Beruflich Dokumente
Kultur Dokumente
Journal of Ethnopharmacology
journal homepage: www.elsevier.com/locate/jethpharm
Short term clinical effect of active and inactive Salvadora persica miswak on
dental plaque and gingivitis
Abier Sofrata a,∗ , Fernanda Brito a , Meshari Al-Otaibi b , Anders Gustafsson a
a
Periodontology Department, Institute of Odontology, P.O. Box 4064, S-141 04 Huddinge, Stockholm, Sweden
b
Dental Department, Security Forces Hospital, P.O. Box 56566, Makkah, Saudi Arabia
a r t i c l e i n f o a b s t r a c t
Article history: Ethnopharmacological relevance: Salvadora persica shrub has been used traditionally in folk medicine
Received 22 February 2011 for different medical condition treatments. The habitual use of Salvadora persica roots (chewing sticks)
Received in revised form 29 June 2011 for dental hygiene is still wildly spread throughout parts of Asia, Africa, and Middle. It is one of the
Accepted 11 July 2011
most important species with its reported strong antibacterial, antifungal, and antiviral effects. Mechan-
Available online 20 July 2011
ical removal of dental plaque is regarded as an effective mean of controlling progression of periodontal
disease.
Keywords:
Aim of the study: To evaluate the effect of active and inactive miswak on dental plaque, subgingival
Salvadora persica
Miswak
microbiota and gingival inflammation in patients with gingivitis.
Gingivitis Materials and methods: In this double blinded randomized controlled trial 68 gingivitis patients were ran-
Dental plaque domly assigned to either active or inactive miswak group, and were instructed to use only issued miswaks
Oral hygiene for oral hygiene during 3 weeks experimental period. Registration of plaque, gingival inflammation, and
Subgingival microbiota plaque samples were taken at baseline and on completion of the study. Plaque samples were analyzed
Traditional medicine by DNA–DNA hybridization technique.
Periodontal disease 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.
© 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction of Asia, Africa and the Middle East (Elvin-Lewis, 1980). The easy
access and low cost of miswak has made it a very cost effective
Dental plaque is considered the main etiologic agent in the initi- plaque control tool in different communities (Bos, 1993; Darout
ation of gingivitis and its progress to periodontitis (Löe et al., 1965; et al., 2000; Wu et al., 2001; Hyson, 2003).
Page and Schroeder, 1976). Gingivitis is an inflammatory condition Throughout the world, 182 species of plants have been used
of the gingiva characterized by edema, redness, and bleeding upon as chewing sticks, the most important is Salvadora persica, also
probing (Mariotti, 1999). known as Arak (Elvin-Lewis, 1982). One of the main constituents
Mechanical removal of dental plaque is generally acknowledged of the Salvadora persica root oil is Benzyl isothiocyanate (BITC)
as an effective measure for controlling progression of dental caries (Bader et al., 2002), which has virucidal activity against Herpes
and periodontal disease (Axelsson and Lindhe, 1981). Chewing stick simplex virus, inhibits the growth and acid production of Strep-
(miswak) is one of the oldest oral hygiene in history (Hyson, 2003). tococcus mutans, and is fungistatic to Candida albicans (Al-Bagieh,
The habitual use of miswak is still wildly spread throughout parts 1992, 1998; Al-Bagieh and Weinberg, 1988). In vitro studies of mis-
wak extracts have also demonstrated some antibacterial activity
against certain bacterial species implicated in periodontal disease
and dental caries. Different miswak extracts of different parts of the
∗ Corresponding author at: Periodontology Department, P.O. Box 4064, S-141 04 Salvadora persica plant were tested using the disk diffusion method
Huddinge, Sweden. Tel.: +46 7 232 444 71/8 524 88331; fax: +46 8 71183 43. and recorded as inhibition zones. The inhibition zones ranged only
E-mail addresses: asofrata@gmail.com (A. Sofrata),
from 2 to 3 mm (Al-Lafi and Ababneh, 1995; Almas, 1999; Almas
fernanda.brito.s@hotmail.com (F. Brito), m alotaibi@hotmail.com (M. Al-Otaibi),
anders.gustafsson@ki.se (A. Gustafsson). and Al-Bagieh, 1999; AbdElRahman et al., 2002). In our previous
0378-8741/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.jep.2011.07.034
A. Sofrata et al. / Journal of Ethnopharmacology 137 (2011) 1130–1134 1131
Fig. 1. Haemophilus influenzae growth associated with testing active and in-active miswak using diffusion antibacterial testing method. (A) Total Haemophilus influenzae
growth inhibition with testing active miswak piece. (B) Complete bacterial growth with testing in-active miswak piece.
