Irrigation Trends among American Association of Endodontists Members: A Web-based Survey Joseph Dutner, DMD, Pete Mines, DDS, and Alfred Anderson, DDS Abstract Introduction: The purpose of this study was to deter- mine current trends in irrigation selection among endodontists. Methods: An invitation to participate in a web-based survey (QuestionPro) was e-mailed to 3844 members of the American Association of Endodon- tists. Survey participants were asked between 10 and 14 questions based on their individual responses. Among other questions, participants were asked about their irrigant selection, irrigant concentration, smear layer removal, and use of adjuncts to irrigation. Results: A total of 3707 survey invitations were successfully deliv- ered by e-mail after accounting for several undeliverable e-mail invitations. There were 1102 participants, with an overall completion rate of 28.5% (n = 1054). Our data indicate that >90% of respondents primarily use sodium hypochlorite, with 57% of them using it at a concentration >5.0%. Seventy-seven percent of respondents aim to re- move the smear layer during endodontic treatment. At least 45% of respondents reported using an adjunct to irrigation. Conclusions: Most of the respondents are using full-strength sodium hypochlorite and are routinely removing the smear layer during endodontic treatment. In addition, almost half of the respondents are using an adjunct, such as ultrasonic activation, to aid in their irriga- tion technique. (J Endod 2012;38:37–40) Key Words Irrigation, irrigation adjuncts, smear layer E ven with modern techniques that use nickel-titanium files, more than 35% of the root canal’s surface can be left uninstrumented after nonsurgical root canal treatment (1). To remove debris and address these uninstrumented surfaces, it is necessary to copiously irrigate the root canal (2). The ideal root canal irrigant has been described by Zehnder (3) as being system- ically nontoxic, noncaustic to periodontal tissues, having little potential to cause an anaphylactic reaction, possessing a broad antimicrobial spectrum, capable of dissolv- ing necrotic pulp tissue, inactivating endotoxins, and either preventing the formation of a smear layer or dissolving it once it has formed. Many irrigating solutions have been studied extensively to determine which best exhibit these ideal properties, but the ideal irrigant has not yet been realized. Sodium hypochlorite is able to meet many of these criteria. It has a broad antibac- terial spectrum, while also possessing some ability to inactivate endotoxin (4–6). Unlike other irrigants, it is effective at dissolving tissue and removing the organic component of the smear layer (7, 8). Although many authors suggest dilution of NaOCl to limit its cytotoxicity, some studies indicate that NaOCl might lose some of its antibacterial effectiveness and tissue- dissolving capability when it is diluted from a full-strength solution (9–13). Because of its irritating properties and the potential for severe inflammatory reactions, efforts have been made to find alternatives to NaOCl irrigation. Although chlorhexidine (CHX) does not dissolve tissue, it is a very effective antibacterial irrigant that also possesses substantivity (14–17). Controversy exists regarding whether it is advantageous to remove the smear layer that is formed during root canal instrumentation. Current methods to remove the smear layer might involve the use of a chelating agent during irrigation or as a final rinse in combination with other irrigants. Ethylenediaminetetraacetic acid (EDTA) is effective for removing the inorganic component of the smear layer. MTAD, a mixture of doxycy- cline, citric acid, and Tween 80 detergent, has also demonstrated the ability to remove components of the smear layer (18). Recent research indicates that QMix (DENTSPLY Tulsa Dental, Tulsa, OK), an experimental irrigant containing a mixture of a bisbigua- nide antimicrobial agent, a polyaminocarboxylic acid calcium-chelating agent, saline, and a surfactant, might be as effective as EDTA and MTAD at removing smear layers when used after an initial rinse with NaOCl (19). In an effort to improve the delivery and effectiveness of irrigants, different adjuncts have been developed. Both sonic and ultrasonic agitation of the irrigant have 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 (20). Although many different irrigants and treatment protocols have been studied, little research has been conducted to determine the widespread practice or acceptance of such methods and materials among American endodontists. The purpose of this study was to ascertain the current trends in irrigation among active endodontists. Materials and Methods An invitation to participate in a web-based survey (QuestionPro; Survey Analytics LLC, Seattle, WA) was e-mailed to 3844 members of the American Association of Endodontists. Survey participants were asked between 10 and 14 questions based on their individual responses. Among other questions, participants were asked about their From the Rohde Dental Clinic, US Army Fort Bragg DENTAC, Fort Bragg, North Carolina. The opinions or assertions contained herein are the private views of the author and not to be construed as official or as re- flecting the views of the U.S. Army Medical Department or the Department of Defense. Citation of commercial organizations and trade names in this manuscript does not constitute any offi- cial Department of the Army or Department of Defense endorsement or approval of the products or services of these organizations. Address requests for reprints to Dr Joseph Dutner, Building D3836 Ardennes Road, Fort Bragg, NC 28310. E-mail address: joseph.m.dutner@us.army.mil 0099-2399/$ - see front matter Copyright ª 2012 American Association of Endodontists. doi:10.1016/j.joen.2011.08.013 Clinical Research JOE — Volume 38, Number 1, January 2012 Irrigation Trends among AAE Members 37