921 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000/2025.921 http://dentistry3000.pitt.edu Evaluation of Irrigation Solutions and Activation Techniques in Endo- dontic Therapy Thanaa Ghani Nema, Hamsa Zaki Al-Assadi, Zaidoon Hasan Mohammed College of Den*stry, University of Kerbala, Iraq Abstract The study examined the current prac=ces of irriga=on and ac=va=on techniques used by dental professionals in Iraq, focusing on the selec=on and applica=on of chemical irrigants and adjunct techniques during endodon=c therapy. A cross-sec=onal survey was conducted among 108 par=cipants, including general dental prac==oners (GDPs) and endodon=c spe- cialists. The survey aimed to capture detailed informa=on about the choice of irriga=on solu=ons, the dura=on, depth, and pressure of irriga=on, and the adjunc=ve techniques employed, such as ultrasonic and sonic ac=va=on. The findings reveal that while sodium hypochlorite remains the most used irrigant, advanced ac=va=on methods like passive ul- trasonic irriga=on (PUI) are underu=lized despite their proven benefits. Addi=onally, most respondents adjust their irriga=on protocols depending on canal anatomy, with an empha- sis on tailored approaches to achieve op=mal disinfec=on. The study highlights the need for beQer training and access to modern irriga=on tools to improve treatment outcomes. Open Access Cita%on: Nema TG, et al. (2025) Evalua%on of Irriga%on Solu%ons and Ac%va%on Techniques in Endodon%c Ther- apy. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.921 Received: May 1, 2025 Accepted: May 26, 2025 Published: June 27, 2025 Copyright: ©2025 Nema TG, et al. This is an open access ar%cle licensed under a Crea%ve Commons AUribu%on Work 4.0 United States License. Email: thanaa.g@uokerbala.edu.iq Introduc)on The evolution of irrigation in endodontics has greatly impacted the success of root ca- nal treatments, with advancements in irri- gant solutions and activation methods play- ing crucial roles. Initially, endodontic irriga- tion relied heavily on sodium hypochlorite, a powerful tissue solvent with broad antibac- terial properties, though its limitations in biofilm removal were soon recognized [1]. Over time, additional solutions like EDTA were introduced to address issues such as smear layer formation [2]. As root canal sys- tems are complex, irrigants alone could not achieve complete disinfection, prompting the development of mechanical activation techniques like ultrasonic and sonic irrigation to enhance the penetration of solu- tions into the apical regions [3]. Recent innovations have focused on improv- ing the efficiency of these activation meth- ods. For example, photon-induced photoa- coustic streaming (PIPS) using lasers has shown promise in improving canal cleaning [4], and passive ultrasonic irrigation (PUI) has been recognized for its ability to reach difficult canal areas [5]. Newer solutions like QMix and MTAD also contribute to effective antimicrobial properties and smear layer re- moval [6]. Studies have shown that these newer techniques, in conjunction with ap- propriate irrigants, significantly enhance the disinfection process and reduce post-opera- tive complications [7]. Furthermore, the combination of multiple irrigation systems has proven beneficial, as no single solution can fully achieve optimal results on its own [8]. This ongoing evolution highlights the im- portance of refining both irrigation protocols and activation devices to improve the out- comes of endodontic treatments. As endo- dontic science continues to progress, the need for effective, biocompatible, and effi- cient irrigation solutions will remain central to achieving long-term success in root canal therapy [9]. Challenges in effective root canal irrigation limitations of current irrigation methods and the need for activation systems root canal ir- rigation remains a significant challenge due to the intricate anatomy of the canal system, including narrow spaces and lateral canals EvaluaAon of IrrigaAon SoluAons and AcAvaAon Techniques in EndodonAc Therapy Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.921 http://dentistry3000.pitt.edu 2 that make it difficult to achieve thorough dis- infection [10]. Traditional syringe irrigation methods, though widely used, often fail to adequately reach the apical third of the ca- nal, which is crucial for effective treatment [11]. This limitation has prompted the devel- opment of advanced activation systems like passive ultrasonic irrigation (PUI) and laser- assisted techniques, which have shown promise in improving the effectiveness of ir- rigant delivery [12]. These systems are par- ticularly useful in cleaning complex canal systems and ensuring that the irrigant reaches areas that syringe irrigation may miss [13]. While these newer systems im- prove bacterial reduction and debris re- moval, no method has proven completely ef- fective, especially in areas such as the isth- mus and the apical third of the root canal [14]. Furthermore, studies have indicated that combining multiple techniques, such as PUI with laser activation, may offer superior results compared to