Effective cleaning, shaping, and disinfection of the root canal system is essential for successful root canal treatment. Mechanical instrumentation removes infected dentin and forms the canal but does not remove microorganisms and tissue remnants from complex root canal anatomy, such as lateral canals, isthmuses, fins, and dentinal tubules [1]. Thus, irrigation is a key component in endodontic therapy, which aids in dissolving organic tissue, the removal of the smear layer, eliminating microbes, and chemical debridement. The most important etiological agents of pulpal and periapical diseases are microorganisms. Hard-to-reach areas of the canal system continue to be a leading cause of endodontic failure and apical periodontitis after treatment [2]. Over the last 20 years, therefore, the protocols for irrigation have changed significantly with the goal of achieving the best possible antimicrobial effect with the least alteration of dentin structure and the least procedure-related complications. Sodium hypochlorite (NaOCl) remains a considered as the best endodontic irrigating solution due to its strong antimicrobial properties and its special solution dissolving property of organic tissue [4]. The various concentrations currently in use range from 0.5% to 5.25%, depending on clinician preference, clinical situation and concerns about cytotoxicity. Sodium hypochlorite is however not sufficient to remove the inorganic part of the smear layer formed during instrumentation and therefore chelating agents like ethylenediaminetetraacetic acid (EDTA) [5] are required. Sodium hypochlorite and 17% EDTA have been recommended as one of the most popular irrigation methods as it removes organic and inorganic debris, which help to maintain cleanliness of the canal and promote penetration of medicaments and obturation materials into intracanal structures [6]. Other irrigants such as chlorhexidine, citric acid, maleic acid and other newer nanoparticle-based antimicrobial solutions have also been added as a means of enhancing the disinfection properties, with results in routine clinical use still somewhat inconsistent [7]. In recent years, in addition to the selection of irrigating solutions, attention has been paid to the ways of activating the irrigating solution. Over the years conventional syringe irrigation has been slowly supplemented by sonic activation, passive ultrasonic irrigation (PUI), negative pressure irrigation systems, laser activated irrigation, and multisonic technologies to enhance irrigant penetration of complex canal anatomy [8]. These techniques improve the fluid dynamics, remove more smear layer, and provide greater bacteria reduction than traditional irrigation [9].

Although there is growing scientific evidence in favor of advanced irrigation systems, there is still a great deal of variation in the clinical use of irrigation, including the choice of irrigants, concentration, activation method, volume, delivery needles and irrigation time. The undergraduate education, post graduate education, years of professional experience, equipment available, cost considerations and continuing educational programs all affect clinical decision-making [10]. As a result, there are significant variations in irrigation procedures between general dentists, postgraduate trainees, endodontists and academic clinicians. Over the past few years, dental education and endodontic practice has seen tremendous growth in Pakistan. However, there is a lack of national information that describes the irrigation methods that are used by clinicians of varying experience levels. To determine the gaps in knowledge, assess compliance with international evidence based recommendations and develop specific educational interventions to enhance endodontic treatment, it is important to understand the current clinical trends [11]. Cross sectional studies can be useful in determining factors related to clinicians' knowledge, attitudes, and usual practices. Such studies can evaluate irrigation solutions that are commonly used, irrigation solution concentration that is preferred, irrigation solutions activation techniques, irrigation sequence, safety measures, and variables impacting clinical decision making [12]. The results could help in the formulation of national clinical guidelines to standardise evidence-based endodontic treatment, curriculum development, and continuing professional education [13]. Nitrogenous irrigation solutions have been proven in several international surveys to be the most widely used worldwide, with significant differences between regions in irrigant concentration, the use of EDTA, activation devices, rubber dam isolation and the use of newer technologies [14]. This is consistent with other studies which have pointed to the need for more dissemination of evidence-based irrigation protocols, especially among general dental practitioners [15]. As the irrigation technique in endodontics is an evolving process, and there is a lack of published data regarding endodontist clinical practice in Pakistan, this is a relevant and timely study of current clinical practice.

Objective

To evaluate the current trends in root canal irrigation protocols among dental practitioners in Pakistan and identify factors associated with adherence to evidence-based endodontic practices.

