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Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 170-175

Current trends in irrigation practice during endodontic treatment among general dental practitioners in Saudi Arabia

1 Department of Dentistry, King Faisal General Hospital, Hofouf, Saudi Arabia
2 Department of Prosthodontics, Dammam Medical Complex, Dammam, Saudi Arabia
3 Dental Intern, Riyadh College of Dentistry and Pharmacy, Riyadh, Saudi Arabia

Date of Web Publication25-Jul-2018

Correspondence Address:
Dr. Mohammed Matooq Al-Ali
Department of Dental, King Faisal General Hospital, Hofouf
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_4_18

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Aim: This study aims to determine the current trends in endodontic irrigation practice among general dental practitioners (GDPs) in Saudi Arabia.
Methodology: An invitation to participate in a questionnaire was electronically sent to 500 affiliates of the Saudi dental association. The members were queried about the irrigation solution(s) they utilize, reasons affecting their selection of irrigant, the concentration of irrigant, the removal of smear layer, the use of an intracanal medicament, the depth of penetration and gauge of the needle used for irrigation, and participation in a course related to endodontic irrigation.
Results: Two hundred and thirteen responses were obtained out of 500 questionnaires sent, 50 of the received questionnaires were answered by a non-GDP and were excluded from the study, leaving 163 responses (32.6%). Our result indicates that 92% of responders use sodium hypochlorite (NaOCl) as their primary irrigant. The main concentration of used NaOCl was 0.5%–1.5% used by 36.8% of responders. 68.7% of responders claimed that they are aiming routinely to eliminate smear layer during root canal treatment. More than half of the participants did not attend any seminars in the field of endodontic irrigation after their scale.
Conclusion: Most of the responders are using NaOCl as a primary irrigant, routinely removing the smear layer, and are using intracanal interappointment medicament. However, the consequences of this survey revealed that there is a big need to enhance and monitor the approach utilized by the dentist in Saudi Arabia.

Keywords: Dental practitioner, irrigants, irrigation needle, sodium hypochlorite

How to cite this article:
Al-Ali MM, Al-Ibrahim AM, Al-Ali SM. Current trends in irrigation practice during endodontic treatment among general dental practitioners in Saudi Arabia. Saudi Endod J 2018;8:170-5

How to cite this URL:
Al-Ali MM, Al-Ibrahim AM, Al-Ali SM. Current trends in irrigation practice during endodontic treatment among general dental practitioners in Saudi Arabia. Saudi Endod J [serial online] 2018 [cited 2019 May 19];8:170-5. Available from: http://www.saudiendodj.com/text.asp?2018/8/3/170/237559

  Introduction Top

The main goals of root canal treatment are to eliminate and remove different irritants and component of pulp tissue, calcification, and bacteria, and the placement of a hermetic three- dimensional obturation that provides a complete apical and coronal seal in a well-shaped and cleaned root canal system. This is done to treat infection and prevent reinfection while promoting healing of the surrounding tissues if needed.[1]

Even with modern endodontic instruments, it is virtually impossible for mechanical root canal instrumentation to shape and completely eradicate microorganisms in the canal system, due to its complex anatomy with multiple fins, isthmuses, ramification, and accessory canals.[2] Therefore, irrigation is an essential part of a root canal treatment, as it allows for cleaning beyond the reach of the conventional root canal instruments.[3]

An ideal irrigation solution should provide mechanical flushing and lubricating action, be microbiocidal, be capable of penetrating entire root canal system, and be able to dissolve residues of either organic or inorganic tissues within the root canal system without harming the tissues. In addition, the root canal irrigant should be biocompatible and nontoxic to the oral tissues. None of the available irrigants alone can be considered as ideal and has all the desirable characteristics of endodontic irrigants. A combination of several irrigants should be used in a specific sequence to safely fulfill the optimal requirement of irrigation.[1],[3],[4],[5]

Sodium hypochlorite (NaOCl) is the most widely used irrigation solution in modern endodontics, which is commonly used in a concentration between 0.5% and 6%. This known potent antimicrobial agent can kill most bacteria instantly on direct contact. Unlike other irrigants, it is the only root canal irrigant that dissolves pulpal remnants (vital and necrotic pulp tissue) and organic components of dentine and smear layer. However, NaOCl is not able to remove the inorganic part of smear layer. Hence, a subsequent irrigation with ethylenediaminetetraacetic acid (EDTA) or citric acid (CA) should be used for making its complete removal possible.[6] Other irrigants like chlorhexidine (CHX) have no tissue-dissolving capacity, but it has a wide antimicrobial spectrum and is effective against yeasts.[3],[7] A mixture of tetracycline isomers, acid, and detergent (MTAD) is an irrigant that has been developed by Torobinjad.[8] The irrigant combines antimicrobial properties against different endodontic microbes and the ability to remove the smear layer. It is recommended to be used as a final rinse in endodontic treatment before obturation.[9],[10]