single-method activa- tion [15]. These innovations highlight the on- going need for improved irrigation systems and activation protocols to ensure optimal disinfection of the entire root canal system [16]. Despite advancements, achieving com- plete eradication of microbial life, particu- larly in the apical and isthmus regions, re- mains a formidable challenge [17]. The inte- gration of advanced technologies such as photodynamic therapy and next-generation irrigation devices could offer more promis- ing solutions for these challenges in the fu- ture [18]. The study aims to assess the effectiveness of commonly utilized irrigation solutions, in- cluding sodium hypochlorite and ethylenedi- aminetetraacetic acid (EDTA), in achieving significant bacterial reduction, smear layer removal, and the ability to penetrate com- plex root canal systems. Additionally, the study seeks to investigate the impact of vari- ous activation systems, such as ultrasonic, sonic, and laser-based devices, on the distri- bution and efficacy of irrigants within the root canal, particularly in areas like the api- cal third, where traditional irrigation often proves less effective. The research further aims to compare the efficacy of manual dy- namic activation methods with machine-as- sisted activation systems, such as passive ul- trasonic irrigation and photoactivated disin- fection, in enhancing root canal cleanliness and disinfection. Ultimately, this study will explore the role of endodontic irrigants and activation methods in preventing reinfection of the root canal system and promoting long- term treatment success. By examining these factors, the study seeks to contribute to the understanding of how modern irrigation protocols can minimize post-treatment com- plications and improve the overall success rates of root canal therapy. Materials and Methods Study Design and Setting This cross-sectional questionnaire-based survey was conducted between February 10th and March 10th, 2023. The study tar- geted dental practitioners and endodontic specialists across Iraq, following approval from the Research Ethics Committee of the College of Dentistry. The survey was distrib- uted electronically to reach dental profes- sionals practicing in both government and private sectors. Government sector dentists were recruited from dental hospitals and primary healthcare centers, while private sector practitioners were randomly selected from private hospitals and polyclinics across Iraq. Study Population and Sampling The study population comprised general dental practitioners (GDPs) and endodontic specialists actively practicing in Iraq. The _i- nal sample included 108 respondents, with 92 GDPs representing 85.2% of participants and 16 endodontic specialists accounting for 14.8%. The participants represented a broad spectrum of clinical experience ranging from one month to 30 years across both govern- ment and private dental sectors. Twenty-six respondents (24%) were public sector workers, while the remainder practiced in private settings. Questionnaire Development and Structure The questionnaire was meticulously de- signed to capture comprehensive infor- mation about irrigation practices during en- dodontic treatment. The instrument was structured into three main domains with a total of 16 questions, incorporating both open-ended and close-ended formats. The demographic domain gathered information about practice settings and professional rankings. The chemical irrigant utilization domain explored aspects such as primary ir- rigation solution selection, concentrations used, reasons for selection, and technical pa- rameters of irrigation procedures. The irri- gation adjunct utilization domain investi- gated the use of various irrigation enhance- ment techniques and devices. The question- naire utilized multiple response formats including numerical rankings, multiple choice questions, and multiple selections with options for free text answers where ap- propriate. The diverse question structure that was developed collected both the quan- titative and qualitative data on irrigation practices. Data Collection Process Profes- sional networks, dental associations and other sources were used to disseminate the electronic questionnaire. Responses were collected over a one-month period and par- ticipants were given clear instructions on how to complete it. The survey was meant to be comprehensive in scope but concise enough that response would be encouraged. Data accuracy and completeness were as- sured using electronic format as it offered easy access and submittance of responses. Variables and Measurements Some of the key variables associated with the practice of irrigation were measured in the study. The study focused on the outcome variables comprised of the irrigation solu- tions chosen by the practitioners, the con- centrations used, delivery methods chosen, and the use of activation techniques. The questionnaire was able to collect detailed in- formation about the types of solutions uti- lized, hence, sodium hypochlorite, chlorhex- idine, EDTA, saline and various combina- tions of the same. The speci_ic