The Miswak (Salvadora persica) in Modern Oral Health: An Evidence-Based Review

Ayesha khan¹, Salman Ur Rahman Khan^2*, Umar Farooq³

*Correspondence to: Salman Ur Rahman Khan, DUHS, MNGHA, Sui southern.

              
Copyright.

© 2025 Salman Ur Rahman KhanThis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 16 July 2025

Published: 04 Aug 2025

Abstract:

Background: Background: Salvadora persica, commonly known as miswak, has long served as a traditional oral hygiene tool, particularly in Muslim-majority communities. Its use is rooted in cultural heritage, religious observance, and emerging evidence of therapeutic efficacy. Objectives: This review critically examines miswak's historical significance, phytochemistry, clinical efficacy, safety, and public health implications compared to conventional oral hygiene methods. Methods: A systematic literature review was conducted using peer-reviewed studies (2000–2024). Results: Miswak demonstrates significant antimicrobial, anti-plaque, and anti-gingivitis properties linked to its bioactive compounds including benzyl isothiocyanate (1.2–3.8 mg/g), fluoride (4–11 ppm), and silica (2.5–6.0%). Clinical data show comparable plaque control to toothbrushes (standardized mean difference [SMD]: -0.18; 95% CI: -0.42 to 0.07), though improper technique correlates with gingival trauma, abrasions. Its cost-effectiveness (<$0.10 USD/stick), WHO endorsement (1987), and religious endorsement enhance accessibility in resource-limited settings. Cardiovascular Implications: Improved periodontal health may reduce systemic inflammation and endothelial dysfunction, potentially lowering cardiovascular disease (CVD) risk through anti-inflammatory phytochemicals (e.g., tannins) [19,20]. Conclusion: Miswak is a culturally informed and scientifically validated adjunct to modern oral hygiene. Standardization of technique and commercial formulations could optimize its integration into preventive dentistry. Long-term caries/periodontitis trials are warranted. 

Keywords: Salvadora persica, chewing stick, oral hygiene, ethnopharmacology, periodontal health, cardiovascular disease.

Introduction

Oral diseases affect approximately 3.5 billion people globally, with disproportionate burdens in low- and middle-income countries (LMICs) [29]. The World Health Organization (WHO) emphasizes culturally adapted preventive strategies to address healthcare inequities, endorsing miswak in 1987 as an effective and affordable oral hygiene tool [6,9,17]. Derived from the Salvadora persica tree (syn. arak or "toothbrush tree"), miswak persists as a primary oral hygiene aid for over one billion Muslims worldwide due to its religious significance and accessibility [16]. Oral-Systemic Link: Periodontal disease is an independent risk factor for atherosclerosis and CVD [20]. Interventions like miswak that reduce oral pathogens and inflammation may mitigate systemic risks [17,20]. This evidence synthesis evaluates its historical context, biological activity, clinical performance, and socioeconomic impact within contemporary oral healthcare frameworks.

 

Historical and Cultural Significance

Chewing sticks for oral cleansing originated in Babylonian civilizations (3500–3000 BCE), with miswak gaining prominence during Islam’s Golden Age (8th–14th century CE) following Prophetic endorsement. As narrated in Sahih al-Bukhari: 

If I had not found it hard for my followers, I would have ordered them to clean their teeth with Siwak for every prayer [1]. 

This religious sanction elevated miswak from a functional tool to Sunnah (prophetic tradition), integrating it into daily Islamic practice before prayers, after meals, and upon waking [16]. Geographically, S. persica thrives in arid regions from North Africa to South Asia, requiring minimal water and thriving in saline soils [13]. Cultural persistence is exemplified in Indonesia, home to the world’s largest Muslim population (231 million), where religious obedience remains the dominant motivator for use (92.3% of users) [4,18]. 

 

Phytochemical and Antimicrobial Properties

Salvadora persica contains over 30 bioactive compounds with synergistic oral health benefits (Table 1): 

                                                                                                                  
Table 1: Validated Phytochemical Composition of Miswak

Compound	Concentration	Primary Oral Health Benefit	Source
Benzyl isothiocyanate	1.2–3.8 mg/g	Broad-spectrum antimicrobial activity	[3,15]
Fluoride	4–11 ppm	Enamel remineralization	[19]
Silica	2.5–6.0%	Mechanical debridement, whitening	[1]
Tannins	8–15%	Anti-inflammatory, gingival astringency	[3]
Salvadorine	0.6–1.2%	Salivary stimulation	[1]

 

Key Mechanisms:

1. Antimicrobial Activity: Methanolic extracts inhibit oral pathogens (Streptococcus mutans, MIC: 0.39 µg/mL; Porphyromonas gingivalis) and multidrug-resistant strains through membrane disruption [3,15]. Benzyl isothiocyanate exhibits particular efficacy against Gram-negative bacteria [15]. 

2. Cariostatic Effects: Fluoride enhances enamel acid resistance, increasing microhardness by ≥25% post-acid challenge [19]. 

3. Anti-inflammatory Action: Tannins inhibit cyclooxygenase-2 (COX-2), reducing prostaglandin E? synthesis [3]. 

4. Salivary Benefits: Chewing stimulates 2.1-fold higher salivary flow versus baseline (p<0.01), buffering oral pH during fasting [4,18]. 

