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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 27-31

Efficiency of Miswak as an oral hygiene aid among the madrasa going children of Nuh – A socioeconomically disadvantaged district of India


1 Department of Dentistry, Shaheed Hasan Khan Mewati Government Medical College, Nuh, Haryana, India
2 Department of Pathology, Kalpana Chawla Government Medical College, Karnal, Haryana, India

Date of Submission10-Aug-2021
Date of Acceptance18-Oct-2021
Date of Web Publication29-Apr-2022

Correspondence Address:
Dr. Sonam Sharma
Department of Pathology, Kalpana Chawla Government Medical College, Karnal, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoralsci.sjoralsci_37_21

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  Abstract 


Introduction: Resources for oral health care remain limited in in rural and backward areas where an inherent need to exists to explore inexpensive cleaning aids at ease.
Aim: To assess the efficiency of Miswak stick as an oral hygiene aid among madrasa-going 12–14 years old children, by comparing it with toothbrush and toothpaste in Nuh district of Haryana, India.
Materials and Methods: The study population comprised of 540 madrasa-going children. 400 cases were Miswak users, whereas 140 toothbrush and toothpaste users were in the control group. Their oral hygiene status was assessed using the Gingival Index (GI), Oral hygiene index- simplified (OHI-S) and Plaque Index (PI). Decayed, Missing, Filled Teeth (DMFT) index was used to measure the dental caries incidence. The data were recorded, tabulated, and statistically analyzed.
Results and Discussion: The results showed that Miswak users had significantly less mean GI score and OHI-S index scores (P = 0.001) but no statistically significant difference in PI score as compared to toothbrush and toothpaste users. Second, DMFT score was more in toothbrush and toothpaste users as compared to Miswak users.
Conclusion: This study concluded that the oral hygiene status of Miswak users in the madrasa-going children of Nuh district was better than that of toothbrush and toothpaste users.

Keywords: Dental caries, miswak, oral hygiene, toothbrush, toothpaste


How to cite this article:
Sharma A, Ranga P, Sharma S. Efficiency of Miswak as an oral hygiene aid among the madrasa going children of Nuh – A socioeconomically disadvantaged district of India. Saudi J Oral Sci 2022;9:27-31

How to cite this URL:
Sharma A, Ranga P, Sharma S. Efficiency of Miswak as an oral hygiene aid among the madrasa going children of Nuh – A socioeconomically disadvantaged district of India. Saudi J Oral Sci [serial online] 2022 [cited 2022 May 20];9:27-31. Available from: https://www.saudijos.org/text.asp?2022/9/1/27/344399




  Introduction Top


Proper oral hygiene maintenance for regular removal of food debris and dental plaque is essential for the prevention of periodontal diseases and dental caries. Oral hygiene practices may vary from region to region and are also affected by the local cultural beliefs. Natural method of tooth cleaning with chewing sticks such as Miswak has been practiced for years in many communities.[1] Miswak is an Arabic word which means the chewing stick prepared from root, stem, twigs, or bark of Salvadora persica also known as Arak/Peelu tree [Figure 1] and [Figure 2].There are various names given to these sticks such as Meswak, Sewak, or Siwak in the Middle East, “Mefaka” in Ethiopia, “Datun” in India and Pakistan.[2] Miswak is very popular in the Muslim world.[3] It is used five times in a day before every Namaz (prayer) as a religious practice. In pre-Islamic and Islamic custom, use of Miswak contributed to ritual purity.[4] It is basically a pencil-sized stick 15–20 cm long with a diameter of 1–1.5 cm. Chewing of Miswak separates fibers and giving it a brush like appearance that helps in cleaning the teeth and massaging the gums.[5] Miswak stick fibres contain silica, sodium bicarbonate, and resins, whereas the aqueous extracts contain tannic acid, alkaloids, essential oils, and Vitamin C along with calcium and fluoride ions. Silica and sodium bicarbonate acts as an abrasive material that removes stains and deposits from the tooth surface and also has germicidal effect. Resins serve a physical function and form a layer over the enamel which protects it from microbial action. Alkaloids show bactericidal effect and stimulate the gingiva. Essential oils have anti-septic effect and stimulate the flow of saliva. Vitamin C helps in healing and repair. Calcium and fluoride ions promote remineralization of tooth structure and have mild anti-bacterial action. Benzyl isothiocyanate (BITC) a major component of Miswak has strong bactericidal effect against oral pathogens involved in periodontal disease.[6] The amount of BITC decreases gradually if the same piece of Miswak is used several times.[7] Hence, chewing sticks when properly used can be efficient in removing dental plaque due to the combined effect of mechanical cleaning, antimicrobial activity, and enhanced salivation. The resultant activity against cariogenic and periodontopathic bacteria, the impediment of formation and activity of dental plaque with the regular use of the chewing sticks reduces the incidence of gingivitis and dental caries, thereby promoting dental health.[8]
Figure 1: Miswak picture (Salvadora persica)

