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A healthy mouth leads to a healthy body. Good oral hygiene is the key to good oral and systemic health. Acceptable level of plaque control, from where periodontal disease cannot be initiated or progressed is the ultimate desire of oral and dental professionals. The body -mouth relationship is of great interest among health care professionals. With the increasing prevalence of oral and dental diseases, the international need for preventive and curative methods has been surfaced. Not only are alternate preventive and treatment methods being expanded but also safe, effective, economical and culture based traditional remedies and products are being explored. A tooth brush and tooth pastes are commonly used in developed and developing countries for cleaning teeth.
The evolutionary development of the modern day toothbrush may be traced to chewing sticks that were used by the Babylonians. The use of chewing stick was recorded by the Babylonians in 5,000 BC and the fashion rapidly spread throughout the Greek and Roman empires. The chewing stick was also used by the Egyptians, the Jews, and among the Muslim world. References to the use of chewing stick can be found in the Talmud, as the Quesum, the Siwak, Miswak and Arak. Its use as a chewing stick or Siwak was documented in the Arabian Muwasha written by Alwashah, in AD 900. It is believed that the modern day tooth brush was not known in Europe until about 300 years ago, Lewis and Lewis (1). Medical texts of ancient India, Susruta Samhita and Charaka Samhita, have also emphasized on oral hygiene and brushing teeth with herbal sticks (2). Today miswak is being used in different parts of the world. Chewing sticks are known by various names including the word “miswak” or “arak” in Arabic, “qesam in Hebrew, “qisa” in Aramaic, “koyoji” in Japanese, “mastic” in Latin (3) and “mefaka” in Ethopia (4) and datun in Pakistan and India (5).
In many Middle Eastern, Asian, and African American communities, traditional methods of tooth cleaning are still used due to low cost, affordability, availability, usage in rituals, and to serve custom, and religious purposes (6). Chewing sticks have various other uses such as: using them as jaw exercisers, inducing a reflex of copious saliva secretion, combating undesirable oral habits including smoking and thumbsucking, and lastly, they can also be used during the teething process (7). In terms of geographical distribution, S. persica usage is widely spread and ranges from countries such as Malaysia, Nepal and India in the East through Iran, Iraq, Pakistan, Saudi Arabia, and Egypt to Mauritania in the West, from North Africa and Central Africa to Southwestern Africa (8).
In the Middle East, Arak (Salvadora persica) is the most common chewing stick. Additionally, the roots of African laburnum (C. siberianba) are used in Sierra Leone and Neem (A. indica) is primarily common in the Indian subcontinent. Other forms of chewing sticks can be found in Western Africa, where the lime tree (C. aurantafolia) and the orange tree (C. sinensis) are utilized for oral health purposes. Not only are miswak used for oral hygiene, they are also related to religious rituals and social purposes (9).
One hundred and eighty-two kinds of plants/shrubs have been used as chewing sticks, throughout the developing world; the most significant is Arak, Salvadora persica (10). The roots, twigs, and stems are the specific parts of the plant that provide dental hygiene (11).
The miswak is a small, upright evergreen tree or shrub with white branches and aromatic roots, rarely ever more than three meters in height and 30 cm in diameter (12). The fresh leaves on the S. persica can be utilized in traditional medicine for treating cough, asthma, scurvy, and other diseases, whereas, the flowers of the tree are used as a stimulant and are mildly purgative (9). Stems and roots of the S. persica are spongy, thus they can be easily chewed and crushed between the teeth. The chewing stick becomes quite spongy after it is soaked in water; therefore, it is highly unlikely to traumatize the gums, if used properly, while brushing (7). The stem or root is chewed on one end, until it becomes frayed and looks similar to the head of a toothbrush (9).
Considering the historical, cultural and religious importance of S. persica miswak as an oral hygiene and maintenance tool, this current review is an update on recent developments in miswak research. Major emphasize is on chemical composition, how to use and when to use miswak for effective cleaning of teeth and mouth. Recent scientific evidence regarding its probiotic role, cell viability and comparative cytotoxicity and research trends are highlighted.
The advantageous effects of miswak, in terms of oral hygiene maintenance and dental health, can be attributed to the mechanical role of brushing and its pharmacological component (9). Chemical analysis shows that miswak contains numerous, natural constituents that are known to benefit oral health. The chemical substances present in S. persica are as follows: chloride, fluoride, saponins, salvadorine, silica, sulfur, sterols, trimethylamine, and vitamin C (7). Another chemical investigation demonstrates the following compounds present in the S. persica plant: b-sitostrol and m-anisic acid chlorides, salvadorea, and gypsum; organic compounds, including pyrrolidine, pyrrole, and piperidine derivatives; glycosides, such as salvadoside and salvadoraside; and flavonoids, including karmpferol, querceting rutin, and a quercertin glucoside (13). The main constituent of the Salvadora persica root oil is Benzyl- isothiocyanate (BITC) (14). This component of the Salvadora persica root, Benzyl- isothiocyanate, exhibits broad-spectrum bactericidal activity (15) and inhibits the growth and acid production of Streptmutans (16). According to Chawla (17) , chewing sticks like Neem (A. indica), S. persica, A. arabica contain a noticeable amount of fluoride.