We all may appreciate the difference between the positive impact made by a smile of pearly-white teeth and the repulsion triggered by yellowed and blackened rotten teeth, but the health issues run much deeper: as our medical knowledge grows, we are discovering that many diseases originate from dental cavities where microbes teem and nest, causing inflammations in many organs and tissues, most notably in the heart, kidneys, and joints.

The use of herbal sticks for cleaning teeth dates back to around 3500 BC, the time of the Babylonians. In several works of Ancient Greek and Roman literature, chewable sticks to aid dental and mouth hygiene are mentioned [1]. Hippocrates (355 BC) advises rubbing a ball of cotton wrapped around a stick and dipped in honey on teeth, to maintain dental hygiene, whereas Romans used pastes obtained from gumwood [2]. Dental hygiene is coming throughout history.

Arabs utilized the miswak for many years [3]. The Japanese used wooden sticks called “koyoji” and Jews used wooden sticks called “kesam.” In the 1920s, in some rural areas across the United States, a stick of blood-twig was used for rubbing on the teeth [3]. And according to a Chinese encyclopedia published in the seventeenth century, the first-ever toothbrush was made in China, in 1498.

Prophet Muhammad, peace be upon him, warned those of his Companions who visited him with bad teeth about the need for dental hygiene (Ahmad ibn Hanbal, Musnad 1/214):

“I oft reiterated my recommendations to you about the miswak.” (Bukhari, Jum’a 8; Nasai, Taharah 5; Ahmad ibn Hanbal, Musnad 3/143; Darimi, Wudhu’ 18)

“(The Archangel) Gabriel counseled me to use the miswak so much that I thought a verse might be revealed about the miswak to decree its use as obligatory for all.” (Ibn Majah)

Obviously he assigned the utmost importance to dental hygiene. It should be noted here that the Araq tree (Salvadora persica) from which the miswaq is obtained has features that are not present in other trees, and the Prophet particularly specified using the roots of that tree as the miswak.

Research has been conducted to discover the scientific and modern medicinal effects of the miswak, which has been used by Muslims in adherence to the Prophet’s practice. In 2010, a Ph.D. study at Karolinka Institute, Sweden, provided a significant message about its effectiveness [4] (Picture 1).

The Araq tree, which is used as the miswak across a geography spanning from Africa to the far east, is a short tree or bush with a slanted trunk, and it is easy to chew its spongy roots, parts of which generally expand and soften when dipped in water (Picture 2).

The roots of the Araq tree are washed to remove the soil, and approximately 1 cm from the tip of the root stick is peeled to be used as the toothbrush. The stick is pummeled or chewed until the fibers become softer (Picture 3). Fresh and soft miswak are preferable: If the miswak is dry, it is advised to dip it in freshwater for 24 hours before use. It is better to peel frequently, so the tip is renewed. The most practical advice is to use the peeled tip until it loses its tang and fragrance, because the fragrant components indicate the beneficial effect of the miswak. According to a study, using the same tip for more than 24 hours lowers its cytotoxic ability to get rid of microbes.

The practice of using miswak in the Muslim World is widespread in Asia, Africa, and some regions in the Middle East. As many Muslims opt for miswak use to maintain a practice of the Prophet, the World Health Organization (WHO) also advises and encourages the use of miswak as an effective dental hygiene tool along with the conventional toothbrush. The miswak is easy to use and effective; it also has chemical properties that help control dental plaque. Based on the basic information we have about the miswak, we can easily say that deeper research is needed for its different components, like its fibers, essence, and essential oils.

Antibacterial effects of the miswak

The antibacterial activities of the essences obtained by crushing different roots of the miswak have been analyzed by microbiological techniques. It was discovered that the miswak essence has a very strong antibacterial effect, predominantly against Gram-negative bacteria, including mouth-cavity microbes like Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans. Two additional studies conducted on five different types of bacteria i.e. Streptococcus mutans, S. faecalis, S. aureus, Haemophilus influenzae, Salmonella enterica, and Candida albicans, and a type of fungus [5, 6, 7, 8] revealed that the miswak essence stops the reproduction of micro-organisms, has a lower effect on Lactobacillus acidophilus, is active against Herpes simplex virus which causes blistered lesions, and suppresses acid production.

The essential oil obtained from miswak essence includes 70% benzyl isothiocyanate, 9.4% limonene, 8.7% I-pinene and 2.55% flavonoid. As the miswak’s main antibacterial component, benzyl isothiocyanate kills bacteria by forming protrusions on their cell membranes. The volatile nature of this substance may open doors to new practices requiring antibacterial treatment. It has been proven that fresh miswak is effective at preventing the formation of dental plaque and gum inflammation, and it has also been acknowledged that it may play a potential role in preventing periodontal diseases.

