Comparison of Miswak with Modern Toothbrushes and Toothpastes

Ahmed Hassan, BSDCP (DH), and Shirley Gutkowski, RDH, BSDH

Comparison of Miswak with Modern Toothbrushes and ToothpastesAhmed Hassan, BSDCP (DH), and Shirley Gutkowski, RDH, BSDH

The exact history of using an aid to clean teeth cannot be estimated, but literature supports toothbrush use up to 7,000 years ago during the Babylonian period. The chewing stick (twig/tooth stick) as a tool for home oral cleanliness acts to clean the tooth, removing plaque, calculus, and debris as well as freshening breath. It is also assumed to be a precursor to today's manual and power toothbrushes. The Chinese invented today's style of manual toothbrush, using hog hairs as bristles and bamboo or bone as the handle. The mass production of toothbrushes and export to the European and American markets started in the 18th century. The concept of the nylon-bristle toothbrush arrived in 1938, and the power toothbrush was introduced in the 1960s. In 2016, a European company launched chewing sticks again as its brand.

Table 1. History of Tooth Cleaning

ORIGIN	DATE	LITERATURE
BABYLON/EGYPTIAN	3500-3000 BC	Babylonians and Egyptians clean their teeth with the frayed ends of twigs
GREEK	800-146 BC	Greeks use toothpicks (karphos) to clean meal residue from teeth
ROMAN	753-27 BC	Romans use toothpicks from mastic tree to clean teeth
CHINA	1600 BC	Chinese use aromatic tree twigs to chew on and give them fresh breath
ARAB NATIONS	6TH -7TH CENTURY	Prophet Mohammad set rules and regulations for tooth cleansing, narrating about indications, contradictions, and the method to clean teeth
CHINA	15TH CENTURY	Chinese invent the toothbrush using hog hairs as bristles and bamboo or bone as the handle
CHINA	18-19th CENTURY	Mass production of toothbrushes and export to European and American markets
USA	1938	Nylon toothbrush created
SWITZERLAND	1939	Prototype of the first electric toothbrush in Switzerland by Dr. Phillippe- Guy Woogin, though not released until 1954.

Types of Chewing Sticks

Different kinds of trees and shrubs have been used for the preparation of chewing sticks called Miswak. Romans used toothpicks from the mastic tree (Pistacia lentiscus), and Greeks used toothpicks (karphos) to clean meal residue from teeth. In the 7th century, the Prophet Mohammad stressed upon his followers the maintaining of oral hygiene and set rules and regulations in choosing chewing sticks.^1,2

At least 182 kinds of plants/shrubs have been used as chewing sticks. Selecting the kind of chewing stick depends upon the availability and budgets. The chemical composition and therapeutic effects of chewing sticks may also differ. In Islamic rituals, the Peelo tree (Salvadora persica) is considered to be finest kind of chewing stick, followed by an olive tree (Olea europea) and Bitam tree. People may select any other kind of bitter chewing stick if none of above kinds are available. Exceptions are pomegranate, bamboo, Raihaan (Ocimum Basillicum), and Chambeilie (Jasmine) because they have been shown to spread disease.

Indications	Contradictions
1. Peelo tree (Salvadora persica)	1. Pomegranate
2. Olive tree (Olea europea)	2. Bamboo
3. Bitam tree	3. Raihaan (Ocimum Basillicum)
4. Most other kinds of bitter chewing stick	4. Chambeilie (Jasmine)

Table 2. Indications/ Contradictions in Chewing Sticks

Today, chewing sticks are being used in different parts of the world. They are known by various names, including miswak or arak in Arabic, qesam in Hebrew, qisa in Aramaic, koyoji in Japanese, mastic in Latin, mefaka in Ethopia, and datun in Pakistan and India. Table 3 describes the composition of chewing sticks.