This cross-sectional questionnaire-based survey was conducted at Darul Sehat Hospital Karachi, from March 2024 to February 2025 and included 140 registered dental practitioners practicing in Pakistan. It was a study of general dental practitioners, postgraduate trainees, endodontists, and academic dental faculty members who regularly carried out root canal treatment in a private practice, public hospitals or academic institutions. Only the following people were eligible to participate in the survey: Registered dental practitioners with a valid professional licence who have at least one year of clinical experience in endodontic treatment and who gave consent to take part in the survey. Completed questionnaires were the only ones analysed. The participants who were undergraduate dental students, house officers, retired dentists who were not practicing dentistry, dentists who were not routinely involved in RCT, duplicate responses, and incomplete questionnaires were excluded from the study.

Data Collection

The study was conducted with the necessary ethical approval from the institutional ethical review committee prior to the study. Structured, self-completed questionnaires were used to collect data. A questionnaire was designed after a review of current international endodontic guidelines and previously published surveys. The questionnaire was pretested for clarity and reliability before being distributed. The questionnaire consisted of four sections. The demographic and professional data was collected in the first section and included: Age, Gender, Qualification, Years of clinical experience, Workplace, Specialty, Average number of root canal treatments performed in a month. The second section evaluated routine irrigation methods such as the main irrigating solution used, concentration of sodium hypochlorite, irrigating solution of saline, chlorhexidine or other, irrigation sequence, irrigation volume, needle type, depth of the needle penetration and duration of the irrigation. In the third part, irrigation activation techniques such as conventional syringe irrigation, passive ultrasonic irrigation, sonic activation, negative-pressure irrigation systems, laser-assisted irrigation, agitation techniques, and intracanal medicaments were evaluated. The last part evaluated knowledge and practice of evidence-based endodontic recommendations, rubber dam isolation, strategies for minimizing sodium hypochlorite accidents, sources for continuous professional development, and perceived barriers to incorporating newer irrigation technologies and general confidence in current irrigation techniques. The main outcome was the status-quo of the root canal irrigation protocol amongst the dental practitioners in Pakistan. Secondary outcomes involved the frequency of different irrigants, different activation techniques, compliance with recommended endodontic guidelines, knowledge of contemporary irrigation protocols, and factors relating to evidence based clinical practice.

Statistical Analysis

SPSS version 26.0 was used for data analyses. All continuous variables were presented as mean ± SD and all categorical variables were presented as frequencies and percentages. The associations of the irrigation practice with the practitioners' characteristics were examined by Chi-square test or Fisher's exact test for the categorical variables and independent t-test or one-way analysis of variance for the continuous variables as appropriate. The independent factors associated with adherence to evidence-based irrigation protocols were determined using multivariable logistic regression analysis. The odds ratios (ORs) with 95% confidence intervals (CIs) were computed and a p value <0.05 was taken as statistically significant.

The mean age of practitioners was 33.9 ± 7.4 years, with males forming the majority (82, 58.6%). Most respondents were general dental practitioners (74, 52.9%), followed by endodontists (28, 20.0%), postgraduate trainees (24, 17.1%), and academic faculty (14, 10.0%). Mean clinical experience was 8.6 ± 5.1 years, and most worked in private practice (89, 63.6%). The average number of root canal treatments performed per month was 24.7 ± 10.8.

Table 1: Demographic and Professional Characteristics of Dental Practitioners (N = 140)

Sodium hypochlorite was the most commonly used primary irrigant, reported by 112 (80.0%) practitioners. The most frequent concentration was 5.25%, used by 63 (45.0%), followed by 2.5% in 38 (27.1%). EDTA was used by 101 (72.1%) practitioners. Conventional syringe irrigation remained dominant at 108 (77.1%), while passive ultrasonic irrigation and sonic activation were less commonly used. \

Table 2: Current Root Canal Irrigation Practices among Dental Practitioners

Most practitioners were aware of international endodontic guidelines (109, 77.9%), while 92 (65.7%) regularly followed evidence-based irrigation protocols. Annual continuing dental education attendance was reported by 84 (60.0%). Awareness of sodium hypochlorite accident prevention was high at 119 (85.0%), but only 46 (32.9%) used irrigant activation techniques. A strong majority, 126 (90.0%), expressed interest in further endodontic training.

