Abstract Background Glass ionomer cements (GICs) are extensively used in restorative dentistry owing to their biocompatibility, sustained fluoride release, and chemical bonding to tooth hard tissues. Nonetheless, their mechanical durability and antimicrobial effectiveness remain suboptimal, particularly in caries-prone areas. Recently, natural bioactive additives such as Salvadora persica (miswak) have attracted interest as potential enhancers of GIC properties. This systematic review investigates the impact of miswak-modified GIC on antimicrobial activity and physicomechanical characteristics, aiming to identify optimal extract types and concentrations for clinical applications. Main text. A comprehensive literature search was performed in March 2025 across PubMed, Scopus, Web of Science, Cochrane Library, and OpenGrey, following PRISMA 2020 guidelines. Inclusion criteria encompassed in vitro and in vivo studies comparing miswak-modified with conventional GICs, focusing on antimicrobial efficacy, compressive strength, surface hardness, and fluoride release. Risk of bias was evaluated using the modified CONSORT checklist and ROB2 tool for in vitro and in vivo studies, respectively. Seven studies met eligibility criteria. Miswak addition consistently enhanced antimicrobial effects against Streptococcus mutans , Lactobacillus spp., and other cariogenic bacteria, with ethanol-based extracts yielding superior inhibition zones. The body of evidence comprised five in vitro studies and two randomized controlled clinical trials. Mechanical outcomes varied with concentration: Low doses (1–2%) preserved compressive and tensile strength, whereas higher doses diminished these properties. Surface hardness was increased with ethanol extract formulations. Fluoride release was reported to rise at specific miswak concentrations in one study. Conclusion Incorporating miswak extract into GIC has promising potential to improve antimicrobial properties without compromising, and occasionally enhancing, mechanical performance. These findings suggest promising preliminary evidence for miswak as a biocompatible, plant-derived additive in glass ionomer cement; however, the available evidence is predominantly laboratory-based and requires further validation through well-designed clinical trials.
Ezzat et al. (Tue,) studied this question.