The amount of needle penetration also plays an important role in effective irrigation procedures. This penetration and flushing action of the irrigant depend not only on the anatomy of the root canal system but also on the system of delivery, the volume of the solution used, fluid properties, and the irrigation needle size, type, and insertion depth.[11]

There were many studies that have been conducted worldwide regarding irrigant's material, technique, and protocol.[12],[13],[14] However, only a few have been conducted to determine the actual clinical practice of it. No study has been conducted before – to the best of our knowledge – in Saudi Arabia in regard to irrigation practice among general practitioners. Thus, the aim of our survey was to determine the current trends in endodontic irrigation practice among general dental practitioners (GDPs) in Saudi Arabia.

  Materials and Methods Top

An invitation to participate in a questionnaire was electronically mailed to 500 members of Saudi Dental Association. Members other than GDP were excluded from the study.

The survey started with a consent to participate in the study, followed by 17 multiple-choice questions, which included numeric rankings and an option to manually write the answer where suitable. The responders were queried about the type of irrigant(s) they use, reasons affecting their selection of irrigants, the concentration of irrigants, the removal of smear layer, the use of an intracanal medicament, the penetration depth and gauge of the needle, and attending courses or workshops related to endodontic irrigation. Following review of the questionnaire by two specialists in endodontics, the survey was distributed for a total duration of 8 weeks. The data were collected and analyzed using absolute frequencies by utilizing IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA).

  Results Top

Two hundred and thirteen responses were obtained out of 500 questionnaires sent. Fifty of the received questionnaires were answered by a non-GDP and therefore were excluded from the study, leaving 163 responses [Table 1]. As a result, the response rate of our survey was 32.6%.
Table 1: Response of participates

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When asked about the types of irrigants used, it was revealed that 150 (92%) of respondents are using NaOCl, followed by saline (65.03%), EDTA (30.7%), CHX (25.8%), hydrogen peroxide (17.8%), CA (2.5%), sterile water (1.8%), and MTAD (1.2%) [Figure 1]. The antibacterial capability was the most important reason for the participants to select their primary irrigant, followed in order by tissue dissolution, biocompatibility, substantivity, and expense.
Figure 1: Irrigating solution preference by general dental practitioners during root canal treatment

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The majority of responders (92%) are utilizing NaOCl as their primary irrigation, while 60 (36.8%) of them were found preferring concentration of 0.5%–1.5% [Figure 2]. One hundred and twelve (68.7%) of responders claimed that they are aiming routinely to eliminate smear layer during root canal treatment. Only 77 (47.3%) of responders were found using irrigation such as EDTA, CA, and MTAD. About half of the dentists in our sample (55.8%) claimed that their selection of irrigation solution adjusted according to periapical and pulpal diagnosis. Approximately two-thirds of the general practitioner in our sample were found using a needle gauge larger than gauge 27 [50 of responder (30.7%) using gauge 22 and 57 of them (34.9%) using gauge 25], with 72 (44.1%) of responders irrigating only the pulp chamber, 34 of responders (20.9%) penetrating up to one-third of the root length, and only 27 (16.6%) of them penetrating up to two-thirds of the root length.
Figure 2: Sodium hypochlorite concentrations used by general dental practitioners during root canal

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When asked for intracanal interappointment medicaments, 96 (58.9%) of responders reported using a formaldehyde -containing material and 33 (20.2%) using calcium hydroxide. Ninety-nine (60.7%) of responders were found not attending any courses related to endodontic irrigation after graduation.

  Discussion Top

This survey aimed to collect data from GDPs in Saudi Arabia in regard to their endodontic irrigation practice by e-mailing the members of the largest dental association in the country, with a positive response rate of 32.6%. An identical survey was attempted amidst the affiliates of the American Association of Endodontists, which had a lower replay percentage of 28.5%.[12] While other similar surveys have larger response rates.[13],[14]

