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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 6  |  Page : 525-531

Deconstructing orthographic knowledge and cultural awareness of miswak practice amongst dental educators: Benefits and barriers: A qualitative study

1 Kulliyyah of Dentistry, International Islamic University Malaysia, Unit of Dental Public Health, Kuantan, Pahang, Malaysia
2 Kulliyyah of Dentistry, International Islamic University Malaysia, Periodontology Unit, Kuantan, Pahang, Malaysia
3 Kulliyyah of Dentistry, International Islamic University Malaysia, Special Care Dentistry unit, Department of Oral Diagnosis and OMFS, Kuantan, Pahang, Malaysia

Date of Submission02-Apr-2020
Date of Decision03-Jun-2020
Date of Acceptance05-Jun-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. Farah N Mohd
Kulliyyah of Dentistry, International Islamic University Malaysia, Special Care Dentistry unit, 25200, Kuantan, Pahang.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIOH.JIOH_116_20

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Aim: Miswak is a chewing stick used for oral hygiene and has both cultural and religious heritage. Concerns have emerged about the limitation of evidences on its effectiveness and guidance to practice. This study aims to explore dental educators’ perceived level of knowledge and awareness of Miswak practice and teaching as oral hygiene tool. Materials and Methods: Dental educators with various socio-religious demographic backgrounds at International Islamic University of Malaysia(IIUM) University were invited to participate in an audio-taped focus group discussion in 2017, conducted in English using a pre-tested topic guide. The qualitative data were recorded, transcribed, and analysed using a Framework Analysis. Results: The dental educators (n = 11) from various socio-religious and educational backgrounds demonstrated low-medium level of knowledge on Miswak given there are limited, restricted, and localized evidences, influenced by their culture, religious values, and past educational training and several domains of practice. This has an implication on their low level of awareness to practice Miswak considering the fact that the barrier identified is more than its benefit. Furthermore, there was a strong mixed sense of valuing evidence-based knowledge and cultural–religious belief among dental educators of postmodern society in meeting both oral health needs and social expectations. Conclusions: Educators of postmodern society with western educational background view metaphorically the level of knowledge and awareness of Miswak usage, although most of them are Asian and Muslim. A flexible strategy is needed to overcome the poor dissemination of Miswak evidence to further educate dental educators in order to frame a Miswak educational guideline for the benefit of society.

Keywords: Awareness, Dental Educator, Knowledge, Malaysia, Miswak

How to cite this article:
Che Musa MF, Muhammad Ali S, Mohd FN, Ab Halim N. Deconstructing orthographic knowledge and cultural awareness of miswak practice amongst dental educators: Benefits and barriers: A qualitative study. J Int Oral Health 2020;12:525-31

How to cite this URL:
Che Musa MF, Muhammad Ali S, Mohd FN, Ab Halim N. Deconstructing orthographic knowledge and cultural awareness of miswak practice amongst dental educators: Benefits and barriers: A qualitative study. J Int Oral Health [serial online] 2020 [cited 2023 Nov 28];12:525-31. Available from:

  Introduction Top

Miswak, or Salvadorapersica, is a chewing stick and oral hygiene tool, with a long line of cultural and scientific heritage.[1],[2] It is also known by various names, such as “Mefaka” in Ethopia,[3] “Qisa” in Aramaic, “Koyoji” in Japanese, “Mastic” in Latin,[4] and “Datum” in Pakistan and India.[5]

The Miswak-chewing stick was first used by Babylonians in 5000 BC. This oral health ritual rapidly spread all over the Greek, Roman,[5] and Egyptian empires and consequently, to Jewish and Muslim countries.[4] It is widely used across the globe and inspired the intervention of the modern-day tooth brush 300 years ago in Europe.[6] In this regard, despite the development of the modern-day toothbrush, Miswak is still being used in different parts of the world for various reasons, for instance, due to its cheaper price, easy availability, and its universal, cultural, religious, as well as ritualistic significance.[1],[7]

