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Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 196-201

Effect of case diagnosis and professional training on endodontic irrigant selection

1 Department of Restorative Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
2 Division of Restorative Dentistry, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
3 General Practitioner, Riyadh, Saudi Arabia

Date of Web Publication25-Jul-2018

Correspondence Address:
Dr. Sumaya O Basudan
Department of Restorative Dental Sciences, College of Dentistry, King Saud University, P. O. Box: 60169, Riyadh 11545
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_88_17

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Aim: The aim of this study is to investigate the type of endodontic irrigants used in cases with different pulpal diagnoses by general dental practitioners (GDPs) and specialists.
Materials and Methods: A questionnaire on irrigant selection was designed and distributed to GDPs, endodontists, and advanced restorative specialists with advanced endodontic training in Riyadh, Saudi Arabia. Participants were asked to select the irrigant(s) they used in vital, necrotic, and retreatment cases and to select the irrigant they think is the best.
Results: A total of 261 dentists responded: 65% were GDPs, 21% were endodontists, and 14% were restorative specialists. Sodium hypochlorite (NaOCl) was the most commonly used irrigant (65%–80%) followed by saline. Other materials such as local anesthetic solutions, chlorhexidine, and ethylenediaminetetraacetic acid (EDTA) were also used. Diagnosis of the case significantly affected the choice of irrigant. NaOCl was selected more in necrotic than in vital or retreatment cases. The endodontists used NaOCl and EDTA as an adjunct significantly more than GDPs, who significantly favored saline (P < 0.001). Choices of restorative specialists were better than GDPs but were not statistically significant than either groups.
Conclusion: This survey shows that irrigant selection is affected by case diagnosis and specialty training.

Keywords: Endodontists, general dentist, pulp diagnosis, root canal irrigants, Saudi Arabia

How to cite this article:
Basudan SO, Alghamdi SM, Alsultan HS. Effect of case diagnosis and professional training on endodontic irrigant selection. Saudi Endod J 2018;8:196-201

How to cite this URL:
Basudan SO, Alghamdi SM, Alsultan HS. Effect of case diagnosis and professional training on endodontic irrigant selection. Saudi Endod J [serial online] 2018 [cited 2019 May 19];8:196-201. Available from: http://www.saudiendodj.com/text.asp?2018/8/3/196/237565

  Introduction Top

Infection of the root canal system is caused by microorganisms that can provoke the formation of periapical inflammatory lesions.[1] Root canal treatment aims to eliminate microorganisms from the infected root canals through adequate cleaning and shaping which will greatly reduce the number of bacteria.[2]

Nevertheless, studies have shown that microorganisms often persist after treatment,[3] which can directly affect its success.[4],[5] Therefore, irrigation with strong antimicrobial agents is imperative to complete the cleaning and shaping process.[6]

The main ideal characteristics for a root canal irrigant are as follows: a broad antimicrobial spectrum; including microorganisms organized in biofilms; dissolving organic and inorganic tissue, removing the smear layer, inactivating endotoxins, and being biocompatible.[7],[8] Currently, there is no single irrigant that possesses all required qualities. However, sodium hypochlorite (NaOCl) exhibits the most. It is antibacterial, dissolves organic tissues, cheap and widely available, except it does not remove inorganic tissue, including the smear layer. For this function, a chelating agent such as ethylenediaminetetraacetic acid (EDTA) is suggested as an adjunctive irrigant.[7] Chlorhexidine (CHX) is an antibacterial agent that may additionally be used in endodontics mainly for its substantivity and its effectivity against Gram-positive microorganisms, especially in retreatment cases.[8] Other solutions, such as saline, alcohol, hydrogen peroxide, iodine, and local anesthetics, have also been reportedly used as irrigants.[9],[10],[11],[12]

Cross-sectional studies have shown a large variation in the use of irrigants. Moreover, while there is no ideal irrigant or irrigation regimen, some practitioners use materials and techniques that are known to be ineffective. The selection of the solution might be influenced by the practitioner's knowledge, training, availability, and clinical diagnosis of the case.[10],[13] Studies on endodontic outcomes show that the preoperative condition of the tooth is a major significant predictor of the treatment success. Cases with a preoperative vital pulp predicted favorable outcomes than necrotic pulps, while retreatment cases presented the least favorable and most resistant microorganisms.[14],[15],[16],[17] This might prompt practitioners to alter their irrigation regimen according to the status of the case and the microbial populations.

There are no reports focusing on irrigant selection among dentists in Saudi Arabia. In addition, two surveys reported saline to be the most commonly used irrigant among a sample predominately of general dental practitioners (GDPs).[18],[19] Since literature shows that endodontic procedures are performed differently by specialists and GDPs,[20],[21],[22] it would be vital to survey the protocols of specialists too. This study aims to investigate the type of endodontic irrigants used in cases with different pulpal diagnoses by GDPs and specialists.