study testing fresh miswak pieces from roots of Salvadora per- Table 1
Number of subjects, gender, and mean age (range) of both test (active miswak) and
sica “with out extraction” using the same diffusion method gave
control (inactive miswak) groups.
inhibition zones ranging from 1.4 to 3.2 cm on Gram positive bac-
teria, and 10.9 to 14 cm on Gram negative bacteria which are much Group Subjects Gender (male–female) Mean age (range)
more than what was reported before. These results clearly demon- Test group 30 16M–14F 32.8 (18–54)
strated much stronger antibacterial effect than that reported by Control group 28 3M–25F 27.7 (18–49)
other extracts (Sofrata et al., 2008). Several clinical studies have M, male; F, female.
reported that the miswak has a positive effect on gingivitis and
plaque removal (Olsson, 1978; Al-Otaibi et al., 2003). Al-Otaibi et al.
(2003) reported that miswak had a significant reduction of plaque one of the authors (M. Al-Otaibi), in consultation with an experi-
(p < 0.001) and gingival (p < 0.01) indices compared to the tooth- enced Arak merchant. The inactive miswaks intended for use as
brush. Clinical studies on saliva showed that using miswak sticks or negative controls were obtained by boiling the sticks in water for
rinsing with aqueous miswak extract has an immediate inhibitory 2 h. Deactivation was confirmed by in vitro antibacterial testing on
effect on salivary bacteria (Gazi et al., 1992; Darout et al., 2002; Haemophilus influenzae (ATCC 49247). Haemophilus influenzae was
Almas and Al-Zeid, 2004). grown and tested as described before (Sofrata et al., 2008) (Fig. 1).
Clinical studies on habitual miswak users have shown some
effects of miswak on the dental health of its users (Darout et al., 2.3. Study design
2000; Wu et al., 2001). However, further controlled clinical studies
on patients with a mild degree of periodontal disease are necessary The study was designed as a double-blind, randomized clinical
to justify the miswak use in daily oral hygiene habits. Moreover, trial. The participants were randomized by assigning an odd or even
there is also a need to standardize the mechanical plaque remov- number according to the random binary outcome of the toss of a
ing tool in order to evaluate a possible chemical antibacterial effect dice: those with odd numbers were assigned to active miswak (test
of miswak. Our aim was to study the effect of miswak on plaque group) and those with even numbers to the inactive miswak (con-
removal, subgingival microbiota, and gingival health in patients trol group). A dental assistant was responsible for randomization
with gingivitis using chemically inactive miswak as a control. and grouping and neither the participants nor the dentist know
which group the participant belonged to.
2. Materials and methods One week before study start, the participants underwent intrao-
ral examination, scaling, and professional tooth cleaning and were
2.1. Participants instructed continue their usual oral hygiene routines during the
following week.
Sixty-eight (21 males and 47 females) regular dental patients at One week later, baseline clinical examinations were conducted
Security Forces Dental Polyclinics, Makkah city, Saudi Arabia; were and samples of the subgingival microflora were collected. The par-
recruited to participate in the study. For inclusion, the patients had ticipants in the test group were then issued with fresh miswaks
to be ≥18 years of age and have a dentition of at least 24 teeth. and those in the control group with inactive miswaks. Each subject
Exclusion criteria were systemic disease, long term medication, was provided with six miswak sticks 20 cm in length and 7 mm in
antibiotics during the last 6 months, and pregnancy. Participants width, to be refrigerated until use. They were instructed to use the
with gingival pockets >5 mm and/or orthodontic appliances were respective miswaks five times a day for the following 3 weeks, and
also excluded. All participants were familiar with the use of the during the study to refrain from using a toothbrush, interdental
miswak and gave their informed consent. The participants were cleaning devices, chewing gum during or any other miswak apart
instructed to refrain from miswak use for 2 weeks prior to study from those issued. After 3 weeks, follow-up examination and col-
start. lection of subgingival microflora samples were undertaken in the
The study was approved by the General Medical Affairs Adminis- same manner as at baseline.
