Exploration of siwak effects on periodontal health and the development of an integrated scientific and Islamic knowledge guideline on the method of siwak practice

Abstract

Periodontal disease can result in tooth mobility and elongation, leading to potential extraction, and significantly affecting daily life quality, hence underscoring the importance of maintaining a healthy periodontium through effective oral hygiene care. While toothbrushes are commonly used, some prefer siwak, a natural oral hygiene aid used for centuries by Muslim communities. Though effective, its potential adverse effect on periodontal health remains debatable. This study aims to investigate siwak practice methods and their effects on periodontal health, ultimately developing a comprehensive guideline that integrates the Islamic knowledge on siwak practice and scientific evidence. The study employs a mixed-method design, incorporating a scoping and systematically literature reviews with meta-analysis (SRMA) to assess its effectiveness in adult clinical trials. The study also explores the siwak method and practice as described by the Prophet (peace be upon him, PBUH) through interviews with five contemporary Islamic scholars. Furthermore, experiences of eight siwak users are gathered through an online focus group discussion (FGD) and analysed thematically. Triangulating these data sources, a guideline is developed, and its content is validated using a modified Delphi technique with 54 experts. The quality of the guidelines is further appraised by three appraisers using Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Although the siwak's effects on subgingival bacteria remains inconclusive, it effectively removes dental plaque and improves periodontium health over time. The SRMA supports these findings, indicating that an adjunctive siwak significantly reduces plaque (p=0.01, SMD: 0.68, 95% CI: 0.14 to 1.22) and gingivitis score (p=0.04, SMD: 0.66, 95% CI: 0.03 to 1.29) compared to exclusive toothbrush. Conversely, siwak users may experience gingival recession and clinical attachment loss (CAL) due to variations and errors in siwak methods and practice. Based on three identified themes—siwak preparation, toothbrushing method, and siwak practice—a knowledge-based guideline is developed, which received expert consensus and rendered high ratings for its quality. This study contributes to existing knowledge by integrating Islamic-scientific evidence-based practices and emphasising etiquette in siwak use. Dental practitioners can utilise this high-quality guideline to improve communication upon oral hygiene education with siwak users while respecting their health beliefs.