The miswak essence hinders acidic (pH) conditions causing tartar and dental plaque, leads to a long-term increase of pH in the mouth, stimulates saliva flow in the parotid glands (located in front of both ears), and prevents tartar formation.

It is necessary to conduct further lab and clinical research to augment the positive results shown so far about the effects of the miswak against the inflammation of the palate and gums, as well as its antiviral and antifungal activities. Some research has additionally suggested that the miswak has antioxidant, analgesic, and anti-inflammatory effects. It is claimed that potassium chloride, salvadourea (a urea derivative), alkaloids, and oleic and linoleic acids in the miswak sap increase the viscosity of saliva, helps it to soak into hard-to-reach corners in the mouth, and contributes to overall dental hygiene. It is reported that a substance named Xylitol in the miswak essence suppresses acid production and the reproduction of mutant streptococci [9, 10].

An interesting substance in the miswak oil

Benzyl-isothiocyanates are effective molecules in the defense systems of several plants such as cabbage, watercress, and broccoli. Secreted after damage to plant tissues, benzyl isothiocyanate forms a protective antibacterial layer on the damaged part of the plant. While dental plaque and tartar are mechanically removed by rubbing the miswak on teeth, this action also helps the substance secreted from the miswak reach deeper parts of the oral cavity. It is especially proven that benzyl isothiocyanates are strongly effective as bactericide on Gram-negative bacteria and have minimal effect on Gram-positives.

Lab tests conducted on animals indicate that these components also have anti-carcinogenic activity, and people who get isothiocyanates by nutrition have a lower risk of cancer. It is fascinating that the miswak, too, has the same substance.

While introducing a new set of ethical principles, Prophet Muhammad, peace be upon him, revoked some customs and habits inherent to the pagan culture before Islam (Age of Ignorance) and kept others. Using miswak was a practice among the Arabs in the region; the Prophet encouraged its use and emphasized its benefits. Eventually, Muslims have adopted it as not only a habitual practice, but also as a healthy spiritual activity and are keeping the memory of the Prophet alive.

References

1. Wu, C.D., Darout, I.A. and Skaug, N. (2001): Chewing sticks: timeless natural toothbrushes for oral cleansing. Journal of Periodontal Research 36, 275-84.
2. Hyson, J.M., Jr. (2003): History of the toothbrush. Journal of the History of Dentistry 51, 73-80.
3. Bos, G. (1993): The Miswak, an aspect of dental care in Islam. Medical History, 37, 68-79.
4. Sofrata, A. H. (2010): Salvadora persica (Miswak). An effective way of killing oral pathogens. Thesis for doctoral degree (Ph.D.). From the Division of Periodontology, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden.
5. Al-Lafi, T. and Ababneh, H. (1995): The effect of the extract of the Miswak (chewing sticks) used in Jordan and the Middle East on oral bacteria. International Dental Journal, 45, 218-222.
6. Almas, K., Al-Bagieh, N. And Akpata, E. (1997): In vitro antimicrobial effect of extracts of freshly cut and 1-month-old miswak (chewing sticks). Biomedical Letters, 56, 145-149.
7. Almas, K. (1999): The antimicrobial effects of extracts of Azadirachta indica (Neem) and Salvadore persica (Arak) chewing sticks. Indian Journal of Dental Research, 10, 23-26.
8. Almas, K. (2001): The antimicrobial effects of seven different types of Asian chewing sticks. Odontostomatolgie Tropicale, 24, 17-20.
9. Kakuta, H., Iwami, Y., Mayanagi, H. and Takahashi, N. (2003): Xylitol inhibition of acid production and growth of mutans Streptococci in the presence of various dietary sugars under strictly anaerobic conditions. Caries Research, 37, 404-409.
10. Miyasawa, H., Iwami, Y., Mayanagi, H. and Takahashi, N. (2003): Xylitol inhibition of anaerobic acid production by Streptococcus mutans at various pH levels. Oral Microbiology and Immunology, 18, 215-219.

A tooth is created with four main layers: enamel, dentine, pulp chamber and cementum (the thin layer where the tooth attaches to the jaw). The hardest tissue of the body, the enamel is the protective, outermost layer of the tooth. Since it does not contain any living matter such as veins or nerves, we are not affected by hot, cold, sweet or sour stimulants via the tooth. If the Owner of an Everlasting Might and Compassion had not created the enamel of the tooth, which He placed at the entrance of the digestion room in the human palace, as he did, the variety of food we would eat would be very limited. Even slight contact with air would cause us great discomfort, and speaking or even opening our mouth would give us great pain.