Table 3: Awareness and Adherence to Evidence-Based Irrigation Protocols

Practitioners following evidence-based protocols were younger (32.5 ± 6.8 vs. 36.8 ± 7.9 years; p=0.002) and had fewer years of experience (7.6 ± 4.4 vs. 10.5 ± 5.8; p=0.004). They were more likely to be endodontists or postgraduate trainees, use EDTA, use irrigant activation techniques, routinely apply rubber dam isolation, and attend continuing dental education, all showing statistically significant differences.

Table 4: Comparison between Practitioners Following and Not Following Evidence-Based Irrigation Protocols

Multivariable analysis showed that endodontic specialization or postgraduate training was the strongest predictor of evidence-based irrigation practice (AOR=4.84, 95% CI: 1.95–12.03; p<0.001).

Table 5: Multivariable Logistic Regression Analysis of Factors Associated with Evidence-Based Irrigation Practice

A cross sectional survey to assess the current trends in irrigation of root canals among 140 dental practitioners of Pakistan. The results showed that the sodium hypochlorite was consistently the irrigant of preference for most of the clinicians, and EDTA was consistently used by a significant portion of clinicians. Overall, there was a high level of awareness of international guidelines, albeit with limited application of advanced irrigation activation techniques. In addition, there was a significant relationship between postgraduate training, continuing dental education, routine rubber dam isolation and evidence-based clinical practice, respectively. The results of this study will be beneficial in understanding the general trend of endodontics in Pakistan and areas that need more professional development. The majority of practitioners were young (33.9 ± 7.4 years old) with a median of 8.6 ± 5.1 years' experience. The largest group of professionals were general dental practitioners followed by endodontists, postgraduate trainees and academic faculty members. The majority of the respondents were in private practice and conducted about 24.7 ± 10.8 root canal treatments per month. This is also consistent with previous studies that reported that GPs accounted for the largest proportion of all practitioners who performed endodontic treatment, with the majority of endodontic treatment performed in the general practice setting [15]. 80.0% of participants used sodium hypochlorite as the main irrigant, with the most popular concentration being 5.25%. The use of 17% EDTA in irrigation was also growing and was used routinely by almost 3/4 of the practitioners as part of the irrigation protocol. The use of conventional syringe irrigation continued to be the predominant method of irrigation, while passive ultrasonic irrigation and sonic activation were limited and used by relatively few clinicians. Similar studies have also revealed that sodium hypochlorite is the most used root canal irrigating solution globally owing to its antimicrobial activity and efficient tissue dissolution properties and EDTA is the most commonly used smear layer removal chelator to date [16]. Although satisfactory knowledge existed on irrigation solutions, the present study showed low utilisation of irrigant activation techniques, with only 32.9% of the practitioners routinely using ultrasonic/sonic irrigation activation techniques. People continued to use conventional syringe irrigation (because it is simple, cheap and readily available). The same studies have shown that irrigant activation has been demonstrated to be an effective way to improve disinfection of canals and removal of smear layer during the canal disinfection, but its use in a clinical setting is limited in many developing countries due to the cost of the irrigants, lack of training and limited access to advanced technologies. Overall, the survey showed a good level of professional awareness with 77.9% of the practitioners being familiar with the international endodontic guidelines and 65.7% indicating that they follow the evidence-based irrigation recommendations on a regular basis. Prevention of sodium hypochlorite accidents was of special concern with a high level of awareness, with 90.0% saying they wanted to undertake further endodontic training. The same has been found in other studies,

which show that dental practitioners have become more conscious of evidence-based endodontics; however, implementation can be inconsistent due to lack of resources and differences in the undergraduate education [17,18].

