Shetty et al International Journal of Public Health Dentistry

RESEARCH ARTICLE

Comparative study to assess the effect of chewing stick and toothbrush on oral
hygiene and periodontal status among Indian population
Raghavendra M. Shetty; Sunaina Shetty; Sachin B. M; Ramesh Amirisetty; Abhishek Agrawal

Abstract
Aim: The purpose of this study was to asses and compare the oral hygiene, gingival and
periodontal conditions among a group of Indian population who used miswak, toothbrush or
combined miswak\brush for their routine daily oral hygiene. Materials and Methods: A total of
528 subjects participated in this study (63.6% females and 36.4% males), ranging in age from
20 to 45 years (mean ± SD = 35.43 ± 12.83). All subjects were interviewed regarding their oral
hygiene habits and use of miswak and conventional toothbrush. After fulfilling the entry criteria
participants were classified according to their oral hygiene habits as miswak users (group I),
tooth brush users (group II) or both miswak users and tooth brush users (group III). All subjects
were assessed using Simplified Oral Hygiene Index (OHI-S), gingival index, pocket depth and
gingival recession. Data was analysed using ANOVA test and Scheffe test according to need.
The level of significance used was 5% level. Results: It showed that there was no statistically
significant difference of OHI-S between groups (P= 0.751). On the other hand, all the three
groups differ significantly in relation to mean gingival index (p= 0.000). Also, Group II
demonstrated a significantly higher mean pocket depth than Group I (p=0.019). However,
gingival recession was significantly higher in Group I in comparison to Group II and Group III
(P=0.000). Conclusion: This study demonstrated that, apart from gingival recession that might
be encountered in miswak users, the miswak exhibits a significantly higher improvement in
gingival and periodontal conditions as compared to tooth brush.
Key Words: Tooth Brush; Oral Hygiene; Gingivitis; Periodontal Pocket; Gingival Recession;
Chewing Stick; Oral Hygiene; Periodontal Status.

Received on: 07/13/2010 Accepted on: 08/15/2010

Introduction
Oral hygiene measures have
been practiced by different populations
and cultures around the world since
antiquity. The oral hygiene habits in a
certain population depend on various
factors, such as cultural background,
religious norms, educational levels and
socioeconomic status(1). There are
different methods available for the
maintenance of oral health. These are
mainly mechanical and chemical.
Toothbrushes and dentifrices are widely
used for cleaning the teeth. The traditional
toothbrush or chewing stick called
“Miswak” has been used since ancient
history(2). Chewing sticks were used by
the Babylonians some 7000 years ago;
they were later used throughout the
Greek and Roman empires and have
been used by Jews, Egyptians, and
Muslims. Today they are used in Africa,
Asia, the Eastern Mediterranean region,
and South America(3). It has different
names in different societies for instance;
miswak, siwak or arak is used in the
Middle East, miswaki, in Tanzania, datan
in India and Pakistan(4). The World
Health Organization has recommended
and encouraged the use of these sticks
as a tool for oral hygiene in areas
where their use is customary(5). The
promotion of good oral health by miswak
is mainly attributed to mechanical
cleansing efficacy, including the
mechanical effects of its fibers. Also, the
release of beneficial chemicals such as
trimethyleamine, salvadorine, mustard oil,
vitamin c, resins, flavodine, saponins,
sterol and fluoride might all play an
important role(6). Therefore, periodontal

