Inhibitory activity of Salvadora persica extracts against oral bacterial strains associated with periodontitis: An in-vitro study

A Randomized Double-Blind Clinical Trial Evaluates the Efficacy of Alternative Herbal Mouthwashes

INTRODUCTION

The removal of dental plaque is the primary step in achieving good oral hygiene. Mechanical plaque removal measures have questionable efficacy in inaccessible areas and proximal aspects of the oral cavity. Out of the several types of mouthwash available, chlorhexidine (CHX) is regarded as the gold standard, but considering its adverse effects, herbal alternatives are being sought after. So, the aim of the study was to evaluate the efficacy of alternative herbal mouthwashes.

MATERIALS AND METHODS

In this randomized, double-blind study, 125 selected patients were divided into five groups. Group 1: negative control - distilled water (DW); group 2: positive control - hexidine mouthwash (ICPA, Gujarat, India); group 3: FeelFresh Herbal Mouthcare Gargle (Able Exports, Gujarat, India); group 4: HiOra mouthwash (Himalaya Wellness Company, Bengaluru, India); group 5: Colgate MaxFresh Fresh Tea mouthwash (Colgate-Palmolive, India). Plaque index (PI), gingival index (GI), and microbial count (CFU) were evaluated before and after the intervention.

RESULTS

The difference among the three types of herbal mouthwash was statistically non-significant. The lowest PI, GI, and CFU values were obtained in the subjects of group 4.

CONCLUSION

 Herbal mouthwashes are a promising alternative and are effective in maintaining oral hygiene.

Green Alternatives as Antimicrobial Agents in Mitigating Periodontal Diseases: A Narrative Review

Periodontal diseases and dental caries are the most common infectious oral diseases impacting oral health globally. Oral cavity health is crucial for enhancing life quality since it serves as the entranceway to general health. The oral microbiome and oral infectious diseases are strongly correlated. Gram-negative anaerobic bacteria have been associated with periodontal diseases. Due to the shortcomings of several antimicrobial medications frequently applied in dentistry, the lack of resources in developing countries, the prevalence of oral inflammatory conditions, and the rise in bacterial antibiotic resistance, there is a need for reliable, efficient, and affordable alternative solutions for the prevention and treatment of periodontal diseases. Several accessible chemical agents can alter the oral microbiota, although these substances also have unfavorable symptoms such as vomiting, diarrhea, and tooth discoloration. Natural phytochemicals generated from plants that have historically been used as medicines are categorized as prospective alternatives due to the ongoing quest for substitute products. This review concentrated on phytochemicals or herbal extracts that impact periodontal diseases by decreasing the formation of dental biofilms and plaques, preventing the proliferation of oral pathogens, and inhibiting bacterial adhesion to surfaces. Investigations examining the effectiveness and safety of plant-based medicines have also been presented, including those conducted over the past decade.

Salvadora persica’s Biological Properties and Applications in Different Dental Specialties: A Narrative Review

Salvadora persica is a tree that belongs to the salvadorecea family. It is also known as Miswak, which is a popular natural toothbrush that was used centuries ago in oral hygiene by Muslims in all parts of the world, especially in the Middle East. Numerous researchers highlighted the biological activity of this plant in medicine, dentistry, and pharmacology. The purpose of this article is to narratively review the biological properties of Salvadora persica. In addition, it expresses variant applications of this herb in different dental specialties. Materials and Methods. The search of the literature was based on PubMed, MEDLINE, and Google Scholar using keywords: Salvadora persica, S. persica, Miswak, Dentistry, and Dental. All relevant articles were reviewed to check if they would fit within the scope of this review, and then, the information was extracted. Results. Multiple biological effects of S. persica have been reported including antibacterial, antiviral, antifungal, antibiofilm, antioxidant, and even antiulcer effects. Dental effects were discussed and presented. Conclusion. The wide biological range of Salvadora persica's effects is promising for dental and nondental fields and allows for an expanded clinical application that has otherwise not been discussed in the literature.