  Materials and Methods Top

The study design was approved by the Research Center of College of Dentistry, King Saud University, Riyadh, Saudi Arabia (NF 2333), and its ethics committee. A questionnaire was designed, piloted, and modified for clarity. It consisted of two parts: the first part collected the participants' demographic data including age, gender, specialty, place of work, and number of cases treated per month. The second part included questions on the type of irrigant used in cases of vital and necrotic pulpal diagnosis, and retreatment and finally which irrigant is the best. Participants could select more than one irrigant and rank them. The question types included multiple choices to indicate their major irrigant, with the option of write-in answers, and numeric rankings if they used more than one irrigant.

The study population were dentists who performed endodontic treatment routinely including general dentists, advanced restorative specialists with advanced endodontic training as part of their training, and endodontists working in Riyadh, Saudi Arabia. Riyadh was stratified by region, and from each, one major governmental dental center or dental department at a governmental hospital and two private dental clinics were included in the study. Two academic institutions, one governmental and one private, were included too.

Each institution's administration was contacted for permission to distribute the questionnaire to the doctors. A paper copy was presented which the administrations distributed among the dentists. One month later, the filled questionnaires were collected. Due to the low number of questionnaires filled by endodontists, a web-based format of the questionnaire was E-mailed to members of the Saudi Endodontic Society in Riyadh.

All of the data from the returned questionnaires were entered and analyzed using the Statistical Package for the Social Sciences, version 21.0 (IBM Corp., New York, USA). Descriptive statistics (means, frequencies, and percentages) were calculated. The relationship between irrigant selection and training and also case diagnosis were analyzed using Chi-square test followed by post hoc tests. Statistical significance was set at P < 0.05.

  Results Top


Two hundred seventy-five dentists in Riyadh responded to our questionnaire. Fourteen dentists were excluded because they do not perform root canal treatment routinely. The total sample size was 261; 165 (63.2%) were GDPs, 57 (21.8%) were endodontists, and 39 (14.9%) were advanced restorative specialists. More than half of the dentists surveyed (160, 61.3%) were younger than 30 years of age, 70 (26.8%) were aged 31–40 years old, and 31 (11.9%) were above 40. There were 114 (43.7%) males compared to 147 (56.3%) females. The vast majority (83.5%) were Saudis. [Table 1] presents the work-related demographics of the participants.
Table 1: Work-related demographics of the 261 participants

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Irrigation choice and case diagnosis

The majority of the participants (78.9%) used more than one irrigant in their practice. [Figure 1] presents the irrigants chosen for each case and their rank.
Figure 1: Rank and score* of choice of irrigation solutions by case diagnosis. *Score is a weighted calculation. Items ranked first are valued higher than the following ranks, the score is the sum of all weighted rank counts. NaOCl: Sodium hypochlorite, EDTA: Ethylenediaminetetraacetic acid, CHX: Chlorhexidine, LA: Local anesthesia

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In vital cases, 65.1% of the respondents selected NaOCl as their first choice while 28.4% selected saline. As a second irrigant, saline was the most frequently chosen (38.3%), followed by NaOCl (22.6%) and EDTA (12.6%). Local anesthesia was the third most common choice (19.5%). In necrotic cases, 79.9% of the respondents chose NaOCl and 12% selected saline as their first irrigant. For a second irrigant, 36.4% selected saline while 17.6% selected EDTA. In retreatment cases, 69.9% selected NaOCl as their first irrigant and 12.9% saline. For a second irrigant, saline (26.4%) was mostly chosen, followed by EDTA (19.9%) and CHX (13.0%).

There was a significant difference in the choice of the main irrigant between the different types of practitioners in vital, necrotic, and retreatment cases (χ2(8) = 31.53, P < 0.001; χ2(8) = 19.24, P = 0.014; χ2(8) = 23.11, P = 0.003) [Table 2]. Although NaOCl was the most frequently selected irrigant by all, significantly more endodontists chose NaOCl in vital and retreatment cases than GDPs, whom significantly favored saline (P< 0.001). However, it was not significant in necrotic cases nor for restorative specialists [Table 2].
Table 2: Contingency table showing the main irrigant selected by the participants from different training backgrounds according to case diagnosis and selection of best irrigant

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For the second irrigant, endodontists also significantly selected EDTA more in vital, necrotic, and retreatment cases (40.0%, 50.0%, and 48.9%) than GDPs (6.0%, 14.0%, and 17.2%) and restorative specialists (12.5%, 16.1%, and 22.6%) (χ2(8) = 41.62, P < 0.001; χ2(8) = 30.07, P < 0.001; χ2(8) = 40.27, P < 0.001). CHX was also used more by endodontists (29.8%), than GDPs (12.5%) or restorative specialists (12.9%) in retreatment cases, although statistically insignificant.

