"Miswak" prevents tooth decay better than conventional toothpastes

[Bint e Aisha]

‘Chewing sticks prevent tooth decay better than conventional toothpastes’

 

Nigerian researchers have demonstrated that three local chewing sticks performed better than fluoride-based and conventional toothpastes in preventing tooth decay. The local chewing sticks are: Fagara zanthoxyloides (candlewood or Senegal prickly ash/orin ata in Yoruba), Vernonia amygdalina (bitter leaf) and Massularia accuminata (chewing stick (pako ijebu in Yoruba/atu uhie in Igbo)).Researchers have also shown that one of the chewing sticks, Massularia accuminata, increased testosterone and libido.

 

The study titled “A Study of the Anticaries Activity of Three Common Chewing Sticks and Two Brands of Toothpaste in South West Nigeria” was published in British Journal of Pharmaceutical Research. The researchers from the Department of Pharmaceutical Microbiology, Faculty of Pharmacy, Olabisi Onabanjo University, Ago-Iwoye, Ogun State, include: Odeleye Olubola Florence; Okunye Olufemi Lionel; Kesi Christopher; and Abatan Temitope Olubunmi.

They concluded: “The chewing sticks used in this study showed good antimicrobial activity against the isolates and could provide better care than fluoride toothpastes. The active compounds if isolated would be good caries-controlling components of herbal toothpastes.”

The researchers evaluated three common chewing sticks and two brands of toothpaste in southwest Nigeria for the ability to control caries-causing bacteria.
With an increase in tooth decay and gum diseases all over the world, there is need to produce oral cleaning agents that will better control caries-causing bacteria. Three common chewing sticks – Fagara zanthoxyloides (FZ), Vernonia amygdalina (VA) and Massularia accuminata (MA)- and two brands of toothpaste- Close Up and Macleans- were evaluated for their anti-caries activities.

Zanthoxylum zanthoxyloides (Fagara zanthoxyloides) is a glabrous shrub or tree with an English or common name of candlewood or Senegal prickly ash. It is called Orin ata in Yoruba. It belongs to the family Rutaceae. Its chewing sticks are obtained either from the stems or the roots and they give a warm pungent and numbing effect on the palate. These plants have also been reported to possess antisickling, antiparasitic and antiseptic activities and have been known to be used to treat other ailments including toothache, sexual impotence, gonorrhoea, malaria, dysmenorrhoea, urinary and venereal diseases and abdominal pain.

Veronica amygdaline commonly called bitter leaf, is a perennial shrub belonging to the family Asteraceae. In Nigeria, the Edo calls it oriwo; Hausa, chusar doki (a horse tonic food containing the leaves); fatefate/mayemaye (a food prepared from the leaves); Ibibio, atidot; Igbo, onugbu; Tiv, ityuna; and Yoruba, ewuro. The plant is used as an anti-helminth, anti-malarial, laxative, digestive tonic, appetizer and febrifuge and for the topical treatment of wounds. This plant also has a measure of anti caries activity. The roots and stems of this plant are used as chewing sticks and have been known to possess a measure of anti caries activity.

Commonly called Chewing stick, Massularia acuminata (synonym Randia acuminata) is of the family Rubiaceae. It is called pako-ijebu and orin-ijebu in Yoruba and atu uhie in Igbo. It grows as a shrub or small tree. The inhibitory properties of the plant are attributed to its phytochemicals, which include saponins, flavonoids, glycosides, tannins and anthraquinones. Massularia acuminata is a traditionally used herb in Yoruba medicine, used as a chewing stick and aphrodisiac; the chewing stick aspect was researched for being an anti-gingivitis agent, and it appears to increase testosterone and libido in research animals.

According to Handbook of African Medicinal Plants, Second Edition, by Prof Maurice Iwu, Massularia acuminata has been shown to possess significant antimicrobial activity against oral pathogens associated with orodental infections, including Bacteroides gingivalis and B. melaninogenicus. The aqueous extract of the plant has a Microbial Inhibition Concentration (MIC) of 0.5 and 2 ug/ml against Bacteroides gingivalis and B. melaninogenicus, respectively. The adherence of Streptococcus mutans to the surfaces of the teeth was effectively inhibited by a one per cent concentration of the aqueous extract of Massularia.

