Introduction
Removal of dental plaque is effected in treating gingivitis, and periodontal
diseases1.Oral health is playing a crucial role for effective healthy life .To prevent
oral and dental diseases a good oral hygiene is mandatory. There are different
methods available for the maintenance of oral health. These are mainly mechanical
and chemicals, among mechanical tooth brushing and chewing stick are widely used
.Traditional Tooth brushing by chewing called MISWAK has been used since
ancient history.2 Local availability and a low cost have made it the tool of choice for
plaque control in different communities
Chewing stick were used by Babylonians some 7000yrs ago .and it is known by
different names, it has been called a natural tooth brush and called DARKHE –IMISWAK.
One hundred and eighty- two species of plants have been used as chewing sticks
throughout the world. The most common type of Miswak is derived from Salvadora
Persica also known as Arak or a small tree or shrub with a spongy stem and root
and easily crush between teeth
5.It
is used as a Traditional tooth
brush for
maintenance of oral hygiene 4. Different studies has reported the oral health status
of chewing stick uses are contradictory studies have claimed that Miswak sticks are
effective in reducing plaque and gingival inflammation.5-8.. Al- Otaibi et al reported
that Miswak significantly reduce plaque (P < 0.001) and gingivitis
(P < 0.01) as compared to the toothbrush. Al-Otaibi M, Al-Harthy M, Soder B, Gustafsson A, AngmarMansson B. Comparative effect of chewing sticks and toothbrush-ing on plaque removal and gingival health. Oral Health Prev
Dent.2003;1:301-307.
studies also reported that miswak is as effective as tooth brush .6.another studies has
claimed that chewing stick removed plaque from interproximal site to virtually the
some extent as from other more accessible sites 6.The mechanical cleansing action
of chewing stick is to believe to its valued. It has found the chewing stick inhibits
plaque formation .chemically and exert anti microbial effect against many oral
bacteria 9
In 1987 WHO encourage to use miswak for oral hygiene because of tradition
availability and low cost 12 and it has proven it gives therapeutic effect on gingival
disease.13
Aim of study
This study was design to clinically evaluate the efficacy of chewing stick as adjunct
to tooth brush on plaque removal in subject with clinically healthy gingival status.
Material and methodology
Subjects were randomly selected from OPD presenting to Sardar Begum Dental
College. Peshawar Pakistan.
A prior written informed consent was taken from all subjects. The study was
approved by ethical and research committee of Gandharah University Peshawar.
Inclusion criteria
The subjects included to be with in the age group of 18 – 35 years subject who were
having 20 teeth at least 5 teeth per quadrant who had clinically healthy gingival
status ,and periodontal depth less than 3mm were recruited in the study. and subjects
showing BPE/CPTIN.
Exclusion criteria were as follows subjects who were systemically compromised,
pregnant and lactating mother ,subjects having orthodontic appliance ,who had
carious teeth ,malposition teeth ,overhang margins restorations and patient who were
on antibiotics in last 3 months were omitted .
Participants were given verbal and written guidelines on how to use the Miswak with
photographs and a brushing.
Study design
Clinical examination
A single examiner blind randomized control trial was conducted over a 1-month
(4weeks) period. The study included 80 dental subjects, with age ranging from 18 to
45 years both male and female, who attended the Periodontology department of
SBDC Gandhara University, Peshawar (KPK) for their routine dental checkup. The
subjects were randomly divided into two groups Group 1 tooth brush with tooth
paste, twice daily for 4 weeks and Group 2 miswak. Twice daily for 4 weeks. A
desired Performa was filled and the involvement of plaque score was seen at base
line from both groups. Plaque disclosing tablet (contain 1.36 % erythrosine) had
been used. Quigley Hein plaque index modified by Turkish et al was used to measure
the plaque levels at four surfaces per tooth (buccal, mesial, distal and lingual. In the
study assessment of plaque levels using Plaque index given by Quigley and Hein
indexi modified by Turesky et al.ii
The Quigley Hein plaque index is recognized a reliable index of measuring using an estimate of
the area of the tooth covered by plaque. Turkeshy et al , strengthened the objectives of Quiqely
Hein criteria by redefining the scores of the gingival third of labial , buccal , lingual or palatal
surfaces of evaluating plaque.
After that professional cleaning was done, and follow up after 4 weeks for the
reassessment of plaque score had been obtained. All patients underwent an intraoral
examination, full- mouth supra, sub- gingival scaling and root planing procedures
with ultrasonic.
In the study assessment of plaque levels using Plaque index given by Quigley and
Hein indexiii modified by Turesky et al.iv
Statistical Analysis
Data was checked in EPI-info version 16.0 for scientific verification. The Data was
finally shifted in SPSS version 16.0 for analysis.
The independent sample ‘t’ test, was used to evaluate significance value, confidence
interval, P value,, standard error of mean and, mean SD of age.. Both groups were
performed with independent ‘t’ test for comparisons at base line and after 4 weeks,
between the plaque score. One sample ‘t’ used for assessment of Plaque score
before and after in each group. size of the study population was based on a previous
study comparing Miswak with tooth brushing (Al- Otaibi et al. 2003).
Results:
Given that a non probability convenient sample was used, results are limited to the
population visited to the Periodontology department of Sardar Begum Dental
Hospital .None of the participants complained of discomfort or adverse reaction
with use of allotted tooth brush, tooth paste and chewing stick.