The dentine, the hard layer just below the enamel, is a tissue sensitive to hot, cold, sweet and sour stimulants. As a reflection of the Creator’s Affection for His Creation, the dentine tissue is repaired when necessary by the restoring cells that he placed there.

The most inner part of the tooth is the organic part called the pulp chamber, which is filled with veins to protect the tooth from decay and feed it with necessary nutrients. Nerve cells in the soft pulp tissue play the greatest role in sensing the stimulants of heat, cold and pressure.

If we examine the anatomical structure of a tooth in detail, only then can we clearly see how it is perfectly equipped with wondrous and intelligent structures. However, are we really conscious of the duties of our teeth, placed in our jaws like pearls, in protecting our general health?

One of the main entrances to our bodies for microbes is the mouth. Because of this, maintaining healthy teeth and a clean mouth is very important in preventing diseases and maintaining a healthy life. When the mouth is not kept hygienic, a suitable environment is formed for the emergence of even very feeble microbes. In an unhygienic mouth, food residue accumulates and forms a bacterial plaque on the teeth. Using the glucose in this plaque, these bacteria produce acids. It is this acid that causes tooth decay and gum diseases.

Are we adequately informed about dental health and hygiene, a very important concept in preventive medicine? That Prophet Muhammad, peace and blessings be upon him, emphasized the importance of cleaning the mouth and teeth whenever one does his/her ablution and after every meal, grants a profundity of worship to God by keeping our teeth healthy.

Importance of Milk Teeth

Milk teeth start to appear in a baby’s gums after about the sixth month of age. The appearance of milk teeth differs from baby to baby according to factors like genetics, birth weight, socio-economics and nourishment level. By cutting a group of teeth every six months, all of the milk teeth appear by the age of 30 months. Between the 6th and 12th months the first incisors, between the 12th and 18th months the first molars, between the 18th and 24th months the first canines and between the 24th and 30th months the second molars erupt. Since the dentine tissue is not fully developed in this period, milk teeth are not at all resistant to decay. Since the pulp chamber is very soft and packed with blood vessels, it is very vulnerable to decay. Sucking fingers, excessive use of a pacifier, sucking or biting lips and gritting teeth all negatively affect the development of milk teeth. During the eruption of milk teeth, babies may have discomfort like itching gums, a need to bite something, excessive saliva secretion, watery eyes, lack of appetite, loss of weight, fever, bad temper and crying. In order to relieve these discomforts, the baby may be given something to chew on to relieve the pressure on the gums, and some cold drinks and cold food to soothe the pain.

As nothing in creation occurs devoid of wisdom, one may ask “What benefits are there after the discomforts when a baby’s milk teeth are coming in?” In other words, why are the milk teeth so important? Most of us do not give them enough care, because we think of them as temporary. The space occupied by the milk teeth is saved for the permanent teeth, and when the permanent tooth starts erupting, the milk tooth guides it into its proper place. If milk teeth are extracted too early, this alignment and spacing function of milk teeth cannot be performed, hence the permanent teeth may erupt in an improper way. Moreover, milk teeth provide proper chewing and correct vocal speech for the baby. When a baby develops unhealthy milk teeth, this may cause problems like poor facial appearance, and therefore some psychological disorders in the future. Untreated defects of milk teeth can cause pain, bad breath, difficulty in chewing, disorders in jaw development, malnutrition, aesthetic and general health problems like rheumatism and heart diseases.

Protection of Milk Teeth

Since tooth decay in babies’ teeth is very difficult to treat, preventive measures are much more important in looking after the milk teeth. Some of these measures are as follows;

• A baby must not allowed to sleep with A milk bottle in her/his mouth,

• Sugar, honey or any other sugary substance must never be added to baby’s milk,

• Baby must be given water after every feeding,

• After baby’s first teeth erupt, after every morning and evening meal, his teeth must be wiped with a soft, wet, clean towel,

• Give a soft learning toothbrush to the baby to play with.