measurement included the solution concentrations for NaOCl (≥5.25, 2.5–5, 0.5%), the volume used per canal, the selection of needle gauge (27, 30, and other), measured irrigation depth (measured from apex) and duration of irri- gation per canal. Statistical Analysis Data analysis was conducted using Statistical Package for the Social Sciences (SPSS) ver- sion 26.0 for Windows. The analysis focused on descriptive statistics to characterize cur- rent irrigation practices among dental pro- fessionals. Results were presented as fre- quencies and percentages, with visual repre- sentations through pie charts and bar graphs to illustrate distribution patterns of various practices. This approach allowed for clear presentation of trends in irrigation solution selection, concentration preferences, and technical aspects of delivery. Quality Control Measures The study implemented several quality con- trol measures to ensure data reliability. The questionnaire underwent expert review to establish content validity and ensure com- prehensive coverage of irrigation practices. Electronic data collection minimized entry errors and facilitated standardized response formats. Regular data veri_ication processes EvaluaAon of IrrigaAon SoluAons and AcAvaAon Techniques in EndodonAc Therapy Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.921 http://dentistry3000.pitt.edu 3 were implemented to maintain data integrity throughout the collection period. Ethical Considerations The study protocol received approval from the Research Ethics Committee of the College of Dentistry. Participant con_identiality was maintained through anonymous data collec- tion, and all responses were handled with strict con_identiality. Participation was vol- untary, and respondents had the right to withdraw at any time. Data storage adhered to institutional security protocols to protect participant information. Study Limitations The study acknowledged certain limitations inherent in its design. The self-reported na- ture of the data may have introduced recall bias. The electronic distribution method, while ef_icient, might have limited reach to some practitioners without reliable internet access. The voluntary participation aspect could have introduced selection bias. These limitations were addressed through stand- ardized questionnaire format and clear in- structions for completion. Timeline and Resources Data collection occurred over a one-month period from February 10th to March 10th, 2023. The study utilized electronic survey platforms for data collection and SPSS soft- ware for analysis. Professional networks and dental associations facilitated questionnaire distribution. The research team managed data collection, entry, and analysis through- out the study period. Results The analysis of 108 completed self-reported questionnaires revealed a clear distribution pattern among dental practitioners. Most re- spondents were general dental practitioners (GDPs), comprising 92 participants and rep- resenting 85.2% of the total sample. In con- trast, endodontic specialists made up a nota- bly smaller proportion, with only 16 partici- pants accounting for 14.8% of the total re- spondents. This distribution pattern demon- strates the predominance of general practi- tioners compared to specialists among the study participants. The data reflects the com- position of dental practitioners who partici- pated in the survey during the study period between February and March 2023, provid- ing a snapshot of the professional distribu- tion among respondents involved in endo- dontic procedures in Iraq. The analysis of practice settings among the study participants revealed that most dental practitioners worked in the private sector, representing 76% of the total respondents. In contrast, public sector workers constituted a smaller proportion of the sam- ple, with twenty-six participants accounting for 24% of the total respondents. This distri- bution pattern shows the predominance of private practice among the surveyed dental professionals during the study period be- tween February and March 2023, providing a clear representation of the practice setting distribution among dental practitioners per- forming endodontic procedures in Iraq. The analysis of chemical solutions usage re- vealed that sodium hypochlorite (NaOCl) alone was used by twenty-nine respondents representing 26.9% of participants. The combination of NaOCl with EDTA and saline was reported by twenty-one participants ac- counting for 19.4%, while fifteen practition- ers (13.9%) used NaOCl combined with EDTA, chlorhexidine, and saline. The use of NaOCl with EDTA only was documented by seven respondents (6.5%), and NaOCl with saline was utilized by six participants (5.6%). A smaller proportion of practition- ers, representing 4.6%, used NaOCl with chlorhexidine and EDTA. The combination of NaOCl with chlorhexidine was employed by two respondents (1.9%), while NaOCl with chlorhexidine and saline was used by three practitioners (2.8%). Other combinations of irrigants, including various permutations of NaOCl, EDTA, chlorhexidine, and saline, were each used by one to