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Comparative Clinical - JPDA

Comparative Clinical

Aeeza Malik                           BDS, MDS

Marium Aftab                        MBBS

Malik Saleem Shaukat         BDS, MSc

Basil Khalid                           BDS, M.Phil

Marij Hameed                        BDS, MSc

Razia A. Ahmed                     MBBS, MCPS, MRCOG

OBJECTIVE: To compare the clinical effects of Salvadora persica oral rinse and commercial Phenolic mouth wash on oral health status of socially deprived madrasa girls after six months of a triple blind randomized clinical trial.
METHODOLOGY: Girls aged 18-22 years living permanently in a madrasa of Multan city were recruited. After determining the sample size and trial duration participants were randomized into group A and Group B and were provided with freshly Salvadora persica oral rinse and commercial Phenolic mouth washes respectively. Pre, mid and post-interventional examinations were executed by a single, blind and calibrated examiner using Turesky Quigley Hein Plaque and Loe and Silness Gingival indices. Statistical analysis was carried out by descriptive statistics, two sample independent t-tests and ANOVA. The p-value of <0.05 was considered significant at 95 % confidence level and 80% power.
RESULTS: Sixty subjects were enrolled for the present trial. The mean age of the participants was found out to be 21.5±0.76 years. No statistically significant difference was identified between the mean Plaque and Gingival scores of the two interventional groups at any of the examination phase.
CONCLUSION: Salvadora persica oral rinse is suggested to be equally effective as the commercial Phenolic mouth wash for the control of plaque deposition and prevention of gingival inflammation.
KEYWORDS: Dental plaque, Gingivitis, Miswak, Mouthwash
HOW TO CITE: Malik A, Aftab M, Shaukat MS, Khalid B, Hameed M, Ahmed RA. Comparative clinical effects of salvadora persica oral rinse and a phenolic commercial mouth wash on human oral health; An invivo randomized trial. J Pak Dent Assoc 2021;30(2):87-93.
DOI: https://doi.org/10.25301/JPDA.302.87
Received: 20 April 2020, Accepted: 14 February 2021

INTRODUCTION

Dental plaque, particularly its supra-gingival deposits has an established etiology for different periopathies.1 Increasing global trends of oral diseases has now imposed the use of both the mechanical and chemical plaque controlling therapies.2 The mechanical oral cleansing practices involve toothbrushes with dentifrices, however, chewing sticks or miswak has now proven its significant competence against effective plaque removal and gingival health.3-8
Miswak is now in its recompensing phase. Laboratory examinations have established that many favorable natural ingredients are present in almost all types of miswak sticks which provide both systemic and local oral curative effects. It has been reviewed that miswak particularly contains ascorbic and tannic acids which have verified effectiveness in healing inflamed and bleeding gums. Trimethylamine generate stimulatory effect on gingiva and Fluoride (1.0ug/ml) have a recognized dental hard tissue remineralization function.9-12 Literature reports the antiperiopathic and anti- carious property of miswak by reducing plaque formation;13-14 also it has an established antimicrobial effect against Streptococcus Mutans and Fecalis which are the most vulnerable microorganisms of oral cavity.12&15 Moreover, different local chemotherapeutic agents are also used as an adjunct to mechanical cleansing predominantly where gingival inflammation is more prevalent.1
The widely known and recommended oral rinse includes Phenolic containing salicylic acid and Chlorhexidine gluconate mouth washes, which have evidently reported their anti-bacterial and anti-plaque efficacy.1,16-17 In the current study Listerine mouth rinse brand was choosen because of its affordability and easy on counter availability in Pakistan. Listerine mouth rinse enclose a blend of phenolic compounds which is reported to have high bactericidal properties and has great ability to restrict the inflammatory diseased processes of oral soft tissues. A nine month clinical study also demonstrated that Phenolic mouth wash has a dramatic effect on plaque toxic activity.17 Keeping in mind the limited awareness and affordability of people in developing countries to use Phenolic and similar products which are prescribed frequently as treatment for highly prevalent periopathies, importance should be given to the comparison of these products to natural and cheaper alternatives whose affordability and availability are never
argued. Also, to date, the reported in-vivo data on such comparison is really sparse. Hence, the testing null hypothesis of this study was “no difference will be observed in the oral health status of subjects using Salvadora persica oral rinse or Phenolic mouth wash”. The objective of this experimental study was to compare the clinical effects of Salvadora persica oral rinse and commercial Phenolic mouth wash on oral health status of socially deprived madrasa girls after six months of a triple blind randomized clinical trial.

