Will you please give information about oral health in terms of religion and science?

Dear Brother / Sister,

It is sunnah to keep the mouth clean.

The mouth is the first entrance gate of the digestive system. The food is tasted there, chewed, partially digested and swallowed piece by piece. 300-400 types of different microorganisms have been identified in the mouth. According to some researchers, it has been reported that there are 500 microorganisms and 700 according to other researchers. They form the oral flora, that is, the microbiota according to the new terminology. They are necessary for oral health as long as they are within normal limits. If cleanliness is not attended to, they become harmful when bacteria form microorganism colonies called biofilm (dental plaque). Therefore, if the entrance and exit of the digestive system are not kept clean, many diseases can occur. Therefore, the entrances and exits must be kept clean.

Our religion also gives importance to the cleanliness of these parts. Even prayer cannot be performed when the exit point of the digestive system is not cleaned. Taharah (cleanliness) is one of the fard deeds before starting to perform a prayer. Cleaning the mouth is also a sunnah of wudu. This sunnah is fulfilled by washing the mouth three times.

“There are degrees in the practices some are compulsory; these may not be given up. This sort are described in detail in the Illustrious Shari‘a. They are incontestable and can in no way be changed. Another sort are voluntary, and these are of two sorts:

One sort includes those practices related to worship. They too are described in the books of the Shari‘a and to change them is innovation. The other sort is known as “conduct” (adab); these practices are mentioned in the books of the Prophet’s (PBUH) biography. Opposition to them cannot be called innovation, but it is opposition of a sort to the Prophet’s (PBUH) conduct and means not benefiting from its light and true courtesy. Following this sort entails emulating him in customary, natural acts and dealings, which are known through unanimous reports. (Nursi, The Flashes, Eleventh Flash)

Based on those rules, cleaning the mouth is a sunnah of wudu and is connected to worship. Altering this sunnah is a bid’ah (something that entered into religion afterwards) and it cannot be changed.

While cleaning the mouth before making wudu, it is a sunnah to do it in detail with various tools. We can say that cleaning the mouth with a miswak, toothbrush and other tools is suitable for this sunnah. This hadith shows the importance of prayer performed by cleaning the mouth:

“A prayer performed using miswak is superior to seventy prayers performed without using miswak.” (see Musnad, 6/272)

Another hadith that gives information about the importance and value of cleaning the mouth is as follows:

“If I knew that it would not be difficult for my ummah, I would order them to make wudu for every prayer and to use miswak for every wudu.” (Bukhari, Jumu'a, 8; Muslim, Taharah, 42)

Oral cleaning is included in which sunnah?

As for miswak, some scholars decree that it is a sunnah of wudu; others decree that it is a sunnah of prayer, and yet some others decree that it is a sunnah of the religion. Abu Hanifa is one of those who say that miswak is a sunnah of the religion.

Miswak is a sunnah that our Prophet (pbuh) both did and recommended to be done; because he recommended it with his words, showed it in action and set an example by practicing it in his life.

Does the toothbrush replace miswak or not?

Let us try to explain this issue from various perspectives:

In terms of health, we see that oral hygiene is poorly practiced or not practiced and misapplied although everyone knows that it is necessary and important.

Cleaning the mouth is one of the daily habits that we should adopt when we were children, like many habits.

There is hardly any place in our body without microorganisms and especially bacteria. Those bacteria are a part of our body and crucial for life. When we say microbes, harmful things always come to mind, but most bacteria are beneficial for us. There is no problem as long as the body balance is not disturbed.

It is necessary to pay attention to the cleanliness of the mouth on a daily basis so as not to disturb the balance in the mouth. It is a mechanical cleaning to remove bacterial plaque that accumulates on the teeth. Today, science has agreed on it. Drugs and chemicals cannot be used for a long time instead of mechanical cleaning; if used, the balance of microbiota in the mouth is disturbed, leading to the emergence of especially fungal diseases.

Tools used in mechanical cleaning are brushes, miswak, dental floss, toothpicks and interdental brushes.

Our scholars state that the purpose of following the Sunnah is to attain the consent of Allah (swt) and the intercession (Shafa’ah) of the Prophet Muhammad (pbuh).