6 International Journal of Public Health Dentistry 1:1 (2010)6-12. © Celesta software Pvt Ltd
Shetty et al
treatment need was found to be low in
habitual miswak users(7).
Contradictory data have been
reported on the oral health of miswak
users. Several reports have indicated
that chewing sticks are effective in
reducing plaque and
inflammation if properly used and
miswak has been reported to be as
effective as tooth brushing(8-10).
Moreover, miswak was found to have a
clinical implication of enhancing the
regenerative opportunity of periodontium
and inhibiting root caries formation (11).
However, some studies found that there
were more plaque formation and gingival
bleeding in individuals who
chewing sticks in comparison with
toothbrush users(12-14). So, the purpose
of study was to assess and compare
the oral hygiene, gingival and periodontal
conditions among a group of population
of Rajnandgaon city who used miswak,
toothbrush or combined
miswak/toothbrush in their daily routine.
Materials and methods
Study design: This study was conducted
as an observational descriptive cross-
sectional study to describe oral hygiene,
gingival and periodontal status among
subjects with different oral hygiene
habits.
Study population: A total of 528 subjects
participated in this study ( 63.6%
females and 36.4% males), ranging in
age from 20 to 45 years (mean ± SD =
35.43 ± 12.83) participated in this study.
All the participants recruited
department of Oral Medicine
Radiology of Chhattisgarh Dental College
and Research Institute, Rajnandgaon city,
India. All subjects were interviewed
regarding their oral hygiene habits and
use of miswak and conventional
toothbrush. The participants
classified according to their oral hygiene
habits as miswak users (group I),tooth
brush users (group II) or both miswak
users and tooth brush users (group III).
Screening criteria into study: All participants
fulfilled these criteria
7 International Journal of Public Health Dentistry 1:1 (2010)6-12. © Celesta software Pvt Ltd
International Journal of Public Health Dentistry
1. Non-smokers and non diabetics
2. No disability or physical handicapping
3. No orthodontic treatment
4. No periodontal treatment or
preventive dental visits for at least
3months
gingival 5. Willing to participate in the study.
Clinical examination: Assessment of oral
hygiene, gingival and periodontal
conditions were performed using :
1. Simplified oral hygiene index (OHI- S
) of Green and Vermillion 1964: Oral
hygiene index simplified (15) scores
calculus and debris together. Both debris
and calculus were scored for each
used examined tooth. OHI-S was expressed as
the sum of the mean debris index (DI-
S) and calculus index (CI-S) of the
examined teeth.
2. Gingival index (GI) of Loe and Sillness
1963: Clinical registration of gingival index
(GI)(Löe and Silness1963)(16) were made
at four sites per tooth (mesial, distal,
mid-facial and mid-lingual) using a
calibrated periodontal probe with a tip
diameter of 0.5 mm (Vivacare TPS
probe). Gingival index for each individual
was calculated as the mean score of the
examined teeth.
3. Pocket depth measurement (PD):
Probing pocket depth (PD) were also
made at mesial, distal, mid-facial and
mid-lingual surfaces of the present teeth
using the same calibrated periodontal
probe. The tip was inserted to the base of
the periodontal pocket with a standardized
from probing force of about 20g. Pocket depth
and for each individual equals the mean
pocket depths of the examined teeth.
Measurements were recorded to the
nearest millimeter.
4. Gingival recession measurement:
Recession of the gingival margin (GR) was
were measured by Vivacare TPS probe. It was
recorded as the mean distance between
CEJ and gingival margin at the mid-facial
surfaces of the present teeth.
Measurements were also recorded to the
nearest millimeter.
Shetty et al International Journal of Public Health Dentistry

Ethical issue: All patients were informed The mean gingival index (GI) for
about the purpose of the study and group I, group II and group III were 0.95,
informed consents were obtained. The 1.20 and 1.44. There was a statistically
ethical clearance was obtained from ethical significant difference of the mean gingival
committee of Chhattisgarh Dental College index among the studied groups as shown
and Research Institute. by ANOVA test (P= 0.000). The difference
Inter-examiner reliability: Inter-examiner of the mean gingival index was statistically
reliability of the examiners were significant between all the groups, miswak
attempted by undergoing a period of users and the conventional brush users or
training together with repeated patients between miswak user and combined users
examinations before the start of the and between conventional toothbrush users
study to bring their diagnostic standards and combined users as revealed by Scheffe
as close together as can possibly be test (P= 0.001), (P=0.000) and (P=0.002)
managed (Kappa= 0.8). consequently (Table 2).
Statistical analysis: Data were collected,
presented and statistically analyzed using Study Mean SD F P
S.P.S.S. package system V.11.5 Mean, groups
0.95 0.63 Gp I
standard deviation, ANOVA test and Group I
Scheffe test were used according to vs
Miswak 22.43 0.000
need. The level of significance used was Users Gp
5% level. II*
Results
1.20 0.59 Gp I
One hundred and forty four subjects Group II
were miswak users (48 females and 96 vs
Brush
males), 216 subjects were conventional users Gp
toothbrush users (72 females and 144 III*
males), 120 subjects were using both
1.44 0.71 Gp II
miswak and tooth brush (72 females and Group III vs
96 males). The mean age of miswak group, Miswak/ Gp
toothbrush group, and miswak/toothbrush brush III*
group was 33.83yr, 35.78yr and 36.36 yr, users
Table 2: The mean gingival index among study
respectively.
Mean oral hygiene index (OHI-S) subjects.
for the miswak users, the tooth brush *significant at 5% level
users and the combined miswak\ brush
users were 1.04, 1.08 and1.09
Regarding pocket depth
respectively. ANOVA test showed that there
measurement, the mean pocket depth of
was no statistically significant difference
group I, group II and group III were
between groups regarding oral hygiene (F=
3.31 mm, 3.90 mm and 3.49 mm
.287, P= 0.751) (Table 1).
Study groups Mean SD F P
respectively. The difference of the mean
1.04 0.64 pocket depth between the miswak users
Group I Miswak 0.287 0.751** (group I) and the brush users (group II) was
Users statistically significant as shown by Scheffe
1.08 0.71 test (P= 0.028). However the mean pocket
Group II Brush
users
depth difference between the miswak users
1.09 0.74 and the combined brush \ miswak users or
Group III between the tooth brush users and the
Miswak/ brush combined users did not reach the level of
users significance (P> 0.05) (Table 3).
Table1: Oral hygiene index among studied groups.
**not significant at 5% level