Scientifically, there are numerous studies that focused on in vitro experiments and clinical trials on Miswak’s usage and its effectiveness in treating dental diseases.[2],[8-10] Miswak has been reported to have antimicrobial,[5],[11] anti-cariogenic,[9] anti-plaque,[12] and anti-gingivitis[1],[5],[7] properties. Moreover, it was also reported to have fluoride content.[13],[14] Nevertheless, scientific evidence on Miswak is still largely unknown to health professionals, specifically dental educators in public health, despite its cost effectiveness.[7] There is an urgent need to address dental diseases[15],[16] of increasing trends, such as the periodontal disease,[17] although there is a reduction in the prevalence of dental caries in certain age-bands reported globally[15],[18],[19] and locally.[17]

Despite historical, cultural, religious, and scientific evidence on the use of Miswak as an oral hygiene tool, it has failed to gain the trust of dental professions and educators. Similarly in Malaysia, there is no or less priority given for Miswak teaching at dental schools, although all prospective dentists are Asian and most of them are Muslim, in which they will serve the same population profile. Therefore, this study is primarily aimed to explore the level of knowledge and awareness of Miswak practice and teaching in dentistry among Malaysian dental educators, with respect to its benefits and barriers.

  Materials and Methods Top

Study population

A qualitative research on focus group discussions (FGDs) was conducted among dental educators in the International Islamic University Malaysia (IIUM). In 2017, the educators (n = 16) were invited to participate in an audio-taped FGD and they were divided into four groups. The first group comprised local and Muslim educators (FG1); local and non-Muslim educators (FG2); international and Muslim educators (FG3); and international and non-Muslim educators (FG4). Expert sampling type was chosen to gain knowledge from individuals that have particular or specific expertise; along with the maximum variation, known as heterogeneous sampling by recruiting interviewees with various background to capture a wide range of views and perspective.[20]

Topic guide

The focus group discussion utilized a topic guide which covered five main areas: (1) individuals and their roles; (2) benefits; (3) barriers; and (5) Miswak practice and teachings that are highly related to the research questions of this study; (5) along with summary and comments/suggestions. The topic areas explored were derived from the previous literature,[1],[2],[9],[11] and based on the objectives of this study, as suggested by Ritchie et al.,[21] only relevant issues were examined and captured from participants’ experiences.[22],[23],[24] The topic guide was then tested by conducting a pilot study to ensure that the topic guide has the knowledge, relevance, and cohesion with the research aim and local setting.

Throughout the FGDs, newly emerging themes, particularly conflicts and underdeveloped issues, were tested and validated in subsequent interviews within the context of the original topic guide; but the main topic areas remained constant. Based on the interviewees’ various social and geographical backgrounds, some of them may respond well to the topics related to their experience with Miswak.


Prior to the study, an invitation letter and a copy of ethical approval were sent to the dental educators in IIUM informing them about the study and its purpose. The approach letter was followed by an email containing an information sheet and consent form. A second email was sent after 7 days and if there was still no response, the researcher would contact them by phone. After obtaining the participants’ consent, arrangements were made for the FGD to be conducted on a confirmed date and time; FGD was conducted in English, as all dental educators are proficient in English.

The FGD session was conducted in a seminar room chosen by the researcher and was anticipated to last around an hour, which is within the standard period for qualitative research.[23] The purpose of the FGD was explained and potential participants had the opportunity to seek clarification prior to providing their consent for the study. A small high-quality audio-tape recorder was placed in a discreet position to record the discussion with the consent of the interviewee. Field notes were also taken.

All recordings were transcribed by a private transcribing service provider. The researcher, who is also the interviewer, listened to the recordings and checked each of the transcripts. This is necessary as the transcription service was not familiar with the accent of some foreign participants and there were gaps present in the initial scripts being produced. Participants were also offered to examine the transcripts for any sensitive issues; however, none requested it. Scripts were also anonymously coded; using a created informants’ ID, for example: (R1).