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Figure 2: Miswak sticks prepared from the roots of Salvadora persica

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Nuh district (earlier officially known as Mewat district) in the state of Haryana is one of the most backward districts in India. It stands at the bottom of the National Institute of Transforming India (NITI Aayog) list of 101 most backward districts in the country.[9] Nuh, is inhabited primarily by Muslims (around 80%), a unique ethnic group called as Meos, which has been categorized as a backward caste. About 90% population resides in rural areas and are engaged in agriculture and livestock. There is a huge gender gap in literacy and enrolment as women are spending substantial time in fetching water and collecting wood for fuel.[10] The concentration of the Muslim population and madrasas normally go hand in hand as it is considered an important institution for promoting religious education and preserving cultural identity. Hundreds of thousands of Muslim children acquire their primary and perhaps the only formal education in these Nuh madrasas.[11]

Resources for oral health care remain limited in developing countries like India, especially in rural and backward areas. There is an inherent need to explore easily available and inexpensive cleaning aids, which are traditional to the society.[12] Hence, the aim of the present study was to assess the efficiency of Miswak stick as an oral hygiene aid among madrasa-going children in Nuh district of Haryana, India.


  Materials and Methods Top


Source of data

Prior to start of the study, a list of madrasas was obtained from Municipal Corporation office of Nuh district, Haryana. From a total of 77 madrasas in the district, 18 were selected as they were attended by both boys and girls.

Ethical clearance

The proposed study was reviewed by the Ethical Committee of Shaheed Hasan Khan Mewati Government Medical College, Nuh, Haryana, India and clearance was obtained (EC/OA– 59/2019). A written consent was obtained from the respective madrasa authorities, parents/guardians before the commencement of this study.

Study population

Study population consisted of total 540 healthy children in the age group of 12–14 years. Both male and female children (as per availability) who were performing oral hygiene practices minimum twice a day since 1 year were included in the study. The study population was divided into two groups:-

  1. Group I (Cases)-Selection of 400 children using fresh end cut of Miswak was done by using sample collection formula:


  2. Sample Size n=Z2PQ/e2



    P = prevalence, Q = 100 - P,

    Z = 1.96, e = 5% of prevalence

  3. Group II (Controls)-Selection of 140 children using tooth brush and toothpaste, based on sample collection formula:


Sample Size n=Z2PQ/e2



Considering Miswak prevalence

(P) in Nuh 90%, Q = 100 - P

Children having any disability/under medication for any systemic diseases/undergoing orthodontic treatment/smokers/long-term tobacco chewers were excluded from the study.

Method of obtaining data

Prior to conducting dental examination, demographic information was obtained from each subject on the following: Age and Gender. Single examiner carried out the examination of the children with recommended sets of sterilized instruments (plain mouth mirror and periodontal probe) in their respective madrasa using natural source of light. The intra-examiner reliability was 0.92 by using weighted Kappa. Data recording was done by using different indices. The oral hygiene status of the subjects was evaluated using the plaque index (PI), gingival index (GI), and oral hygiene index-simplified (OHI-S).[13],[14],[15] Dental caries assessment was done by using the Decayed, Missing, Filled Teeth (DMFT) Index.[16]

Statistical analysis

Stepwise multiple linear regression analyses were executed to analyze the association between various sociodemographic data such as age, sex, and clinical variable scores (PI, GI, OHI-S and DMFT). The mean and standard deviation were performed to reveal the statistical significance. The confidence level of the study was proposed to be 95%, hence P < 0.05 was considered significant, P < 0.01 was considered highly significant and P < 0.001 was considered very highly significant.