8 International Journal of Public Health Dentistry 1:1 (2010)6-12. © Celesta software Pvt Ltd
Shetty et al International Journal of Public Health Dentistry

Study Mean SD F P Scheffe The use of chewing sticks is

groups test most common in Asian countries
3.31 2.12 Gp I
Group I
especially in the Indian subcontinent and
vs. Gp the Middle East region, furthermore
Miswak 4.01 0.019
Users II* chewing sticks are cheap, readily
3.90 1.88 Gp I available in urban and rural areas of the
Group II countries. Despite the introduction of
vs. Gp
Brush modern oral hygienic devices, miswak
users III have been used as a traditional
3.49 2.13 Gp II toothbrush in many developing countries.
Group III vs. Gp Their taste is agreeable and not
Miswak/ III unpleasant and reported to have anti-
brush
users plaque and many other pharmacological
Table 3: Studied groups according to pocket depth. properties (9, 17).
*significant at 5% level In the present study, 59.1% of
As shown in table 4, the mean the subject was classified as miswak
gingival recession of the miswak users was users either exclusively or combined,
2.17 mm, 1.37mm of the conventional while 40.9% used the toothbrush alone
brush users and 1.30 mm of the combined which is similar to other study conducted
miswak\ brush users with a statistically by Asadi 1997(1). On the other hand
significant difference as revealed by prevalence of miswak use detected in
ANOVA test (F= 15.91, P= 0.000). Scheffe this work was less than that reported by
test showed that there was a statistically Al-Otaibi et al., 2003 who found that
significant difference of the mean gingival 73% of rural population used a toothbrush
recession in between the miswak users daily, while a miswak was used daily by
and the tooth brush users (P= 0.000), as 65% in an urban area in Saudi Arabia(18).
well as between the miswak users and This might be due to the younger age
the combined users (P= 0.000). group of the participants of present study
Meanwhile, no statistically significant with less deeply-rooted social and cultural
difference was detected in between the influences emphasizing the importance of
combined users and the brush users. miswak use.
The present study revealed that,
Study Mean SD F P Scheffe there was no statistically significant
groups test difference in oral hygiene index between
2.17 1.64 Gp I vs miswak users, toothbrush users and the
Group I Gp II* combined users (p>0.05). This
Miswak 15.91 0.000
Users
demonstrates that miswak users were
1.37 1.35 Gp I vs able to control oral hygiene as
Group II Gp III* effectively as those who used a
Brush toothbrush which was in accordance with
users the results of the previous studies(8, 9,
1.30 1.58 Gp II
19). This may be explained by the fact
Group III vs Gp
Miswak/ III that the miswak, in addition to its
brush mechanical cleansing effect, release a
users variety of beneficial chemicals such as
Table 4: Relationship between gingival recession and fluoride, saponins and sterol which
oral hygiene habits among study subjects.
*significant at 5% level
posses antibacterial properties that inhibit
plaque formation(6, 20). Additionally, the
miswak is generally used for longer
Discussion periods of time than the toothbrush(20).
These combined mechanical and