Incorporation of Plant Extracted Hydroxyapatite and Chitosan Nanoparticles on the Surface of Orthodontic Micro-Implants: An In-Vitro Antibacterial Study

In our study, the structural and morphological applications of hydroxyapatite and chitosan nanoparticles and coated micro-implants were assessed for their ability to combat oral pathogenic bacteria. The hydroxyapatite, as well as chitosan nanoparticles, were synthesized from the Salvadora persica plant. The crystal morphology, phase composition, particle size, and surface functional groups of the nano-samples were analyzed via classical examinations and energy dispersive X-ray analysis. The prepared nanoparticles have been examined for antibacterial activity against four common oral bacterial strains. The antimicrobial effect was also assessed by the Live/Dead BacLight technique in combination with confocal scanning laser microscopy. Titanium micro-implants were coated with regular hydroxyapatite (HAP) and chitosan nanoparticles, and the surface was characterized by scanning electron microscopy. The analysis asserted elemental composition of the prepared nanoparticles and their textural features, metal crystallization, and functional bonds. The antibacterial activity of the nanoparticles was evaluated against oral pathogenic microorganisms by the disc diffusion method, minimum bacterial concentration (MBC), and minimum inhibitory concentration (MIC). Chitosan nanoparticles showed (MICs) of 8 μg mL⁻¹ for (Streptococcus salivarius, Streptococcus mutans and Enterococcus faecalis), and 16 μg mL⁻¹ for Streptococcus sanguinis. HAP nanoparticles showed (MICs) of 16 μg/mL for E. faecalis, and S. sanguis, 8 μg/mL for S. salivarius and finally 4 μg/mL for S. mutans. HAP nanoparticles showed enhanced antibacterial activity and more obvious damage in the bacterial cell membrane than that of synthesized chitosan nanoparticles. The prepared nanoparticles could successfully coat titanium microplates to enhance their efficiency.

Antimicrobials from Medicinal Plants: An Emergent Strategy to Control Oral Biofilms

Oral microbial biofilms, directly related to oral diseases, particularly caries and periodontitis, exhibit virulence factors that include acidification of the oral microenvironment and the formation of biofilm enriched with exopolysaccharides, characteristics and common mechanisms that, ultimately, justify the increase in antibiotics resistance. In this line, the search for natural products, mainly obtained through plants, and derived compounds with bioactive potential, endorse unique biological properties in the prevention of colonization, adhesion, and growth of oral bacteria. The present review aims to provide a critical and comprehensive view of the in vitro antibiofilm activity of various medicinal plants, revealing numerous species with antimicrobial properties, among which, twenty-four with biofilm inhibition/reduction percentages greater than 95%. In particular, the essential oils of Cymbopogon citratus (DC.) Stapf and Lippia alba (Mill.) seem to be the most promising in fighting microbial biofilm in Streptococcus mutans, given their high capacity to reduce biofilm at low concentrations.

Antiprotozoal potential of Salvadora persica against three virulent subtypes of Blastocystis sp

Blastocystis sp. is a group of anaerobic protozoa parasitizing the gastrointestinal tract of humans and a broad variety of animals. Evidences of Blastocystis parasites resistance development to antiprotozoal drugs urge the exploration of new therapeutics. Antiprotozoal potential of Salvadora persica, a medicinal plant traditionally used for oral hygiene, was evaluated in vitro against Blastocystis sp. human isolates. Until now, no study has described the effect of S. persica extracts on this parasitic protozoa. Blastocystis sp. positive stool samples collected from patients with gastrointestinal complaints and asymptomatic individuals diagnosed by microscopy were furthermore cultured in vitro and characterized by PCR and multiplex-PCR using sequence-tagged-site primers to determine their subtypes. Out of 21 Blastocystis sp. isolates, five were determined as ST1, 14 as ST3, and two as ST5 subtypes. Antiprotozoal activity of untreated and heat-treated S. persica roots aqueous extracts was evaluated in vitro by serial dilutions on three Blastocystis sp. subtypes; ST1, ST3, and ST5 isolated from symptomatic patients. A significant killing activity was observed with both, untreated and heat-treated aqueous extracts of S. persica at minimal concentration of 2.5 μl/ml compared to parasites' growth controls (P < 0.05). Maximal antiprotozoal effect was reached at a concentration of 20 µl/ml of S. persica aqueous extract. Means of growth inhibition effect obtained with untreated and heat-treated extracts at 40 µl/ml against the three subtypes of Blastocystis sp. were 80% (SD 2.3) and 82% (SD 1.1), respectively. No significant difference was observed in the inhibitory effect of S. persica extracts between the three Blastocystis sp. subtypes. Aqueous extract of S. persica roots contains therefore heat-stable components with significant antiprotozoal activity against Blastocystis sp. subtypes ST1, ST3, and ST5 in vitro. Further investigations are required to determine and characterize the active antiprotozoal components of S. persica roots and their evaluation in vivo.

