INTRODUCTION

The success of endodontic treatment depends primarily on the eradication of

microorganisms from the root canal system and prevention of The their reinfection.[ 1
]Even with modern techniques that use nickel–titanium files, more than 35% of the root
canal’s surface can be left uninstru-mented after nonsurgical root canal treatment.[ 2]
To remove debris and address these uninstrumented surfaces, it is necessary to
copiously irrigate the root canal and help by killing microorganisms, flushing debris,
and remov-ing both the organic and inorganic portions of the smear layer from the root
canal system.[3] However, there is no single irrigating solution that alone sufficiently
covers all the functions required for an irrigant.Some irrigating solutions dissolve either
organic or inorganic tissue in the root canal. In addition, several irri-gating solutions
have antimicrobial activity and actively kill bacteria and yeasts when introduced in
direct contact with the microorganisms. At the same time, several irri-gating solutions
also have the cytotoxic potential, and they may cause severe pain if they gain access
into the periapical tissues.[ 4]The most widely used endodontic irrigant is 0.5 to 6.0%
sodium hypochlorite (NaOCl), because of its bac-tericidal activity and ability to dissolve
vital and necrotic organic tissue.[ 5,6] However, NaOCl solutions exert no effects on
inorganic components of smear layer. Chelant and acid solutions have been
recommended for removing the smear layer from instrumented root canals, including
ethylene diaminetetraacetic acid (EDTA), citric acid, and phosphoric acid.[ 7] Ethylene
diaminetetraacetic acid is effective for removing the inorganic component of the smear
layer. In an effort to improve the delivery and effectiveness of irrigants, different
adjuncts have been developed. Both sonic and ultrasonic agitation of the irrigant has
been studied for their ability to improve canal cleanliness. Systems, such as EndoVac
(Discus Dental, Culver City, CA) use negative pressure to safely bring irrigants into
contact with all surfaces of the root canal.[ 8]Although many different irrigants and
treatment protocols have been studied, little research has been conducted to determine
the widespread practice oracceptance of such methods and materials among General
Dental Practitioners (GDPs). So the present survey was conducted to ascertain the
current trends in irrigation among dental practitioners in Iraqi cites `

Sodium hypochlorite (NaOCl)