two respondents, collec- tively accounting for the remaining percent- age of chemical solution usage among the study participants during the survey period. The analysis of NaOCl concentration usage revealed that most respondents (55.6%) used full-strength NaOCl with concentra- tions ≥5.25%. A smaller proportion of prac- titioners (19.4%) utilized NaOCl concentra- tions between 2.5-5%, while 22.2% of re- spondents used 0.5% concentration. A mini- mal number of participants (2.8%) reported not knowing the concentration of NaOCl they used in their practice. Regarding distribution of chlorhexidine (CHX) concentration usage among participants, 46.3% reported not us- ing CHX at all in their endodontic treatments, while 38% used 2% CHX concentration, and 15.7% utilized 0.2% concentration. When participants were asked about their reasons for selecting irrigation solutions, antibacte- rial capability emerged as the primary factor, cited by 55.6% of respondents. Tissue disso- lution ability was the second most important reason, reported by 33.3% of participants. Biocompatibility was considered the main factor by 7.4% of respondents, while sub- stantivity was cited as the primary reason by only 3.7% of the participants. The analysis of smear layer removal prac- tices revealed that most respondents, com- prising 87 participants (80.6%), aimed to re- move the smear layer during endodontic therapy, while 21 participants (19.4%) did not attempt smear layer removal in their practice. 76 respondents, representing 70.4% of the participants, reported that their selection of irrigant would change depend- ing on whether the apex is open or closed, whereas 32 participants (29.6%) main- tained the same irrigation protocol regard- less of the apical status. These findings pro- vide a clear representation of the practition- ers' approaches to smear layer management and their consideration of apical anatomy when selecting irrigation solutions during the study period between February and March 2023. Regarding needle gauge selection, fifty re- spondents (46.3%) used 27-gauge needles, while thirty-two participants (29.6%) pre- ferred 30-gauge needles. Twenty-four prac- titioners (22.2%) utilized 25-gauge needles, and only two respondents (1.9%) used other needle sizes. Concerning the depth of needle penetration during irrigation, forty-three participants (39.8%) irrigated to 3 mm from the apex, while twenty-six respondents (24.1%) irrigated to 4 mm from the apex. Twenty-three practitioners (21.3%) irri- gated to 2 mm, and sixteen participants (14.8%) irrigated to 1 mm from the apex. Re- garding irrigation duration, forty-four re- spondents (40.7%) applied irrigant for 30 seconds to 1 minute per canal, while twenty- five participants (23.1%) irrigated for over 2 minutes. Twenty-five practitioners (23.1%) irrigated for less than 30 seconds, and four- teen respondents (13%) applied irrigant for 1-2 minutes per canal. In terms of irrigation volume, fifty-two participants (48.1%) used 5 mL of irrigating solution, while twenty- eight respondents (25.9%) used 2 mL. Six- teen practitioners (14.8%) utilized 10 mL, and twelve participants (11.1%) used other volumes of irrigating solution during their endodontic procedures. The analysis of adjunct usage during irriga- tion revealed that sixty-one respondents (56.5%) reported using adjuncts to irriga- tion, while forty-seven participants (43.5%) did not utilize any adjuncts during their en- dodontic procedures. The distribution of dif- ferent techniques used for irrigation ad- juncts, where manual agitation was the most employed method reported by forty-nine participants (45.4%), followed by ultrasonic activation used by twenty-six respondents (24.1%). Sonic activation and subsonic acti- vation were utilized by smaller proportions of practitioners, with seven participants (6.5%) using each method. The combination of ultrasonic activation with manual agita- tion was reported by seven respondents (6.5%), while negative pressure irrigation systems such as EndoVac were used by three EvaluaAon of IrrigaAon SoluAons and AcAvaAon Techniques in EndodonAc Therapy Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.921 http://dentistry3000.pitt.edu 4 participants (2.8%). Various other combina- tions of activation techniques were each em- ployed by one to two practitioners, repre- senting smaller percentages of the total re- spondents during the study period. The analysis of adjuncts to irrigation usage revealed that manual agitation was the most frequently used technique, employed by 45.4% of respondents, followed by ultra- sonic activation which was utilized by 24.1% of participants. Sonic activation and the com- bination of ultrasonic activation with manual agitation were each used by 6.5% of practi- tioners. Negative pressure irrigation sys- tems such as EndoVac and subsonic activa- tion combined with manual agitation were each employed by 2.8% of respondents. Sev- eral combinations of techniques were used by smaller proportions of participants, with negative pressure combined with manual ag- itation, sonic activation with manual agita- tion, sonic