Qualitative data analysis

Interviews were transcribed and analysed using framework analysis. This framework analysis has several stages, it begins with data management, followed by descriptive analysis, and finally, the explanatory analysis.[21] The key steps involved with data management are familiarization with the data, development of an index or conceptual framework of themes and sub-themes, indexing of the data, sorting of theme or concept, and finally, synthesizing the data to provide descriptive and explanatory summaries.

  Results Top

Interview participants

Eleven respondents from IIUM participated in four FGDs. Each group session was conducted based on the respondents’ background: (1) local and Muslim (n = 5); (2) local and non-Muslim (n = 2); (3) international and Muslim (n = 2); and (4) international and non-Muslim (n = 2). The majority of respondents were female (54%; n = 6) and had over 20 years of working experience (30%; n = 3). All the respondents were Asian, have postgraduate qualifications, and mostly trained at western countries.

Dynamic interactions of knowledge and awareness for Miswak practice

The study which was conducted among dental educators (n = 11) of diverse socio-cultural and educational backgrounds demonstrated low-to-moderate degree of knowledge for Miswak due to limited, restricted, and localized evidences as effective oral hygiene tool. Such low level of knowledge was attributed to their culture, religion, and past educational training. Consequently, this leads to either low or high level of awareness to practice while balancing its benefit and barriers. As knowledge and awareness are interrelated, a change in one area will likely impact the others and both are highly related to several domains, namely, teaching, research, self-care, and policy-politics [Figure 1].
Figure 1: Dynamic interactions between Miswak awareness and knowledge among dental educators at International Islamic University of Malaysia (IIUM)

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The level of knowledge and awareness are presented separately based on the anonymous quotes in support of the concepts. Each quote is labeled according to the informant focus group (FG) number; identity (ID) number, location in the transcript (page) and local/international status, and gender to provide insights into the background of the informant, while at the same time protecting their identity. Quotes have been grammatically corrected to ensure ease of understanding. In each section, a broad overview is presented first, followed by the divergent views to provide a holistic understanding of relevant practical issues.

Degree of evidence-based knowledge to practice

Most respondents acknowledged the presence and availability of Miswak at global and local settings based on its historical, cultural, and religious significance. Nevertheless, there were divergent views on certain factors and the degree to which they are evidence-based and appropriate that drives their decision to practice miswak. Divergence is most apparent across scientific evidence and educational background which are limited, thus restricting them to practice. On the other hand, some value the cultural–religious factor as important in practicing the Miswak, which is demonstrated in the following quotations.

Limited and restricted evidences for Miswak

Primarily, respondents agreed that Miswak has been less practiced at present due to lack of information on how to use this tool effectively.

“It is a twig from a tree, neem tree. Long time ago; been used in our culture, to clean the tooth. I’ve never seen one use [Miswak] now.”

FG4: (R1) 2 [international, male (♂)]

“Maybe [we not practice because], we don’t know how to use the miswak.”

FG3: (R1) 2 [international, female (♀)]

As educators who rely on evidence-based information, they accredited the importance of evidences to introduce and embed this tool in educational curriculum and training. Evidences such as unavailability of guidelines in the curriculum and limited facts about Miswak have further restricted them to teach and advice Miswak practice at the dental school.

“So, as a dental educator, I teach everything that is evidence based. In terms of curriculum during the study itself, there is no guideline in the book. So, we don’t have that guidelines (for teaching).”

FG1: (R2) 7 [local, ♀]

“One thing, there is no or less evidence that Miswak have some benefit of cleaning the tooth.”

FG3: (R2) 5 [international, ♂]

Localized sources to Miswak knowledge

On the other hand, some respondents perceived differently and reported there are some scientific evidences on the benefits of using Miswak; however, they were not documented and disseminated effectively around the world. Such limited and localized evidences eventually will invite criticism in regard to whether it will benefit the society and the dental profession.