The main purpose of following the Sunnah is to gain the consent of Allah. Sunnahs are also a means of world bliss.  For example, as we earn thawabs by eating less with the intention of following the sunnah, we also protect our health. Sunnahs are a means of assistance for happiness in the world and the hereafter.  Especially the sunnahs that are related to customs are generally necessary for our worldly health. When we abandon such sunnahs because of our laziness, we do not commit sins, but we become deprived of their benefits.

Some scholars suggest that some types of customary sunnahs may change over time. For example, they interpret archery and riding horses like that: “Everything with which a man amuses himself is vain except three (things): a man's training of his horse, his playing with his wife, and his shooting with his bow and arrow. If anyone abandons archery after becoming an adept through distaste for it, it is a blessing he has abandoned.“ (al-Jami' as-Saghir, 1/478, No: 955)

Cars have replaced the horse these days, and tomorrow other vehicles can replace them. Besides, riding a horse and shooting arrows is beneficial and sunnah as long as it is done with the intention of following the sunnah and training. Today's weapons and vehicles are not an obstacle to do it.

“These three things are the bliss for son of Adam; a suitable wife, a spacious house, a comfortable mount.” (Musnad, 1/168) The Prophet  describes a mount as one of the basic elements of our happiness. While camels, horses, donkeys and mules were mounts at the time of the Prophet Muhammad (pbuh), today there are cars, even private planes and helicopters in our daily life.

The 60th verse of Surat al-Anfal encourages a Muslim to work and to be strong:

“Prepare against them what you believers can of military power “

“Beware, strength consists in archery. Beware, strength consists in archery. Beware, strength consists in archery.” (see Muslim, Imarah,167; Abu Dawud, Jihad,23; Tirmidhi, Tafsiru sureti 8; Ibn Majah, Jihad, 19).

This description of strength will continue to be valid until Doomsday. In every era, those who held the advantage of shooting were superior. (arrow, gun, howitzer, missile, anti-missile, etc.)

The Prophet Muhammad (pbuh) advised a Muslim to be strong.

Being strong is possible with the health, which is necessary for all good things. The most important blessing given to man after the blessing of belief is health. One of the important elements of being healthy is possible by paying attention to material and spiritual cleanliness.

Islam attaches importance to external and spiritual cleanliness.

There is almost no one who has not heard the hadith "Cleanliness is half of belief". The Covid-19 outbreak has highlighted the importance of cleaning even more these days. Oral cleaning has also attracted a lot of attention due to this virus because one of the ways for the disease to enter the human body is the mouth. The Prophet Muhammad (pbuh) emphasized the cleanliness of the mouth with his many hadiths and practices.

Therefore, one of the most important sunnahs that are about to be forgotten, improperly applied or not understood well is using miswak and similar materials in mouth cleaning.

Miswak

Miswak is a cleaning tool that was used by many tribes and that dates back to very old times. The Babylonians, Romans, Greeks, Egyptians, Africans, South Americans and Arabs used the arak tree for mouth cleaning. In addition, other plants have been used for cleaning the mouth (olive tree, orange tree, etc.). Miswak came to the fore more with the Prophet Muhammad (pbuh).

Especially unbelievers opposed and rejected miswak, as in everything else, because it came to the fore with Islam.

Those who are sensitive to the Sunnah and use miswak say, “We will use only miswak” and opposed other cleaning tools because the Prophet Muhammed (pbuh) used it.

Thus, they went to extremes. The wise one is the moderate one, to use either one when it is appropriate.

Miswak, which is derived from the word "siwak", which means "to rub something", is obtained from the branches of a tree called arak (Salvadora persica linn). Miswak is the name of the branches or roots of the tree used for mouth cleaning. Miswak and Siwak are used in the same sense in hadiths.

So, the main thing is to clean the mouth and do it mechanically.

The thin branches of the wild olive tree are also used as a miswak now and were used at the time of the Prophet Muhammad (pbuh).

No chemicals or drugs can replace mechanical cleaning and cannot be used for a long time. Apart from mechanical cleaning, the only chemical agent that can prevent plaque formation is chlorhexidine digluconate. This substance is harmful to health if it is used more than 10-15 days in some diseases.

By using miswak, the Prophet Muhammad (pbuh) showed that mechanical cleaning is indispensable in cleaning the mouth. Toothbrushes also do this partially.  Using only the brush is insufficient for cleaning the teeth.