Best irrigant

[Figure 1] shows the scores of the participants' responses. NaOCl was selected as the best by 79.3% while 4% indicated they did not know. Significantly more endodontists and restorative specialists selected NaOCl as the best than GDPs (χ2(8) = 20.49, P = 0.009) [Table 2]. The most commonly second ranked irrigants were CHX (31.5%) and saline (30%), followed by EDTA (19.7%). CHX and EDTA were selected significantly more by endodontists (45.5%, 29.5%) and restorative specialists (41.9%, 22.6%) than GDPs (24.2%, 15.6%) (χ2(8) = 27.61, P = 0.001).

For all three diagnosis types, irrigant choice was not affected by the dentist's age, gender, place of work, or number of endodontic cases treated per month (P > 0.05). Except for years of practice, participants with 6–10 years of experience used EDTA more in retreatment cases (χ2(16) = 29.02, P = 0.024) and indicated CHX to be the best irrigant (χ2(16) = 55.23, P < 0.001) while participants with >20 years of experience believed saline to be the best irrigant (χ2(16) = 23.06, P = 0.003). Notably, the most significant factor affecting irrigant selection was the diagnosis of the case; NaOCl was selected significantly more in necrotic (n = 207, Z = 1.9013, P = 0.029) than in vital (n = 170, Z = 0.48, P = 0.31) or retreatment cases (n = 179, Z = 1.425, P = 0.78).

However, the proportion of participants who selected NaOCl as the best irrigant (79.3%, n = 207) was significantly higher than the proportion of participants who used it in vital (65.1%, n = 170, Z = 0.48, P = 0.028) or retreatment cases (69.9%, n = 179, Z = 1.425, P = 0.029). However, the difference was insignificant in necrotic cases (79.9%, n = 207, Z = 1.9013, P = 0.99).

  Discussion Top

While surveys are subjective, as they are a form of self-reported measurement, they provide insightful information concerning the understanding, practices, attitudes, and trends of a large number of a specific population at a given time. Although the response rate of this survey was not high, it was difficult to calculate because some questionnaires were distributed by hand to dentists. The number of responses received depended greatly on the cooperation of the institution. More than one institute refused to distribute the questionnaire for no reason. The high number of respondents younger than 30 years old could be attributed to the increase in the number of recent graduates.[23] The majority of these respondents have not received graduate training yet, and they accounted for a large percentage of the GDPs in this study. In addition, there is a low representation of private clinics in our sample. This could be due to the small number of dentists working per approached practice. Nationally, 65% of dentists in Saudi Arabia work at private practices and 36% of them are in Riyadh.[23] In the future, more practices need to be included for more responses and a better presentation.

According to the responses, the most commonly used irrigant was NaOCl, followed by saline. Natto [24] has also found that 70% of dentists in Saudi Arabia use NaOCl for irrigation. These findings disagree with previous reports by Al-Fouzan [18] and Iqbal et al.,[19] in which the most commonly used irrigant by dentists in Saudi Arabia was saline (55%), whereas NaOCl was used by only 26%–31%. These differences could be attributed to several dissimilarities in the sample demographics of the reports. Al-Fouzan's [18] survey targeted GDPs from different regions of Saudi Arabia who worked in private clinics only while this report included specialists in the city of Riyadh who worked in large dental centers such as academic and major governmental institutions. Only 13% of our respondents were practicing in private clinics, while literature demonstrates better treatment results in university and specialist settings.[14],[15],[25] This also led to over-representation of Saudi dentists in our sample (84%). National statistics show that only 8% of dentists in private practices are Saudi, compared to 70% in governmental centers. In contrast, only 3% of dentists in Al-Fouzan's report [18] were Saudi, which may reflect a difference in the educational background, and thus clinical decisions of the participants of the reports.[21]