  Results Top


Amongst a total of 540 children, 375 (69.44%) were male and 145 (26.85%) were female. The results were calculated for the two groups [Figure 3]. Group I comprised of 74.04% subjects, whereas Group II included 25.93% subjects. The mean PI score was higher in Group II as compared to Group I, but it was not statistically significant (P > 0.05). The mean GI score and OHI-S score for Group I were lower than Group II which was statistically very highly significant [Table 1]. The mean DMFT score was found to be significantly lower in Group I, i.e. Miswak users [Table 2].
Figure 3: Mean of plaque index, gingival index, oral hygiene index-simplified, and decayed, missing, filled teeth index scores among Group I and Group II

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Table 1: Mean of plaque index, gingival index, and oral hygiene index-simplified scores among study subjects

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Table 2: Mean of Decayed, Missing, Filled Teeth index scores among study participants

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  Discussion Top


Periodontal diseases and dental caries are the two main threatening dental conditions to mankind. The methods mainly available for maintenance of oral health are mechanical and chemical. The mechanical method generally includes the use of toothbrush and toothpaste or chewing sticks. The chewing sticks are potentially effective due to their medicinal efficiency to cure various dental ailments.[17] These sticks are widely used in different countries, available with different names such as Acasia nilotica, Albizia coriaria, Balanites aegyptiaca, Berchemia discolor, Salix subserrata and Vernonia amygdalina which are mainly found in Southern-Eastern Africa, while lime tree (Citrus aurantafolia) and orange tree (Citrus sinesis) are famous in West Africa. The roots of Senna (Cassia vinnea) are mostly used by black Americans and African laburnum (Cassia sieberianba) is used in Sierra Leone. In India, commonly used sticks are Neem (Azadirachta indica), Babool (Acacia leucophloea), Khair (Acacia catechu), Kiker (Acacia nilotica), Dhak (Butea monosperma), Arjun (Terminalia arjuna), Gular (Ficus racemosa), Tejowati (Zanthoxylum aroenatum), and Mulhati (Glycyrrhiza glabra). These sticks are inexpensive and easily available in rural areas.[18]

Nuh district of Haryana has majority of the population belonging to Muslim community with low socioeconomic status. They have been using Miswak to clean their oral cavity due to their cultural belief and its ready availability in their natural surroundings. In this region, majority of the children go to madrasas for education where they are advised to carry out the ritual practice of using Miswak for cleaning their mouth before prayer (namaz). This age old habit of using Miswak as an oral hygiene aid in this population group impelled us to conduct the present study in this rural and backward region of Haryana state, India.

Our study demonstrated no statistically significant difference in PI between children using Miswak and those using toothbrush and toothpaste, thus proving that Miswak was able to control plaque as effectively as a toothbrush and toothpaste. This may be explained by the fact that the fresh Miswak along with its mechanical cleansing action also releases a variety of beneficial chemicals such as fluoride, saponins and sterol which possess antibacterial properties inhibiting the plaque formation.[6] Batwa et al. also carried out a comparative study to assess plaque removal in both Miswak and toothbrush users and revealed that Miswak was as effective as tooth brushing for plaque removal. The reasons were that all participants were issued with identical conventional toothbrushes and fresh chewing sticks of fairly uniform length and width. This showed better cleansing efficacy of Miswak including the mechanical effects of its fibers and the release of beneficial chemicals or combination of both.[19] Goyal et al. also concluded that Miswak help in reduction of plaque by mechanical cleaning which enhanced salivation and leaching-out of antimicrobial substances.[20]

The mean GI score among Miswak users was statistically less than the toothbrush and toothpaste users in the present study which may be attributed to the tannic acid present in Miswak which acts as an astringent on the mucous membrane, thus reducing the clinically detectable gingivitis by inhibiting the action of glucosyltransferase.[21] Clerehugh et al. conducted similar study and observed relatively low GI score among 14-year-old school children of Ghana using different tooth cleaning methods such as chewing sticks, chewing sponge, or toothbrushes.[22]

