on dental plaque, subgingival microbiota and gingival inflammation in patients with gingivitis. MATERIALS AND METHODS: In this double blinded randomized controlled trial 68 gingivitis patients were randomly assigned to either active or inactive miswak group, and were instructed to use only issued miswaks for oral hygiene during 3 weeks experimental period. Registration of plaque, gingival inflammation, and plaque samples were taken at baseline and on completion of the study. Plaque samples were analyzed by DNA-DNA hybridization technique. RESULTS: Active miswak significantly reduced dental plaque (p = 0.007). There were no differences between active and inactive miswak in reduction of approximal plaque and composition of subgingival microbiota. CONCLUSIONS: Miswak has an overall effect on dental plaque and gingival inflammation scores. Similar results were achieved by active and inactive miswak in difficult to reach areas, indicating miswak has limited chemical effects on this study population. Therefore, miswak can be used as a dental hygiene method in conjunction with interproximal cleaning aides.

The miswak (chewing stick) and oral health. Studies on oral hygiene practices of urban Saudi Arabians.

The miswak, a traditional chewing stick for cleaning teeth, is made from the plant Salvadora persica. For religious and cultural reasons, miswak use is firmly established and widespread in Saudi Arabia and most other Muslim countries. Only recently has scientific evaluation of the miswak been undertaken. The aims of the thesis were: 1) to explore current oral hygiene habits and oral health awareness among urban Saudi Arabians in relation to age, gender and educational level (papers I and II); 2) to compare mechanical plaque removal and gingival health after miswak use and toothbrushing (paper III); 3) to compare the effect of miswak use and toothbrushing on subgingival plaque microflora (paper IV). In papers I and II, structured interviews were conducted with 1200 regular patients at two centres in the city of Makkah, providing dental care for university and military staff and their families, respectively. Consecutive patients were stratified according to gender and age, into 6 age groups from 10 to 60 years, with 50 male or female subjects in each group at each centre. Oral hygiene habits were correlated with the subjects' age, gender, and educational levels and analysed statistically by a generalized linear model and ANOVA. In papers III and IV, the subjects comprised 15 healthy Saudi Arabian male volunteers aged 21 to 36 years, attending the Dental Center at Al-Noor Specialist Hospital in Makkah City. A single-blind, randomised crossover design was used. The Turesky modified Quigley-Hein plaque and Löe-Silness gingival indices and digital photographs of plaque distribution were recorded in Paper III and in Paper IV plaque was sampled for DNA-testing. Inhibition zones around miswak material were examined on agar plates with Actinobacillus actinomycetemcomitans and the leukotoxicity of this bacterium was analysed in a bioassay with macrophages +/- miswak extracts (paper IV). In papers I and II, 73% of the subjects used a toothbrush and 65% used a miswak daily. There were significant differences between genders and age groups, and between the centres. Regular miswak use was more prevalent among men (p < 0.01), while women used a toothbrush more often than a miswak (p < 0.05). For the majority (88%) of the individuals, oral hygiene began late, after the age of 7 yrs. Oral hygiene habits were strongly correlated to educational level (p < 0.001). The miswak was preferred by less educated people. Tooth brushing started earlier among the better educated (p < 0.001). In paper III, compared to tooth brushing, use of the miswak resulted in significant reductions in plaque (p < 0.001) and gingival (p < 0.01) indices. In paper IV, A. actinomycetemcomitans was significantly reduced by miswak use (p < 0.05) but not by tooth brushing. These results were supported by the in vitro observations that extracts from S. persica interfered with growth and leukotoxicity of A. actinomycetemcomitans. It was concluded that oral hygiene practice is introduced very late, is strongly correlated to educational level, and that more women prefer toothbrushing to miswak use. It was further concluded that miswak use was at least as effective as toothbrushing for reducing plaque and gingivitis, and that the antimicrobial effect of S. persica is beneficial for prevention/treatment of periodontal disease. There is clearly a need for further oral health education in Saudi Arabia. Because of its close association with Islam, maximum benefits may be achieved by encouraging optimum use of the miswak. Oral hygiene may be improved by complementing traditional miswak use with modern technological developments such as toothbrushing and by tailoring oral hygiene recommendations to educational level.

Oral hygiene habits and oral health awareness among urban Saudi Arabians.