“The information [Miswak benefits] are not disseminated well.”

FG1: (R3) 6 [local, ♀]

“There is a study discusses its benefits like antibacterial, antiplaque and anti-gingivitis. However, the data is not being published internationally and disseminated well. Because of this, we don’t know whether the claiming is strong or not. So, in my opinion, the evidences on its [Miswak] benefit could be said as still lacking.”

FG1: (R2) 5 [local, ♀]

Having said that there are limited and localized evidences on Miswak, along with no teaching guidelines for the tool, some participants rule out the resolution on how to improve its acceptance in the health profession and among the public through inter-sectoral collaboration with the market industry.

“We have to first, make sure the evidence is really established, after that, we have to work with the industry because they are the ones who’s going to market it to all, to the society.”

FG1: (R2) 7 [local, ♀]

Cultural and religious values of Miswak

In addition, some participants reported that Miswak is used to fulfill cultural value as well as for religious purpose. More than half of the respondents are Muslim educators that are following the sunnah (religious practice according to Prophet Muhammad PBUH).

“Long time ago; been used in our culture, to clean the tooth.”

FG4: (R1) 2 [international, (♂)]

“It is sunnah (religious practice).”

FG3: (R2) 5 [international, ♂]

Cultural awareness

Generally, the domain of awareness is characterized by the respondents’ perception pertaining to their level of knowledge for Miswak in regard to its benefits and barriers. The respondents felt that the availability of limited evidences has an impact on their level of awareness to either use or not use Miswak in daily practice.

“I also think [there is a] lack of awareness or confidence [to use and teach] amongst dental educators because you know, for us, we learn from books and evidences.”

FG1: (R2) 7 [local, ♀]

Benefits of Miswak

Despite the limited evidence on Miswak, some respondents nevertheless have some knowledge on the general benefits of Miswak as characterized by its ability to (1) clean the teeth and gums and (2) remove stains.

“I know it can clean your teeth and gum.’’

FG2: (R1) 2 [local, ♂]

“For me, I use this Miswak for my children because it is much easier to remove stain.’’

FG1: (R5) 2 [local, ♀]

Barrier of Miswak

On the other hand, some respondents also articulated that Miswak has been less practiced due to several factors, such as (1) physical appearance lead to ineffective tooth cleaning; (2) hygiene issue; (3) no proper guidelines on how to use; and (4) toxicity issue.

“It is not comfortable to use and I see they use it without guideline. It should be used as addition [tool].”

FG3: (R2) 2 [international, ♂]

“I’ve seen patients with calculus for example, because of misusage or they used only the Miswak.’’

FG1: (R1) 1 [local, ♀]

“And addition to that, from a hygienic point of view, they brought the Miswak in the pocket, and there is no special container.”

FG3: (R2) 3 [international, ♂]

“I a bit of worried because of the issue of, like issue of toxicity.”

FG2: (R1) 2 [local, ♂]

Some even perceived there is a possibility of political influence in placing this tool in the global market effectively.

“It’s politics. They control the market; they don’t want other new thing.”

FG1: (R3) 7 [local, ♀]

Balancing the benefits and barriers to enhance Miswak usage

Having said the benefits and barriers that eventually affect the level of awareness among respondents to practice Miswak, they, however, seemed positive to consider to use this tool in practice. Nonetheless, Miswak should be used as a complementary rather than stand-alone tool to curb dental illnesses. Joint efforts and innovation is required to transform Miswak productively for a better acceptance among society in order to maximize its benefits, thus reducing potential undesirable risks.

“It should be used as addition [tool]. They should modify it to make it comfortable.”

FG3: (R2) 2 [international, ♂]

“If it being developed by a good and great company. Like you change its appearance, I think more people will be more receptive.”

