Ethnopharmacological relevance: Salvadora persica L. and Azadirachtaindica A.Juss. are listed within the most common sources of miswak or chewing stick that widely used among Western Asia and Muslim populations worldwide. Miswak use in conjunction with toothbrush (adjunctive) has become apparent among the adults. Furthermore, miswak has been reported to have mechanical and pharmacological activities, and benefits to the oral health, by many studies. Aim of the study: To assess the effectiveness of miswak in maintaining periodontal health among adults. Materials and methods: We searched for randomised controlled trials (RCTs) investigating the effect of miswak published in PubMed, EBSCOHOST (Dentistry & Oral Sciences), SCOPUS, and Cochrane Database for Systematic Review (CDSR) from inception to May 08, 2022. The primary outcomes of interest were changes in the periodontal health measured with plaque and gingivitis scores as well as subgingival bacteria load. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach while the estimates of effect were pooled using a random-effects model. Results: Ten eligible articles were identified, of which 9 could be analysed quantitatively. The remaining report was included as part of the qualitative analysis. The meta-analysis showed that miswak was comparable with the toothbrush in reducing the mean plaque score (p= 0.08, SMD: 0.39, and 95% CI: −0.05 to 0.83) and mean gingivitis score (p= 0.37, SMD: 0.13, and 95% CI: −0.16 to 0.43). Even higher certainty of evidence for the effect of miswak on mean plaque reduction on labial surface of anterior teeth. However, the adjunctive effect of miswak was significantly more superior for reducing plaque (p= 0.01, SMD: 0.68, and 95% CI: 0.14 to 1.22) and gingivitis score (p= 0.04, SMD: 0.66, and 95% CI: 0.03 to 1.29). Conclusions: Miswak effectively reduced plaque and gingivitis scores to a level comparable to toothbrush when used exclusively. Adjunctive miswak use was particularly effective in improving periodontal health. However, the included studies inadequately reported on the method of toothbrushing using miswak and the frequency of miswak use. Therefore, further clinical studies are recommended to explore on the advantages and proper method of miswak practice for optima outcome and safety.

Islamic religion emphasised siwak (chewing stick) use as tooth and mouth cleaning tool, but the practice that modelled towards the Prophet’s Muhammad, peace be upon him (PBUH) behaviour is unclear. A study was conducted via individual semi-structured interviews, aimed to explore and map various aspects of the siwak practice from the perspective of contemporary Muslim scholars. These experts concurred that current siwak users vary in their observance towards the purpose, handling and timing of the siwak routine. It is a concern that deviations from the Prophet’s actual practices may limit the advantages of siwak, cause adverse effects on oral tissues and falsely portray siwak as an inferior option among modern communities. Findings from this study are derived from a triangulation of literatures and modern-day scholars’ interpretation which may be used as a basis for developing future guidelines on effective and safe siwak practice that is well-fitted to contemporary modern lifestyle.

Oral hygiene care and practice, siwak, which adopts Prophet Muhammad’s (Peace be upon Him, hereafter, PBUH) sunnah, remains unclear. As such, this study aims to explore and critically appraise the Prophetic practice of siwak according to Islamic literature, and in the light of current clinical evidence to clarify siwak as the oral hygiene practice prescribed by the Prophet (PBUH). Semi-structured one-to-one interviews was conducted among local contemporary Islamic scholars. The questions prepared were based on literature review and focused on toothcleaning practices of the Prophet (PBUH) as well as how the siwak was prepared and kept, as reported in documented narrations. Interview transcripts were analysed using thematic approach while content analysis of the referred narrations of hadith was made to provide a triangulation of the overall siwak use framework. The investigation revealed that horizontal tooth-brushing was highly recommended, and that al-Arak tree sticks are preferred to be 1) specifically prepared, 2) held steadily in the right hand, 3) used between two to five minutes depending on the goal, and 4) hygienically stored. It was also found that improper siwak practice may significantly suppress the clinical advantages. Thus, these findings substantiate future evidence-based guidelines on optimal oral hygiene care for siwak user based on authentic Islamic source.