According to the narrations of the Companions, the Messenger of Allah (pbuh) used miswak day and night. He always used miswak, especially when entering the house, before going to sleep, when he got up from bed and before leaving house for prayer. He also used miswak while resting in his house or in the mosque.

Many substances enter the body through the mouth. This entry is caused by absorption from the digestive tract, the mucosa covering the mouth, and the salivary ducts. People with high blood pressure are given sublingual antihypertensive drugs to lower blood pressure. It acts faster than the drug injected into the serum which is given through the vein because there are a lot of receptors on the palate and at the base of the mouth. Miswak and its ingredients are absorbed by dissolving in saliva in this way stimulating the taste buds and mucosa in the mouth.

How to use Miswak?

It is necessary to use the miswak for 2-3 minutes in order to benefit sufficiently from it in the mouth and teeth cleaning. Approximately 3-5 seconds are necessary for one tooth to mechanically remove the microbial dental plaque. For an individual with 28 teeth, that makes 84-140 seconds. And it is approximately 1.5-2.5 minutes.

Abu Musa (r.a) narrates: “I visited the Messenger of Allah (pbuh). He was brushing his teeth with a miswak in his hand and he was producing a sound like ‘u’ as if he was vomiting." (Bukhari, Wudu, 73)

Abu Imama (r.a) narrates: The Messenger of Allah (pbuh) said: “Use miswak for your teeth because miswak is a means of cleaning the mouth. It is conducive to Allah's consent. Every time Jibril came, he recommended miswak to me so much that if I had not worried that I would cause hardship to me and my ummah, I would have made it fard to them. I use miswak so much that I feel worried that my front teeth (or gums) will be abraded from the bottom.” (Ibn Majah, Taharah 7)

Those two hadiths show that the Prophet (pbuh) used miswak for a long period.

As far as we can see around us, most people use miswak horizontally from right to left, but for up to 5 seconds and we observe that the tip of the miswaks they use are worn so much as to have lost their effectiveness. Yes, that person gets a thawab due to his intention, but he does not follow the sunnah completely. We think that he will not be able to fully benefit from the health benefits of this sunnah.

Likewise, most people use the toothbrush for 10-15 seconds. With such short-term brushing, the teeth are not fully cleaned.

The tip of the miswak should be fibrous. Thinned and bent miswak tips should be renewed. In the same way, the toothbrushes should be replaced when the tips are bent.

Miswak and toothbrush should be used gently as if caressing teeth and gums. It should be used horizontally and vertically. When applied vertically, we are recommended to use it downward from the upper teeth and upward from the lower teeth. We should use brush the teeth, gums and even tongue with miswak.

How to clean the mouth if there is no miswak or toothbrush?

If our miswak or toothbrush is not with us, there are occasions that will guide us in the hadiths about how to clean our mouth after making wudu or after eating.

"How good are those members of my ummah who clean between their fingers while taking wudu and clean their teeth after eating." (Musnad, 5/416)

“Clean between your teeth with a toothpick after eating because it is cleanliness. And cleanliness calls for belief. Belief is with its owner in Paradise.” (al-Jaami' as-Saghir, 3/236, No: 3267)

After washing our hands, we can also partially clean our teeth and gums by rubbing with our index fingers. It is especially useful to massage the gums in this way. Sturdy and triangular shaped toothpicks can be used to clean between teeth.

Qadi Ayyad states that it is understood from the hadith mentioning that the first thing the Prophet Muhammad (pbuh) did when he came home was to clean his teeth with miswak that he frequently used miswak, that he did not regard it enough to use it only once during the day and once at night, and that it is understood from his practices that miswak should be used at home rather than in places where people gather. Abu Shama includes this interpretation to support the opinion that it is not pleasant for some people to bring miswak to the mosque and use it before every prayer. (as-Siwak, Tanta 1410/1990, p. 72)

In addition, in the books related to education and good manners, attention is drawn to
- the importance of using miswak in terms of taking care of cleaning on the one hand, (Abdülhay el-Kettânî, Hz. Peygamber’in Yönetimi: at-Taratibul-Idariyya (translated by Ahmet Özel), Istanbul 2003 2/402-403),
- and that it is not appropriate for a person to clean their teeth with a toothpick in the presence of a group of people on the other hand. (Ghazzali, Adabus-Suhba wal-Muashara, Baghdad 1984, p. 311)

What is the last thing the Prophet Muhammad (pbuh) used before his death?

