Abstract
BackgroundThe plant Salvadora persica (miswak) has a long history of use in oral hygiene. Associations between the use of Salvadora persica and decreased oral bacteria numbers and plaque scores have been reported. This systematic review and meta-analysis assessed the ability of Salvadora persica mouthrinses to reduce plaque/cariogenic bacteria, in comparison to that of chlorhexidine and/or placebo rinses.MethodsA comprehensive literature search for clinical trials reporting the use of Salvadora persica rinses as an antibacterial and/or antiplaque agent in comparison with chlorhexidine and/or placebo rinses was conducted, with no restriction to language. MEDLINE-PubMed, Cochrane Central Register of Controlled Trials, Wiley Online Library, ScienceDirect, and Google Scholar databases were searched to include all articles published up to December 2018. Based on inclusion/exclusion criteria, data were extracted from the identified reports by two independent reviewers. The primary and secondary outcomes measured from the eligible studies were mean plaque scores and mean cariogenic bacterial counts, respectively. Risk of bias of these studies was assessed. A statistical test of homogeneity was used to determine if the results of the separate studies could be combined. Based on the chi-square test, an inconsistency coefficient was computed (I2 statistic). Sensitivity analyses using subgroups and homogeneity evaluation were conducted.ResultsA total of 1135 potentially eligible articles were identified, of which 19 were eventually included in the qualitative analysis whereas 18 were included in the quantitative meta-analysis. The meta-analysis showed that Salvadora persica rinses exhibited strong antiplaque effects (P < 0.00001, MD: 0.46, and 95% CI: 0.29 to 0.63). In addition, it had statistically significant anti-streptococcal (P < 0.0001, MD: -1.42, and 95% CI: -2.08 to − 0.76) and anti-lactobacilli effects (P < 0.00001, MD: -1.12, and 95% CI: -1.45 to − 0.79) when compared to placebo. However, its effects were inferior compared to those by chlorhexidine rinse (P = 0.04, MD: 0.19, and 95% CI: 0.01 to 0.37). Subgroup analyses yielded results similar to those prior to subgrouping.ConclusionThe use of Salvadora persica extract was associated with a significant reduction in the plaque score and cariogenic bacterial count. Although, this reduction was lower than that achieved with the gold standard chlorhexidine mouthwash, Salvadora persica-containing rinse could be considered as a suitable oral hygiene alternative for use in individuals of all ages, socioeconomic backgrounds, and health conditions especially as a long-term measure due to its efficacy, safety, availability, cost-effectiveness, and ease of use.
Highlights
The plant Salvadora persica has a long history of use in oral hygiene
The results showed significant difference favoring the use of both 0.12 and 0.2% of chlorhexidine over Salvadora persica (P < 0.00001, mean differences (MD): 0.52, and 95% confidence interval (CI): 0.35 to 0.69; and P = 0.010, MD 0.12, and 95% CI: 0.03 to 0.21, respectively)
Addition, whenever possible, subgroup analysis was performed for factors considered to be sources of heterogeneity. This meta-analysis and systematic review indicated clear antiplaque and anticariogenic effects of Salvadora persica extracts with a recommendation evidence of Ia and class A strength [39]
Summary
The plant Salvadora persica (miswak) has a long history of use in oral hygiene. Associations between the use of Salvadora persica and decreased oral bacteria numbers and plaque scores have been reported. 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]. 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]
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