Miswak Chewing Sticks for Plaque and Gum Health

Table of Contents

1. Where the Miswak Comes From
2. The World Health Organization Statement as Reported
3. What the Wood Contains
4. How a Chewing Stick Is Used
5. Miswak Used Alone Compared With a Toothbrush
6. Miswak Added to a Toothbrush
7. Individual Trials in More Detail
8. Laboratory Studies on Oral Bacteria
9. Miswak Rinses and Miswak-Bristle Brushes
10. Gum Recession, Tooth Wear and Other Reported Harms
11. Other Chewing Sticks
12. What Is Not Known
13. Key Research Papers
14. Connections
15. Featured Videos

Where the Miswak Comes From

Salvadora persica is described in a 2010 review as a large, well-branched evergreen shrub or small tree of dry, arid regions; in India it is called kharijal. Two later reviews give its common names as arak in Arabic and peelu in Urdu, and both note that the frequent use of the stick as a toothbrush is highly recommended in the sayings of the Prophet Muhammad. A 2021 review adds that the plant has also been used for food, cosmetics, fuel and folk medicine, not only for teeth.

The custom is old. A 2015 review describes the miswak as a natural method of tooth cleaning used in many parts of the world for thousands of years, and a 2021 scoping review ties it to Muslim communities across the globe for more than 1,500 years. The authors of a survey in Sudan described the sticks as widely used in several African and Middle Eastern countries, and the authors of a 2011 trial wrote that the habit is still widespread in parts of Asia, Africa and the Middle East. A 1997 analysis called the stick inexpensive and customary, and noted that many people use it for religious reasons as well as for hygiene.

The miswak is not the only chewing stick. Twigs of neem (Azadirachta indica) are the other common source named in the clinical literature, and West African communities use the stems of several other plants (see Other Chewing Sticks).

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The World Health Organization Statement as Reported

The World Health Organization (WHO) statement on chewing sticks is often mentioned in the miswak literature. The original WHO document was not read for this page, so it is reported here only as two research papers describe it:

• A 2010 review of Salvadora persica states that chewing sticks have been used for centuries for tooth cleaning and are recommended by the World Health Organization in areas where their use is customary.
• The authors of a 2023 randomized trial describe the miswak as recommended by the World Health Organization as a customary oral hygiene tool.

Both descriptions tie the statement to places where the stick is already customary. Neither describes it as a statement that chewing sticks replace toothbrushes everywhere.

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What the Wood Contains

Several substances in the wood have been measured or named. Each is reported here exactly as the study abstract reports it.

• Fluoride. A 1997 laboratory analysis of Salvadora persica sticks found that the fluoride released from a stick soaked in water was negligible, below 0.07 micrograms per millilitre. About 39% of the total fluoride in the sticks was in a form that could leach out. The author concluded that the miswak is probably not particularly active against tooth decay through its fluoride content.
• Calcium and silica. The same analysis found that leached calcium averaged 582 micrograms per millilitre, 19.6% of the calcium in the sticks, and that the ash of the wood held a substantial amount of silica. The author's reading was that the stick works mainly as a brush that removes dental plaque and polishes the teeth.
• Benzyl isothiocyanate. A 2011 study used gas chromatography and mass spectrometry on oil distilled from the root and on vapours released by fresh root. It identified benzyl isothiocyanate, a sulfur-containing compound, as the main antibacterial component of both.
• Trimethylamine and other root contents. A 1994 laboratory study listed the root contents as including chlorine, trimethylamine, an alkaloid resin and sulfur compounds.
• Broader chemistry. A 2021 review reports that the plant's parts contain flavonoids, glycosides, sterols, terpenes, carbohydrates and alkaloids, along with organic sulfur-containing compounds and elemental sulfur.

The alkaloid salvadorine is not described on this page, because none of the abstracts read for it mentions that compound.

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How a Chewing Stick Is Used

The authors of the Sudanese survey describe miswak sticks as prepared from the roots or twigs of the plant, and a 2015 review adds the stem. The stick is used to brush the teeth, either as the only cleaning tool or together with an ordinary toothbrush. The research compares both patterns.

