The Antiplaque/Anticariogenic Efficacy of Salvadora Persica (Miswak) Mouthrinse in Comparison to That of Chlorhexidine

A Systematic Review and Meta-analysis

Elaf Jassoma; Lina Baeesa; Heba Sabbagh


BMC Oral Health. 2019;19(64) 

In This Article


Dental plaque is considered the major etiological factor for the initiation and progression of the two predominant oral diseases such as dental caries and periodontal disease. These diseases are preventable by regular personal and professional mechanical plaque debridement measures.[1]

Salvadora persica, also known as miswak or siwak, comes from Arak or the toothbrush tree that grows in west India and Africa.[2] Miswak sticks gained its popularity in Dentistry in 5000 B.C., and were originally used by Babylonians and later used widely throughout other nations.[3] Historically, it has been used in various forms, such as sticks, extract, and toothpaste, for its potent properties. It is still being used globally; in many Muslim countries, it is used in a religious ritual,[4] and in developing countries, it is extensively used due to its availability and low cost or as a traditional practice.[5] The effectiveness of this medicinal plant is related to the presence of benzyl isothiocyanate, which is a major component inhibiting acid production and growth of Streptococcus mutans.[6] It also has virucidal activity against Herpes simplex virus and is fungistatic against Candida albicans.[7]Salvadora persica has exhibited the ability to inhibit the adherence of Streptococcus mutans to human buccal epithelial cells[8] and has been most sensitive against such bacteria in comparison with other types of bacteria.[9] The inclusion of sulfur and alkaloids (saladorine) has an antibacterial effect and improves gingival health.[10] In addition, tannis forms a protective layer on the enamel against caries, while chloride protects against calculus formation.[10] The plant contains other chemical components, such as tri-methyamin, salvadrin, fluoride, silica, mustard, vitamin C, calcium, and phosphorous.[11] Besides having an antimicrobial effect, Salvadora persica has mild laxative, diuretic,[10] anti-pyretic, anti-inflammatory, astringent, and analgesic effects.[12] The World Health Organization (WHO) has recommended the use of Salvadora persica sticks as an effective oral health tool attributed to the mechanical action of the soft wood fibers and the therapeutic action of its chemical constituents.[13] The first reference to mouthrinsing is credited to Chinese medicine, practiced as far back as 2700 B.C. as a treatment for gingival diseases.[13] In more modern times, mouthrinses containing active therapeutic agents have been advocated as vehicles to deliver chemical agents and used as a daily oral health care measure to control dental plaque.[14] Mouthrinses have been shown to be the most feasible, safe, and effective means for achieving an acceptable antimicrobial ecosystem, in conjunction with daily mechanical methods.[15]

Chlorhexidine digluconate oral rinse is one of the most common antimicrobials prescribed in the dental field.[16] It has both bacteriostatic and bacteriocidal effects[16] against a variety of micro-organisms including gram-positive and gram-negative aerobic and anaerobic bacteria[17] as well as fungi including yeasts.[18] Chlorhexidine is regarded as the gold standard due to its substantivity effects and high antimicrobial activity. Substantivity refers to its ability to be continually released into the oral cavity and adhere persistently to oral tissues.[19]

It has been demonstrated that Salvadora persica-containing rinses inhibited the growth of cariogenic bacteria.[9,20,21] In this regard, Al-Dabbagh et al. (2016) compared the antimicrobial effects of miswak mouthwash, miswak toothpaste, and ordinary toothpaste, and found that the miswak products, especially mouthwashes, were more effective in reducing the growth of cariogenic bacteria than that by ordinary toothpaste.[22] Numerous studies have established that Salvadora persica extracts are effective in reducing plaque accumulation. However, in terms of which antimicrobial agent being regarded as more effective, some studies indicated that Salvadora persicaand chlorhexidine rinses showed similar antiplaque effects,[23–27] while others favored the use of chlorhexidine.[28–34] On the other hand, interestingly, two studies had reported that the mean plaque index of Salvadora persica was significantly lower than that observed with chlorhexidine.[35,36]

Previous studies showed inconsistent and dissimilar findings as to which antimicrobial mouthwash is more effective in reducing plaque scores. Further, no meta-analysis has been previously performed on the effects of Salvadora persica versus chlorhexidine. Gaining more insight into the properties of Salvadora persica may pave the way for its use as an alternative for plaque control and caries prevention, particularly in communities with low socioeconomic status, where it is more conveniently and easily obtained. Therefore, the aim of this systematic review and meta-analysis was to assess the use of Salvadora persica-containing mouthrinses among healthy individuals in comparison to the gold standard (chlorhexidine gluconate mouthrinse) and/or placebo rinses in terms of decreasing both plaque and cariogenic microbial load.