9 International Journal of Public Health Dentistry 1:1 (2010)6-12. © Celesta software Pvt Ltd
Shetty et al
chemical plaque control properties of
miswak could compensate for its limited
anticalculus effect compared to
toothbrush(21). This in turn was reflected
in the nearly equal levels of OHI-S
measuring both plaque and calculus
among either miswak users, conventional
brush users or combined miswak and
brush users.
The results of the present study
demonstrated that there was significant
difference between all the groups regarding
gingivitis, miswak was more effective in
reduction of gingivitis compared to tooth
brush alone or combined users (p<0.05).
This findings was in a contrast with
several previous studies(8-10) in which
the difference obtained was between
miswak users and toothbrush users but no
difference was obtained between miswak
and combined users and between tooth
brush users and combined users. This
may be explained by the fact that the
miswak possesses several properties that
inhibit plaque formation. In addition to its
mechanical effect, the enzyme inhibitory
properties of miswak may play a
significant role in deactivating the
virulence effects of subgingival species
that are associated with periodontal
disease(22). Also, miswak posses an
inhibitory action on protease and
peptidase enzymes which are produced
by periodontopathic bacteria as suggested
by Homer et al, 1992(22). In the
present study it was found that the
combined users possess more gingivitis
than the miswak users alone this may
be due to the fact that the mean age of
combined users was more than miswak
users alone.
Furthermore, Darout et al, 2002(19),
identified several anionic components,
including thiocyanate from miswak.
Thiocyanate has potent promoter effects on
the salivary peroxidase antimicrobial system
and increase unspecific and specific
resistance mechanisms of the tissues
against the infection. Moreover, in vitro
studies have shown that extracts from
miswak inhibited growth of various oral
10 International Journal of Public Health Dentistry 1:1 (2010)6-12. © Celesta software Pvt Ltd
International Journal of Public Health Dentistry
aerobic and anaerobic bacteria and
Candida Albicans (23, 24).
On the other hand this study
showed that gingival recession
significantly increased in miswak users in
comparison to toothbrush users or
combined users (p<0.05). This was in
accordance with Eid et al, 1990 who
noticed that the severity of gingival
recession was significantly more
pronounced in the miswak users than it
was in the toothbrush users(13). Also, the
results of the present study paralleled
that of Norton and Addy, 1989 and
Mumghamba et al, 1995 who reported that
miswak is frequently accompanied by a
marked gingival recession (12, 25).
Gingival recession induced by
miswak is partly due to improper
technique or due to trauma from hard
fibers of miswak on the gingival tissues
as proposed by Akhter and Ajmal,
1981(20).
Despite its wide use, few studies
have examined it effects on gingival and
periodontal health(8-10). The purpose of
this study was to asses and compare
the oral hygiene, gingival and periodontal
conditions among Indian population who
used regularly miswak in comparison
with conventional toothbrush users.
Conclusion
Finally, this study demonstrated
that, apart from gingival recession that
might be encountered in miswak users
as a result of improper technique, the
miswak exhibit a significantly higher
improvement in gingival and periodontal
conditions as compared to tooth brush.
Provided that miswak is available at low
cost, it is strongly recommended that
miswak should be encouraged in
developing countries as an oral hygiene
tool coinciding with socioeconomic, cultural
and religious background. However, to
obtain a significant oral hygiene gains,
proper technique of using miswak should be
taught to the habitual miswak users.
Affiliations of Authors: 1. Dr. Raghavendra M.
Shetty, MDS, Associate Professor,
Shetty et al
Department of Pediatric Dentistry,
Chhattisgarh Dental College and Research
Institute, Rajnandgaon, Chhattisgarh, 2. Dr.
Sunaina Shetty, BDS, Postgraduate Student,
Department of Periodontics, A. B. Shetty
Memorial Institute of Dental Science, Mangalore,
3. Dr. Sachin B. M, MDS, Associate
Professor, Department of Periodontics, 4. Dr.
Ramesh Amirisetty, MDS, Sr. Lecturer,
Department of Periodontics, Chhattisgarh
Dental College and Research Institute,
Rajnandgaon, 5.Dr. Abhishek Agrawal, BDS,
Postgraduate Student, Department of
Conservative and Endodontics, Sharad Pawar
Dental College, Sawangi (M,) Wardha, India.
References
1.Asadi S, Asadi Z. Chewing sticks and the oral
hygiene habits of the adult Pakistani population.
International Dental Journal 1997;47(5):275-8.
2.Al Sadhan R, Almas K. Miswak (chewing
stick): a cultural and scientific heritage. Saudi
Dental Journal 1999;11(2):80-7.
3.Lewis W, Lewis M. Medical Botany. Willy Inter
Science Publication. London1977.
4.Almas K, Al-Lafi T, editors. The natural
toothbrush1995: Geneva: World Health
Organization, 1980-1998.
5.Organisation WH. Prevention of oral disease.
Geneva: WHO; 1987. p. 60-1.
6.Hardie J, Ahmed K. The Miswak as an aid in
oral hygiene. The Journal of the Philippine
Dental Association 1995;47(1):33-8.
7.Al-Khateeb T, O'Mullane D, Whelton H,
Sulaiman M. Periodontal treatment needs
among Saudi Arabian adults and their
relationship to the use of the Miswak.
Community Dental Health 1991;8(4):323-8.
8.Gazi M, Saini T, Ashri N, A. L. Miswak
chewing stick versus conventional toothbrush as
an oral hygiene aid. Clin Prev Dent 1990;12:19-
23.
9.Darout I, Albandar J, Skaug N. Periodontal
status of adult Sudanese habitual users of
miswak chewing sticks or toothbrushes. Acta
Odontologica Scandinavica 2000;58(1):25-30.
11 International Journal of Public Health Dentistry 1:1 (2010)6-12. © Celesta software Pvt Ltd
International Journal of Public Health Dentistry
10.Al-Otaibi M, Al-Harthy M, Söder B,
Gustafsson A, Angmar-Månsson B.
Comparative effect of chewing sticks and
toothbrushing on plaque removal and gingival
health. Oral health & preventive dentistry
2003;1(4):301-7.
11.Almas K. The effect of Salvadora persica
extract (miswak) and chlorhexidine gluconate on
human dentin: a SEM study. J Contemp Dent
Pract 2002;3(3):27-35.
12.Norton M, Addy M. Chewing sticks versus
toothbrushes in West Africa. A pilot study.
Clinical preventive dentistry 1989;11(3):11-3.
13.Eid M, Al-Shammery A, Selim H. The
relationship between chewing sticks (Miswak)
and periodontal health. 2. Relationship to
plaque, gingivitis, pocket depth, and attachment
loss. Quintessence international (Berlin,
Germany: 1985)1990;21(12):1019-22.
14.Mengel R, Eigenbrodt M, Schünemann T,
Florès de Jacoby L. Periodontal status of a
subject sample of Yemen. Journal of clinical
periodontology 1996;23(5):437-43.
15.Greene J, Vermillion J. The simplified oral
hygiene index. Journal of the American Dental
Association (1939)1964;68:13-7.
16.Silness J, Löe H. Periodontal disease in
pregnancy II. Correlation between oral hygiene
and periodontal condition. Acta Odontologica
Scandinavica 1964;22(1):121-35.
17.Lewis M. Plants and dental health. J
Preventive Dentistry 1980;6:75-80.
18.Al-Otaibi M, Zimmerman M, Angmar-
Månsson B. Prevailing oral hygiene practices
among urban Saudi Arabians in relation to age,
gender and socio-economic background. Acta
Odontologica Scandinavica 2003;61(4):212-6.
19.Darout I, Albandar J, Skaug N, Ali R. Salivary
microbiota levels in relation to periodontal
status, experience of caries and miswak use in
Sudanese adults. Journal of clinical
periodontology 2002;29(5):411-20.
20.Akhtar MS, M. A. Significance of chewing-
sticks (miswaks) in oral hygiene from a
pharmacological view-point. J Pak Med Assoc
1981;31(4):89-95.
Shetty et al International Journal of Public Health Dentistry

