For religious and cultural reasons, the miswak (chewing stick) is preferred to the toothbrush in the Middle East. A key question in public dental health planning is whether strategies to improve oral hygiene should be based on the toothbrush, the miswak, or both. Objectives: To analyze prevailing oral hygiene practices among Saudi Arabians in relation to age, gender and educational level. Methods: Structured interviews with 1200 regular patients at two centers providing dental care for university and military staff and their families, respectively, in the city of Makkah. Consecutive patients were stratified by gender and age, into 6 categories from 10 to 60 years, with 50 male or female subjects in each group at each center. Oral hygiene habits were correlated with age, gender and educational levels, using ANOVA. Results: Oral hygiene practice started very late, after the age of 7 yr, for the majority (>86%) of the individuals. Oral hygiene habits were strongly correlated to the level of education (p<0.001). The miswak was preferred by less educated people. Toothbrushing started earlier among the better educated (p<0.001). Regular miswak use was more frequent in older age groups (p<0.001). Among less educated 50-60 yr olds 44% never used a toothbrush. Females used a toothbrush more often than males (p<0.0001), and miswak use by women was less frequent than by men (p<0.0001). Conclusions: These pronounced variations in oral hygiene habits, related mainly to age and educational levels, should be taken into account in planning oral health strategies. Oral hygiene should be established early in life. Systematic, effective use of the miswak should be encouraged, especially among the elderly and the poorly educated. To benefit from fluoride exposure, use of the toothbrush and fluoride toothpaste should be encouraged among younger Saudis.

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