activation with subsonic activa- tion, and ultrasonic activation with sonic ac- tivation each being utilized by 1.9% of re- spondents. The remaining combinations, in- cluding subsonic activation alone, ultrasonic activation with sonic activation and negative pressure with manual agitation, ultrasonic activation with subsonic activation, and ul- trasonic activation with subsonic activation and manual agitation were each used by 0.9% of practitioners. Other unspecified techniques accounted for 0.9% of responses, bringing the total to 100% of surveyed par- ticipants. Regarding the preference for using adjuncts to irrigation in different endodontic treat- ments, most respondents comprising _ifty- nine participants (54.6%) reported using ad- juncts in all cases of endodontic treatment. Thirteen practitioners (12%) used adjuncts speci_ically for non-surgical root canal treat- ment, while twelve respondents (11.1%) employed adjuncts only during non-surgical root canal re-treatment procedures. Twenty- four participants (22.2%) indicated that they did not use any adjuncts to irrigation during their endodontic procedures. These _indings represent the distribution of adjunct usage preferences among the surveyed dental practitioners during the study period be- tween February and March 2023. Discussion The scientific rationale behind this study lies in the critical role of irrigation solutions and activation techniques in the success of endo- dontic therapy, particularly in root canal treatments. Effective irrigation is essential for thorough disinfection and the removal of debris and biofilm from complex root canal systems. With the development of new irri- gation technologies, full completion of disin- fection is not achieved hard to reach areas such as the apical third and lateral canals. The current methods, notably syringe irriga- tion, have been well described as being lim- ited in delivering cleaning to these areas re- sulting in incomplete cleaning as well as pos- sible post treatment complications. To over- come these limitations, over the years, a va- riety of innovation was developed, for in- stance different irrigants as well as mechan- ical activation, such as passive ultrasonic ir- rigation (PUI) and laser-based systems. Cur- rently, these newer techniques are adopted and integrated with varying levels of differ- ences between dental professionals because of factors like familiarity, cost and training. The aim of this study is therefore to deter- mine and evaluate the present knowledge, attitudes and practices of existing Iraqi den- tal professionals concerning the endodontic irrigation methods. The scientific problem considered in this study is the lack of implementation of ad- vanced irrigation techniques and solutions once it is known that these techniques and solutions can improve the cleaning and dis- infection of root canals. Although literature supports use of newer techniques, a signifi- cant gap exists between them and their widespread use. This point of discrepancy emphasizes the difference between theoreti- cal advantages of an advanced irrigation sys- tem and achievable practicality of an ad- vanced irrigation system in a daily practice. On top of the complexity of root canal anat- omy, these solutions must be highly effective and targeted, not provided by traditional methods. Central to this is why dental pro- fessionals still use older techniques despite being able to choose a superior solution. The main objective of this study involves the identification of current practices, prefer- ences and hurdles observed by dental pro- fessionals in Iraq in gutta percha and activa- tion techniques for endodontic irrigation. Secondly, the study desires to investigate into the factors which are responsible for se- lection of irrigating terminals, the amount of the awareness of other, more efficient tech- niques of activation in consumers and the hurdles its application into the hands of pro- fessionals. A second goal involves assessing the connection between professional back- ground, time on the job and choice of meth- ods of irrigation and exploring the perceived effectiveness of these different systems. This study uses methodology of distributing a structured questionnaire among the de- tached sample of dental professionals in Iraq. The questionnaire seeks to gather in- formation on the various irrigation systems utilized, the technique of activation employed, the training received and the bar- riers to the integration of newer systems into professional practice. The advantage of this approach lies in its ability to have a complete knowledge of the current state of endodontic irrigation practices in the region and getting a precise picture of the contributing reasons why advanced techniques are not being adopted. This study is seeking to provide the findings to amplify whatever changes may be found necessary to improve irrigation proto- cols, training protocols, and overall out- comes of root canal therapy in Iraq and pos- sibly other areas facing this dilemma. Results from the present study on the distri- bution of chemical irrigation solutions show high