The weak point of the research is technique. The authors of a 2022 meta-analysis wrote that the trials they pooled did not report well how the stick was used to clean the teeth or how often. A 2021 scoping review concluded that the lack of standardised reporting on miswak use may explain why studies disagree about both its benefits and its harms. The authors of a 2023 trial noted that the stick in its natural form can be difficult to move around in some parts of the mouth. That difficulty led to the design of a toothbrush with bristles made from the plant (see Miswak Rinses and Miswak-Bristle Brushes).

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Miswak Used Alone Compared With a Toothbrush

Three systematic reviews have pooled the trials that compared a chewing stick with a toothbrush.

The 2022 meta-analysis. Researchers in Malaysia searched for randomized controlled trials in adults up to May 2022 and found 10 eligible articles, 9 of which could be combined. The chewing sticks came from Salvadora persica or neem. When the stick was used on its own, it lowered plaque and gingivitis scores to a level the authors called comparable to a toothbrush:

• Plaque: standardized mean difference 0.39 (95% confidence interval −0.05 to 0.83; p = 0.08).
• Gingivitis: standardized mean difference 0.13 (95% confidence interval −0.16 to 0.43; p = 0.37).

A standardized mean difference puts studies that used different scoring scales on one common footing. In both results the confidence interval crosses zero, which means the analysis found no statistically clear difference between the stick and the toothbrush. The certainty of evidence was higher for plaque on the lip-side surfaces of the front teeth.

The 2021 meta-analysis. A second team screened 1,736 titles and abstracts, kept eight articles, and pooled five. For plaque, the pooled standardized mean difference was −0.07 (95% confidence interval −0.60 to 0.45), again no clear difference from a toothbrush. For gum bleeding the pooled figure was −2.07 (95% confidence interval −4.05 to −0.10), which the authors read as a better anti-gingivitis effect for the stick. The heterogeneity (I², a measure of how much the individual studies disagreed with each other) was 80% for plaque and 82% for bleeding, so the trials varied a great deal.

The 2026 systematic review. A review of traditional oral hygiene practices searched up to April 2024 and included 31 studies of miswak, oil pulling and herbal products. It reported that miswak significantly reduced plaque and gum inflammation and performed comparably to or better than conventional toothbrushes. The authors added that methodological limitations and variation between studies call for cautious interpretation.

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Miswak Added to a Toothbrush

The clearest result in the pooled evidence concerns people who used a chewing stick in addition to a toothbrush. In the 2022 meta-analysis, this combined (adjunctive) use did significantly better than the toothbrush alone:

• Plaque: standardized mean difference 0.68 (95% confidence interval 0.14 to 1.22; p = 0.01).
• Gingivitis: standardized mean difference 0.66 (95% confidence interval 0.03 to 1.29; p = 0.04).

Unlike the stick-alone results, these confidence intervals stay above zero.

A small crossover trial published in 2021 tested the same idea directly. Twenty participants used a toothbrush plus a miswak for two weeks and a toothbrush alone for two weeks, in random order. While using both, the share of gum sites that bled on probing fell from 32.2% to 14.93%. While using the toothbrush alone it fell from 34.00% to 26.0% (p = 0.014 for the difference). Plaque, gingival and bleeding scores were also better in the combined group at the end of the second period. The counts of two bacteria in the plaque, Streptococcus mutans (linked to tooth decay) and Aggregatibacter actinomycetemcomitans (linked to gum disease), did not differ between the groups.

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Individual Trials in More Detail

Active and inactive miswak (2011). In a double-blind randomized trial, 68 people with gingivitis used only the miswak sticks they were given, either active or inactive, for three weeks. Active miswak significantly reduced dental plaque (p = 0.007). Active and inactive sticks did not differ in plaque between the teeth (approximal plaque) or in the bacteria living below the gum line. The authors concluded that the miswak's chemical effect was limited in this group, so the cleaning came mostly from the mechanical action. They described miswak as a hygiene method to be used together with tools that clean between the teeth.