On the effect of Massularia acuminata on male reproductive system, the Handbook of African Medicinal Plants noted: “Extracts of the stem at various doses (20-1000 mg/kg) produced a significant increase in testes- body weight ratio, testicular protein, glycogen, sialic acid, cholesterol, testosterone, and luteinizing and follicle-stimulating hormone concentrations of male rats throughout the period of administration…”

Meanwhile, a study published in the journal Evidence Based Complement Alternative Medicine, have revealed that the aqueous extract of Massularia acuminata stem at the doses of 500 and 1000 mg/kg body weight could be used as a stimulator of sexual behaviour in male rats. The study thus supports the acclaimed aphrodisiac use of the plant in folk medicine of Nigeria. The data obtained revealed that the action of M. acuminata extract was due to the influence on both sexual arousal and performance. “The aphrodisiac effect of the plant extract may be due to the presence of alkaloids, saponins and/or flavonoids through a multitude of central and peripheral means. Work is in progress on the isolation and characterization of the aphrodisiac principle(s) in the plant extract, the actual mechanism of action as well as the toxicity risks of the crude extract and bioactive agent(s),” the researchers noted.

Meanwhile, according to the study on local chewing sticks, fifty isolates of Staphylococcus aureus, one of the bacteria often implicated in dental caries, isolated from patients presenting with various dental problems at the University College Hospital (UCH), Ibadan, Nigeria were obtained from the Medical Microbiology Department of the Hospital.

The isolates were challenged with the toothpastes, undiluted, as well as ethanol and aqueous extracts of the chewing sticks using the agar cup diffusion method. The chewing sticks were also screened for secondary metabolites using standard procedures.The results showed that the ethanol extracts of Fagara zanthoxyloides (FZ) showed the highest anti-caries activity followed by Vernonia amygdalina (VA) and then Massularia acuminata (MA). 43 isolates (86 per cent) were sensitive to the ethanol extract of Fagara zanthoxyloides while 36 (72 per cent) and 25 (50 per cent) were sensitive to Vernonia amygdalina and Massularia acuminata respectively.

“Both brands of toothpaste were inferior to the ethanol extracts of all the chewing sticks in anti-caries activity. Only 15 (30 per cent) and 20 (40 per cent) of the isolates were sensitive to Close up and Macleans respectively. 16 (32 per cent), 14 (28 per cent) and 10 (20 per cent) of the isolates were sensitive to the aqueous extracts of FZ, MA and VA respectively.” The researchers concluded: “The active constituents in the ethanol extracts of the chewing sticks will be useful as anti caries components of herbal toothpastes which are becoming common in the market.”

Until now, some of these chewing sticks have been shown to possess varying degrees of antimicrobial activity against oral microbial flora which indicates therefore, that the chewing sticks, in addition to providing mechanical stimulation of the gums, also destroy microbes, a feature which is absent in the common toothpaste and brush method. This advantage of the chewing sticks over the conventional toothpaste and brush could explain why many Africans have strong teeth.

The extracts of some chewing sticks have been demonstrated to have anti-plaque and antimicrobial activities against certain oral bacteria like Streptococcus mutans, Bacteroides gingivitis and oral anaerobes commonly implicated in dental caries and orodental infections. The researchers added: “Chewing sticks therefore can safeguard against dental problems, which is probably the reason why dental caries (decay) is not rampant in certain parts of Nigeria where the use of chewing sticks is frequent. Thus, the World Health Organization has encouraged the use of chewing sticks. In Nigeria, about 80-90 per cent of the population in rural areas use chewing sticks, mainly because they are readily available, cheap and efficacious.

“The cleansing efficacy of chewing sticks is attributed to the mechanical effects of its fibers, the release of beneficial chemicals or a combination of both. Some African chewing sticks have also been reported to contain fluoride ions, silicon, tannic acid, sodium bicarbonate and other natural plaque inhibiting substances that can reduce bacterial colonization and plaque formation.