METHODOLOGY

Approval to conduct this trial was attained from the official Institutional Review Board of Multan Medical & Dental College, Multan (IRB/MDC/005-24-07-2019). This triple blind randomized controlled trial over a span of six months (August 2019 – January 2020) was conducted in the Madrasa for girls, Multan city. Present trial is based upon the guidelines of CONSORT (Consolidated Standards of Reporting Trials)
and has strickly followed the checklist provided by the CONSORT.18 Also, “The ethical standards of World Medical Association for human experimentation 2008 version of the Helsinki Declaration” has been followed in the current study.19 The sample size and trial duration were considered using “The American Dental Association, Acceptance Program Guidelines for Chemotherapeutic Products for Control of Gingivitis, 2009”.20-22
Written permission was obtained from the madrasa administration and verbal consent after notifying about the intention and purpose of the study was attained from all the girls present in the madrasa. Participants/girls with any medical or dental disease, dental prosthesis, those taken antibiotics in last 6 months, those received any periodontal therapy in last 3 months were excluded, while, participants
with at least 10 sites of chronic mild gingivitis with bleeding on probing but not having periodontal pockets of greater than 3mm were included in the trial. (Figure 1)

Figure 1: Flow Diagram of the Phases of the Randomized Trial, According to the Consolidated Guidelines for Reporting Trials (CONSORT)

 

PRE-TRIAL PHASE

Earlier the commencment of this trial, a pre-trial workshop was led where the participants of the two groups were given certain instructions to standardize each activity of the trial. This was done by inculcating all subjects to uniformly use similar quantity (15 ml) of the given mouthwash for one minute twice daily (after breakfast and before going to bed). They were instructed to store the given bottles in refrigerators
having temperature around 40C. They were also advised to brush their teeth with the same brushing technique to control the plaque deposition during the trial period. For this the most appropriate and recommended brushing technique (Bass method) was demonstrated individually to every participant on tripodents. Participants were also shown the related video of Bass method on multimedia. Later the
participants were asked to reproduce the taught brushing technique on the own teeth in front of a mirror and in presence of the same single examiner/instructor. All the participants were asked to apply toothpaste on full length of toothbrush and brush teeth two times a day (after breakfast and before going to bed) for 2 minutes. All these standards were strictly reinforced through regular telephonic calls. Feed backs were
also obtained from the administration and supervisors of the Madrassa.

TRIAL PHASE

For this trial the participants were the cohort of young girls between age 18-22 years living permanently in the same madrasa. A total of 100 girls were enrolled in the madrasa and all of them were assessed for eligibility. However, 40 girls did not meet the inclusion criteria and were therefore excluded from the trail. Ultimately, 60 participants were included for the present trial. These 60 girls were then randomly allocated to two interventional groups (n=30 in Group A and n=30 in Group B) by means of Simple Random Sampling using random number table. The principal investigator (AM) who was not going to be concealed or blind to the group assignment, enrolled and randomized the participants. Particulars of the participants who were randomized was sealed off in sequentially numbered, opaque, sealed envelopes (SNOSE). The participants, examiners and the data analysts (outcome assessor) were blind to the intervention allocation (Figure 1). Each participant of Group A and B was weekly provided with a coloured coded bottle. The rinses in all the bottles had same color so that none of the participant may not recognize the type of mouthwash and remain blinded to the intervention. Each coded bottle contained 500 ml of mouth wash. Freshly prepared Salvadora Persica oral rinse was then given to Group A, while Group B was provided with Commercial Phenolic mouthwash.