Sodium hypochlorite (NaOCl) is the most commonly used solution in endodontic

irrigation because of its antimicrobial dissolving and tissue-activities. The ability of
sodium hypochlorite to dissolve organic substances and thus to dissolve pulp fragments
and debris is well known and documented. Tissues from a number of different sources
have been used in studies assessing the tissue-dissolving ability of sodium hypochlorite
[ 9 ]. Porcine muscle tissue [ 10 ], rabbit liver [ 11-12 ], rat connective tissue [ 13 ], pig
palatal mucosa [ 14 ], bovine muscle tissue [ 15 ], bovine pulp [ 16 ], and pig pulp [ 17]
have been used to determine the dissolution ability of different irrigants. There are a
couple of methods to evaluate the dissolution in an in vitro study. One way is to measure
the time of visualizing the end point of sample dissolution. However, it is difficult to
determine the end point of complete dissolution of the tissue because of the large
number of bubbles (resulting from the saponification reaction) attached to the sample
surface. Therefore, fixed time has been used instead, and the samples have been weighed
before and after exposure. Other methods have used different approaches, for example,
measuring the changes in the solutions, such as the amount of available chlorine after
completed dissolution [ 12 ] or the amount of hydroxyproline in the residual tissue after
incubation with the solution [ 17 ]. The effectiveness of sodium hypochlorite relies on
its concentration, volume, and contact time but also on the surface area of the exposed
tissue [ 12 ]. High concentration NaOCl has a stronger effect, but it is also potentially
more toxic to periapical tissue [ 18 – 19 ] in case of extrusion. Changes in dentin
mechanical properties such as microhardness and roughness have also been reported
after long-term exposure to sodium hypochlorite in concentrations of 2.5 and 5.25 % [
20 ]. In one study [ 21 ] the authors reported that a 24-min exposure time to 2.5 % NaOCl
caused a significant drop in flexural strength, while the modulus of elasticity was not
affected during this time. Other authors found a decline of both flexural and elastic
strength after a 2-h submersion of dentin bars in NaOCl [ 22 ]. The loss of calcium ions
appears to be dependent on both the NaOCl concentration (5 % showing the greatest
amount of decalcification) and the exposure time [ 23 ]. However, one of the
shortcomings 4 Research on Irrigation: Methods and Models 84 in models used in many
of the studies of the effect on dentin properties by NaOCl and other solutions is that the
natural anatomy/structure of dentin is often changed before the exposure. Dentin bars
cut from the root dentin are usually devoid of the cement layer, thus allowing rapid
penetration of the solutions through the entire thickness of the dentin pieces. In reality
in the root canal, hypochlorite penetration into the surrounding root dentin is much more
limited. Some studies have used powdered dentin which has been exposed to the
irrigating solutions. The process of powdering may remove some of the hydroxyapatite
protection around collagen fibers, possibly allowing more dramatic effects to occur.
Therefore, new models where the structural integrity of the root dentin is preserved
before the exposure are needed to secure a realistic understanding of the effects of
endodontic irrigating solutions on dentin. There are several ways to improve the effi -
cacy of hypochlorite in tissue dissolution. These include increasing the pH [ 24 ] and
the temperature of the solutions, ultrasonic activation, and prolonged working time [ 25
]. Despite a general consensus that increased temperature enhances the effectiveness of
hypochlorite solutions, relatively few articles have been published of the topic [ 26 , 27
, 28 ]. Preheating low-concentration solutions improves their tissue-dissolving capacity
with no effect on their short-term stability. Also, systemic toxicity is lower compared
with the higher-concentration solutions (at a lower temperature) with the same efficacy
[ 29 ]. The impact of mechanical agitation of the hypochlorite solutions on tissue
dissolution has been suggested to be important [ 11 ]. The study emphasized the great
impact of violent fluid flow and shearing forces caused by ultrasound on the ability of
hypochlorite to dissolve tissue [ 12 ]. However, the mechanisms involved are not
completely understood [ 30 ]. Negative pressure irrigation was introduced to endodontic
treatment several years ago as a safe method to effectively irrigate the most apical
canals. Recently, a novel technology, the Multisonic Ultracleaning System (Sonendo
Inc, Laguna Hills, CA), has been developed for cleaning of the root canal system. The
system uses sound energy to create cavitation within the solution to remove soft tissue
and bacteria inside root canals. Haapasalo et al. [ 31 ] compared the tissue-dissolving
effectiveness of the Multisonic Ultracleaning System with conventional methods of
irrigation using NaOCl in concentrations ranging from 0.5 to 6 % and at different
temperatures (21 and 40 °C) of the irrigating solution. The results showed that the
Multisonic Ultracleaning System demonstrated the by far fastest tissue dissolution.
Tissue dissolution was more than eight times faster than the second fastest device tested,
the Piezon Master 700 ultrasonic system. For all irrigation devices tested, the rate of
tissue dissolution increased with a higher concentration and temperature of the NaOCl
solution. Sodium hypochlorite has a relatively low surface tension. Some investigators
[ 32 ] have proposed adding a surfactant to sodium hypochlorite, in order to lower its
surface tension and improve its ability to penetrate the principal canal, lateral canals,
and tubules of dentin and predentin. The addition of surfactant would lower the surface
tension by 15–20 %. The effect of the surface active agent to hypochlorite was first
shown by Cameron [ 33 ] who demonstrated that the addition of the surface modifiers
enhanced the ability of sodium hypochlorite to dissolve organic material. Clarkson et
al. [ 12 ] tested the dissolution ability of three different brands of sodium hypochlorite
available in Australia and reported that the products with surfactants dissolved porcine
pulp in a shorter time than regular sodium hypochlorite at the same concentration.
However, Jungbluth et al. [ 34 ] and Clarkson et al. [ 35 ] found no improvement in pulp
tissue dissolution by NaOCl solutions containing surfactant compared with similar
solutions without surfactant. The differences may be due to the study design and
evaluation method. It should be noted that these investigations were all performed in the
in vitro environment. Results may therefore not be directly extrapolated to the clinical
situation. The active compound in NaOCl is the chlorine. NaOH-stabilized NaOCl has
been suggested to have a stronger tissue-dissolving effect compared with the standard
preparation [ 36 ]. The reason for this is that the OCl − /HOCl equilibrium Y. Shen et
al. 85 adjusts itself exceedingly fast in non-stabilized solutions [ 36 ]. A study of 100
permanent molars revealed that 79 % had lateral/accessory foramina with diameters
ranging from 10 to 200 μm [ 37 ]. The largest diameter was smaller than the mean
diameters reported for the main apical foramen [ 38– 39 ]. Therefore, disinfection of
lateral canals in cases of pulp necrosis and apical and/or lateral periodontitis should be
considered an important goal of the treatment, although it is difficult to achieve with
current procedures. A model allowing the quantitative assessment of necrotic pulp tissue
dissolution in simulated accessory canals was developed by Al-Jadaa et al.