The researchers noted: “The presence of saponins and tannins in all the three plants, of anthraquinone in Massularia acuminata and of alkaloids in Fagara zanthoxyloides and Vernonia amygdalina can be linked to the antibacterial activity of the plants. Cowan had shown that antibacterial effect of plant materials was due to the presence of alkaloids, tannins and anthraquinones. It had also been reported by Hagerman et al. that tannins form irreversible complexes with proline- rich proteins which could lead to inhibition of cell wall protein synthesis, a property that may explain the mode of action of the chewing stick extracts used in this work. In addition to its antibacterial effect, saponins also have antifungal properties.

“The test organism used for this study, Staphylococccus aureus is one of the organisms often implicated in dental caries. It accounts for over 70 per cent of dental caries cases from the research works carried out by Daniyan and Abalaka and had highest proportion in the work of Oluremi et al. It is a pathogenic organism that causes dental infections and are now widely isolated from the oral cavity.

“The extracts of the three chewing sticks produced a greater activity at a concentration of 100mg/ml than the two brands of toothpaste. This is similar to the work carried out by Antwi-boasiako et al. where the plant extracts of Garcinia kola (bitter kola) had a greater antimicrobial effect than the pepsodent toothpaste used. The ethanol extract of Fagara zanthoxyloides gave a better antimicrobial activity against all the fifty isolates than the ethanol extracts of Vernonia amygdalina and Massularia acuminata. 43 (86 per cent) of the isolates were sensitive to the ethanol extracts of Fagara zanthoxyloides while 36 (72 per cent) and 25 (50 per cent) were sensitive to Vernonia amygdalina and Massularia acuminata respectively.

“The ethanol extracts of the plant materials had a better antimicrobial action than the aqueous extracts which is in accordance with a research work by Isawumi and Rotimi et al. The aqueous extracts of the plant materials showed a poor inhibitory action against the test organism. This may be due to poor solubility nature of the active principles of the plants in water. The two brands of toothpaste had weaker antimicrobial activity than the plant extracts. This is not unexpected since chemical toothpastes owe their antimicrobial property to the presence of fluorides as part of their ingredients. Macleans however had a better inhibitory action than close up.

Source

[Bint e Aisha]

 

Found another good article: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545237/#!po=73.1481

 

Miswak: A periodontist's perspective

Parveen Dahiya, Reet Kamal, [...], and Gaurav Saini

Additional article information

Abstract

Meticulous plaque control on a daily routine basis is the single most important step to achieve good oral health. Herbal chewing sticks, commonly known as Miswak, are among the ancient and traditional oral hygiene aids popular in India, Pakistan, most of the Arabian countries, and several African countries. But nowadays, because of low cost, free availability, unique chemical composition, and spiritual beliefs, miswak is being used worldwide. A large number of studies have proved that miswak is as effective as, or even superior to the present day′s most common oral hygiene aid, i.e., toothbrush. The aim of this review article is to discuss various pharmacological and therapeutic aspects of miswak and also to compare the effectiveness of miswak with modern toothbrushes in terms of oral hygiene practice.

Keywords: Chewing stick, miswak, oral health, toothbrush

INTRODUCTION

An old but time-tested proverb “If the eyes are a window to the soul, then the mouth is the doorway to the body” reflects the importance of oral health. Even the evidences from the early civilizations like the Babylonian, Assyrian, and Sumerian suggest an interest in cleanliness of the mouth. Medical books of ancient India, Susruta Samhita and Charaka Samhita, have also stressed on oral hygiene and brushing teeth with herbal sticks.

Teeth-cleaning sticks, commonly known as Miswak or Siwak, are popular oral hygiene aids in India, Pakistan, most of the Arabian countries, and several African countries whereas toothbrushes with nylon bristles are the most common oral hygiene aid in most of the developed countries. Because of free availability, unique chemical composition and religious beliefs, the use of miswak and other herbal products are increasing at an exponential rate in both developing and developed countries. The World Health Organization (WHO) has also recommended and encouraged the use of miswak as an effective tool for oral hygiene.[1]

Recently, various authors have concluded that these chewing sticks or their extracts have therapeutic effect on gingival diseases.[2,3] Sofrata AH et al. Studied the antibacterial effect of miswak pieces and found it most effective against Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and H. influenza whereas less effective against Streptococcus mutansand least effective against Lactobacillus acidophilus.[4] A very recent study by Patel PV et al. showed significant improvement in plaque score and gingival health when miswak was used as an adjunct to tooth brushing.[5]

It is quite surprising, despite the widespread use of miswak since ancient times; relatively little scientific attention has been paid to its oral health beneficial effects. So, the aim of this review article is to discuss various pharmacological and therapeutic aspects of miswak and also to compare the effectiveness of this traditional oral hygiene aid with that of modern toothbrushes. Internet database Medline/Pubmed search for word “Miswak” resulted in 61 articles, “Miswak and oral health” showed 32 articles, “Miswak and Periodontal disease” and “Miswak and Periodontitis” revealed 24 and 7 articles, respectively. Only highly relevant articles from manual and Pubmed search in English language were considered for the present review article.