EXAMINATION PHASE

Dental examination was later conducted at baseline, then after 3 and 6 months, that is, Pre-Interventional, Mid Intervention and Post-Interventional phases respectively. It was executed on inclined chairs in day light using a sterilized dental mirror and CPITN (Community Periodontal Index of Treatment Need) probe. This probe has a ball ended tip with a diameter of 0.5mm. This probe have two coloured bands of 2mm graduations each, one at 3.5 to 5.5mm and second at 8.5 to 11.5mm. These bands determine the bleeding on probing which correspond to respective gingival score as per Loe and Silness Gingival index (1962).25,26 This index which was used as a tool for examination which is universally accepted to determine the oral gingival status. Dental plaque was identified and measured using commercialy available plaque disclosing lozenges. These lozenges were biocompatible and had Iodine as basic chemical compound.
The participants were asked to chews this lozenge, swishes it all over the teeth for 30-60 seconds and then rinse it completely. The coloured plaque was then scored according to Turesky Quigley Hein Plaque index (1962).24 All these dental examinations were executed by a single, blind, trained and calibrated examiner.The examiner was trained in the Out Patient Department of Multan Dental College by the Professor of Periodontology by undergoing multiple exersicing of using the trial diagnostics, indices and instruments on selected patients. These selected patients were the cohorts having both normal and inflamed gingiva.
After multiple exercises, the examiner was calibrated for the two indices to be measured. Later, the intra-examiner reliability of the single examiner was achieved on 10% of total trial sample in the madrasa campus. These 10% of the trial participants were evaluated just to obtain the examiner’s reliability and were not included in the final trial. The mean Kappa value of intra-examiner reliability determined on
these 10% of the participants was identified as 0.95.

LABORATORY PHASE

The Salvadora Persica oral rinse was prepared in the Environmental Research Department of Bahauddin Zikria University, Multan city. One senior person nominated by this department was contacted and provided with all the necessary documents of the current study including the referenced methodology (Standard Operating Procedures) to be stricktly followed. Samples of fresh vacuum packed Salvadora Persica (Peelu miswak) sticks were collected from local market. These sticks were then being cut into small pieces and allowed to dry at room temperature for two days. Then these were ground to powder. Successive 10 g quantity was put into a sterile screw capped bottle to which 100 ml of sterile deionized distilled water was added. The extract was allowed to soak for 48 hours at 4°C and then centrifuged at 2000 rpm for 15 minutes. The supernatant was passed through filter paper (0.45 m pore size) and the extract was prepared at 50% concentration.23 This procedure was performed several times by the same person each time during the study period of 6 months. The miswak extract was suggested by the laboratory to be consumed within one week, the provision was made on weekly basis for 6 months.

STATISTICAL ANALYSIS

Data collected was subjected to statistical analysis using Statistical Package for Social Sciences (SPSS) Version 21 software and has been described in terms of Mean and standard deviations. As the data was normally distributed, two sample independent t-test was employed to see the difference of the mean plaque scores as well as the gingival scores of the two groups at baseline, 3 months and 6 months of the examination. Considering the comparisions at three intervals Analysis of Variance (ANOVA) test was also conducted. Intra-examiner reliability was calculated using Cohen’s Kappa. The p-value of <0.05 was considered as statistically significant at the 95% confidence level as the power level was kept 80%.

RESULTS

Figure 1 demonstrates the total number of participants assessed for eligibility (n=100) and those who were excluded (n=40). Therefore, 60 subjects were enrolled for the present trial, 30 in each of the two interventional group. The follow-up attrition was 12% as 7 subjects lost to follow-up during the total trial period of 6 months. The mean age of the participants was found to be 21.5 ± 0.76 years. Comparative mean plaque scores and mean gingival scores for both the interventional groups at pre-, mid- and post-examination phases are demonstrated in Table 1. The same table illustrates that no statistically significant difference was identified between the mean plaque and gingival scores of two interventional groups at any of the examination phase.

Table 1: Comparative Mean Plaque and Gingival Scores of Two Groups at Pre, Mid and Post Examination Phases

*p-value = Level of significance of change in mean plaque and gingival scores obtained e mploying independent t-test

Table 2 describes the findings of ANOVA which suggest that no statistical difference was found between the the two interventional groups when their plaque and gingival scores were compared at three different examination phases

Table 2: Analysis of Variance between the Two Groups at Pre, Mid and Post Examination Phases

*F = variance between mean plaque and gingival scores obtained employing ANOVA test.