reliance on sodium hypochlorite (NaOCl), usually used primarily because of its effectiveness in tissue dissolution and broad-spectrum antibacterial properties. Along with this, the study also shows a trend with many practitioners using NaOCl along with chelating agents such as ethylenedia- minetetraacetic acid (EDTA) for the best ef- fect of smear layer removal. This finding sup- ports previous studies that show the need for combination therapies to gain control over the different aspects of the disinfection and cleaning in the root canal system dis- charge. For example, in [19] on the trends of irrigation practices among Saudi Arabian dental professionals, they also found that dental professionals favor some types of NaOCl, including full strength, which is in line with the present study findings about the dominance of NaOCl in clinical settings. Nevertheless, little to no (47%) of respond- ents in this study used adjuncts such as ultra- sonic activation as has been among adjuncts only used by a minority of participants though adjuncts are known to increase irri- gant penetration and overall cleaning [19]. Additionally, the findings of the present study regarding the use of NaOCl in valence with EDTA or saline are consistent with the previous work [6,20] on combination of so- dium hypochlorite with chelators as EDTA or newer solutions such as MTAD, showing that the combination with chelators such as EDTA or newer solutions, like MTAD could enhance the antimicrobial activity of sodium hypochlorite as well as maximize the smear layer removal. The present findings indicate that though NaOCl still is the most preferred irrigant, newer irrigation like MTAD and QMix are being availed to equip these tradi- tional solutions in overcoming some of these limitations, viz., the antimicrobial efficacy and biocompatibility of the treatment [6,20]. The present study also emphasizes another critical aspect, namely the variation of irriga- tion protocols on clinical factors such as root canal anatomy with 71% of the participants are dependent upon condition of the apex EvaluaAon of IrrigaAon SoluAons and AcAvaAon Techniques in EndodonAc Therapy Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.921 http://dentistry3000.pitt.edu 5 either (open)or (closed). However, this vari- ation is of particular importance since root canal complexity usually necessitates a more thorough disinfection protocol. This is in line with the results of the several past studies and recently a systematic review [21] high- lighted the demand of anatomical specializa- tion of the root canal system and specified the irrigation strategies accordingly. Addi- tionally, 47 per cent of respondents utilized adjunctive activation techniques as found in other literature; these adjunctive activation techniques can significantly enhance the penetration of irrigants into complex canal system, particularly in the apical third of a canal which are difficult to reach. Results of the current study showed a global trend in use of NaOCl as a primary irrigant, which is increasing in the interest for newer solutions as well as adjunctive techniques, as compared to other studies. Yet, as pointed out previously [20,21], although activation techniques are to more advanced, there is a gap between the adoption of such techniques and adjuncts because knowledge, training, and cost are still important barriers to their widespread use. The results of the study also suggest that dental professionals may be us- ing these adjuncts below their potential to improve treatment outcomes and thus sug- gest that further education and evidence for such integration into routine practice may be required. Finally, while the present study reaffirms the continued reliance on NaOCl as the basis of chemical irrigation in endodontics, it also highlights the need to use newer adjunctive solutions, as well as activation techniques, in combination with NaOCl for maximum effec- tiveness. It then compares to recent studies to illustrate both the consistency and the dif- ferences in clinical practices, especially as it pertains to the how recent studies adopted advanced irrigation protocols and new acti- vation methods. The present study examined the analysis of smear layer removal practices which re- vealed that eighty percent (80.6%) of the re- spondents performed to remove the smear layer during the endodontic therapy. This is a usual way in endodontics, as smear layer cleaning is necessary to ensure sealing root canal for proper antiseptics action of irri- gants. Nevertheless, only a small percentage (19.4%) did not attempt to remove the smear layer, which could indicate either a lack of knowledge as how leaving the smear layer behind may cause unfavorable conse- quences or difficulties associated with the adoption of methods for its removal. Some previous studies have indeed found that so many practitioners have iteratively and somewhat idiosyncratically come to balance about how much they want to remove the smear layer, but to do so with widely dis- crepant methods. For instance, [22] showed that lasers activated irrigation (LAI) com- prising 