DISCUSSION

Miswak-chemical composition and unique properties

Miswak is basically a pencil-sized stick 15 to 20 cm long with a diameter of 1 to 1.5 cm from Arak (Salvadora persica) or the Toothbrush tree. But, in areas where it is not available, sticks from other local shrubs/trees like orange (Citrus sinensis), lime (Citrus aurantifolia), and neem (Azadirachta indica) can also be used as teeth-cleaning aid.

The use of miswak for oral hygiene serves dual function, i.e., mechanical plaque control by friction between plant fibers and tooth surface and chemical plaque control due to its chemical composition. Each of these components has some specific role in oral health and its unique pharmacological and therapeutic properties can also be explained on the basis of its composition.[6] Silica acts as abrasive material that removes stains and deposits from the tooth surface. Sodium bicarbonate has mild abrasive and germicidal effect. Tannic acid has astringent effect on mucus membrane and found to be good anti-plaque and anti-gingivitis. Resins serve a physical function and form a layer over the enamel which protects it from microbial action. Alkaloids show bactericidal effect and stimulate the gingiva. Essential oils have anti-septic effect and stimulate the flow of saliva. Vitamin C helps in healing and repair. Calcium and fluoride ions promote remineralisation of tooth structure and have mild anti bacterial action.

Oral microorganisms and miswak

Dental plaque, which is mainly composed of various aerobic and anaerobic bacteria, is the main etiological agent for initiation and progression of periodontal disease. Certain species, such as A. actinomycetemcomitans, P. gingivalis, Prevotella intermedia, and Treponema denticola, are more commonly associated with destructive periodontal disease.[7]

It has been found that the bacteria cultivated from healthy sites consist predominantly of Gram-positive facultative rods and cocci (approximately 75%). The recovery of this group of microorganisms is decreased proportionally in gingivitis (44%) and periodontitis (10 to 13%). These diseases are accompanied by an increase in the proportion of Gram-negative rods, from 13% in health to 40% in gingivitis and 74% in advanced periodontitis.[8]

Al-Lafi and Ababneh in 1995 reported that the use of miswak inhibits the formation of dental plaque chemically and also exerts antimicrobial effect against many microorganisms.[9] Later on, Almas and Al-Bagieh in their in vitro study demonstrated that aqueous extract of miswak has growth-inhibitor effect on several microorganisms.[10]

In 2002, Darout et al. used checker board DNA-DNA hybridization and stated that miswak has selective inhibitory effect on salivary bacteria. They found that there were significantly higher levels of A. actinomycetemcomitans, Prevotella melaninogenica, Campylobacter rectus, Peptostreptococcus micros, Veillonella parvula, S. mutans, Streptococcus anginosus, Actinomyces israelii, Capnocytophaga sputigena, and P. gingivalis, and significantly lower levels of P. intermedia, Fusobacterium nucleatum, C. sputigena, Eikenella corrodens, L. acidophilus, Streptococcus sanguis, Streptococcus salivarius, Streptococcus oralis, and Streptococcus mitis in the miswak than in the toothbrush group.[11] But, Al-Otaibi M et al. observed that the use of miswak, in contrast to toothbrush, significantly reduced the amount of A. actinomycetemcomitans in the subgingival plaque, which indicated that extracts from Salvadora persica might interfere with the growth and leukotoxicity of A. actinomycetemcomitans. The difference in results of these two studies could be explained on the basis of the different study design.[12]

Benzyl isothiocyanate, a major component of Salvadora persica, exhibited rapid and strong bactericidal effect against oral pathogens involved in periodontal disease as well as against other Gram-negative bacteria, while Gram-positive bacteria mainly displayed growth inhibition or remained unaffected.[13] Mansour MI et al. compared the bactericidal activity of alcoholic and aqueous extract of miswak and found that alcoholic extract was more bactericidal than aqueous extract.[14]