Stick, miswak-bristle brush and standard toothbrush (2023). A single-blinded trial divided 78 participants among a Salvadora persica chewing stick, a toothbrush with Salvadora persica bristles and a standard toothbrush, each used in a standardized way for three weeks. All three groups improved significantly in plaque and gingivitis (p < 0.001). On the front teeth, the inflamed-gum score (Periodontal Inflamed Surface Area) improved more in the chewing-stick group: from 16.35 to 3.41, compared with 25.20 to 3.57 for the miswak-bristle brush and 26.54 to 6.17 for the standard toothbrush. The chewing-stick group started from a lower score than the other two. The authors concluded that, with correct technique, the stick and the miswak brush were as effective as a standard toothbrush.

Children with a high risk of decay (2020). A randomized trial in Jeddah, Saudi Arabia, enrolled 94 schoolchildren aged 8 to 9 with a high risk of cavities. One group received miswak sticks, the other fluoride toothpaste and soft toothbrushes. Plaque scores fell significantly in both groups (p = 0.007 and p = 0.001). In the miswak group, the number of children with abundant Streptococcus sanguinis in their saliva rose from zero to six after three months. The authors read this as a shift toward bacteria that carry less risk of causing decay. The trial measured bacteria and plaque, not new cavities.

Habitual users in Sudan (2000). This was a survey of existing habits, not a trial. It compared 109 men who habitually used miswak with 104 who used toothbrushes, aged 20 to 65. In the back of the mouth, miswak users had less tartar (dental calculus) and fewer deep gum pockets of 4 mm or more, but more attachment loss of 4 mm or more (gum tissue detached from the tooth). They also showed a tendency (p = 0.09) to less gum bleeding. These differences were not significant for the front teeth. The authors judged miswak comparable to or slightly better than the toothbrush in this population.

Dental patients (1990). A study of 236 patients compared miswak users, toothbrush users and people who used both. It concluded that miswak use may influence plaque build-up and gum health. A companion paper from the same group on gum recession is described under reported harms.

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Laboratory Studies on Oral Bacteria

The studies in this section were done on bacteria and fungi in laboratory dishes, not in people. Laboratory results show what a substance can do to germs in a dish. They do not show what happens in a living mouth.

• Pieces of stick against bacteria (2008, in the laboratory). Researchers tested small, weighed pieces of miswak (0.07 g and 0.14 g) without extracting them first. The pieces inhibited all the bacteria tested. The effect was strongest on Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans (both linked to gum disease) and on Haemophilus influenzae, weaker on Streptococcus mutans, and weakest on Lactobacillus acidophilus. Pieces hung above the dish, not touching it, still inhibited growth, which pointed to an active compound that evaporates from the wood.
• Benzyl isothiocyanate (2011, in the laboratory). Members of the same group later identified that compound as benzyl isothiocyanate. Root extracts and the pure compound killed oral bacteria involved in gum disease and other Gram-negative bacteria quickly and strongly. Gram-positive bacteria were mostly slowed rather than killed, or were not affected.
• Candida yeast (1994, in the laboratory). A water extract of miswak root at a concentration of 15% or more stopped the growth of an oral Candida albicans strain for up to 48 hours, without killing it. Candida is the yeast behind oral thrush.

The clinical studies give a more cautious picture. In the 2021 crossover trial, adding a miswak did not change the counts of Streptococcus mutans or Aggregatibacter actinomycetemcomitans in plaque. In the 2011 active-versus-inactive trial, the bacteria below the gum line did not differ between the two kinds of stick. A 2021 scoping review of 21 studies called the stick's effect on the bacteria below the gum line inconclusive. The strong antibacterial results in laboratory dishes have not been clearly matched in people's mouths.

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Miswak Rinses and Miswak-Bristle Brushes

Extracts of the plant are also made into mouthrinses. A 2019 meta-analysis included 19 clinical trials and combined 18 of them. Compared with a placebo rinse, Salvadora persica rinses showed a strong anti-plaque effect (mean difference 0.46; 95% confidence interval 0.29 to 0.63). They also lowered counts of streptococci (mean difference −1.42; 95% confidence interval −2.08 to −0.76) and lactobacilli (mean difference −1.12; 95% confidence interval −1.45 to −0.79), two groups of bacteria linked to tooth decay. Compared with chlorhexidine, the antiseptic rinse that dentists use as a reference, the miswak rinses did less well (mean difference 0.19; 95% confidence interval 0.01 to 0.37; p = 0.04). A separate page on mouthwash and blood pressure covers a separate question about antiseptic rinses.