PURPOSE: To analyze prevailing oral hygiene practices and oral health awareness among urban Saudi Arabians in relation to age, gender and educational level. MATERIALS AND METHODS: Structured interviews with 1155 regular patients at two centers providing dental care for university and military staff and their families, respectively, in the city of Makkah. Consecutive patients were stratified by gender and age, into 6 categories from 10 to 60 years, with 50 male or female subjects in each group at each center. Oral hygiene habits and attitudes to oral health were correlated with age, gender and educational levels, using ANOVA. RESULTS: For the majority (> 88%) oral hygiene routines were introduced very late, after the age of 7 yr. Habits were strongly correlated to the level of education (p < 0.001); subjects with less education favored the miswak. Among the better educated, toothbrushing started earlier (p < 0.001). Regular miswak use was more frequent in older age groups (p < 0.001). Females used a toothbrush more often than males (p < 0.001), and miswak use by women was less frequent than by men (p < 0.001). Despite the availability of free dental care at the public health centers, 89% of the participants at the military center sought only emergency care, in contrast to 54% at the university center. CONCLUSIONS: Among urban Saudi Arabians, oral hygiene routines are introduced relatively late in life and knowledge and awareness of oral health is very low. There are pronounced variations in oral hygiene habits, related mainly to age and educational levels. Such factors should be taken into account when planning oral health strategies.

Prevailing oral hygiene practices among urban Saudi Arabians in relation to age, gender and socio-economic background.

The aim was to analyze prevailing oral hygiene practices among urban Saudi Arabians in relation to age, gender, and socio-economic background. Structured interviews were performed with 1155 regular patients at two centers providing dental care for university and military staff and their families, respectively, in the city of Makkah. Consecutive patients were stratified according to gender and age into 6 age categories from 10 to 60 years, with 50 male or female subjects in each group at each center. Oral hygiene habits were correlated with the subject's age and gender, and analyzed statistically using a generalized linear model. It was found that 73% used a toothbrush daily, while a miswak was used daily by 65%. Significant differences were found between genders and age groups, and between the centers. Regular miswak use was more prevalent among men (P < 0.01), while women used toothbrush more than miswak (P < 0.05). Regular miswak use was more frequent at older age (P < 0.001) and tooth brushing was less prevalent. Forty-four percent of the 51- to 60-year-old patients at the military center never used a toothbrush. Regular toothbrush use was more prevalent in the youngest age groups (P < 0.001). Among the 10- to 15-year-olds, 45% at the university center used only a toothbrush, while no adolescents at the military center used only a toothbrush. We conclude that there are large differences in current oral hygiene habits among Saudi Arabians, and that these are related mainly to age and socio-economic level, and to a lesser extent gender. This should be taken into account when planning oral health strategies for different categories.

Comparative effect of chewing sticks and toothbrushing on plaque removal and gingival health.

PURPOSE: The aim of the study was to compare the effect of the chewing stick (miswak), and toothbrushing on plaque removal and gingival health. MATERIALS AND METHODS: The participants comprised 15 healthy Saudi Arabian male volunteers aged 21 to 36 years, attending the Dental Center at Al-Noor Specialist Hospital in Makkah City in Saudi Arabia. The study was designed as a single, blind, randomized crossover study. The Turesky modified Quigley-Hein plaque and Löe-Silness gingival indices and digital photographs of plaque distribution were recorded at baseline, one week after professional tooth cleaning, and again following three weeks use of either the miswak or toothbrush. Professional tooth cleaning was repeated, and after a further three weeks use of either the miswak or toothbrush (using the alternative method to that used in the first experimental period), plaque and gingival indices, and digital photographs of plaque distribution were recorded anew. RESULTS: Compared to toothbrushing, the use of the miswak resulted in significant reductions in plaque (p < 0.001) and gingival (p < 0.01) indices. Image analysis of the plaque distribution showed a significant difference in reduction of plaque between the miswak and toothbrush periods (p < 0.05). CONCLUSION: It is concluded that the miswak is more effective than toothbrushing for reducing plaque and gingivitis, when preceded by professional instruction in its correct application. The miswak appeared to be more effective than toothbrushing for removing plaque from the embrasures, thus enhancing interproximal health.