Almas K et al. assessed the anti-microbial activity of eight commercially available mouth rinses (Corsodyl, Alprox, Oral B advantage, Florosept, Sensodyne, Aquafresh mint, Betadine, and Emoform) and 50% miswak extract against several microorganisms. It was observed that mouth rinse containing Chlorhexidine had maximum anti-bacterial activity while Cetylpyridinium chloride mouth rinse was with moderate and miswak extract was with low anti-bacterial activity.[15]

Toothbrushes vs miswak in oral health

Bristle toothbrush, which is the most common and widely used aid for oral hygiene, was first time patented in America in 1887 and has since then undergone little change. The American Dental Association has described the range of dimensions of acceptable brushes: a brushing surface 1 to 1.25 inches (25.4 to 31.8mm long) and 5/10 to 3/8 inch (7.9 to 9.8 mm) wide, 2 to 4 rows of bristles, and 5 to 12 tufts per row.[16] The diameter of commonly used bristles ranges from 0.0071 inches (0.2 mm) for soft brushes to 0.012 inches (0.3 mm) for medium brushes and 0.014 inches (0.4 mm) for hard brushes.[17]

These tooth brushes are usually used with dentifrices which aid in cleaning and polishing the tooth surfaces.

Dentrifices are commonly available in the form of tooth pastes, tooth powders and gels. Dentifrices are made up of polishing/abrasive agents (calcium carbonate, silicon oxides, aluminium oxide etc.), binding/thickening agents (carrageenates, alginates, sodium carboxymethyl cellulose, colloidal silica etc.), detergents/surfactants (sodium lauryl sulphate), humectants (sorbitol, glycerine, polyethylene glycol etc.), antibacterial agents (triclosan, metallic ions, Zn citrate trihydrate, delmopinol etc.), flavouring agents (peppermint/spearmint oil) and therapeutic agents (as fluoride and pyrophosphates).

Most of the studies discussing the efficacy of miswak and modern tooth brush have shown a superior or comparable effect of miswak over the use of tooth brushes. Danielsen B et al. compared the efficacy of miswak and use of tooth brush and they found that the use of miswak was associated with a significant reduction of dental plaque and gingivitis along with comparable or superior oral hygiene effect.[18]

Gazi et al. compared the periodontal status of habitual miswak and toothbrush users and showed that the former had lower gingival bleeding and interproximal bone height than the toothbrush users. They also suggested that 5 times a day use of miswak might offer a suitable alternate for tooth brushing in reducing plaque and gingivitis.[19] However, Eid et al. reported that there wereno significant differences in gingival or bleeding indices between miswak and modern toothbrush users.[20] Sote EO also did not find any difference in plaque and gingival bleeding in chewing stick and toothbrush users.[21]

Darout IA et al. conducted a study on 213 males, aged 20 to 65 years, to evaluate the periodontal status of miswak and toothbrush users. They reported that periodontal status of miswak users in Sudanese population is better than that of toothbrush.[22] In a single-blind cross-over clinical study, after professional instruction of the proper use of miswak and toothbrush, miswak was found to be more effective than use of tooth brush for reducing plaque and gingivitis in a sample of male Saudi Arabians.[23]

Although both miswak and toothbrush serve similar function, they vary in their design. Unlike a conventional toothbrush, the bristles of the Miswak lie in the same long axis as its handle. Consequently, the facial surfaces of the teeth can be reached more easily than the lingual surfaces or the interdental spaces. The angulation in the toothbrush enables it to adapt more easily to the distal tooth surfaces, particularly on the posterior teeth.[24]

Two basic holds for miswak: pen-grip (three finger grip) and the palm-grip (five finger grip) have been documented in literature. In each case, the aim is to ensure firm but controlled movement of the brush end of the Miswak within the oral cavity, so that every area of the mouth is reached with relative ease and convenience. The basic technique employed for removing plaque mechanically are similar to that for toothbrush and the chewing stick, i.e., vertical and horizontal brushing. The cleaning movement should always be directed away from the gingival margin of the teeth (away from the gums) on both the buccal and lingual surfaces.[25]

Miswak chewing sticks have been found to be associated with high level of gingival recession and tooth wear. Eid MA et al. reported high level of gingival recession in Miswak chewing stick users. These findings could be explained on the basis of high frequency per day (5 times per day) and uninstructed manner of use of miswak.[26,27] However, Johansson et al. correlated miswak use with high level of tooth wear.[28] But despite these side effects, this traditional oral hygiene practice is so common in our population that it needs further investigations on modern scientific lines.

