The effect of Miswak varnish on streptococcus Mutans count and gingival inflammation in orthodontic patients

Objective: Primary objective: To evaluate the effect of Miswak extract varnish on streptococcus mutans (S.mutans) counts in saliva and plaque, gingival bleeding index (GBI) and plaque index (PI) in orthodontic patients. Secondary objective: to suggest an appropriate frequency Miswak varnishes application to produce maximum efficiency. Material and methods: Enrolled patients (n=75) were randomly and equally divided into 3groups. Chlorhexidine varnish group, Miswak varnish group and control group. S.mutans counts in plaque and saliva, GBI and PI were evaluated at different time points; T0: before brackets bonding, T1: two weeks after brackets bonding, T2: one months after brackets bonding and T3: three months after brackets bonding. Results: Both chlorhexidine and Miswak varnishes reduced plaque S.mutans counts significantly at T2 compared to the controls, with no significant difference between Chlorhexidine and Miswak varnishes at this timepoint. After 3 months, chlorhexidine varnish group had the lowest S.mutans plaque counts followed by Miswak varnish group, while the control group had the highest counts. GBI was reduced significantly in both chlorhexidine and Miswak varnishes groups, when compared to the control group at both one month and 3 months timepoints with no statistically significant differences between chlorhexidine and Miswak neither at one month nor at 3 months. PI showed no statistically significant differences between the 3 study groups at different timepoints. Conclusions: Miswak varnish can be an acceptable natural substitute to chlorhexidine varnish as an anticariogenic agent if applied at monthly basis. Mechanical brushing is mandatory to reduce plaque accumulation and maintain proper gingival health. Introduction White spot lesions (WSL) are a common side effect in 50% to 70% of patients undergoing fixed orthodontic appliances treatment(1). The cause of these lesionsis multifactorial, mainly caused by the inability to maintain proper oral hygiene together with pH levels lower than 4.5 recorded in the plaque around fixed orthodontic appliances components(2). Moreover, Orthodontic treatment may induce disturbances of the complex oral ecosystem leading to an increase in cariogenic microorganisms such as Streptococcus mutans (S.mutans) in saliva(3– 5). Chlorhexidine has the ability to prevent and reduce bacterial growth(6) and consequently inhibit acid production and pH falls in plaque(7); therefore, chlorhexidine is considered the gold standard to inhibit enamel demineralization(6,8–11). However, prolonged use of chlorhexidine preparations may have adverse side effects on oral structures such as; mucosal irritation and burning sensation, bitter taste, , teeth discoloration and tongue staining(12,13). Moreover, S.mutans and the other oral microorganisms have developed Egyptian Orthodontic Journal 59 Volume 59 – June 2021 ISSN: 1110.435X resistance to chlorhexidine due to its routine use in dental care products(14). Recently, the use of natural plant extracts for dental caries controlhas been increasing as they are economical and with no apparent side effects(15). Studies tested different plants with different preparation methods and results were always promising(16–18). World Health Organization (WHO) recommends the use of chewing sticks obtained from natural plants due to its promising results in promoting oral health(19). Among 182 species of natural plants used for this purpose worldwide,Salvadora persica plant (the commonly known as miswak tree) is the most commonly used plant for this practice(20). A wide variety of oral health promoting organic and inorganic components have been isolated from miswak extract(21)and researches found it to have antiplaque(22), antibacterial (23,24) and consequently anticariogenic(25) properties. Miswak extract showed potential antibacterial activity against S.mutans and Lactobacillus acidophilus(26). Miswak use resulted in better periodontal status than normal toothbrush (27); due to its inherited antibacterial activity against cariogenic and periodontopathic bacteria(28). To our knowledge, few studies have investigated the antibacterial effect of Miswak extract in orthodontic patients. The primary aim of this study was to evaluate the effect of Miswak extract varnish on streptococcus mutans counts in saliva and plaque, gingival bleeding index (GBI) and plaque index (PI) in patients undergoing fixed orthodontic appliance therapy in comparison to a varnish containing the chlorhexidine gold standard. The secondary aim is to suggest an appropriate frequency for chlorhexidine or Miswak varnishes application to produce maximum efficiency. Material and methods Study design: Prospective randomized controlled clinical study. Study sample: Consisted of patients assigned to start fixed orthodontic appliance treatment in the department of Orthodontics, Faculty of Dentistry, Alexandria University. Investigators supplied the patients or their guardians (for patients younger than 18 years old) with full detailed information about the study procedures and aim.An informed consent was signed for every participant before being involved in the study. The investigators had the study protocol approved from the ethics committee in Faulty of Dentistry, Alexandria University. Sample size estimation, randomization, and