Cytotoxicity of fluconazole on canine dental pulp-derived stem cells

Objective

In order to use fluconazole as an antifungal in cell cultures, we evaluated its possible cytotoxic effects and its influence on the proliferation and viability of canine dental pulp-derived stem cells (cDPSCs).

Methods

Samples from permanent canine teeth were placed in a sterile tube with IMDM, penicillin-streptomycin, sodium heparin, and different concentrations of fluconazole. Dental pulp was digested (collagenase type II) and expanded in vitro. After 12 days of culture, enzymatic dissociation of the cDPSCs was performed to quantify, differentiate, and characterize the cells. Cytotoxicity was evaluated based on cell viability in response to fluconazole treatment using the 7-AAD dye.

Results

Characterization of the cDPSCs revealed that fluconazole had no influence on the immunophenotypic characteristics and differentiation of these cells. Cell proliferation assay revealed that fluconazole did not significantly interfere with the replication capacity of the cDPSCs. Cytotoxicity analysis revealed a loss of cell viability as the fluconazole concentration increased. Although there was an increase in cell mortality, the number of dead cells remained low. Though the higher concentration of fluconazole (240 μg/mL) resulted in a higher number of non-viable cells, it remained safe for use.

Conclusion

To prevent fungal contamination that causes a loss of samples during expansion of cDPSCs and to maintain minimal cell toxicity, we suggest adding 120 μg/mL of fluconazole to the teeth collection medium and cDPSCs culture.

The effect of brushing with Salvadora persica (miswak) sticks on salivary Streptococcus mutans and plaque levels in children: a clinical trial

Background

The aim of the randomized double-blinded clinical trial was to evaluate the effect of tooth brushing with Salvadora persica (miswak) sticks on Streptococcus mutans count and the mean plaque score relative to brushing with fluoridated tooth paste (FTP).

Methods

Our sample included 94 healthy, high caries-risk, 8 to 9-year-old students recruited from a government school, in Jeddah, Saudi Arabia between February and April 2016. Subjects were randomly grouped into test (provided with miswak sticks) and control groups (provided with FTP and soft brushes). Both groups were introduced to a preparatory period (PPP) of 3 weeks. Plaque score and saliva sampling were conducted prior to the PPP and in follow-up visits by a single, calibrated and blinded dentist.

Results

Both groups showed a statistically significant decrease in the mean plaque score across the study (P = 0.007 and P = 0.001, respectively). In addition, subjects in the test group with abundant S. sanguinis increased from zero to six after 3 months.

Conclusions

Salvadora Persica (miswak) and brushing with FTP significantly reduced plaque scores among school children. In addition, Salvadora persica was found to change the proportions of salivary bacteria in favor of species with less risk of inducing caries.

Trial registration

ClinicalTrials.gov ID #: NCT04137393.