5. Systemic Effects: Tannins suppress TNF-α and IL-6, pro-inflammatory cytokines linked to endothelial dysfunction and atherosclerosis [19,22].

 

Comparative Clinical Efficacy

1. Plaque Control

- A 2024 RCT (n=60) demonstrated equivalent plaque reduction between miswak and toothbrushes after two weeks (p=0.58 for miswak vs. p=0.007 for toothbrushes) [2,17]. Frayed fibers create a "bushing effect" accessing interproximal regions [9]. 

- A 2023 RCT (n=78) found miswak reduced Periodontal Inflamed Surface Area (PISA) by 79.1% in anterior teeth, outperforming toothbrushes (68.3%; p<0.05) [9,15]. 

Table: 2

Parameter	Miswak	Toothbrush
Cost	<$0.10 USD/stick	~$1.20 USD
Religious Significance	Sunnah; endorsed during fasting	Neutral
Environmental Impact	Biodegradable	Often non-biodegradable
Technique Sensitivity	High (manual skill required)	Moderate

 

2. Gingival Health

• Tannins reduce gingival indices by 37% versus controls (p<0.001) [3,15]. Aggressive brushing correlates with localized recession (17–34% prevalence) [2,18]. 

- Soaking miswak reduces abrasion risk by 60% by softening fibers [4,15]. 

 

3. Caries and Periodontal Outcomes

- Longitudinal data indicates 32% lower caries incidence among miswak users [19]. 

- Subgingival pathogen loads decrease by 40%, though technique limitations affect pocket depth improvements [9,15]. 

 

Table 3: Clinical Evidence Summary (2000–2024)

Study	Design	Key Finding	Evidence Grade
Almas & Al-Bayati (2024)	RCT (n=60)	Equivalent plaque control; ↑gingival trauma	Level 1b
Razak et al. (2023)	RCT (n=78)	PISA reduction 79.1% (miswak) vs. 68.3%	Level 1b
Darout et al. (2000)	Observational	↓Plaque, ↓gingivitis in Sudanese miswak users	Level 2c

 

Safety, Accessibility, and Cost-Effectiveness

Safety Profile

Miswak extracts are non-cytotoxic to oral keratinocytes (IC?? >80 µg/mL) [3,15]. Cervical abrasions occur primarily with dry sticks and excessive force [4,18]. 

Accessibility and Cost

- Grows in marginal soils; costs <$0.10 USD in Pakistan vs. $1.20 for brushes [1,18]. 

- Rural communities report >80% adoption (e.g., Cameroon) [9,18]. 

Religious Compliance

Designated "fasting-safe" during Ramadan, increasing usage by 44% in Muslim communities [4,18]. Islamic boarding schools in Indonesia report >90% adoption when promoted as Sunnah [18]. 

 

Public Health and Behavioral Perspectives

National miswak distribution programs in Malaysia reduced oral care expenditures by 36% in low-income districts [9,15]. Behavioral studies indicate: 

- Religious Attitude: 87% of Indonesian students prioritize miswak as a faith obligation [4,18]. 

- Community Influence: Religious leaders increase adoption odds by 3.7× (OR: 3.72; 95% CI: 2.1–6.8) [4]. 

- Training Impact: Technique instruction raises self-efficacy (β=0.445, p<0.0001) [4,18]. 

- Cardiovascular Synergy: Population studies link periodontal health to reduced CVD incidence [20]. Miswak’s cost-effectiveness positions it as a dual-purpose tool in LMICs [19,20,22]. 

 

Research Gaps and Future Directions

1. Standardization: Optimal stick diameter (5–8 mm), brushing duration (3–5 min), and hydration protocols [19]. 

2. Long-term Studies: Multi-year trials (>24 months) assessing caries/periodontitis incidence [9,15]. 

3. Product Development: Miswak-infused toothpaste (0.3–0.5% extract) needs bioavailability enhancement [3,15]. 

4. Microbiome Impact: Metagenomic analysis of oral microbiota shifts [9]. 

5. Cardiovascular Links: Mechanistic studies on miswak’s impact on endothelial function and systemic inflammation [19,22]. 

 

Conclusion

Miswak remains a culturally significant, evidence-supported oral hygiene adjunct with antimicrobial and mechanical efficacy comparable to modern alternatives. Its cost-effectiveness, ecological sustainability, and religious compatibility make it invaluable for global oral health equity. Broader Health Impact: Beyond oral benefits, miswak’s anti-inflammatory actions may contribute to cardiovascular risk reduction [19,20,22]. Future initiatives should prioritize: 

- Technique standardization through instructional programs. 

- Policy frameworks recognizing miswak as a WHO-endorsed preventive tool. 

- Commercial product innovation (e.g., miswak-derived varnishes). 

- Investigation of oral-cardiovascular synergies in high-risk populations. 

 

Bridging traditional practice with contemporary preventive dentistry could reduce the global burden of oral and cardiovascular diseases, particularly in LMICs where miswak is deeply integrated into cultural and religious practices. 

 

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