21.Babay N, Almas K. Effect of miswak extract of Candida albicans. Microbios 1994;80(323):

on healthy human dentin an in vitro study. Saudi 107-13.
Dental Journal 1998;11(2):46-52.
25.Mumghamba E, Markkanen H, Honkala E.
22.Homer K, Manji F, Beighton D. Inhibition of Risk factors for periodontal diseases in Ilala,
protease activities of periodontopathic bacteria Tanzania.Journal of clinical periodontology
by extracts of plants used in Kenya as chewing 1995;22(5):347-54.
sticks (mswaki). Archives of Oral Biology 1990;
35 (6): 421-4. Address for Correspondence
Dr.Raghavendra M.Shetty, MDS,Ph.D.
23.AbdElRahman H, Skaug N, Francis G. In Associate Professor,
vitro antimicrobial effects of crude miswak Department of Pediatric Dentistry,
extracts on oral pathogens. Saudi Dental Chhattisgarh Dental College,
Journal 2002;14(1):26-32. Rajnandgaon, Chhattisgarh-491 441,India.
Ph:0091.9993987421
24.Al-Bagieh N, Idowu A, Salako N. Effect of Fax:0091.7744 281930
aqueous extract of miswak on the in vitro growth E-Mail:raghavendra77@yahoo.com

12 International Journal of Public Health Dentistry 1:1 (2010)6-12. © Celesta software Pvt Ltd