The effect of concentration, time of exposure, and temperature on the penetration

of NaOCl into dentinal tubules was recently studied [ 40 ]. The depth of penetration of
NaOCl was determined by the bleaching of the stain and measured by light microscopy.
The results showed that the ability of sodium hypochlorite to penetrate dentinal tubules
was dependent on time, concentration, and temperature, but the relative effect of the
three factors was much smaller than expected. For instance, penetration after 20-min
exposure was only twice (not ten times) as much as after 2-min exposure, and the
differences between penetration by 1 and 6 % NaOCl were rather small (Fig. 1).

Maximum penetration of300 μm was seen when 6 % sodium hypochlorite was used for
20 min at 45 °C in coronal and midroot dentin. Several studies have reported that dentin
weakens the antibacterial effectiveness of calcium hydroxide, iodine potassium iodide,
and sodium hypochlorite [ 41 , 42 ]. The survival of the bacteria could therefore also be
attributed to their invasion into the dentinal tubules where they are better protected from
endodontic medicaments than in the main canal. This may be caused by the difficulty
of the solutions to penetrate into the tubules, inactivation of the medicaments by dentin,
or the microbial biomass in the tubules [ 42 ]. During chemomechanical preparation of
the root canal, use of chelating agents and acids results in selective removal of inorganic
dentin components, exposing collagen fi bers. Portenier et al. [ 43 ] studied the potential
inhibitory effect of bovine dentin matrix (collagen), demineralized dentin powder
(treated with EDTA or citric acid), and skin collagen on the antibacterial activity of 0.02
% CHX and 0.1/0.2 % iodine potassium iodide (IPI) solution. Dentin matrix (3 % w/v),
which mostly consists of purified dentin collagen, was a potent inhibitor of both CHX
and IPI, with most E. faecalis cells surviving after 24 h of incubation with the
medicaments in the given concentrations. Dentin matrix was a slightly less effective
inhibitor of IPI than dentin, but on CHX its effect was stronger than that of dentin. This
is in accordance with earlier reports which have shown that IPI was more susceptible to
dentin than to organic compounds, whereas the opposite was true for CHX [ 41 , 42 ].
When EDTA or citric acid was fi rst used to dissolve the apatite, dentin inhibited the
activity of CHX more than untreated dentin powder but less than purifi ed dentin matrix.
No difference was detected between EDTA and citric acid treatment [ 43 ]. When IPI
was tested, demineralized dentin (pretreated with EDTA or citric acid) showed no
inhibitory activity. It can be speculated that rinsing with EDTA or citric acid before
irrigation with disinfecting agents might weaken the effect of CHX but strengthen the
effect of IPI. Comparative experiments have indicated that skin collagen is a weaker
inhibitor of IPI and CHX than dentin matrix [ 34 ]. Together with the observation that
dentin treated with EDTA or citric acid caused inhibition that was stronger than with
skin collagen but weaker than with dentin matrix, this indicates that there are important
differences between type I collagen products obtained from different sources and
through different production and purification methods. In summary, dentin is a complex
chemical and anatomical environment that needs to be carefully considered when
designing studies looking at the effects of irrigation. ). So the present survey was
conducted to ascertain the current trends in irrigation among dental practitioners in Iraqi
cites by following method