DISCUSSION

This experimental study was conducted to evaluate the comparative effectiveness of the Salvadora persica oral rinse and commercial Phenolic mouth wash on oral health status of selected socially deprived population and has identified no difference in the clinical efficacies of the two interventions in the given trial duration of 6 months. The present trial has followed “the American Dental Association (ADA) guidelines to conduct clinical studies for the assessment of chemotherapeutic agents”. ADA suggests that the clinical advantage of plaque control may be demonstrated by a significant reduction in gingivitis. It
also explains that products meant to achieve their anti-gingivitis effectiveness through plaque reduction should determine significant reductions in both plaque and gingival scores at the end of the study.20-22 This trial has accomplished all these given commendations when mean plaque and gingival scores were compared from baseline to 6 months. Phenolic mouth wash was chosen for this trial as other commercial mouthwashes like chlorhexidine formulations, which has more proven anti-gingivitis efficacy is only recommended for short periods.27,28 However, phenolic antiseptic rinses can be used for long terms. They destroys and constrains the growth of both gram-positive and gramnegative colonoies of bacteria. Phenolic group of mouth washes are also reported to have efficient antimicrobial activity which not only abolishes bacterial cell surface and prevents the growth of oral bacterial biofilm but also increases the time of bacterial regrowth.17 Salvadora persica miswak was selected in this trial to study its comparative antimicrobial activity with phenolic compounds because of its easy availability and affordability in Pakistan. Also, Salvadora persica miswak has an established oral therapeutic properties, acceptable taste and odor and significant antiplaque efficacy.3-8,29&30
The results of the present study are in line with the study of Patel who has reported beneficial anti-gingivitis effect of miswak juice.31 This study is also in accordance with the study of Khalid Almas about the effects of Chlorhexidine and miswak extract on healthy and periodontally involved human dentin and concluded that Chlorhexidine 0.2% and miswak extract 50% had a similar effect on dentin specimens.32 Another double-blind clinical trial by Khalessi had studied the comparative antimicrobial activity of Persica and Chlorhexidine against certain pathogens in periodontal tissues such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans in vitro. The study reported superior antimicrobial activity of Persica which is in accordance with our study.33 Another study of Babol studied the effect of chewing gum containing Persica extract on periodontal health in a double-masked, randomized trial and reported significant reduction of gingival and bleeding scores of subjects using chewing gums having miswak extract compared with other placebo groups.34 This is significant to be reported to support the current study as it explains the healthy outcomes of miswak extracts on oral tissues and therefore validate the effect of miswak extract.
Miswak use may also be promoted in stick form as the previously published literature supports both the mechanical and chemical efficacy of miswak.31,32,-34 However, mechanical cleansing efficacy of miswak has reported high plaque and gingival scores in few of the subjects using miswak stick when matched with those using toothbrushes. In this context, few investigations have likewise discovered that those subjects who were using chewing sticks and were found to have poor oral hygiene scores, was probably a consequense of improper cleansing techniques in using chewing sticks by the subjects in that particular study.35 Therefore, it may be suggested that if miswak stick is used with appropriate technique, it can efficiently provide anti-plaque and antigingivitis effects both mechanically and chemically. Currently, several over the counter mouthwashs are available in Pakistan, and none of them contain miswak extract which has an established therapeutic remedy for the control of plaque and gingivitis.3-8 This study strongly recommends the incorporation of miswak extract in local mouth washes not only because of its natural pharmaceutical oral health benefits, high fluoride content but for being a cheaper product for the population of any developing country having financial constraints and limited oral health care amenities. However, more controlled trials are needed to establish miswak as a therapeutic medicament both mechanically and chemically for the prevention and control of periodontal diseases.

CONCLUSION

This trial has revealed no statistically significant difference in the oral health status of the two comparative groups, suggesting that Salvadora persica (miswak) oral rinse may be equally effective as the commercial Phenolic mouth wash for controlling dental plaque and preventing gingival inflammation.

FUTURE RECOMMENDATIONS

Some of the confounding variables responsible for the development of plaque and gingivitis such as few systemic undiagnosed diseases, disturbed hormones, genetics, drugs, malnutrition etc. which may influence the signs and symptoms of the disease must also be evaluated in future studies. Also some sort of objective assessment of the effectiveness of brushing amongst the study participants in all groups may be included in the future trials. Using a third group of true controls (not using any mouth wash but only brushing in the recommended way) in future will also increase the credibility of the study.

CONFLICT OF INTEREST

No conflict of interest was identified among the authors that may profit or loss in the publication of this paper.

ACKNOWLEDGEMENT

Heartfelt thanks to all the study participants from the Madrasa and Multan and Environmental Research Department of Bahauddin Zikria University, Multan.