FG2: (R1) 6 [local, ♂]

In summary, it is clear that there is low-to-moderate level of Miswak knowledge among dental educators due to the limited and localized evidence-based knowledge on its usage and practice. This is contributed by their culture, religious values, and past educational training; and several domains of practice, namely teaching, research, self-care, and policy-politics which have interrelated impact on their level of awareness to use Miswak as their oral hygiene tool. There is also a strong sense of valuing evidence-based knowledge and cultural–religious belief among the current generation in meeting both oral health needs and social expectations. Most local and international educators agreed that the significant benefits and risks explored through evidence-based knowledge are critical in considering Miswak usage.

  Discussion Top

Dynamic interactions between knowledge and awareness of Miswak practice

This study involved dental educators from an international dental institution in Malaysia, comprising mixed socio-religious and educational backgrounds and who came from several countries in Asia.[25] Their perception and knowledge with regards to Miswak are limited, localized, and embedded orthographically at low-to-moderate level of thought. This reflects consistently on their low level of awareness to practice Miswak. Although there is a lack of comprehensive and systematic review with regards to Miswak benefits and risks,[26] it clearly demonstrated that the restricted knowledge evolves Malaysian dental educators’ panache, then influencing their critical awareness towards what they believe in. Such association fits comfortably with the effect of theory of knowledge on awareness which has been proposed by many epistemologists.[27] As illustrated in [Figure 1], the domains reported for practice do not operate in isolation but occurs in and through the context of dynamic knowledge–awareness interaction.

Evidence-based knowledge and cultural awareness to practice

The respondents’ responses reflect that greater emphasis has been given to knowledge rooted from peer-reviewed evaluation and academic literacy rather than ordinary knowledge transfer.[28] This may be explained by the fact that dental educators are well trained professionally and ethically,[29] therefore, their actions are based on evidence-based as practiced in other health care disciplines.[30],[31],[32] Moreover, there is the need for physicians in exercising benefit–risk analysis while considering any type of procedures and choice of treatments for better health outcomes.[33],[34] The restricted evidence based practice (EBP) has also influenced dental educators’ interest and awareness in teaching the Miswak topic along with other oral hygiene tools at their dental school. This could be due to having different priorities and directions in governing the dental educational system among policy makers.[35],[36]

The different level of knowledge to practice have always created tensions especially when valuing the cultural–religious aspect although there is no specific guideline on how to practice it.[4],[9],[37] This could be further explained even though they were mostly trained in western countries[37],[38]; they are mostly Asian and Muslim educators who are keen to keep this behavior as part of their lives.

Poor disseminates of Miswak benefit

The presence of evidenced-based knowledge for Miswak is not just limited but also circulated locally among Asian and Arabic literacies.[5],[9] Most studies are published not in higher citing index publishers and, consequently, the key search terms for Miswak are rarely searched in the database. Therefore, it is hard to convince other policy makers or the industry to appreciate the credibility of the research findings from this publisher. Low level of audience probably was the main reason why Miswak has not been accepted by those high rank journal. This, however, necessitates further research and investigation.

Although Miswak has proven to have several benefits,[2],[5],[8],[9]it is, however, ignored in the dental field. Therefore, it is practically important to encompass perception and views from relevant stakeholders qualitatively rather than solely based on the evidences produced through quantitative or laboratory methods; to further explain and clarify unexplained dynamic phenomena effectively[21]; of people and healthcare workers influenced by several drivers for change[29],[39],[40]; for a better consideration and acceptance in future policy.

Interestingly, there is an increasing number of public practicing Miswak especially in developing countries[1],[41] and among postmodern communities. It has highlighted the need to deal with the existing needs/demands for care using Miswak for some of the population. Stakeholders should also recognize the importance of continuing professional development for dental practitioners to cope with the challenges of social expectation for Miswak. Through scientific and technological developments, Miswak chewing stick could be placed on par with other effective dental care tools, as strongly recommended by other studies.[36],[42]

