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


With the advancement in the field of dentistry, the focus is leaning more towards preventive measures that target the causative factors of oral diseases. The control of plaque accumulation is, therefore, of primary importance specifically using natural antimicrobial mouthrinses to complement and synergistically aid mechanical plaque removal. Since the most commonly used herbal plant is Salvadora persica, the emphasis of the current study was to investigate its efficacy in comparison to chlorhexidine.

The present meta-analysis results indicate that extracts of Salvadora persicasignificantly inhibited plaque formation and yielded mean plaque index scores lower than that of placebo. However, its effectiveness is inferior compared to either 0.12% or 0.2% of chlorhexidine. Such findings are in accordance with several other studies.[28–30] There is no evidence that one concentration of chlorhexidine is more effective than the other in reducing gingivitis and plaque.[42] This could explain why Salvadora persica rinses are less effective than either concentration of chlorhexidine. In addition, different concentrations of chlorhexidine can achieve similar effects when the correct volume is used. Larger volumes of a low concentration (0.12%) can be just as effective as smaller volumes of a high concentration (0.2%) of chlorhexidine.[43] The antiplaque effects of chlorhexidine and Salvadora persica were not statistically significant when mechanical plaque measures were used. Therefore, in order to gain maximum benefits of using Salvadora persica mouthrinses, it should be supplemented with regular mechanical plaque control such as brushing.

Studies that used a cross-over design were included in the meta-analysis, in which each of its trial periods was added to the quantitative analysis as an individual study. The established substantivity effect of chlorhexidine has been reported to be 12–14 h[19] whereas, Salvadora persica extracts had a residual effect lasting to 3 h post-rinsing.[31] Since the wash-out periods of the studies were no less than 2 days, the wash-out phase between the trial periods was considered sufficient to rule out a carry-over effect of the assigned mouthwashes.

Once long-term use of mouthrinse is needed, chlorhexidine substitutes should be considered due to the adverse effects that have been associated with its long-term use such as discoloration of teeth and some restorations, alteration in taste sensation,[38] stomatitis, ulceration/erosions,[39] sloughing off of the oral mucosa, supragingival calculus formation,[40] and sensation of tongue burning,[41] amongst others. For this reason, not only did the Food and Drug Administration of the USA recommend limiting the use of chlorhexidine rinses to 6 months ( but also the World Health Organization (WHO) advised to investigate the possible use of natural plants and herb extracts.[13,28] Since the result of subgrouping according to duration indicate similar antiplaque properties of Salvadora persica-containing rinses and chlorhexidine when used for a period exceeding 3 weeks, Salvadora persica rinses can be considered as a viable alternative in refractory cases and as a daily rinse when desired. Additionally, Salvadora persica mouthwashes are suitable for children and individuals with special needs who run the risk of accidentally ingesting chemically formulated mouthrinse solution or fluoridated toothpaste. It is also an affordable choice for patients of low socio-economic status. Collectively, Salvadora persicarinses is an option that can improve the oral health-related quality of life of individuals of different ages, socioeconomic background, and medical conditions.