Bizarre tooth surface loss and the Miswak stick

Does the use of miswak reduce plaque and gingivitis among adults?

Data sources Searches were performed using broad search terms and suitable Boolean operators and Medical Subject Headings terms on the electronic databases PubMed (US National Library archive), EBSCOHost (Dentistry and Oral Sciences) (US Corporate Research Database), Scopus (Elsevier Archive) and the Cochrane Database for Systematic Reviews with no relevant time limit.Study selection Randomised control trials were included where adults were participants and using miswak sticks to brush was the independent variable. The primary outcome reviewed was the effect on periodontal health, with secondary outcomes including oral health practices. Exclusion criteria were applied to studies including patients with orthodontic appliances.Data extraction and synthesis Data extraction was led by a single author, with further authors (where necessary) assessing accuracy and appropriateness. Data extracted included first author, publication year, study design and setting, sample size, description of the participant, the intervention and comparison, clinical measurements, assessment interval and wash-out period. An I2 test with confidence intervals was performed, showing the included studies to display heterogeneity in methodology and outcome measures. As such, a random effects model was used for the meta-analysis of effect size. Further subgroup analysis of the included papers was completed and presented in a forest plot format. The Cochrane risk of bias tool was employed.Results In total, 150 abstracts were screened, with ten RCTs included and nine utilised in a descriptive meta-analysis. The findings claimed that miswak offered similar outcomes to toothbrushing when considering mean plaque score (p = 0.08; SMD: 0.39 and 95% CI: 0.05-0.83) and mean gingivitis score (p = 0.37; SMD: 0.13, and 95% CI: 0.16-0.43). A further significant secondary outcome was noted, showing reduced mean plaque scores (p = 0.01; SMD: 0.68, and 95% CI: 0.14-1.22) and reduced gingivitis score (p = 0.04; SMD: 0.66, and 95% CI: 0.03-1.29) when miswak was used in addition to toothbrushing.Conclusions Miswak sticks may offer similar plaque reduction to brushing and may reduce plaque-induced gingivitis when used as an adjunct to toothbrushing. However, more evidence is required in this area.

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

ETHNOPHARMACOLOGICAL RELEVANCE

Salvadora persica L. and Azadirachtaindica A.Juss. are listed within the most common sources of miswak or chewing stick that widely used among Western Asia and Muslim populations worldwide. Miswak use in conjunction with toothbrush (adjunctive) has become apparent among the adults. Furthermore, miswak has been reported to have mechanical and pharmacological activities, and benefits to the oral health, by many studies.

AIM OF THE STUDY

To assess the effectiveness of miswak in maintaining periodontal health among adults.

MATERIALS AND METHODS

We searched for randomised controlled trials (RCTs) investigating the effect of miswak published in PubMed, EBSCOHOST (Dentistry & Oral Sciences), SCOPUS, and Cochrane Database for Systematic Review (CDSR) from inception to May 08, 2022. The primary outcomes of interest were changes in the periodontal health measured with plaque and gingivitis scores as well as subgingival bacteria load. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach while the estimates of effect were pooled using a random-effects model.

RESULTS

Ten eligible articles were identified, of which 9 could be analysed quantitatively. The remaining report was included as part of the qualitative analysis. The meta-analysis showed that miswak was comparable with the toothbrush in reducing the mean plaque score (p= 0.08, SMD: 0.39, and 95% CI: -0.05 to 0.83) and mean gingivitis score (p= 0.37, SMD: 0.13, and 95% CI: -0.16 to 0.43). Even higher certainty of evidence for the effect of miswak on mean plaque reduction on labial surface of anterior teeth. However, the adjunctive effect of miswak was significantly more superior for reducing plaque (p= 0.01, SMD: 0.68, and 95% CI: 0.14 to 1.22) and gingivitis score (p= 0.04, SMD: 0.66, and 95% CI: 0.03 to 1.29).

CONCLUSIONS

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.

Clinical benefits and adverse effects of siwak (S. persica) use on periodontal health: a scoping review of literature

BACKGROUND

Siwak is a chewing stick used as an oral hygiene aid associated with Muslim communities across the globe since more than 1500 years ago. Used either exclusively or in conjunction with a regular toothbrush, there is evidence supporting its clinical effectiveness in plaque control, but adverse effects on periodontal health remains inconclusive.

OBJECTIVE

This study aims to systematically review the wide range of data and literatures related to siwak practice and its effect on periodontal health.

METHOD

The review was conducted based on scoping review techniques, searching literature in EBSCOHOST, PubMed, SCOPUS and Google scholar databases using the following search terms: "siwak' or 'miswak' or 'chewing stick" for intervention, and "periodontium or 'periodontal' or 'periodontal health' or 'periodontal disease" for outcome. Articles published between January 1990 to March 2021 and written in English language were included.

RESULTS

A total of 721 articles collected from the search and 21 of them were eligible for the final analysis. Results of this study was described based on clinical and antibacterial reporting of siwak, method of siwak practice and its adverse effect on oral health. Siwak was found effective at removing dental plaque and improving periodontal health over time although its effect on subgingival microbiota was inconclusive. Presence of gingival recession and clinical attachment loss were much more commonly reported in siwak users, attributable to variations in the methods employed for tooth cleaning using the siwak.

CONCLUSION

There is substantial evidence that the lack of standardised reporting for effective siwak use may have resulted in contradictory findings about its oral hygiene benefits and adverse effects. As such, future work on safe and effective siwak practice is to be advocated among its users.