Our result indicates that 92% of responders use NaOCl as their primary irrigant, with more than a third of them (36.8%) using a concentration of 0.5%–1.5%. The results were higher than a survey conducted in North Jordan, which reported that only 32.9% of GDPs used NaOCl, with the main concentration of 0.5%.[13] The possible cause for the widely use of NaOCl perhaps referred to its strong antibacterial characteristic, effective ability on tissue dissolution, and its unique antibiofilm activity.[15],[16] The antibacterial feature raised to be the most common motive for irrigants choice in this survey. Even though NaOCl is widely used in endodontics, there is no existing agreement regarding the optimal concentration of NaOCl. In endodontic therapy, NaOCl is commonly used in concentrations between 0.5 and 5.25. Several studies have shown that there is no significant difference in the tissue-dissolving and antibacterial capabilities of NaOCl at higher or lower concentrations.[16] Nonetheless, NaOCl placed at the higher concentration required a shorter time for neutralizing and inhibiting the growth of bacteria, and the ability to dissolve pulp tissues is increased, in addition to tissue toxicity and caustic potential.[6],[17],[18]

Even though 55.8% of practitioners in this survey claimed that their selection of irrigation solution adjusted according to periapical and pulpal diagnosis, NaOCl was chosen to be the primary irrigant employed for teeth in all pulpal and periapical diagnosis, and very few (9.8%–12.9%) were found using CHX for previously endodontically treated teeth and teeth with radiographic proof of apical periodontitis. Enterococcus faecalis was reported as being frequently associated with failed root-filled teeth and asymptomatic chronic periradicular lesions.[19],[20] Chlorhexidine gluconate was found to be a very effective irrigant against Enterococcus faecalis and was recommended to be used,[21],[22] especially in failed cases and in root canal retreatment.[23] Zandi et al.[21] evaluated the clinical efficacy of 2% CHX in comparison with 1% NaOCl used as irrigants in the treatment of infected root-filled teeth with apical periodontitis. They reported that both irrigants are effective in reducing the count of total bacteria with no significant differences between them.

Although 68.7% of responders claimed to aim routinely to remove smear layer, the majority of responders were not using irrigants such as EDTA, CA, and MTAD to remove the smear layer. Considering the weakness of NaOCl irrigant as it lacks the ability to remove the inorganic parts of smear layer, EDTA-like solutions should be utilized to get rid of this portion of the smear layer.[24]

Irrigation is commonly applied by a syringe and a needle, which vary in sizes. The relationship between a prepared canal and irrigation needle size is important for apical irrigation.[25] In addition, the proximity of the needle used for irrigation to the root apex plays an important role in removing debris root canal system.[26],[27],[28] In the current study, 44.1% of responders were found to penetrate the irrigation needle up to pulp chamber and 20.9% up to coronal one-third of the root. The reasons of that are possibly due to the utilizing of big needle gauge (22 and 25 gauges) by the majority of responders (65.6%), or due to the use of needle gauge larger than canal being prepared, which is not included in the survey.

In this survey, most of the responders used intracanal medicament between appointments. Calcium hydroxide was used by only 20.2% of responders, while 58.9% of responders used the formaldehyde-containing material. Despite the wide use of formaldehyde by the GDPs due to their fixation and antibacterial properties, it is cytotoxic to the pulpal tissue and cariogenic.[29],[30] In fact, calcium hydroxide is recognized as the standard intracanal medicament for inter-appointment dressing to which all other intracanal dressings are compared.[31] The antimicrobial effectiveness and the ability of calcium hydroxide to neutralize the biological activity of microorganism toxin should promote their use among dental practitioners. Calcium hydroxide also helps in controlling pain, reducing inflammation, and drying wet canals.[32]

It was frightening and distressing to reveal that 60.7% of the responders did not join any seminars in the field of endodontic irrigation after their scale. This indicates that more than half of the participants are relying on their bachelor studies knowledge, which may happen to be outdated or forgotten.

The results of this survey suggest the necessity to refresh the GDPs in regard to the endorsed utilizing of endodontic irrigants for highest results in root canal treatment. Surveys with greater replay percentage are required for superior depiction of practices of GDPs in Saudi Arabia. The responder's academic backgrounds and year of graduation can be used in similar future studies to delineate their effect on irrigation practices. Other factors such as the use of adjuncts in irrigation, irrigation solution volume, and the duration of usage of the irrigant are also significant regarding the complete elimination of microbes from root canal system and should be encompassed in future surveys.

  Conclusion Top

The majority of the responders use NaOCl as the primary irrigant, routinely remove the smear layer, and use intracanal medicament between appointments. However, the consequences of this survey indicate that GDPs in Saudi Arabia are not following the current recommended endodontic irrigation techniques in several areas, which indicates a high need to upgrade and monitor the irrigation techniques adopted by the dental practitioners in Saudi Arabia to ensure high success rates of endodontic treatment.

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Conflicts of interest

There are no conflicts of interest.

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