Table 3. Composition of Chewing Sticks^3,4,5 Active Ingredients of Salvadora Persica

	Pharmacological Properties of Miswak
Silica	It acts as an abrasive material to remove plaque and stains from teeth. Researchers at the University of Birmingham found that silica could be used in restorative treatment of sensitive teeth and preventing the onset of tooth decay. Silica has bone-building and bone-protecting properties; improves bone density and bone flexibility; strengthens joints, tendons, ligaments, and connective tissues; and hence protects enamel and dentin from unbearable pressure.
Tannins (Tannic acid)	These have also been reported to exert many physiological effects, such as accelerating blood clotting. They reduce clinically detectable gingivitis as well as Candida albicans counts, plaque, and bleeding. They also reduce blood pressure, decrease the serum lipid level, produce liver necrosis, and modulate immune responses. They act as a universal antidote, with the potency to absorb poison.
Resin	Resin boosts immunity, increases bone strength, prevents bad breath, provides proactive action against dental caries, t prevents anemia, regulates blood pressure, and is helpful to reduce weight.
Alkaloids (Salvadorinc)	It provides defense against bacteria, fungi, and viruses, and act as an anticancerous, antidepressive, antihypertensive agent. It also stimulates gingiva.
Essential oil	It possesses an aroma that stimulates the flow of saliva, hence increasing antibacterial action.
Sulfur	It is essential for strong connective tissue, bones, teeth, skin, hair, and muscles. The natural mineral also helps us metabolize and absorb fat while aiding in blood sugar management. It has bactericidal effects on teeth.
Vitamin C	It helps ward off infections. It helps in healing tissue repair, reduces bleeding gums, protects from heart attack, and is anti-cancerous.
Sodium bicarbonate	It acts as a mild abrasive and can be used as dentrifice. It removes germs from sticking on teeth, gums, and tongue, and helps in the whitening of teeth.
Calcium	It inhibits demineralization and induces remineralization of enamel.
Fluoride	It provides anti-cariogenic activity and remineralizes enamel.
Chloride	It inhibits the formation of calculus.
N-benzyl 2-phenylaceamide	It inhibits human collagen-induced platelet aggregation against E.coli.
Benzyl isothiocynate	It acts as a chemo-preventive agent, preventing cariogenic and genotoxic compounds.
Trimethylamide	It has gum-stimulating effects.
Flavonoids	Natural sources of medicine, and said to be antibacterial and anti-inflammatory, with antioxidant properties, and stimulating the immune system. They bound and seal viruses, stimulating white blood cells and lymphocytes and producing interferon, therefore the stimulating immune system. They disrupt the formation of plaque and thereby prevent yellowing of teeth.
Saponins	Saponins boost immunity, are said to be anticarcinogenic, decrease blood lipids, and improve glucose response.
Sterols	Sterols are taken by mouth to lower cholesterol levels and help prevent heart disease and heart attacks. Plant sterols are also used for some cancers such as stomach cancer, colon cancer, and rectal cancer. Plant sterols are also used for weight loss.

Indications of Using Chewing Stick

A length of 15 cm is recommended, which is easy to grasp and maneuver in a mouth. The diameter is normally less than 1 centimeter, which allows flexible movement required in transmitting the pressure to clean the teeth without breaking.

Miswak bark should be freshly removed; after 5 to 10 mm of the bark is removed from one end, the wood will be supple, easily chewed, and still rich in active components. Crush the debarked end with molar teeth until the wood fibers stand out like bristles of a brush and the juices within the wood release. Rub the buccal, lingual, occlusal, and interdental surface of teeth as well as the dorsum surface of tongue with the chewed end of the stick. The root tip of the miswak should be whitish-brown in color; a dark brown color shows that the miswak is no longer fresh. If the stick gets dry after multiple uses or due to dry weather conditions, then the chewing end of the miswak should be soaked in water for 15 to 24 hours. It should be noted that excessive soaking may cause loss of active components and diminish the therapeutic properties, although the mechanical effects on the teeth can still occur.