A 2024 randomized comparison gave 30 adults aged 18 to 35 one of three brushes for eight weeks: a biodegradable brush with miswak bristles, a bamboo brush or a regular plastic toothbrush. All three groups had lower plaque scores at the end. Gum-bleeding sites fell by 16.68% with the miswak brush, 21.04% with the bamboo brush and 22.7% with the regular brush. When the used bristles were tested, the regular toothbrushes carried almost four times more microbial contamination than the bamboo brushes and more than twice as much as the miswak brushes.

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Gum Recession, Tooth Wear and Other Reported Harms

The research on harms comes mostly from surveys and case reports rather than trials. These are the findings:

• Gum recession. A 1991 study measured gum recession on the outer surfaces of the front and middle teeth in 238 dental patients. Miswak users had significantly more sites with recession than toothbrush users, and their recession was more severe (p ≤ 0.05).
• Attachment loss. In the 2000 Sudanese survey, miswak users had more attachment loss of 4 mm or more in the back teeth than toothbrush users, even though they had less tartar and fewer deep pockets.
• The pattern across studies. A 2021 scoping review screened 721 articles and analysed 21. It found that gum recession and attachment loss were much more commonly reported in miswak users. The authors attributed this to differences in the way people clean their teeth with the stick.
• Tooth wear. A 1991 study of 90 young Saudi adults (average age 22) found that wear on the biting surfaces of the teeth was linked to tooth grinding (bruxism), biting habits such as pen and nail biting, miswak use and a high intake of fruit juice. The authors suggested that the harsh desert environment may be the main abrasive factor in that group.
• A case of severe wear. A 2014 case report described tooth-surface loss affecting the patient's whole remaining set of teeth, on both the tongue side and the cheek side. Detailed questioning traced it to excessive use of a miswak stick.
• Enamel in the laboratory. A 2002 microscope study on extracted front teeth (20 enamel specimens) rubbed each surface for 60 seconds with light pressure. Miswak fibres and one nylon toothbrush showed less effect on enamel than a second nylon toothbrush. The authors concluded that the texture of the bristle ends plays a major role in how abrasive a cleaning tool is.
• Between the teeth. In the 2011 active-versus-inactive trial, neither kind of stick changed the plaque between the teeth any differently, and the authors described miswak as a method to be combined with between-teeth cleaning aids. None of the abstracts read for this page reports a chewing stick cleaning between the teeth as well as floss or interdental brushes.

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Other Chewing Sticks

The 2022 meta-analysis pooled trials of chewing sticks from both Salvadora persica and neem. The Neem for Dental Health page covers the neem twig separately.

In West Africa, the stems of many other plants serve as chewing sticks. A 2012 laboratory study made alcohol extracts from 7 plants commonly used this way. None of the extracts stopped the growth of Aggregatibacter actinomycetemcomitans. A highly toxic strain of this bacterium (the JP2 clone) is common in some African populations and strongly linked to gum attachment loss in teenagers. One extract, from guava (Psidium guajava), completely neutralized the toxin the bacterium makes, which otherwise kills human white blood cells in the dish and triggers inflammation. The other six extracts did not. This was laboratory work on cells, and its meaning for people who chew guava sticks has not been tested.

The 2026 systematic review grouped finger brushing, twigs and charcoal as indigenous methods. It found that they offer accessibility and sustainability but lack extensive clinical testing.

