Oral health has a major impact on the general feature of life and well-being. For thousands of years, the use of plants have been closely associated with dental hygiene and therapeutic practices. Chewing sticks of plants were prehistorically used by the early Arabs, Babylonian, Greek, and Roman societies for cleaning teeth.
Miswak Chewing Sticks
Despite the widespread use of toothbrushes and dentifrices, natural methods of tooth cleaning using chewing sticks are observed in several parts of the world. In many traditional cultures, plastic-bristle brushes are not used. Instead, the use of herbal “chewing sticks” is common. Chewing sticks are usually taken from plants, shrubs, or trees with high anti-microbial activity.
Chewing sticks are known by different names in different cultures. “Miswak” (which has synonyms in different Arabic dialects and countries, including “miswaak,” “misswak,”“miswaki,” “meswak,” “mswaki,” “sewak,” “siwak,” and “siwaki”) is an Arabic word. The conventional meaning of miswak is ‘tooth-cleaning stick’ or “stick used on teeth and gums to clean them”.
It is affordable and easily available in majority of urban and rural areas of developing countries. In Pakistan, the main factor attributed to the selection of chewing sticks against toothbrush is its acquisition by more than 50% of its population living in rural areas. It is observed that the affordability of toothbrush is low among rural (only 8%) than urban (38%) societies of Pakistan.
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Historical Significance and Usage
The exact origin of mechanical devices for cleaning teeth is unknown. The first early devices include the tooth stick, referred to as the toothpick, and the wood mop, twig brush, miswak, or siwak. Toothpicks have been traced as far back as prehistoric times. They have been excavated along with other articles of toiletry in the ancient Babylonian city of Ur, which flourished in approximately 3500 BC. The Greek sophist Alciphron in the second century BC recommended the use of a toothpick to clean the “fibrous residue” remaining between the teeth after meals.
The historical forerunner of the modern toothbrush might be the Babylonian fiber brush, called the “chew stick,” “fiber stick,” or “fiber pencil,” which was used as early as 3500 BC. Before the emergence of Islam, people in Arab countries used miswak derived from root of the ‘Arak’ tree (Salvadora persica). In the early Islamic period, the use of miswak became a part of a cultivated and elegant mode of life. The use of miswak as a tool of basic oral hygiene has been incorporated into Islam as part of religious practice.
Islam has given an elevated status to the miswak, and its importance has been stressed in many Prophetic narratives by Muslim commentators. According to Muslim commentators of Prophetic narration, the use of miswak was a constant practice of Prophet Mohammad (Peace Be Upon Him) prior to sleeping, after rising, after entering the house, before and after meals, during fasting, and before recitation of prayers and reading of the holy texts.
Thus, the influence of Islam on the spread and use of chewing sticks in different parts of the world is significant. The religious and spiritual impact of the miswak probably is the principal reason why it is extensively used by Muslims all over the globe. Today, both the traditional miswak and the modern toothbrush are used commonly in Muslim countries.
The World Health Organization (WHO) recommended the use of the miswak in 1986, but in 2000, an international consensus report on oral hygiene concluded that further research was needed to document the effect of the miswak.
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How to Brush Your Teeth With a Miswak ? Dr Muhammad Salah
Chemical Properties and Benefits
Chemical examinations have revealed a new era of chewing sticks reimbursement, which established that these sticks contain natural ingredients, which are beneficial for oral health. It has been reviewed that it contains ascorbic acid, tri-methylamine, chloride, fluoride, silica, resins, and salvadorine. It has been reviewed that it contains ascorbic acid, tri-methylamine, chloride, fluoride, silica, resins, and salvadorine, which have proved potency to heal the inflamed and bleeding gums, produce stimulatory effect on gingiva, remove tartar, and other stains from the teeth, re-mineralize dental hard tissue, whitens teeth, provide enamel barrier, and increase salivary flow, respectively.
A variety of natural bioactive components have been identified in Salvadora persica extracts by researchers. These constituents are considered to be essential for good oral and dental hygiene. The miswak's properties have been described as follows: "Apart from their antibacterial activity which may help control the formation and activity of dental plaque, they can be used effectively as a natural toothbrush for teeth cleaning. The stick contains cleaners, disinfectants and even fluorides.