Barriers of Miswak practice

Primarily, dental educators have raised concerns about the effectiveness of using Miswak. Similar to a toothbrush, it has an end-stick at the long axis, however, not perpendicular to tooth surfaces.[5],[8],[9] Therefore, it highly recommended to use Miswak as an alternative rather the main tool for oral hygiene. Moreover, respondents expressed potential effects of using Miswak, such as toxicity and hygiene, which have not been well documented and tested. However, there is an in-vitro evidence discussed at an international conference which showed that Miswak has less cytotoxic effect compared with ordinary chlorhexidine mouthwash.[43] On the other hand, using fresh and clean bristles with every cut could ensure and preserve good hygiene.[1],[44]

Meanwhile, there is evidence that excessive and improper use of the chewing sticks can cause occlusal tooth wear, attrition, and a small degree of gingival inflammation.[1],[9],[44] Thus, there is an urgent need for a comprehensive guideline to be made in order to minimize its risk. In this regard, there is only one published guideline to teach on how and when to use Miswak properly.[44] Additional study is needed to evaluate and assess the effectiveness of this technique; and how it could be modified to encourage better acceptance among public and global industry.[1],[4],[9],[44]

In this qualitative study, the FGDs involved people with different backgrounds, but they were grouped into homogeneous characteristics to allow freedom of speech and to avoid sensitive issues. Their views, knowledge, and experiences reflect their current knowledge, awareness,[21],[45] and practice related to Miswak. In this light, the strength of the focus group study approach is its ability to describe and explain a process or phenomenon[21] that is central to the current research problem from the participants’ own perspective.[24] Furthermore, this study utilized a topic guide that comprised open-ended questions.[21],[22],[23] It has offered more freedom for the interviewees to express their views in their own terms unlike a structured interview.[22] As Miswak is an unknown topic for some of the respondents, FGDs provided a rich data[21],[24] that complemented other findings[46] obtained from the questionnaire survey. This method has been successfully used in dentistry[47],[48] and has provided dental researchers and health experts a better way to examine oral practice issues.[46]

The issue related to the qualitative study is that the respondents’ views seem to represent their perspectives at the time the research was conducted. Given the nature and pace of the issue, such perspective could evolve over time, so there is a need to review and update the research findings. In this regard, there might be a growing trend for using Miswak among the public and the local dental professionals and a questionnaire survey is useful for future research as it may provide large-scale data on the need for formal teaching and guidance on Miswak practice.

  Conclusion Top

In conclusion, extensive change in dental curriculum requires knowledge and awareness of Miswak practice. Thus, the relationship between these key elements needs to be identified and understood, alongside the cultivation of evidence-based knowledge to support positive transformational change.

Clinical relevance

There is an increasing trend of considering Miswak as an oral hygiene tool, although there are no proper guidelines on Miswak usage, with greatest concern on its clinical complications. However, there is a strong sense of valuing evidence-based knowledge on Miswak effectiveness in treating dental diseases and cultural–religious belief among people in meeting oral needs and social expectations. Therefore, extensive change in dental curriculum requires knowledge and awareness of Miswak among educators, with cultivation of evidence-based knowledge to support positive transformational change in education and practice.


The authors acknowledge the contribution of all dental educators who participated in the study.

Funding Sources

This study has only received financial support from local university grant with id no: RIGS 17-087-0662.

Conflicts of interest

There are no conflicts of interest.

Authors contributions

MCFM conceived and designed the study.All authors contributed to the study and approved the final version of the manuscript..

Ethical policy and Institutional Review board statement

Approval for the research program was obtained from IIUM Research Ethics Committee (IREC) (Reference number: IREC 771) in accordance with the World Medical Association Declaration of Helsinki.

Patient declaration of consent

All participants consented to the conduct of the study and dissemination of research data and findings.

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1 Clinical benefits and adverse effects of siwak (S. persica) use on periodontal health: a scoping review of literature
Haslinda Ramli, Tuti Ningseh Mohd-Dom, Shahida Mohd-Said
BMC Oral Health. 2021; 21(1)
[Pubmed] | [DOI]


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