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What Is Not Known

• Technique and frequency. The trials pooled in the 2022 meta-analysis did not report well how the stick was used or how often. The best way to use it, and the way that causes the least gum recession, has not been established.
• Long-term results. The randomized trials described here lasted between two weeks and three months. Long-term outcomes such as tooth loss, cavities or gum disease getting worse have not been measured in randomized trials of the stick.
• Tooth decay. The children's trial measured plaque and bacteria, not cavities. The 1997 chemical analysis found that the stick releases very little fluoride. Whether a chewing stick protects against tooth decay without fluoride toothpaste is not established by the studies read for this page.
• Chemical versus mechanical effect. Laboratory dishes show strong antibacterial action, while the active-versus-inactive trial found the chemical effect limited in people. How much of the benefit comes from the wood's chemistry, rather than simple scrubbing, is still open.
• The size of the harm. The links to gum recession and attachment loss come from surveys and case reports. The 2021 scoping review called the evidence on adverse effects inconclusive overall.
• Mixed study quality. The two meta-analyses that compared the stick alone with a toothbrush found large differences between individual studies, and the 2026 review called for cautious interpretation.

Decisions about dental care belong with a dentist or other clinician who knows the person's teeth and gums. Related conditions are covered on the Periodontitis and Gum Disease pages.