There were some significant differences between those who did and did not follow evidence-based irrigation protocols. People following evidence-based recommendations were younger, had fewer years of experience in clinical practice, were more likely to be endodontist or post-graduate trainees. They also reported much higher levels of use of EDTA, irrigant activation techniques, rubber dam isolation and continuing dental education activities [19,20]. Similarly, previous studies have also revealed that postgraduate-trained clinicians and those with recent academic exposure have a higher adoption rate of the up-to-date endodontic recommendations. 62.1% reported using a rubber dam in routine practice and evidence-based practitioners were significantly more likely to do so than clinicians who did not use the rubber dam. With the use of rubber dam, the practice of endodontics today is greatly advanced, as it provides better asepsis, less chance of contamination from saliva and a reduced risk of sodium hypochlorite accidents. The use of rubber dam in endodontics is significantly higher in endodontists compared with general dentists in previous studies and is strongly correlated with high quality of treatment [20]. The endodontic specialization or postgraduate training was the strongest independent predictor of the evidence-based irrigation practice determined by multivariable logistic regression.

Limitations

This study has several limitations. First, the cross-sectional design captured practitioners' responses at a single point in time and therefore cannot establish causal relationships between practitioner characteristics and irrigation practices. Second, the study relied on self-reported questionnaire data, which may be subject to recall bias and social desirability bias, with respondents potentially overreporting adherence to recommended clinical protocols. Third, the survey included 140 dental practitioners, and although participants represented different professional backgrounds and practice settings, the sample may not fully represent all dental practitioners across Pakistan. Clinical practices were not independently verified through direct observation or clinical audits, preventing confirmation of the reported irrigation protocols. In addition, factors such as availability of endodontic equipment, institutional policies, financial constraints, and patient-related considerations that may influence irrigation practices were not comprehensively assessed.

The present study demonstrates that sodium hypochlorite, particularly in combination with EDTA, remains the most commonly employed root canal irrigation protocol among dental practitioners in Pakistan. Although awareness of international endodontic guidelines was generally satisfactory, the routine use of advanced irrigant activation techniques and complete adherence to evidence-based recommendations remained limited. Practitioners with postgraduate endodontic training, regular participation in continuing dental education, routine rubber dam isolation, and use of irrigant activation methods were significantly more likely to follow evidence-based irrigation protocols.