Several studies have also claimed that miswak has anti-oxidant, analgesic, and anti-inflammatory effects. The use of a miswak has an immediate effect on the composition of saliva. Several clinical studies have confirmed that the mechanical and chemical cleansing efficacy of miswak chewing sticks are equal and at times greater than that of the toothbrush.
Tests have shown that African chew sticks contain natural antibiotics, fluoride, and other anti-cavity ingredients. When Africans came to the United States, they brought their revolutionary idea with them. Many older people are finding themselves in their 80s with healthy gums and cavity-free teeth, and they are using nothing but chew sticks to take care of them! The chewing action keeps the gums healthy, cleans the food from teeth and freshens the breath.
Antimicrobial Activity
Much effort has focused on examining the antibacterial activity of miswak extracts against a variety of human pathogens. Several studies have shown that miswak (Salvadora persica) has significant antimicrobial activity against both aerobic and anaerobic bacteria.
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Almas and Al-Zeid found out that the reduction of Streptococcus mutans was significantly greater using miswak in comparison with tooth brushing, and there were no significant differences in Lactobacilli reduction. Therefore, authors concluded that miswak may have an immediate antimicrobial effect and that Streptococcus mutans were more susceptible to the antimicrobial activity of miswak than Lactobacilli.
Clinical Evidence and Studies
In order to reestablish chewing sticks as an effective and exclusive oral hygiene tool in today's nylon toothbrush society where newer attractive products are being introduced everyday in market, clinical evidence proving not only its chemical but also its mechanical superior properties is of prime importance.
A clinical study was conducted on dental students (age 18-22 years) of a public sector dental hospital were recruited. Participants were randomized into two interventional groups and provided with either chewing sticks or toothbrushes. Pre- and post-intervention examinations were executed by two blind and calibrated examiners using plaque and gingival dental indices.
The recommendations for toothbrush users included brushing teeth according to BASS method with toothpaste application of full length on toothbrush and brushing teeth twice daily (after breakfast and before going to bed) for 2 minute. The demonstrations and instructions for chewing stick users included the technique of preparation of working end of chewing sticks and its appropriate brushing technique. It was advised to prepare a new working end every day and brushing twice daily (after breakfast and before going to bed) for 2-5 minutes.
Turesky Quigley Hein Plaque index (1962) and Loe and Silness gingival index (1962) were used as basic examination tools to assess dental plaque and gingival status respectively.
According to the results of this trial, it is interpreted that the testing null hypothesis has partially been accepted, as no difference in gingival scores was observed for different sites of the examined teeth among chewing stick and toothbrush users and therefore chewing stick was found to be equally effective as toothbrush in terms of gingival status. On the other hand, chewing stick had shown even better results in terms of reduction in plaque scores than in subjects using toothbrush.
As far as the antimicrobial actions of chewing stick is concerned, literature has shown that the risk of dental caries identified was 9.35 times more in subjects using toothbrush than those using chewing sticks. Also lower occurrence of dental caries due to less plaque deposits has been observed in populations using the Neem and Arak miswak sticks.
Chewing sticks (miswak) has revealed parallel and at times greater mechanical and chemical cleansing of oral tissues as compared to a toothbrush. The anti-plaque efficacy of chewing stick was significantly demonstrated in this study. This indicates that it may effectively and exclusively replace the toothbrush.
Comparative Study Results
Table 1 demonstrates the observed mean (standard deviation) of plaque and gingival scores for both group A and group B, which were calculated at pre-interventionand post-intervention examination phases. The same table illustrates the paired t-test values which imply comparative (pre and post intervention) differences in plaque and gingival mean scores within chewing stick users, as well as within toothbrush users.
| Group | Examination Phase | Plaque Score (Mean ± SD) | Gingival Score (Mean ± SD) |
|---|---|---|---|
| Group A (Toothbrush) | Pre-intervention | [Insert Value] | [Insert Value] |
| Group A (Toothbrush) | Post-intervention | [Insert Value] | [Insert Value] |
| Group B (Chewing Stick) | Pre-intervention | [Insert Value] | [Insert Value] |
| Group B (Chewing Stick) | Post-intervention | [Insert Value] | [Insert Value] |
Conclusion
The use of chewing sticks also fulfils the fundamental requisite of primary health care and may be a proper substitute to the modern manual toothbrush to accomplish the goal of prevention of oral diseases, especially in countries with economic restraints and countries with restricted oral health care services for general population.