The end should be washed with water after use. It is then chewed repeatedly and should be cut away every 24 hours.

Methods of Using Chewing Sticks

There are two basic holds for chewing sticks: Pen-grip (three-finger) and palm-grip (five-finger). 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 techniques employed for removing plaque mechanically are similar with both a toothbrush and a chewing stick: 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.

Chewing Sticks vs Toothbrushes

Many studies discussing the efficacy of miswak and modern toothbrushes have shown a superior or comparable effect of miswak. Danielsen et al compared the efficacy of miswak and use of toothbrushes and 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.⁶ Bhambal et al found that chewing sticks had shown even better results in terms of reduction in plaque scores than in subjects using toothbrushes; the results of this trial are in close proximity with the results of a previously reported literature.⁷

Ability to Kill Pathogens, Remineralize teeth, and Protect from Dental Caries

Good toothbrushing not only efficiently removes plaque and calculus but also protects teeth from caries, remineralizes, and has the ability to kill pathogens. The risk of dental caries identified was 9.35 times more in subjects using toothbrushes than in those using chewing sticks.⁸

Bhat et al wrote in 2012 that miswak extract displayed greater reduction in cariogenic bacteria counts while comparing 50% aqueous miswak extract with toothbrush and saline.⁹

Comparative Effects of Miswak and Modern Toothbrushes on the Body

Antioxidants may help the body to protect itself against various types of oxidative damage caused by reactive oxygen species, which are linked to a variety of diseases including cardiovascular diseases, cancers, neurodegenerative diseases, and inflammatory diseases. The antioxidant capacity of miswak was also attributed to the presence of antioxidant enzymes, peroxidase, caltalase, and polyphenoloxidase. The synergistic actions of antioxidant compounds and antioxidant enzymes make miswak an instrument for cleaning teeth, oral hygiene, and food removing purposes.^10,11,12,13 whereas power toothbrushes are contradicted in patients with hypersensitivity and cardiovascular disease.¹⁴

Comparison of Miswak and Toothpaste

El-Desoukey compares hot and cold aqueous extracts of S. persica miswak and toothpaste containing sodium ﬂuoride (in vitro and in vivo) in 2015, concluding that miswak extracts (10%) inhibited both tested microorganisms. The zone of inhibition of miswak (25 mm/37 mm) was greater than that of toothpaste (14 mm/29 mm) and the positive control (unspeciﬁed tested concentration), ciproﬂoxacin (25 mm), and nystatin (16 mm). The hot extract exhibited less antimicrobial eﬀect than the cold one. A greater zone of inhibition was observed in well diﬀusion compared to a disc diﬀusion method. Oral swabs cultivated on a nutrient agar plate before and after use of both miswak and toothpaste revealed that miswak was more eﬀective than toothpaste in decreasing microbial growth.¹⁸ Haixia Yang found in her study that sodium fluoride and triclosan accelerate the development of colitis-inflammation that leads to rectal bleeding, diarrhea, abdominal pain, and abdominal spasms along with tumors. In one group of mice, it reduced lifespan.¹⁹ Mohamed A. Lebda et al revealed that miswak aqueous extract favored the healing and prevention of gastric ulcers induced by ethanol.²⁰

Conclusion

It seems that miswak alone is more beneficial than toothbrushes and toothpaste/mouthwash. Beside removing plaque, calculus, and debris, it also provides the remedy to anti-sensitize the teeth; prevents the onset of tooth decay, bone building, and bone protecting properties; strengthens joints, tendons, ligaments and connective tissues; kills pathogens; remineralizes tooth structure; regulates blood pressure; boosts immunity; helps ward off infections; heals tissue repair; reduces bleeding gums; protects from heart attack; and is anti-cancerous. No direct comparison between power toothbrushes and miswak are found in literature. More studies are needed to compare miswak with power toothbrushes and toothpaste.

References

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