CONCLUSION

The present review article not only discusses the composition, prophylactic and therapeutic properties of miswak, but also describes the basics of toothbrush and dentifrices. Most of the studies on interaction of miswak with periodontopathogens favored the use of miswak as an oral hygiene aid.

The indigenous system of medicine like herbal chewing sticks (miswak) has been popular since ancient times; further long-term clinical trials are needed to evaluate the therapeutic and pharmacological effects of various chemical components of miswak. More and more studies should focus on clinical effectiveness of miswak as compared with the toothbrush on clinical periodontal parameters such as probing depth, gingival bleeding, clinical attachment level, etc. Effect of miswak should be evaluated separately on periodontally healthy and diseased individuals. Efficacy of Miswak should not be compared with toothbrush alone but also with various fluoridated and non-fluoridated dentifrices. The results from these studies would definitely open new vista in the field of dentistry in providing a foundation for various preventive oral health programs for rural and urban society of India.

Footnotes

 

Source of Support: Nil.

 

 

Conflict of Interest: None declared.

 

Article information

J Ayurveda Integr Med. 2012 Oct-Dec; 3(4): 184–187.

doi:  10.4103/0975-9476.104431

PMCID: PMC3545237

PMID: 23326088

Parveen Dahiya, Reet Kamal,¹ R.P. Luthra,²Rahul Mishra, and Gaurav Saini³

Department of Periodontics and Implantology, Himachal Institute of Dental Sciences and Research, Paonta Sahib, Sirmour, India

¹Department of Oral Pathology, H.P. Govt. Dental College, Shimla, Himachal Pradesh, India

²Department of Prosthodontics, H.P. Govt. Dental College, Shimla, Himachal Pradesh, India

³Department of Prosthodontics, B. K. Civil Hospital, Faridabad, Haryana, India

Address for correspondence: Dr. Parveen Dahiya, MDS, Reader, Department of Periodontics and Implantology,Himachal Institute of Dental Sciences and Research,Paonta Sahib, Sirmour, HP 173025, India moc.oohay@231_neevrap

Received 2012 Mar 13; Revised 2012 May 2; Accepted 2012 May 11.

Copyright : © Journal of Ayurveda and Integrative Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Articles from Journal of Ayurveda and Integrative Medicine are provided here courtesy of Elsevier

REFERENCES

1. Prevention Methods and Programmes for Oral Health. Report of a WHO Expert Committee Technical Report Series 713. Geneva: WHO; 1984. World Health Organisation.[PubMed]

2. Wu CD, Darout IA, Skaug N. Chewing sticks: Timeless natural toothbrushes for oral cleansing. J Periodontal Res. 2001;36:275–84.[PubMed]

3. Al-Obaida MI, Al-Essa MA, Asiri AA, Al-Rahla AA. Effectiveness of a 20% Miswak extract against a mixture of Candida albicans and Enterococcus faecalis. Saudi Med J. 2010;31:640–3. [PubMed]

4. Sofrata AH, Claesson RL, Lingström PK, Gustafsson AK. Strong antibacterial effect of miswak against oral microorganisms associated with periodontitis and caries. J Periodontol. 2008;79:1474–9.[PubMed]

5. Patel PV, Shruthi S, Kumar S. Clinical effect of miswak as an adjunct to tooth brushing on gingivitis. J Indian Soc Periodontol. 2012;16:84–8.[PMC free article] [PubMed]

6. Al-Sadhan, Almas K. Miswak (chewing stick): A cultural and scientific heritage. Saudi Dent J. 1999;11:80–7.

7. Van der Weijden GA, Timmerman MF, Reijerse E, Wolffe GN, van Winkelhoff AJ, Van der Velden U. The prevalence of A. actinomycetemcomitans, P. gingivalis and P. intermedia in selected subjects with periodontitis. J Clin Periodontol. 1994;21:583–8. [PubMed]

8. Slot J, Rams TE. Microbiology of Periodontal disease. In: Slot J, Taubman MA, editors. Contemporary Oral Microbiology and Immunology. Mosby: St Louis; 1992.