REFERENCES

  1. Rahmani ME, & Radvar M. The Antiplaque Effects of Salvadora persica and Padina Essential Oil Solution in Comparison to Chlorhexidine in Human Gingival Disease; a Randomized Placebo-controlled Clinical Trial. Int. J. Pharmacol. 2005;1:311-15. https://doi.org/10.3923/ijp.2005.311.315
  2. Petersen PE. The World Oral Health Report: Continuous Improvement of Oral Health in the 21st Century, the Approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003; 31(Suppl 1):3-24. https://doi.org/10.1046/j..2003.com122.x
  3. Malik A, Shaukat SM, Qureshi A & Abdur R. Comparative effectiveness of chewing stick and toothbrush: A randomized clinical trial. N Am J Med Sci, 2014;6:333-37 https://doi.org/10.4103/1947-2714.136916
  4. Bhambal AB, Kothari SK, Saxena SS, Jain MJ. Comparative effect of neemstick and toothbrush on plaque removal and gingival health – A clinical trial. J. Adv. Res. 2011;2:51-6. https://doi.org/10.1177/2229411220110322
  5. Fatemeh Ezoddini-Ardakani, Mahmoud Nouri Shadkam, Hasan Fotouhi, Farah Bolouri. S, et al.. Study of the effects of natural toothbrush (Salvadora persica) in prevention of dental caries and
    plaque index. Health. 2012; 4:612-18. https://doi.org/10.4236/health.2012.49096
  6. Patel PV, Shruthi S and Kumar SK. Clinical effect of Miswak as an adjunct to tooth brushing on gingivitis. J Ind Soc Periodontol. 2012; 16:84-8. https://doi.org/10.4103/0972-124X.94611
  7. Meshari Al-Otaibi, Mohammed Al-Harthy, Birgitta Soder, Anders Gustafsson, Birgit Angmar Mansson. Comparative effect of chewing sticks and toothbrushing on plaque removal and gingival health. Oral Health Prev Dent. 2003;1:301-07.
  8. Bergstrom J, Batwa S, Al-Otaibi BM. The effectiveness of chewing stick miswak on plaque removal. Saudi Dent J. 2006;18:125-33
  9. Tubaishat RS, Darby ML, Bauman DB and Box CE. Use of miswak versus toothbrushes: Oral health beliefs and behaviours among a sample of Jordanian adults. Int J Dent Hyg. 2005; 3:126-36. https://doi.org/10.1111/j.1601-5037.2005.00136.x
  10. Halawany HS. A review on miswak (Salvadora Persica) and its effect on various aspects of oral health. Saudi Dent J. 2012; 24:63-9. https://doi.org/10.1016/j.sdentj.2011.12.004
  11. Dahiya PD, Kamal RK, Luthra RP, Mishra RM and Saini GS. Miswak: A Periodontist Perspective. J Ayurveda Integr Med. 2012;3:184-87. https://doi.org/10.4103/0975-9476.104431
  12. Almas, K. The antimicrobial effects of extracts of Azadirachta Indica (NEEM) and Salvadora Persica (Arak) chewing sticks. Ind J Dent Res.1999;10:23-6.
  13. Hassan Suliman Halawany. A review on miswak (Salvadora persica) and its effect on various aspects of oral health. Oral Health Prev Dent. 2003;1:301
  14. Singh A, Purohit B. Tooth brushing, oil pulling and tissue regeneration: a review of holistic approaches to oral health. J Ayurveda Integr Med. 2011;2:64-8. https://doi.org/10.4103/0975-9476.82525
  15. Al-lafi T. and Ababneh H. The effect of the extract of the Miswak (chewing sticks) used in Jordan and the Middle East on oral bacteria. Int Dent J.1995;45:218-22.
  16. Almas K. The effects of Salvadora persica extract (miswak) and chlorhexidine gluconate on human dentin: a SEM study. J Contemp Dent Pract. 2002;3:27-35. https://doi.org/10.5005/jcdp-3-3-27
  17. Fine DH, Letizia J, & Mandel ID. The effect of rinsing with Listerine antiseptic on the properties of developing dental plaque. J cli periodontology. 1985;12:660-66 https://doi.org/10.1111/j.1600 051X.1985.tb00937.x
  18. Schulz KF, Altman DG, Moher D. Group, CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMC Med. 2010;8:1-8. https://doi.org/10.1186/1741-7015-8-18
  19. World Medical Association. World medical association declaration of Helsinki. [Internet]. C2010 [cited 2015 Jan 5]. Available from: http://www.wma. net/en/30publications/10policies/b3/index.html.