tration at Makkah city and the regional Research Ethics Committee
in Stockholm (Registration No. 2009/1077–31/4). 2.4. Clinical examination
2.2. Miswak The clinical parameters measured were: (a) modified gingival
index (GI) (Löe, 1967), and (b) plaque index according to Turesky
The miswaks (prepared from Salvadora persica), were bought modified Quigley–Hein plaque index (Quigley and Hein, 1962;
fresh from the local market in Makkah city, Saudi Arabia. Identi- Turesky et al., 1970). Both gingival inflammation and plaque were
fication of the plant as Salvadora persica (Arak) was confirmed by recorded at four sites per tooth (buccal, mesial, distal and lingual)
1132 A. Sofrata et al. / Journal of Ethnopharmacology 137 (2011) 1130–1134
Table 2
Mean and standard deviation of plaque index and approximal plaque at baseline and follow-up visit for both test (active miswak) and control (inactive miswak) groups.
Parameter Time point Test group, n = 30 Control group, n = 28 p-Value (between the
two groups)
Table 3
Median and quartile range of gingival index and approximal gingival index at baseline and follow-up visit for both test (active miswak) and control (inactive miswak) groups.
Parameter Time point Test group, n = 30 Control group, n = 28 p-Value (between the
two groups)
for all teeth except the third molars. Plaque was stained with ery- range and the differences were tested using Mann Whitney U-test
throsine before scoring. Approximal plaque (AP) was registered and and Wilcoxon Signed rank test.
expressed separately.
3. Results
2.5. Subgingival microflora
3.1. Study population
Sterile paper points were used to collect subgingival plaque
samples from four sites in each subject: Supragingival plaque was Fifty-eight of the original 68 participants completed the study.
removed with a sterile cotton roll and samples were then collected Of the 10 dropouts, 2 men and 3 women were from the test group
from the distobuccal aspects of all second molars (in case of missing and 5 women from the control group (Table 1).
second molars, the first molars were sampled). The four samples
were pooled in one Eppendorf tube and stored at −20 ◦ C until 3.2. Plaque index
subsequent analysis. All samples were sent to the microbiology lab-
oratory at the University of Bern, Switzerland for analysis using the In the test group, supragingival plaque decreased significantly
checkerboard DNA–DNA hybridization technique (Socransky et al., during the 3-week study (p = 0.007). The decrease in the control
1994, 2004; Katsoulis et al., 2005). The assay panel comprised 74 group was not reach significant (p = 0.46). While the PI of the test
bacterial species (Baumgartner et al., 2009). and control groups was similar at baseline (p = 0.18), the difference
at follow-up was significant (p = 0.016).
2.6. Statistical analysis Both the test and control groups showed intergroup signifi-
cant decrease in AP (p = 0.024 and p = 0.003 respectively). However,
The sample size calculation was based on a previous cross there was no significant difference in the change of PI and AP
over study comparing miswak and toothbrush in 15 participants, between the two groups (Table 2).
in which a significant difference in PI and GI between miswak
and toothbrush was found (Al-Otaibi et al., 2003). Based on this 3.3. Gingival index
study, the power calculation revealed a sample size of 25 in each
group would have 80% power to detect a difference between In the test group, the GI has decreased significantly by the end
groups in plaque index means of 0.19, assuming that the com- the 3-week test period (p = 0.02), while no such reduction occurred
mon standard deviation is 0.23 using a two group t-test with a in the control group (p = 0.15). With respect to approximal GI, nei-
0.05 two-sided significance level. The data were analyzed using ther group showed any inter group significant decrease (p = 0.46,
the Statistica (8.0) program1 : p ≤ 0.05 was considered statistically and p = 1.00 respectively). When comparing the two groups, the
significant. The results from the plaque registrations were nor- change in GI and approximal GI did not differ significantly between
mally distributed (tested with Kolmogorow–Smirnow test), and the two groups (Table 3).
were expressed as mean and standard deviation. Differences were
tested using Student’s t-test. The gingival index results were not 3.4. Microbial analysis
normally distributed and were presented as median and quartile
The microbial analyses disclosed no significant changes
between baseline and follow-up samples in either group (data not
1
StatSof, Inc. Tulsa, OK, USA. shown).
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