Evaluation and Comparison of Antibacterial Efficacy of Herbal Extracts in Combination with Antibiotics on Periodontal pathobionts: An in vitro Microbiological Study

Background: In the past few decades focus of research has been toward herbal medicines because of growing bacterial resistance and side effects of antimicrobial agents. The extract derived from the plants may increase the efficacy of antibiotics when used in combination against pathogenic bacteria. In the current study, the synergistic antibacterial efficacy of plant extracts in combination with antibiotics has been assessed on selected periodontal pathogens. Methods: Ethanolic extracts were prepared from Salvadora persica (Miswak) and Cinnamomum zeylanicum (Ceylon cinnamon), by the soxhalate method. Plaque samples were collected from clinical periodontitis patients to isolate and grow the periodontal pathobionts under favorable conditions. Susceptibility of bacteria to the extracts was assessed by gauging the diameter of the inhibition zones. Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of plant extracts were determined against each bacterium. Synergistic activity of plants extract in combination with antibiotics against the bacteria was also assessed by measuring the diameter of the inhibition zones. Results: Ethanolic extract of both the plants showed an inhibitory effect on the proliferation and growth of all four strains of periodontal pathobionts. Maximum antibacterial activity was exhibited by C. zeylanicum against Tannerella forsythia (MIC = 1.56 ± 0.24 mg/mL, MBC = 6.25 ± 0.68 mg/mL), whereas among all the studied groups the minimum activity was reported by C. zeylanicum against Aggregatibacter actinomycetemcomitans the (MIC = 12.5 ± 3.25 mg/mL, MBC = 75 ± 8.23 mg/mL). Combination of herbal extracts with different antibiotics revealed a synergistic antibacterial effect. The best synergism was exhibited by S. persica with metronidazole against A. actinomycetemcomitans (27 ± 1.78). Conclusions: Current in vitro study showed variable antibacterial activity by experimented herbal extracts against periodontal pathobionts. The synergistic test showed significant antibacterial activity when plant extracts were combined with antibiotics.

Fabrication and characterization of a titanium dioxide (TiO2) nanoparticles reinforced bio-nanocomposite containing Miswak (Salvadora persica L.) extract - the antimicrobial, thermo-physical and barrier properties

Objective: The microbial, physico-chemical and optical corruptions threaten a variety of foods and drugs and consequently the human biological safety and its accessible resources. The humanbeing's tendency towards bio-based materials and natural plant-extracts led to an increase in the usage of antimicrobial biocomposites based on medicinal herbs. Miswak (Salvadora persica L.) extract (SPE) has been proved effective for its antimicrobial and other biological activities. Therefore, in this study, titanium dioxide (TiO₂) nanoparticles (TONP) and SPE were applied to fabricate antimicrobial carboxymethyl cellulose (Na-CMC) based bio-nanocomposites which would simultaneously promote some thermo-physical and barrier properties. Methods: CMC-neat film (C1), CMC/TONP-2% (C2) and CMC/TONP-2% with 150, 300 and 450 mg/mL SPE (SPE150, SPE30 and SPE450, respectively) were fabricated. The physical and mechanical properties; elemental mapping analysis (MAP), X-ray diffraction (XRD), scanning electron microscopy (SEM), thermal gravimetric analysis (TGA-DTG); fourier transform infrared (FTIR), energy-dispersive X-ray (EDX) and UV-vis spectroscopies were done to further validate the results. Results: Addition of TONP (2%) improved the blocking of UV light at 280 nm while SPE-containing nanocomposites completely blocked it. FTIR, XRD and SEM confirmed the formation of homogeneous films and high miscibility of applied materials. TONP led to an increase in Young's modulus (YM) and stress at break (SB) while SPE decreased them and enhanced the elongation to break (EB) (flexibility) of the active nanocomposites. Compared to CMC-film, the thermo-gravimetric analysis (TGA-DTG) showed a higher thermal stability for CMC/TONP and CMC/TONP/SPE nanocomposites. The EDX spectroscopy and elemental mapping analysis (MAP) proved the existence and well-distributedness of Na, K, Cl, S, Ti, F and N elements in SPE-activated nanocomposites. The pure SPE and SPE-activated nanocomposites showed a favorable antimicrobial activity against both gram-positive (Staphylococcus aureus) and negative (Escherichia coli) bacteria. Conclusion: The CMC-TiO₂-SPE nanocomposites were homogeneously produced. Combination of TiO₂ nanoparticles and dose-dependent SPE led to an improvement of thermal stability, and high potential in antimicrobial and UV-barrier properties. These results can generally highlight the role of the fabricated antimicrobial bio-nanocomposites as a based for different applications especially in food/drug packaging or coating.