  20. Imrey PB, et al. Recommended revisions to American Dental Association guidelines for acceptance of chemotherapeutic products for gingivitis control. J. Periodont. Res. 1994;29:299-304. https://doi.org/10.1111/j.1600-0765.1994.tb01225.x
  21. Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. J Dent. 2010; 38 (Suppl 1), S6-S10. https://doi.org/10.1016/S0300-5712(10)70004-X
  22. Acceptance Program Guidelines Toothbrushes, American dental association, council on scientific affairs. 2009; 9-10.
  23. Bhat PK, Kumar A, & Sarkar S. Assessment of immediate antimicrobial effect of miswak extract and toothbrush on cariogenic bacteria-A clinical study. J. Adv. Or Res. 2012;3:25-9. https://doi.org/10.1177/2229411220120106
  24. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc. 1962; 65:26-9. https://doi.org/10.14219/jada.archive.1962.0184
  25. Silness J, Loe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odontol. Scand. 1964; 22:121-35. https://doi.org/10.3109/00016356408993968
  26. Loe H. The Gingival Index, the Plaque Index and the Retention Index Systems. J Periodontol.1967; 38:610-16. https://doi.org/10.1902/jop.1967.38.6.610
  27. Flotra L, Gjermo P, Rolla G, & Waerhaug J. Side effects of chlorhexidine mouth washes. Eur J Oral Sci 1971;79:119-25. https://doi.org/10.1111/j.1600-0722.1971.tb02001.x
  28. Brecx M, Netuschil L, Reichert B, & Schreil G. Efficacy of Listerine®, Meridol® and chlorhexidine mouthrinses on plaque, gingivitis and plaque bacteria vitality. J. Clin. Periodontol. 1990; 17: 292-97. https://doi.org/10.1111/j.1600-051X.1990.tb01092.x
  29. Akhtar M, Ajmal M. Significance of chewing sticks (Miswak) in oral hygiene from a pharmacological view-point. J Pak Med Assoc. 1981;31:89-95.
  30. Farooqi MIH, Srivastava JG. The toothbrush tree (Salvadora persica). Q J Crude Drug Res. 1968;8:1297-99. https://doi.org/10.3109/13880206809083356
  31. Patel PV, Shruthi S, & Kumar S. Clinical effect of miswak as an adjunct to tooth brushing on gingivitis. J Ind Soc Periodontol. 2012;16:84-8 https://doi.org/10.4103/0972-124X.94611
  32. Almas K. The effects of Salvadora persica Extract (Miswak) and chlorahexidine gluconate on Human Dentin: A SEM study. J. Contemp. Dent. Prac. 2002; 3:27-35. https://doi.org/10.5005/jcdp-3-3-27
  33. Khalessi AM, Pack AR, Thomson WM, Tompkins GR. An in vivo study of the plaque control efficacy of Persica: a commercially available herbal mouthwash containing extracts of Salvadora persica.
    Int Dent J. 2004; 54:279-83. https://doi.org/10.1111/j.1875-595X.2004.tb00294.x
  34. Babak Amoian, Ali Akbar Moghadamnia, Soozan Barzi, Sepideh Sheykholeslami, Afsaneh Rangiani. Salvadora persica extract chewing gum and gingival health: improvement of gingival and probe-bleeding
    index. Complement Ther Clin Pract. 2010; 16:121-23. https://doi.org/10.1016/j.ctcp.2009.11.002
  35. Gazi M, Saini T, Ashri N, Lambourne A. Meswak chewing stick versus conventional tooth- brush as an oral hygiene aid. Clin Prev Dent. 1990;12:19-23.

1. Assistant Professor, Department of Community Dentistry, Multan Medical & Dental College, Multan, University of Health Sciences, Lahore. Pakistan. Pakistan.
2. Ex-Student and House Officer, Dow University of Health Sciences, Karachi, Pakistan.
3. Associate Professor, Department of Science of Dental Materials, Multan Medical & Dental College, Multan, University of Health Sciences, Lahore. Pakistan.
4. Assistant Professor, Department of Oral Pathology, Multan Medical & Dental College, Multan, University of Health Sciences, Lahore.
5. Assistant Professor, Department of Periodontology, Multan Medical & Dental College, Multan, University of Health Sciences, Lahore.
6. Associate Professor, Department of Family & Community Medicine, King Khalid University, Abha, Saudi Arabia.
Corresponding author: “Dr. Aeeza Malik” < aeezamalik@gmail.com >