MATEREAL AND METHODE:

A self-prepared questionnaire was personally given to a total of 507 Person including(

dentists and dental student and endodontic specialists )practicing in Iraq country
specially middle and south areas . :this survey including information in the table (1):

(a) Irrigant selection

(b) Irrigant concentration

(c) Use of Rubber dam

(d) Adjuncts irrigation solution used

(e) Choice of irrigant used for different clinical situations

(f) Gauge of needle used

(g) Tip design of needle

(h) Depth of needle penetration

(i) Duration of irrigation

(j) Irrigation accident

(k)Methods of activation

Table (1) table show the information that gathering from this survy .
The questionnaire was made up of 15 questions with multiple-choice answers and
blanks and multiple answers covering all the aspects of irrigation protocol in
endodontics

1-what is your educational degree - *

a- Student
b- Endodontist
c- Specialist but not endodontist
d- General dentist

2-What is the source of your information in irrigation of endodontics? *

a- From the college

b- Endodontic course
c- Textbooks
d- Youtube video

3- how many years are you practicing endodontic therapy? *

a- Less than 5year

b- 5-10years
c- 11-20 years
d- More than 20years

4-Did you have an irrigation accident? , *

a- Exudate out the apical foramen

b- oral mucosa burning
c- ecchymosis
d- swelling
e- Never

5-Which irrigants do you use? (Please select all that apply) *

 o Sodium hypochlorite
o Chlorhexidine
o EDTA
o MTAD
o Saline
o Citric acid
o Sterile water

6-Which irrigant do you primarily use? *

a. Sodium hypochlorite
b. Chlorhexidine
c. EDTA
d. MTAD
e. Saline
f. Citric acid
g. Sterile water

7-Which concentration of NaOCl do you primarily use? *

a. 0.5%-1.5%
b. 1.5-3%
c. 3-5.25%
d. I do not use Naocl

8- Which concentration of chlorhexidine do you primarily use?

a. 0.2%
b. 0.2%-1.9%
c. 2%
d. More than 2%
e. I do not use Chlorhexidine
9- Which of the following irrigants would you primarily utilize when treating a
tooth with a vital pulp?

a- Sodium hypochlorit
b- Sterile water
c- Chlorhexidine
d- Saline

10-Which method of activation you prefer during irrigate?) *

a-Ultrasonic activation

b -Negative pressure

c- Sonic activation

d- Manually

e-No adjuncts used

11-What is the gauge of the needle you use during syringe irrigation? *

a- 21gauge
b- 27gauge
c- 30gauge

12-How much depth of penetration of needle do you prefer for irrigation? *

a- 1 -2mm from apical foramen

b- 2-3 mm from apical foramen

c -to the middle third of the canal

d-to the coronal third of the canal

13-Which tip design of the needle do you use? *

a. open-ended needle
b. close-ended needle

14-What is the duration of irrigation do you use during endodontic treatment?

a- 10minutes
b- 15minutes
c- 30 minutes
d- 40minutes or more

15-Do you use rubber dam in endodontics treatment ? *

a- Never
b- Rarly
c- Often
d- Alwase

The questions were so framed to cover all the information regarding irrigation, ranging
from irrigant selection, irrigant concentration, (c) Use of Rubber dam , Adjuncts
irrigation solution used, ) Choice of irrigant used for different clinical situations, Gauge
of needle used, Tip design of needle, Depth of needle penetration, Duration of irrigation,
Irrigation accident, M‫ل‬ethods of activation. Questions consisted of numeric rankings,
multiple choices, and multiple selections with options for write-in answers where
appropriate. The data were compiled by a single assessor and analyzed using