A review of the traditional and modern uses of Salvadora persica L. (Miswak): Toothbrush tree of Prophet Muhammad

ETHNOPHARMACOLOGICAL RELEVANCE

Salvadora persica L., also known as Arak (in Arabic) and Peelu (in Urdu), is the most common traditional source of tooth or chewing stick (miswak) highly recommended by Prophet Muhammad. To date, extensive studies have probed primarily into the validation of its traditional uses in oral care. Nonetheless, there is still a dearth of updated compilation and critical analysis of other potential ethnopharmacological properties of S. persica. This review therefore aims to provide an up-to-date detailed structured description of the traditional uses of S. persica and a critical analysis of its modern uses, highlighting its phytochemistry, pharmacological properties, and bioapplications.

MATERIALS AND METHODS

Various databases (Science Direct, PubMed, Wiley Online Library, and Google Scholar), books, and relevant primary sources were probed, surveyed, analysed, and included in this review. The literature cited in this review dated from 1979 to 2017.

RESULTS

S. persica was found to possess a plethora of bioactive compounds and broad pharmacological properties, including antimicrobial, antioxidant, enzyme inhibitory activity, antiulcer, anticonvulsant, sedative, analgesic, anti-inflammatory, hypoglycemic, hypolipidemic, antiosteoporosis, and antitumor activities. Studies also revealed the potential use of S. persica as a natural food preservative and a novel functional food ingredient. In addition, improvement in growth and reproductive performances have been observed by the introduction of S. persica in animal feed. Lastly, S. persica has also been used in the green synthesis of nanoparticles showing potential biotechnological applications.

CONCLUSION

S. persica showed a wide scope of application and its uses have been extended far beyond the initial traditional uses of its roots, stems, and twigs in oral care. We found a number of other ethnopharmacological uses and potential bioapplications of different parts of S. persica that warrants further investigations. Though widely studied using several in vitro and in vivo models, and tested clinically for oral hygiene mainly, several gaps and research priorities have been identified which needs to be addressed in future.

Efficacy of Miswak toothpaste and mouthwash on cariogenic bacteria

Objectives:

To evaluate the efficacy of Salvadora persica (Miswak) products on cariogenic bacteria in comparison with ordinary toothpaste.

Methods:

The study was conducted in Zakho city, Kurdistan region, Iraq during the period from October 2013 to January 2014. A randomized controlled clinical trial of 40 students randomly allocated into 4 groups. They were instructed to use Mismark toothpaste, Miswak mouthwash, and ordinary toothpaste with water or with normal saline. Salivary samples were collected at 3-time intervals: before, immediately after use, and after 2 weeks of use. The effect of each method on Streptococcus mutans and Lactobacilli was evaluated by using caries risk test.

Results:

One-way repeated measure analysis of variance (ANOVA), one-way ANOVA, and least significant difference tests were used. Miswak wash has a significant reduction effect on both bacteria immediately and after 2 weeks of use. Miswak paste has a similar effect on Lactobacilli, while Streptococcus mutans showed a significant decrease only after 2 weeks of use. Ordinary paste showed a non significant effect on both bacteria at both time intervals; while the addition of normal saline showed a significant effect on both bacteria only after 2 weeks of use.

Conclusion:

Miswak products, especially mouth wash, were more effective in reducing the growth of cariogenic bacteria than ordinary toothpaste.