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Key Research Papers

1. Ramli H, Nor Aripin KN, Mohd Said S, Mohamad Hanafiah R, Mohd Dom TN. The effectiveness of miswak (Salvadora persica L. and Azadirachta indica A.Juss.) practices in reducing plaque and gingivitis among adults: A systematic review and meta-analysis. J Ethnopharmacol. 2022;298:115598. PubMed PMID: 35944735
2. Adam FA, Mohd N, Rani H, Baharin B, Mohd Yusof MYP. Salvadora persica L. chewing stick and standard toothbrush as anti-plaque and anti-gingivitis tool: A systematic review and meta-analysis. J Ethnopharmacol. 2021;274:113882. PubMed PMID: 33513418
3. Shahzad M, Ahmad HA, Ambadi S, Peterson S, Yang I. Traditional Oral Hygiene Practices and Their Effectiveness: A Systematic Review of the Evidence. Oral Health Prev Dent. 2026;24:107-118. PubMed PMID: 41670379
4. Ramli H, Mohd-Dom TN, Mohd-Said S. Clinical benefits and adverse effects of siwak (S. persica) use on periodontal health: a scoping review of literature. BMC Oral Health. 2021;21(1):618. PubMed PMID: 34861857
5. Azizan NF, Mohd N, Nik Azis NM, Baharin B. Effectiveness of Salvadora persica toothbrush and Salvadora persica chewing stick in plaque and gingivitis control: a randomized control trial. BMC Complement Med Ther. 2023;23(1):456. PubMed PMID: 38098022
6. Rifaey N, AlAdwani M, Karched M, Baskaradoss JK. A clinical investigation into the efficacy of miswak chewing sticks as an oral hygiene aid: A crossover randomized trial. Int J Dent Hyg. 2021;19(2):223-230. PubMed PMID: 33258168
7. Sofrata A, Brito F, Al-Otaibi M, Gustafsson A. Short term clinical effect of active and inactive Salvadora persica miswak on dental plaque and gingivitis. J Ethnopharmacol. 2011;137(3):1130-4. PubMed PMID: 21798329
8. Sabbagh HJ, AlGhamdi KS, Mujalled HT, Bagher SM. The effect of brushing with Salvadora persica (miswak) sticks on salivary Streptococcus mutans and plaque levels in children: a clinical trial. BMC Complement Med Ther. 2020;20(1):53. PubMed PMID: 32054468
9. Darout IA, Albandar JM, Skaug N. Periodontal status of adult Sudanese habitual users of miswak chewing sticks or toothbrushes. Acta Odontol Scand. 2000;58(1):25-30. PubMed PMID: 10809396
10. Eid MA, al-Shammery AR, Selim HA. The relationship between chewing sticks (Miswak) and periodontal health. 2. Relationship to plaque, gingivitis, pocket depth, and attachment loss. Quintessence Int. 1990;21(12):1019-22. PubMed PMID: 2082419
11. Eid MA, Selim HA, al-Shammery AR. The relationship between chewing sticks (Miswak) and periodontal health. 3. Relationship to gingival recession. Quintessence Int. 1991;22(1):61-4. PubMed PMID: 1784721
12. Johansson A, Fareed K, Omar R. Analysis of possible factors influencing the occurrence of occlusal tooth wear in a young Saudi population. Acta Odontol Scand. 1991;49(3):139-45. PubMed PMID: 1882647
13. Karia R, Kelleher MG. Bizarre tooth surface loss and the Miswak stick. Dent Update. 2014;41(4):355-6, 359-60, 363-4. PubMed PMID: 24930258
14. Almas K, Atassi F. The effect of miswak and tooth brush filaments end-surface texture on enamel. A SEM pilot study. Indian J Dent Res. 2002;13(1):5-10. PubMed PMID: 12420561
15. Hattab FN. Meswak: the natural toothbrush. J Clin Dent. 1997;8(5):125-9. PubMed PMID: 9487831
16. Sofrata A, Santangelo EM, Azeem M, Borg-Karlson AK, Gustafsson A, Pütsep K. Benzyl isothiocyanate, a major component from the roots of Salvadora persica is highly active against Gram-negative bacteria. PLoS One. 2011;6(8):e23045. PubMed PMID: 21829688
17. Sofrata AH, Claesson RL, Lingström PK, Gustafsson AK. Strong antibacterial effect of miswak against oral microorganisms associated with periodontitis and caries. J Periodontol. 2008;79(8):1474-9. PubMed PMID: 18672998
18. al-Bagieh NH, Idowu A, Salako NO. Effect of aqueous extract of miswak on the in vitro growth of Candida albicans. Microbios. 1994;80(323):107-13. PubMed PMID: 7898373
19. Kwamin F, Gref R, Haubek D, Johansson A. Interactions of extracts from selected chewing stick sources with Aggregatibacter actinomycetemcomitans. BMC Res Notes. 2012;5:203. PubMed PMID: 22537711
20. Jassoma E, Baeesa L, Sabbagh H. The antiplaque/anticariogenic efficacy of Salvadora persica (Miswak) mouthrinse in comparison to that of chlorhexidine: a systematic review and meta-analysis. BMC Oral Health. 2019;19(1):64. PubMed PMID: 31029127
21. Fageeh HN, Mansoor MA, Fageeh HI, Abdul HN, Mawkili LK, Faris SM, Zubayni BM, Alfardan ZA, Zaidan MS, Patil S, Bhati AK. Plaque Removal and Gingival Bleeding Using Biodegradable Toothbrushes: Salvadora persica, Bamboo, and Nylon: A Comparative Study. Med Sci Monit. 2024;30:e944469. PubMed PMID: 39511862
22. Khatak M, Khatak S, Siddqui AA, Vasudeva N, Aggarwal A, Aggarwal P. Salvadora persica. Pharmacogn Rev. 2010;4(8):209-14. PubMed PMID: 22228963
23. Aumeeruddy MZ, Zengin G, Mahomoodally MF. A review of the traditional and modern uses of Salvadora persica L. (Miswak): Toothbrush tree of Prophet Muhammad. J Ethnopharmacol. 2018;213:409-444. PubMed PMID: 29196134
24. Farag M, Abdel-Mageed WM, El Gamal AA, Basudan OA. Salvadora persica L.: Toothbrush tree with health benefits and industrial applications - An updated evidence-based review. Saudi Pharm J. 2021;29(7):751-763. PubMed PMID: 34400870
25. Haque MM, Alsareii SA. A review of the therapeutic effects of using miswak (Salvadora Persica) on oral health. Saudi Med J. 2015;36(5):530-43. PubMed PMID: 25935172

PubMed Topic Searches

1. PubMed: miswak, plaque and gingivitis in randomized trials
2. PubMed: Salvadora persica and benzyl isothiocyanate
3. PubMed: chewing sticks and gum recession
4. PubMed: chewing sticks and oral hygiene in Africa

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Connections

• Dentistry — the parent section
• Gingivitis — the gum inflammation these trials measured
• The Oral Microbiome — the bacteria the laboratory studies tested
• Neem for Dental Health — the other common chewing-stick tree
• Oil Pulling — another traditional practice reviewed alongside miswak
• Periodontitis — the attachment loss described under reported harms
• Tooth Decay — the question of fluoride and cavities
• Myrrh for Oral Health — another traditional oral-care plant

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