"Hz. Aisha (ra) narrates: During the illness of Prophet Muhammad (pbuh), my brother Abdurrahman Ibn Abu Bakr (ra) came. He had a miswak in his hand; he was brushing his teeth. The Messenger of Allah (pbuh) looked at that miswak and I said, "Give me that miswak!" He gave it. I gnawed and chipped it with my teeth and softened the tip and gave it to the Messenger of Allah (pbuh). The Messenger of Allah (pbuh) brushed his teeth with that miswak while his head was leaning against my chest." (Bukhari, Maghazi 83; Muslim, Salah 90)

Acting upon this hadith, some scholars decreed that the moment of death of a believer using miswak would be easier.

Is it useless for non-Muslims to use miswak?

A non-Muslim who uses miswak benefits from the worldly advantages of miswak but he cannot benefit from its otherworldly advantages.

Everyone is equal before the laws Allah (swt) has set in the universe, whether they are Muslims or not. Whoever obeys these laws better will succeed. Therefore, whoever uses the miswak properly will benefit from it.

Which miswak is more useful?

If Miswak is fresh or 1-2 months old, its benefit is more. There are more volatile compounds and substances that give a good smell in fresh miswak than non-fresh ones. Miswak is recommended to be 15-20 cm long and as thick as a little finger. Our scholars described this measure practically as “each person's own handspan and the thickness of his own little finger." There is no harm in using a thinner miswak than this measure. We can use all kinds of miswaks that are intact and not moldy. 1 cm of the bark of the tip of the miswak is removed and this peeled part of the tip is left in clean water until softened. The softened tip is made fibrous with the tooth or the handle of the knife and used in this way.

Miswak can be used like holding a pencil or a toothbrush. Some of the scholars advised that the lower part of the miswak should be kept on the little finger. It is used for a longer period than the toothbrush. It is used for teeth, gums and tongue without putting any substance on it.

Miswak must be clean and always kept clean.

Hz. Aisha (r.a) narrates: "I would prepare three covered pots at night for the Messenger of Allah: One pot for wudu, one pot for miswak and one pot for his drink.” (Ibn Majah, Ashriba, 16)

As can be understood from the hadith, miswak must be washed after use and stored in a clean container. It is important in terms of both religion and health. When using it again, after rinsing the mouth, miswak is applied dry. The toothbrush is also applied dry to the teeth. It is important in order to increase the mechanical effect.

Most of the foreign resources call the miswak as “chewing stick” probably because we make the miswak fibrous with our teeth.  In other sources, miswak is named as "natural toothbrush" and miswak tree as "toothbrush tree".

Scientific studies on miswak and benefits of miswak

There is the PubMed site, which is a widely used search engine for articles in medicine and other healthcare fields. When we searched for Salvadora persica in Pubmed, we found 169 articles, and when we searched it as “miswak”, we found 152 articles. When we searched for miswak or salvadora persica, we found 250 articles. (This research was carried out on 19. 07. 2020)

There are thousands of articles on Google Scholar, too. In the light of this research, let us try to explain briefly the substances in the miswak.

The benefits of miswak are explained in three ways in scientific studies:

- Mechanical effect of fibrils,

- The effect of chemical substances in miswak,

- And the effect of those two together.

Miswak contains organic and inorganic compounds. Of the 100 units of miswak, 27 percent is composed of solid substances. (Substances that produce ash when burned.) It contains a high proportion of alkaloids. Miswak extract has a high antimicrobial and antioxidant effect.

Sodium chloride, sulfur, calcium chloride, vitamin C, potassium chloride, phosphorus, sodium bicarbonate, fluorite, silicon (silica) and calcium form its inorganic structure.

Silica, which is widely used in toothpastes, helps to remove stains and deposits on the teeth. It is an abrasive substance. Sodium chloride prevents tartar formation and is antiseptic. It has a moderate antibacterial effect. Fluorite, which is frequently used in toothpaste, prevents the formation of caries; it is effective in remineralization, which means the repair of micro-level losses of the enamel (crown) that forms the hardest layer of the tooth. Minerals and compounds such as sodium bicarbonate and calcium also play an important role in remineralization.

