The prevalence of gingival recession among miswak (Salvadora persica L.) chewing stick users: a systematic review

Background: Miswak, a natural chewing stick from Salvadora persica L., is traditionally used for oral hygiene in Africa, Asia, and the Middle East. Despite evidence of its effectiveness in plaque reduction and periodontal health improvement, its relationship with gingival recession remains understudied. Aim of the study: This systematic review evaluates existing literature to determine whether miswak use is associated with gingival recession compared to conventional toothbrush use. Materials and methods: Literature was retrieved from Web of Science, Scopus, PubMed, Ovid MEDLINE, Ovid Emcare, CINAHL, and LILACS to analyse studies evaluating gingival recession prevalence among miswak users from 1983 to 2024. The Joanna Briggs Institute Critical Appraisal tool was used for quality assessment. Results: Analysis of studies including 6 315 individuals showed varying results. Seven studies reported higher gingival recession prevalence (9.88–67.85%) among miswak users compared to conventional toothbrush users, while two studies reported no recession. Additional findings included increased anterior tooth wear, clinical attachment loss, and tooth loss. Usage frequency, technique, fibre texture, and user age influenced outcomes. Conclusion: The lack of standardised miswak usage techniques contributed to variable outcomes across studies. Some studies suggest increased tooth wear, gingival recession, and abrasion with miswak use, while others report no difference or positive effects on oral health. Miswak's overall impact on periodontal health remains inconclusive, requiring standardised methods and controlled studies to better understand miswak's long-term effects and develop evidence-based usage recommendations.