17% EDTA was very effective at re- moving the smear layer, which agrees with findings in the current study that the practi- tioners are becoming more and more con- scious of the importance of more extensive cleaning procedures. Yet, these advanced methods are not applied universally, and this may explain the variability in practitioner practice observed in the present study. The results of the present study also showed that many respondents (70.4%) modified their irrigation protocol based on the apical anatomy (open or closed apex). It is in ac- cordance with current literature which acknowledges that the techniques of irriga- tion should be devised for the anatomical conditions of root canal. For example, these techniques have shown it more effective to reach areas near the apex with complex anatomy, such as cases commonly encoun- tered when PUI and laser-activated irriga- tion are used. Studies such as those by Faus- Llácer et al. (2020) [23] demonstrated that paradigms of irrigant activation are most likely advantageous in the apical canal third, which tends to be inaccessible with conven- tional syringe irrigation alone. Thus, the pre- sent study’s findings support those observa- tions that practitioners are becoming very aware of the necessity to adjust to the bio- form characteristics to achieve satisfactory results in root canal treatment. Nevertheless, just as in the work of Sahar-Helft et al. (2015) [22], the study also pointed out that not all practitioners adjust as much as they should, which may stem from, among others, limited access to high level tools or unfamiliarity with such methods. To ensure that the full root canal length is properly disinfected, it is crucial that the var- iation in the use of irrigant based on the api- cal anatomy is utilized. Iandolo et al.’s (2023) study [24] established the point again that modern irrigation techniques such as PUI are useful in improving cleaning of the apical third, which is difficult to treat using tradi- tional methods. Further, the findings from the current study regarding the variability of irrigation protocols also indicate that practi- tioners understand the need for more per- sonalized approach, although practical barri- ers such as training and availability of new technologies could restrict more widespread implementation of these methods. Finally, it is also concluded that most practi- tioners believe that canal cleaning and disin- fection, including smear layer removal, is a critical component of root canal therapy, but that adoption of more advanced techniques such as ultrasonic and laser activated irriga- tion is inconsistent. The findings support existing research indicating the usefulness of such methods, but also impediments for their widespread use. Practitioners need to continue to educate themselves and have ac- cess to modern tools, now that the role of customized irrigation protocols in improv- ing the outcome of endodontic treatments is understood. The present study showed that of partici- pants, 46.3% preferred 27-gauge needles, 29.6% 30-gauge needles and just 24% the market standard needles. This is a consensus in endodontics that favors the use of such smaller gauge needles (27 and 30), as they can pass through the intricate anatomy of root canal, especially in narrower canals. Alt- hough the studies may differ slightly on exact needle size and needle types, they have shown that smaller needles are better able to penetrate and have a better ability to put the irrigant down in those hard-to-reach areas, with possibly higher-pressure requirements. For instance, Boutsioukis et al (2007) [25], reported that smaller needles (30-gage) caused higher intra-barrel pressure while ir- rigating, that would then affect flow rate and delivery of the irrigant deeper into the canal, indicating that needle selection significantly affects the efficiency of irrigation. The results of the current study regarding the depth of needle penetration show that 39.8% of the respondents irrigated to 3 mm from the apex, 24.1% to 4 mm, and 14.8% to just 1 mm. The concepts agree with a more general understanding that root canal disin- fection requires deeper penetration of the ir- rigation, and in the apical third where clean- ing has been shown to be most difficult. Ac- cording to previous work [26], needle of pen- etration depth to the apical third alters api- cal preparation and is dependent on the em- ployed gauges. The findings of their study demonstrate the clinical significance of tak- ing the depth of placement into account when disinfecting, especially in the presence of complex canal anatomy [26]. Regarding irrigation duration, the current study identified various practices with 40.7% of the respondents irrigating 30 sec- onds - 1 minute per canal. As previously pub- lished [27], irrigation volume and duration were studied to understand the impacts on cleaning of the two parameters and the re- sults indicated that the cleaner of choice is dependent on the volume used with the total time of irrigation adding to the volume used in the optimization. The results of the pre- sent study, almost a