Introduction

Bacterial plaque is the primary etiology but not solely responsible for the initiation and progression of periodontal diseases.  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.¹

Miswak (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 in the Islamic empires.  It is believed that this precursor to the modern day toothbrush was used in Europe until about 300 years ago.²  Today, miswak is being used in Africa, South America, Asia, the Middle East including Saudi Arabia, and throughout the Islamic countries.³ It has different names in different societies, for instance, miswak, siwak, or arak are used in the Middle East; miswak in Tanzania; datan and miswak in India and Pakistan.¹  The use of the chewing stick is deeply rooted in many cultures.  In the Middle East, the most common source of chewing sticks is the Arak (Salvadora persica) tree.  In West Africa the lime tree (citrus aurantafolia) and the orange tree (Citrus sinesis) are used.  The roots of Senna (Cassia vinnea) were used by black Americans and those of African laburnum (Cassia sieberianba) were used in Sierra Leone.  Neem (Azadirachta indica) is widely used in the Indian subcontinent.⁴

Many studies have demonstrated the antibacterial, anti-caries, anti-periopathic, and anti-fungal properties of aqueous extracts of various chewing sticks.^5,6,7,8  There are only three studies comparing the antimicrobial effects due to the age of the miswak.^9,10,11  The relative accessibility and popularity of chewing sticks in the Middle East and Africa as an oral hygiene tool make it a cost effective agent for plaque control in such communities.^12,13

Chlorhexidine gluconate (CHX), a cationic bisbiguanide, is the best-known and most widely used member of the bisbiguanide class.  The efficacy of CHX in significantly reducing plaque and gingivitis (compared with placebos) when used twice daily as a supplement to tooth brushing is well established.  The mechanism of action of CHX is due mainly to the rupture of the bacterial cell wall and precipitation of the cytoplasmic content.

Early studies used 10 ml of a 0.2% solution for a total of 20 mg CHX per use.  There are studies supporting the effectiveness of 0.12% CHX using 15 ml of this solution.^15,16,17  The total amount of CHX per use was essentially the same, and the clinical findings with the two formulations were similar: plaque reductions in the 50-55% range and reduction in gingivitis of about 45%.  The major side effects of CHX are a brown staining of the teeth and tongue, formation of supragingival calculus, taste alteration, and oral desquamation in children.^18,19,16,20  Allergic reactions have been reported in some patients, especially Asians.²¹

When CHX is used following brushing, one should allow at least 30 minutes after tooth brushing and before rinsing with this chemical because of an interaction (and possible activation) between various positively charged dentifrice detergents and the cationic CHX.²²  Also, an antagonistic interaction can occur with the anionic fluoride ion in mouthrinses, toothpastes, and stannous fluoride products.  The 30-minute interval is intended to minimize the diminution in activity of CHX.²¹

To date, there are no studies comparing miswak extract and CHX solution on the dentinal root surface.  The aim of this study was to compare the dentin surface changes after the application of 50% aqueous extract of miswak (Salvadora persica) and 0.2% CHX on etched and unetched healthy and periodontally involved dentin.

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Citation Number: Vol. 3, No. 3, Page 028