9. AI-Lafi T, Ababneh H. The effect of the extract of the Miswak (chewing sticks) used in Jordan and the Middle East on oral bacteria. Int Dent J. 1995;45:218–22. [PubMed]

10. Almas K, Al-Bagieh NH. The antimicrobial effects of bark and pulp extracts of miswak, Salvadora persica. Biomedical Letters. 1999;60:71–5.

11. Darout IA, Albandar JM, Skaug N, Ali RW. Salivary microbiota levels in relation to periodontal status, experience of caries and miswak use in Sudanese adults. J Clin Periodontol. 2002;29:411–20.[PubMed]

12. Al-Otaibi M, Al-Harthy M, Gustafsson A, Johansson A, Claesson R, Angmar-Mansson B. Subgingival plaque microbiota in Saudi Arabians after use of miswak chewing stick and toothbrush. J Clin Periodontol. 2004;31:1048–53. [PubMed]

13. Sofrata A, Santangelo EM, Muhammad Azeem M, Karlson AK, Gustafsson A, Putsep K. Benzyl isothiocyanate, a major component from the roots of salvadora persica is highly active against gram- negative bacteria. PLoS One. 2011;6:e23045.[PMC free article] [PubMed]

14. Mansour Ml, Al-Khateeb TL, Al -Mazraoo AA. The analgesic effect of Miswak. Saudi Dent J. 1996;8:87–91.

15. Almas K, Skaug N, Ahmad I. An in vitro antimicrobial comparison of miswak extract with commercially available non-alcohol mouthrinses. Int J Dent Hyg. 2005;3:18–24. [PubMed]

16. Accepted Dental Therapeutics.3. Chicago: American Dental Association; 1969-1970.

17. Hink MK. Toothbrush. Int Dent J. 1956;6:15.

18. Danielsen B, Baelum V, Manji F, Fejerskov O. Chewing sticks, toothpaste, and plaque removal. Acta Odontol Scand. 1989;47:121–5. [PubMed]

19. Gazi M, Saini T, Ashri N, Lambourne A. Meswak chewing stick versus conventional toothbrush as an oral hygiene aid. Clin Prev Dent. 1990;12:19–23.[PubMed]

20. Eid MA, al-Shammery AR, Selim HA. The relationship between chewing sticks (Miswak) and periodontal health. 2. Relationship to plaque, gingivitis, pocket depth, and attachment loss. Quintessence Int. 1990;21:1019–22. [PubMed]

21. Sote EO. The relative effectiveness of chewing sticks and toothbrush on plaque removal. Afr Dent J. 1987;1:48–53.[PubMed]

22. Darout IA, Albandar JM, Skaug N. Periodontal status of adult Sudanese habitual users of miswak chewing sticks or toothbrushes. Acta Odontol Scand. 2000;58:25–30. [PubMed]

23. Al-Otaibi M, Al-Harthy M, Soder B, Gustafsson A, Angmar-Mansson B. Comparative effect of chewing sticks and toothbrushing on plaque removal and gingival health. Oral Health Prev Dent. 2003;1:301–7. [PubMed]

24. Al-Lafi T. M Sc. Thesis.University of London; 1988. Effectiveness of Miswak as a tool for oral hygiene.

25. Almas K, Al-lafi T. The natural tooth brush. World Health Forum. 1995;16:206–10. [PubMed]

26. Eid MA, Selim HA, Al-Shammery AR. The relationship between chewing sticks (Miswak) and periodontal health.III.Relationship to gingival recession. Quintessence Int. 1991;22:61–4. [PubMed]

27. Eid MA, Selim HA. A retrospective study of the relationship between miswak chewing stick and periodontal health. Egypt Dent J. 1994;40:589–92. [PubMed]

28. Johansson A, Fareed K, Omar R. Analysis of possible factors influencing the occurrence of occlusal tooth wear in a young Saudi population. Acta Odontol Scand. 1991;49:139–45. [PubMed]