In the present study, the DMFT score was more in the tooth brush and toothpaste users as compared to Miswak users with respect to dental carries. The children were cleaning their teeth two times a day with fresh end of Miswak which may be contributing to the lower caries index. Albabtain et al. in their research study also concluded that the fresh end of Miswak contain high quantity of BITC which showed the antibacterial properties against dental carries bacteria's like Streptococcus faecalis, Haemophilus influenzae, Aggregatibacter actenomycetemcomitans, and Porphyromonas gingivalis.[7] Similar findings were reported in other studies which showed that Streptococcus fecalis is the most sensitive microorganism affected by Miswak.[23],[24] A similar study on efficacy of Miswak (S. persica) in preventing dental caries was conducted in the year 2010 by Ezoddini-Ardakani, who found that Miswak users had DMFT score (0.52) less than the toothbrush users (1.18). However, in our study, these scores were found to be 2.49 and 2.94, respectively. The DMFT score of Ezoddini-Ardakani study was less as compared to the present study because of the dissimilarity in age group and monitoring system.[25] Elvin-Lewis et al. found that Miswak showed antibiotic effects by preventing carries formation as it contain intracellular polysaccharide product, fluoride which showed interaction with bacteria and prevented their attachment with tooth surface.[26]

In developing countries where the use of toothbrush and toothpaste is still considered expensive, Miswak is an inexpensive and natural alternative oral hygiene tool. However, it is suggested to conduct further research on a larger group of population including adults so that efficacy of Miswak can be completely established and justified for use as an oral hygiene aid, especially in the regions with limited resources.


  Conclusion Top


In the present study, regular fresh Miswak users showed decrease in PI, GI, OHI-S, and DMFT Index scores as compared to tooth brush and toothpaste users.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Albabtain R, Azeem M, Wondimu Z, Lindberg T, Borg-Karlson AK, Gustafsson A. Investigations of a possible chemical effect of Salvadora persica chewing sticks. Evid Based Complement Alternat Med 2017;2017:1-10.  Back to cited text no. 7
    
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9.
Kumar A. Nuh at Bottom of Niti Aayog's 101 Most Backward Districts. Available from: https://www.thehindu.com. [Last update on 2018 Mar 29].  Back to cited text no. 9
    
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Mehta PK. “Identifying backwardness of Mewat region in Haryana: A Block-Level Analysis,” NITI Aayog, Government of India, June 2015.  Back to cited text no. 10
    
11.
Ishtiaque M, Hurera A. Traditional education system: Its impact on socio-economic development in Mewat District, Haryana, India. In: Szymańska D, Biegańska J, editors. Bulletin of Geography. Socio-economic Series, No. 23. Toruń: Nicolaus Copernicus University Press; 2014. p. 73-86.  Back to cited text no. 11
    
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Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.  Back to cited text no. 13
    
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Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.  Back to cited text no. 15
    
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Hooda A, Rathee M, Singh J. Chewing sticks in the era of toothbrush: A Review. Internet J Fam Pract 2009;9:2.  Back to cited text no. 18
    
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Batwa M, Bergstorm J, Batwa S, Al-Otaibi MF. The effectiveness of chewing stick Miswak on plaque removal. Saudi Dent J 2006;18:125-33.  Back to cited text no. 19
    
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Goyal M, Sasmal D, Nagori BP. Salvadora persica (Meswak): Chewing stick for complete Oral Care. Int J Pharmacol 2011;7:440-5.  Back to cited text no. 20
    
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22.
Clerehugh V, Laryca U, Worthington HV. Periodontal condition and comparison of tooth cleaning using chewing sponge, chewing sticks and toothbrushes in 14-year old school children in Ghana. Community Dent Oral Epidemiol 1995;23:319-20.  Back to cited text no. 22
    
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Al lafi T, Ababneh H. The effect of the extract of the Miswak (chewing sticks) used in Jordan and the Middle East on oral bacteria. Int Dent J 1995;45:218-22.  Back to cited text no. 23
    
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Ezoddini-Ardakani F. Efficacy of Miswak (Salvadora persica) in preventing dental caries. Health 2010;2:499-503.  Back to cited text no. 25
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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