1. Bhatti, Usman Anwer, Beenish Qureshi, and Saima Azam. "Trends in Contemporary Endodontic Practice of Pakistan: A National Survey." Journal of the Pakistan Dental Association27.2 (2018).
2. Lodhi, Saood Khan, et al. "Trends in Endodontic Protocols Amongst Dentists in Lahore." Journal of the Pakistan Dental Association 29.4 (2020): 239.
3. Rehman, A. (2020). Endodontic Irrigation Trends among Dental Practitioners in Karachi. EC Dental Science, 19, 68-73.
4. Yaqoob, Hassan, Nighat Naved, Shahrukh Ali Khan, Syeda Farah Jabeen, Syed Saqib Raza, and Taimur Khalid. "Evaluation of dentists' clinical practices and antibiotic use in managing endodontic emergencies in Karachi, Pakistan: a cross-sectional survey." BMC Oral Health 24, no. 1 (2024): 1565.
5. Riaz, Sidra, et al. "Knowledge and Awareness of Dentists about Hypochlorite Emergencies and their Management during Endodontic Treatment." Annals of Punjab Medical College 18.4 (2024): 278-283.
6. Abdullah, A., Hussain, S. M., Khan, A. S., Zubair, M., & Khurshid, T. (2026). Comparative Evaluation of Postoperative Pain After Using Endoactivator, Side Vented, And Open Ended Endodontic Needles As Final Irrigation Protocols During Root Canal Treatment. Pakistan Armed Forces Medical Journal, 76, S260.
7. Alam, F., Gul, K., Shah, F. A., Yousafzai, B., Zohaib, M., & Rahman, F. U. (2024). DENTAL PRACTITIONER'S AWARENESS, KNOWLEDGE, AND ATTITUDES TOWARDS THE USE OF LASER TECHNOLOGY IN ENDODONTIC DISINFECTION: A CROSS SECTIONAL STUDY. JOURNAL OF KHYBER COLLEGE OF DENTISTRY, 14(4), 2-8.
8. Mazumdar, P., & Datta, S. (2024). Recent trends of irrigation practices during non-surgical root canal treatment among registered dental practitioners in India: A cross-sectional questionnaire-based survey. General dentistry, 200, 48-08.
9. Alzamzami, Z. T., Alqurashi, A. A., Almansour, L. A., Ashi, H. M., Abulhamael, A. M., Alghamdi, F. T., ... & Alghamdi, F. (2022). Current trends in irrigation solution and adjunct use during endodontic therapy among dental professionals in Jeddah, Saudi Arabia: a cross-sectional study. Cureus, 14(12).
10. Javed, M. Q., Khan, M., Khan, K. I., & Almutairi, N. (2023). Endodontic infection control practices among Pakistani general dental practitioners: A national cross-sectional questionnaire survey. Journal of Taibah University Medical Sciences, 18(6), 1342-1349.
11. Abdullah, A. M. S., Alfeitouri, F. O., Elkumati, I. A., & Betamar, N. M. (2025). Knowledge and Practice of Endodontic Irrigants among Dentists in Benghazi City: A Questionnaire Study. Journal of Research in Dentistry, 13(1), 23-37.
12. Maqbool, Manahil, Syeda Sobia Masood Tirmazi, Asma Shakoor, Zunaira Akram, Rutaba Nazir, Arham Nawaz Chohan, Mohmed Isaqali Karobari, and Tahir Yusuf Noorani. "Perception of dental house officers Mohanty, A., Patro, S., Das, A., Miglani, S., Luke, A. M., Pawar, A. M., ... & Testarelli, L. (2023). Nationwide trends of modern endodontic practices related to working length, instrumentation, magnification, and obturation: a comparative cross-sectional survey comparing endodontic and non-endodontic specialties practicing root canal treatment in India. Journal of Multidisciplinary Healthcare, 865-873. regarding endodontic file separation during endodontic treatment." BioMed Research International 2023, no. 1 (2023): 1044541.
13. Virdee, S. S., Ravaghi, V., Camilleri, J., Cooper, P., & Tomson, P. (2020). Current trends in endodontic irrigation amongst general dental practitioners and dental schools within the United Kingdom and Ireland: a cross-sectional survey. British dental journal, 1-7.
14. Mohanty, A., Patro, S., Das, A., Miglani, S., Luke, A. M., Pawar, A. M., ... & Testarelli, L. (2023). Nationwide trends of modern endodontic practices related to working length, instrumentation, magnification, and obturation: a comparative cross-sectional survey comparing endodontic and non-endodontic specialties practicing root canal treatment in India. Journal of Multidisciplinary Healthcare, 865-873.
15. Jouhar, R., Ahmed, M. A., Almomen, H. A. A., BuHulayqah, A. A. J., Alkashi, M. Y. A., Al-Quraini, A. A. A., & Ahmed, N. (2022). Assessment of the current endodontic practices among general dental practitioners in the Kingdom of Saudi Arabia. International Journal of Environmental Research and Public Health, 19(11), 6601.
16. Karobari, M. I., Adil, A. H., Iqbal, A., Arshad, H., Zahra, F., Umer, F., ... & Noorani, T. Y. (2026). Analysis of root canal anatomy configuration in permanent anterior teeth among the Pakistani subpopulations using cone-beam CT. Frontiers in Oral Health, 7, 1750120.
17. Al-Afifi, N. A., & Al-Amery, S. (2026). Assessment of the Endodontic Practices among General Dental Practitioners in Aden, Yemen. Yemeni Journal for Medical Sciences, 20(4).
18. Hassan, H., Ali, S. M., Khawar, B., Riaz, S., Zia, R., & Hameed, M. (2023). Endodontic file separation and its management among dentists in Punjab, Pakistan: a cross-sectional study. Brazilian Journal of Oral Sciences, 22, e233938.
19. Asdaq, M. A. H., Naz, S., Singh, H. M., Singh, A., Haque, M., Shah, H. K., ... & Khatoon, S. (2023). Reasons and Pattern of Demand for Root Canal Treatment Among Patients Attending A Tertiary Care Center of Madhesh Province: A Descriptive Cross-Sectional Study. Journal of National Medical College, 8(1), 26-32.
20. Riaz, K., Khan, S., & Batool, H. T. (2025). Challenges in Implementing Regenerative Endodontic Procedures: Clinicians' Perspective.