Plants and other natural products used in the management of oral infections and improvement of oral health

Challenges of resistance to synthetic antimicrobials have opened new vistas in the search for natural products. This article rigorously reviews plants and other natural products used in oral health: Punica granatum L. (pomegranate), Matricaria recutita L. (chamomile), Camellia sinensis (L.) Kuntze (green tea), chewing sticks made from Diospyros mespiliformis Hochst. ex A.D.C., Diospyros lycioides Desf., and Salvadora persica L. (miswak), honey and propolis from the manuka tree (Leptospermum scoparium J.R. Forst. & G. Forst.), rhein from Rheum rhabarbarum L. (rhubarb), dried fruits of Vitis vinifera L. (raisins), essential oils, probiotics and mushrooms. Further, the review highlights plants from Africa, Asia, Brazil, Mexico, Europe, and the Middle East. Some of the plants' antimicrobial properties and chemical principles have been elucidated. While the use of natural products for oral health is prominent in resource-poor settings, antimicrobial testing is mainly conducted in the following countries (in decreasing order of magnitude): India, South Africa, Brazil, Japan, France, Egypt, Iran, Mexico, Kenya, Switzerland, Nigeria, Australia, Uganda, and the United Kingdom. While the review exposes a dire gap for more studies on clinical efficacy and toxicity, the following emerging trend was noted: basic research on plants for oral health is mainly done in Brazil, Europe and Australia. Brazil, China, India and New Zealand generally conduct value addition of natural products for fortification of toothpastes. African countries focus on bioprospecting and primary production of raw plants and other natural products with antimicrobial efficacies. The Middle East and Egypt predominantly research on plants used as chewing sticks. More research and funding are needed in the field of natural products for oral health, especially in Africa where oral diseases are fuelled by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

Antibacterial Activity of Salvadora persica L. (Miswak) Extracts against Multidrug Resistant Bacterial Clinical Isolates

Much effort has focused on examining the inhibitory effect of Salvadora persica (miswak) on oral microorganisms, but information concerning its antibacterial activity against other human pathogens, particularly multidrug resistant (MDR) isolates, is scarce. Therefore, this study aimed to assess the in vitro antibacterial activities of Salvadora persica L. extracts against 10 MDR bacterial clinical isolates other than oral pathogens. The antibacterial activity of aqueous and methanol miswak extracts was assessed using the agar dilution and minimum inhibitory concentration (MIC) methods. Overall, the 400 mg/mL of miswak extract was the most effective on all strains. The methanol extract exhibited a stronger antibacterial activity against Gram-negative (3.3–13.6 mm) than Gram-positive (1.8–8.3 mm) bacteria. The lowest MIC value was seen for E. coli (0.39, 1.56 µg/mL), followed by Streptococcus pyogenes (1.56 µg/mL). The highest MIC value (6.25, 12.5 µg/mL) was recorded for methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter baumannii, and Stenotrophomonas maltophilia. This study demonstrates, for the first time, the moderate to strong antibacterial activity of miswak extracts against all tested MDR-pathogens. Methanol extract appears to be a potent antimicrobial agent that could be considered as complementary and alternative medicine against resistant pathogens. Further studies on a large number of MDR organisms are necessary to investigate and standardize the inhibitory effect of miswak extracts against these emerging pathogens.

A review of the therapeutic effects of using miswak (Salvadora Persica) on oral health

Miswak is a traditional chewing stick prepared from the roots, twigs, and stem of Salvadora persica and has been used as a natural method for tooth cleaning in many parts of the world for thousands of years. A number of scientific studies have demonstrated that the miswak (Salvadora persica) possesses antibacterial, anti-fungal, anti-viral, anti-cariogenic, and anti-plaque properties. Several studies have also claimed that miswak has anti-oxidant, analgesic, and anti-inflammatory effects. The use of a miswak has an immediate effect on the composition of saliva. Several clinical studies have confirmed that the mechanical and chemical cleansing efficacy of miswak chewing sticks are equal and at times greater than that of the toothbrush. The present article provides a review of the various therapeutic effects of Salvadora persica on oral health, which will help to elucidate the significance and importance of this indigenous oral hygiene tool.