Similar to our findings, NaOCl is recognized as the most commonly used irrigant in different countries too.[13],[26],[27],[28] However, there are other commonly used irrigants. A study in North Jordan [9] reported that one-third of their respondents used hydrogen peroxide as the primary irrigant, followed by NaOCl, then saline, although saline does not possess antibacterial or tissue-dissolving properties. The main advantages of saline could be its safety and nontoxicity. A survey in the United Kingdom [12] showed that local anesthesia was the most commonly used endodontic irrigant (63%), followed by NaOCl (55%), saline (20%), and CHX (15%). The use of local anesthesia as an irrigant could be attributed to its ready availability and its small needle gauge, which allows deeper placement into the canal and a better flushing action.[29] However, local anesthesia lacks significant requirements for an irrigant, namely, antibacterial and tissue-dissolving capabilities. It was noted that local anesthesia was frequently associated with vital cases [Figure 1], suggesting that it might be used to control the bleeding of the vital tissues. Whitworth et al.[12] reported a relationship between the use of rubber dam and irrigation selection. Dentists who applied rubber dam used NaOCl more frequently than nonrubber dam users, who preferred local anesthesia as an irrigant. The current survey did not include the use of rubber dam, but this factor could explain the occurrence of irrigation with local anesthesia and saline since surveys in Saudi Arabia show that only 3%–22% of GDPs apply rubber dam during endodontic procedures.[18],[30]

Around only 13%–20% of participants used EDTA as an adjunct irrigant (especially in necrotic and retreatment cases), suggesting the removal of smear layer which can harbor microorganisms. EDTA was the only adjunctive irrigant with a significant difference in its use between the different practitioners. In all three cases, GDPs were the least to use it. Other reports in the literature show more positive findings. In Spain, 73% of GDPs attempted to remove the smear layer by EDTA,[28] while in the US, 77% of the endodontists do,[13] compared to only 50% of the endodontists in our sample.

Regardless of irrigant preference, the number of practitioners using NaOCl increased when the pulp was necrotic. Similarly, around 34%–78% of dentists participating in surveys reported that they too would change irrigants based on the case's diagnosis.[10],[13] It is known that the preoperative pulpal diagnosis can affect the prognosis of a case.[16] Necrosis is usually equated with infection, which may progress to apical periodontitis, thus decreasing the success of the case.[15],[31] The choice of NaOCl as the primary irrigant coincided with the reported belief that it is the best irrigant. This correlation was not observed in vital and retreatment cases. It is understandable that participants would be more inclined to use NaOCl in necrotic cases; however, retreatment cases present even lower success rates and more challenges with resistant microbes and complicated anatomy.[8],[14],[16] CHX has been suggested in these cases as a final irrigant because of its antibacterial action; however, only 13% of the participants used it as an adjunctive irrigant while 33.5% still used saline. The reason behind the practitioners' choice needs further investigation, especially that a number of them do not use NaOCl in these cases despite their belief of its superiority.

This survey also aimed to compare the practices of dentists with different levels of endodontic training. Research has shown that specialists make clinical decisions differently than GDPs.[21],[22] Eventually, specialists have higher clinical success rates and provide higher treatment quality.[14],[20],[31] However, due to the low number of qualified endodontists, more GDPs are performing root canal treatments, with varying levels of difficulty. Al-Fouzan [18] reported that 87% of private practice GDPs in Saudi Arabia perform molar endodontics. Our results confirm that endodontists do make significantly different choices; they used NaOCl more frequently while GDPs used saline more, even in necrotic and retreatment cases. This observation was shared in different reports. More endodontists in the US (91%)[13] and Australia (93.5%) select NaOCl as the primary irrigant than GDPs (74%).[27] The attempt to remove the smear layer was also significantly different between our endodontists and GDPs, which was also reported by de Gregorio et al.[28] If GDPs irrigated with saline, root canals will not be disinfected optimally, which may explain the inferior outcomes reported in the literature. The better choices made by restorative specialists who have received advanced endodontic training suggest that further training and education would improve the dentists' practices. It is not enough to rely on undergraduate dental school teachings as it has been observed that the procedures taught and implemented in dental school are not always implemented in practice after graduation;[32] therefore, continuing professional education is increasingly important. Dentists of Riyadh have the advantage of the highest availability of continuing education activities. One suggestion by Al-Fouzan [18] was the stronger credibility criteria for professional registration, which we agree with too. This report is the largest in Saudi Arabia to include specialists. It included more places of work and practitioners with different levels of training. Although limited within one city only, Riyadh is the largest city and actually accounts for a third of the nation's dentists. It is suggested that in the future, studies would include the whole nation with sufficient demographic representation. Furthermore, reasons for the dentists' opinions and conflicting practices need further investigation.

  Conclusion Top

This survey showed that the most common irrigant used among dentists in Riyadh is NaOCl. Irrigant selection was affected by case diagnosis and varied significantly between the different practitioners. Endodontists significantly made better choices, followed by restorative specialists, then GDPs, indicating the importance of continuing professional development.


The authors would like to express their gratitude to the statisticians Mr. Nassr Al-Maflehi and Dr. Tarig Othman for their guidance and comments during the statistical analysis of this project and to Dr. Khalid Al-Fouzan for his help in distributing the questionnaire to the members of the Saudi Endodontic Society.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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