Table 1 shows over all age groups and their mean and standard deviation. Table 2
shows the independent t test value of whole mouth plaque score at base line and
after use of 4 weeks of both tooth brush and chewing stick. A significant difference
has been seen between tooth brush and chewing stick.
Table 01: Age group range of N=80
Age Group
Frequency
Percentage (%)
(10-20) Years
15
18.75
(21-30) years
53
42.5
(31-40) years
12
2.5
Mean
25.54
S.D
6.004
Table 02 shows group statistic of independent t test of N=80 ,QHPI whole mouth score
base line of Tooth brush and miswak ,and after 4 week of tooth brush and miswak.
Group
Mean
SD
SE
5.001
1.50
2.380
Whole mouth
BASE LINE
(maxilla & Mandible)
Tooth Brush
Miswk
Whole mouth
4.923
0.63
0.101
After 4
week
(maxilla & Mandible)
Tooth brush
2.52
7.82
1.23
Miswak
1.37
0.427
0.06
P –value
0.00
SD= standard debiation, SE= standard error
Plaque score
mean
SD
t value
P value
QHI Plaque
1.366
0.371
3.331
0.812
2.5099
1.195
3.331
0.736
1.251
0.617
3.15
0.460
score BL in max
QHI Plaque
score BL in
mand
QHI Plaque
score After
4Week in max
QHI Plaque
score After 4
Week in man
0.701
Table 04 shows one sample t test result of N=80, Quigelyhein plaque index base line and
after 4 week.
Plaqe score
Mean
SD
‘t’ value
P-value
QHI Plaque score
1.366
0.371
3.331
0.812
2.5099
1.195
3.331
0.736
1.251
0.617
3.15
0.460
0.701
0.085
3.15
0.000
BL in max
QHI Plaque score
BL in mand
QHI Plaque score
After 4Week in
max
QHI Plaque score
After 4 Week in
man
Discussion
Plaque is well known multi factorial entity and in vivo condition. Microorganisam of plaque
S.sanguis being the primary colonizer of the plaque film in the oral cavity , and is placed in the
deeper layer of plaque ,therefore dentifrices may not be able to stop its colonization. In comparison
to our study result Poureslami et al have reported that the minimum concentration of S.pmiswak
stick required for effectively killing of S.Sanguismicroorganisams and the concentration was 7.4
mg/ml and miswak is effective against S.Sanguis.
Increased efficacy of miswak may be due to several reasons. Traces of S.persica 10mg/10ml
solution were detected in the mouth up to 6 hrs after use expectoration this substantivety in
approximate, but it gives a comparable picture. Moreover, miswak is generally used for longer
period of time than tooth brush, cleaning usually done 5 -10 min each time, plant fibers remove
the plaque and message the gum.
The reason of choosing this chewing stick of salvadorapersica tree in the present study was based
on a number of factors. The use of miswak is very common in middle east region104, Indian
subcontinent and Pakistan. Its taste is acceptable, it is inexpensive and has been reported to have
anti plaque and many therapeutic pharmacological properties.1,v,vi,vii.
The choice of toothbrush and tooth paste of Shield company® was made because it is one of the
popularand leading brands among dental setups in Pakistan. The use of tooth paste with brush
could be the reason of significant reduction of plaque in tooth brush group .other study used tooth
brush alone in comparison with chewing stick.
In the current clinical trial, participants of the study were observed over a period of 4 weeks. This
decision was based on the fact that previous studies have shown that after 9 to 21 days without
proper oral hygiene , healthy gingiva develops heavy accumulation of plaque and lead to
generalize mild gingivitis.viii
This study was designed to be a convenient model for detection of plaque inhibitory ability of the
chewing stick and to determine its relative activity in relation to the well-established tooth brush.
Similar study designs were utilized by al Otaibi et al in 2004 and Mohammadbatwa et al
ix
, in
2006.
Current dental literature describes several clinical indices and methods for measuring plaque and
gingival inflammation both quantitatively and qualitatively and are based on subjective estimation
of the plaque.x Quigley Hein plaque index was chosen in this study to measure the plaque score
because it is the most commonly utilized index in previous similar investigations. It is a visual
determination of disclosed plaque on cervical 1/3rd of tooth surface. Plaque disclosing agent is
available in the form of chewable tablets, lozenges gums, and rinses and contain 1.36%
erythrosine.
Al-mas conducted a study and compared the seven different kinds of chewing stick their role in
micro biota and arak (salvadoraperscia) miswak purchased from Pakistan and few from Saudi
Arabia. Result showed that 50% used arak miswak (salvadoraPersica tree of Pakistan ) had higher
anti microbial activity.
In summary a rational explanation of the attractiveness of S. persica chewing stick as a tool for
teeth cleaning is .it is in inexpensive, safeness, its shape is like tooth brush bristles, contain
chemical constituents with variable actions. It seems to be two in one, which means it gather the
toothpaste and tooth brush in one implement.
Conclusion:
The use of chewing stick fulfills the basic requirements of primary health care and can be a good
alternate to tooth brush as a means of preventing oral diseases. Both miswak and tooth brush
removes plaque clinically. It was concluded that Salvadorapersica chewing stick remains a good
anti plaque agent and hence study rejected the null hypothesis. Plaque was reduced in toothbrush
group it could be the efficacy of tooth paste that removes the plaque significantly. Our findings
clearly indicate that miswak can be used as an alternative to the tooth brush.
i
Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power
brushing. J Am Dent Assoc 1962;65:26-9.
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ix
x
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