In addition, miswak contains organic substances such as volatile oils (benzyl nitrile, eugenol, thymol, isothymol, eucalyptol, isoterpinolene, β- caryophyllene), phenolic compounds, fatty acids (oleic, linoleic, stearic acids),tannic acid, alkaloids (salvadorine, trimethylamine), mustard oil, resin, flavonoids (kaempferol, quercetin, quercetin rutin, quercetin) glycosides, salicylic acid, saponin, sterols, alpha amylase, benzyl isothiocyanate. We will briefly mention the effect of some of those substances here.

The resin prevents the formation of caries by creating a physical barrier on the enamel. Mustard oil relaxes the stomach and has an antiulcer effect. It is carminative. Fatty acids have antiseptic and buffering effects. Thanks to their bitter taste, they stimulate and increase saliva flow. Volatile oils have a buffering, analgesic and antiseptic effect. They increase the flow rate of saliva. Tannic acid is effective on plaque and inflammation. It has an astringent effect on the gums. It prevents formation of tumor (antitumor effect). Benzyl isothiocyanate is found in large amounts in miswak. It has a fast and powerful effect against pathogenic bacteria and especially gram-negative bacteria. Alkaloids have antibacterial and anti-inflammatory effects. They have a stimulating effect on the gums.

The benefits of miswak should not be limited only to oral and dental health. It also benefits general health, especially eyes, memory, stomach and kidneys.

Although our scholars think miswak made from arak tree is more appropriate in terms of sunnah, they say that miswak can be made from other trees (such as wild olive trees). Nylon brushes can also be used, although they are not a substitute for the miswak made of arak tree.

Thus, regards cleaning the teeth essential. Islamic scholars state that the best means of it is the miswak made from arak tree, but it is not necessary to insist that it must be the miswak obtained from the arak tree.

According to Abu Hanifa, miswak is a sunnah of both wudu and the religion. It is recommended to use miswak regularly.  It is inexpensive, simple and easy to use. Therefore, it is of human nature to use brushes and miswak.

Some people use the toothbrush and the miswak together. There are those who do the rough cleaning with a toothbrush and even sometimes they add coconut oil on toothbrush. Occasionally, it may be appropriate to brush teeth with the plainest toothpaste. However, there are also those who prefer to use the toothbrush without toothpaste. After that, cleaning can be done with miswak. We should try to use miswak as much as we can before wudu. If there is no brush or miswak with us, we should try to clean our teeth by rubbing with our index fingers while performing wudu. Application and preference may vary depending on the person.

The important thing is to try to protect oral and dental health with the intention of following the Prophet Muhammad (pbuh), and the trust given to us by Allah (swt). We should use the way and the method that is easier or more appropriate to do while doing it.

Hadith sources:
1. Sahih Kaynaklardan Seçme Hadisler Camiüs Sağir Muhtasarı Tercüme ve Şerhi, İsmail Mutlu, Şaban Döğen, Abdülaziz Hatip, Yeni Asya Neşriyat, 2002.
2. Prof.Dr.İbrahim Canan Akçağ Kütüb-ü Sitte Muhtasarı Tercüme Şerhi, Akçağ Yayıncılık.
3. İmam-ı Nevevi. Riyâzü’s – Sâlihîn Tercümesi, Çelik Yayınevi 1979, Tercüme Salih Uçan.
Other sources:
1. Sofrata A. H. et al. Strong Antibacterial Effect of Miswak Against Oral Microorganisms Associated With Periodontitis and Caries. J Periodontology 2008;79:1474-1479.
2. Al-Otaibi M. et al. Subgingival plaque microbiota in Saudi Arabians after use of miswak chewing stick and toothbrush. J Clinical Periodontology 2004; 31: 1048–1053.
3. Dahiya P. et al. Miswak: A periodontist's perspective Journal of Ayurveda and Integrative Medicine.  2012; 3:(4) 184-187.
4. Halawany H. S. A review on miswak (Salvadora persica) and its effect on various aspects of oral health. The Saudi Dental Journal 2012; 24: 63–69.
Note: American Journal of Periodontology, Journal of Clinical Periodontology are important old journals which are included in the European SCI. Otherwise, many articles have been published in various journals.

(Prof. Dr. Yasin Çiçek - Adıyaman University, Faculty of Dentistry, Faculty Member)

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