quarter of respondents took more than 2 minutes using irrigation, agree with recommendations that a longer duration may lead to better efficacy, espe- cially, in complex canals for full antimicro- bial action [27]. EvaluaAon of IrrigaAon SoluAons and AcAvaAon Techniques in EndodonAc Therapy Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.921 http://dentistry3000.pitt.edu 6 For irrigant used volume 48.1% of the re- spondents used 5 mL, 25.9% used 2 mL, 14.8% used 10 mL. Therefore, proper canal disinfection depends on the volume of irri- gant. In wider or more curved canals, smaller volumes may not sufficiently irrigate the en- tire length of the canal. Although studies have demonstrated that greater irrigation volumes will enhance the flushing capacity of irrigants, and ability to remove debris and bacteria, the application of large volumes of irrigants without proper technique carries the risk of irrigant extrusion beyond the apex and subsequent post treatment complica- tions. Consequently, the current study’s find- ings that higher volumes help in the removal of the smear layer and that biofilm are also supported by previous research [28] that showed that the volume used directly affects the removal effect of the smear layer and bio- film. Finally, the results of the present study agree with the current literature as far as the im- plications of the needle gauge, penetration depth, irrigation duration and volume in root canal disinfection. They are tightly inter- linked to such an extent that optimizing them all can greatly improve treatment out- come. It is proposed such a comparison with other studies [25,27] served to further drive the importance of selection of appropriate ir- rigation parameters with respect to individ- ual case, such as canal anatomy and the clin- ical objectives. More research is needed to further refine guidelines regarding the irri- gation techniques that maximize clinical effi- ciency and minimize complications. Regarding the adjunct techniques used for ir- rigation, the results of this study on how the participants used them show that 45.4 per- cent used manual agitation. This matches the conventional manner of increasing the effi- ciency of the irrigation solution. Manual agi- tation by gutta-percha cone is considered a simple, easy and reliable method to distrib- ute irrigants throughout the root canal sys- tem. It is known to aid in debris removal and augment the chemical effects of the irrigant upon disinfection when used with sodium hypochlorite (NaOCl). Nevertheless, the pre- sent study also demonstrated that a rela- tively small percentage of practitioners (24.1%) used ultrasonic activation, even though this has been proven to increase irri- gant flow and reach apical and lateral canal difficult medication. Ultrasonic activation is effective in improving post-operative out- comes and root canal cleanliness through fa- cilitated deeper penetration of irrigants into the intricate canal anatomy [29]. Combinations of techniques including sonic activation with manual agitation (6.5%) and ultrasonic activation with manual agitation (6.5%), also were reported; however, these combinations were less used. These findings indicate the use of multi-modal irrigation techniques with the combination of mechan- ical activation and other methods to increase the canal disinfection efficiency. Hybrid ap- proaches are proven to improve on the effec- tiveness of single methods of cleaning and disinfection, paying special attention to com- bined manual agitation with other activation techniques [30]. In addition, the study noted the use of nega- tive pressure systems such as EndoVac and subsonic switch with manual agitation as at 2.8% of respondents. Negative pressure irri- gation systems have become accepted as good at clearing debris into the apical region, notably decreasing the risk of extruded irri- gants. Nevertheless, the costs associated with these systems and limited availability make these systems underused in the cur- rent study. Later, Plotino et al. (2016) [31] reported on the advantages of using negative pressure systems in removal of debris while minimizing the risk of extrusion. The finding of the present study is in line with global trend in which manual agitation is a staple and newer and more sophisticated systems such as ultrasonic and negative pressure irrigation are slowly supplanting it. The present study`s finding echoed Sinusila and Minu (2019) [32] that mechanical acti- vation systems improve debridement and cleaning efficiency; while manual techniques still dominate, the interest in integrating them to improve the endodontic treatment outcomes increases. Finally, we conclude that although the technology of manual irri- gation agitation extends its use, more ad- vanced devices, such as ultrasonic and nega- tive pressure systems, are introduced. Man- ual agitation is a practical and reliable ap- proach that can still be used but advance- ments in new technologies have a great po- tential for improving root canal disinfection, especially for complex canal anatomies. 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