A child must start using a toothbrush after his molars erupt, at the age of 2.5 to 3 years old. The size of the toothbrush should be suitable to the child’s mouth. It should be soft and made of nylon. Children can only brush the front of their teeth. Since the space between the teeth should also be cleaned to provide a shield against decay, parents should supervise their children when brushing their teeth. At this age, a child cannot brush his/her teeth properly, but the main aim to be achieved is for him/her to get into the habit of brushing teeth. Toothpaste may start to be used for the child after the age of three. We must not forget that the important thing for oral hygiene is not the toothpaste itself, but brushing the teeth properly and thoroughly. If these measures are not taken, or if it is already too late, any disorder in the milk teeth must be treated immediately without making the mistake of thinking the milk teeth will be replaced anyway.

Permanent Teeth

The first permanent teeth are the first big molars, which erupt when the child is about six years old. Between ages 7 and 9, the lower and upper incisors, between ages 9 and 10, the lower canines, between 10 and 12, the first and second small molars, between 11 and 12, the upper canines, between 12 and 13, the second big molars, and finally, between 17 and 21, the wisdom teeth, the third molars erupt. During the eruption of permanent teeth, some problems like distorted development may occur. Genetic factors, early loss of milk teeth, breathing disorders, untreated cavities between milk teeth and a mismatch of jaw and tooth sizes, may cause irregular development of teeth. The dental treatment practiced for aligning such irregular teeth is called ‘orthodontic treatment.’ Since irregularities of teeth form spaces suitable for the accumulation of food residue which allows microorganisms to increase and then leads to decay, orthodontic treatment should be done before the permanent teeth are firmly positioned. Irregular teeth may cause jaw-aches because of abnormal interlacing of upper and lower teeth.

There are different thoughts about whether the wisdom teeth should be pulled out or not. Wisdom teeth are placed at the furthest back part of the jaw curvature. This part of the mouth is very suitable for food residue and microorganisms to accumulate. Because of this, wisdom teeth are very vulnerable to decay. In addition, any decay in these teeth may also affect the adjacent molars. If a positive result will not be achieved from treatment, these teeth can then be pulled out. However, if the wisdom teeth will erupt correctly into their places and do not negatively affect the surrounding tissues, and if there is sufficient space for them in the jaws, it is definitely beneficial for them to stay.

Another tooth problem that seems to concern today’s aesthetic conscious individuals is the color of teeth. However, tooth color is completely a personal phenomenon, like eye or skin color. But still, we must know that some external factors, like tea, coffee, smoking, feeding habits and tooth injuries, and some internal factors, like genetic attributes and aging, may also affect the color of the teeth.

What should we do to obtain Dental Health?

Mouth and tooth hygiene is an important issue that was emphasized strongly by Prophet Muhammad, peace and blessings be upon him, and the most effective method he used was brushing the teeth. However, after eating acidic foods or drinking acidic drinks like fruit juice, fruits, soft drinks or fizzy drinks, you should wait for about 30 minutes, because the dental enamel will be softer and more sensitive just after consuming such foods and drinks and if you brush straightaway, you may rub the acid into the enamel tissue of your teeth. You can clean the residues of acidic foods and drinks by rinsing your mouth with water or a fluoride based mouth rinse.

Having a healthy mouth and teeth mainly depends upon applying a good brushing technique to the teeth and gums. By applying the brush in a circular manner, you should always start brushing the gums towards the teeth, then the outer surfaces and finish with all inner surfaces. You must avoid damaging the masticator surfaces by applying too much force. Brushing the teeth twice a day at least is necessary to prevent the formation of bacterium plaque.

In order to achieve ideal hygiene for your teeth, you should also use dental floss for cleaning between the teeth. This will help to clean places where a brush cannot reach and thus prevent dental plaque. Also, special mouth rinses may be used in order to provide an effective general cleanliness.

Toothpicks can also be used between the teeth. While they are cheaper, they cannot provide a hygiene as comprehensive as dental floss, since they are thicker than floss. When using toothpicks, you should choose those with blunted tips to prevent any inflammation of the gums. Food residue that has stayed too long between the teeth should not be swallowed, since large amount of harmful microorganisms may grow on it.

In elderly people, due to a lack of sufficient calcium, disorders like gum retraction and wobbly teeth may occur. For people who have lost their teeth completely, because of osteolysis of the lower jaw, dental prostheses may not fit properly in the jaw. During this time of life, extra calcium intake should be provided by following a calcium-rich diet.

With age, the amount of calcium also decreases in the body. In relation to this situation, teeth also become more fragile. Using the teeth to break open nuts may cause cracks that cannot be seen with the eye, which may later cause fractures in the teeth. Therefore, we must never use our teeth to break hard foods, such as nuts, at any age, and we must be careful about breaking teeth, especially during old age.