# Patterns and Practices in the Use of Endodontic Materials: Insights from Romanian Dental Practices
## 4 Discussions
Studies have compared different concentrations of NaOCl with other irrigants like chlorhexidine and peracetic acid, highlighting varying effects on cytotoxicity and antimicrobial efficacy, with cytocompatibility being a critical aspect in developing materials used in dentistry [29; 30; 31]. Alternative irrigants, such as chlorhexidine (CHX) and EDTA, address some limitations. CHX is less cytotoxic and offers long-lasting antimicrobial action through substantivity [32], but it lacks the tissue-dissolving properties of NaOCl. EDTA, conversely, is effective at removing the smear layer and enhancing canal cleanliness but does not eliminate bacteria as effectively [33]. A more comprehensive perspective involves exploring protocols that combine sequentially these irrigants to balance their strengths and weaknesses. For example, using NaOCl for its tissue-dissolving ability and CHX for its antimicrobial substantivity can enhance disinfection while reducing risks associated with over-reliance on a single agent [34]. Understanding the interplay between different irrigants and tailoring their use to patient-specific needs can optimize clinical outcomes and minimize adverse effects. Chlorhexidine (CHX) belongs to the category of cationic antimicrobial agents and exhibits broad-spectrum antibacterial activity. It effectively eliminates _E. faecalis_ biofilm at a concentration of 2% and reduces bacterial types and quantities in initially infected root canals [35]. Chlorhexidine gluconate penetrates bacterial cells, inducing leakage of intracellular components and leading to cell death. Gram-positive bacteria are particularly susceptible due to their negatively charged nature [36]. Chlorhexidine is less favored among Romanian dentists, beginning to be used after 1999 and ranking third in preference after hypochlorite and hydrogen peroxide. EDTA (ethylenediaminetetraacetic acid) ranks fourth in preference among Romanian dentists. It functions as a calcium chelator, removing minerals from the smear layer of root canal walls. Nevertheless, it is essential to consider the risk of dentin erosion in the study of [PERSON] et al., who warned that the chelating agents, particularly EDTA, exhibited a significant decalcifying effect [37]. The smear layer can impede the penetration of chemical irrigants and serve as a bacterial habitat. EDTA is commonly used with NaOCl (2.5%) to eliminate the smear layer in clinical practice [38]. MTAD (a mixture of tetracycline, acid, and detergent) is used by a small percentage (0.23%) of practitioners in this study as an endodontic irrigant. As for interim medication, calcium hydroxide (Ca(OH)\({}_{2}\)) is widely used in root canals for its disinfectant properties, achieved by releasing hydroxyl ions in water, creating an alkaline environment. Additionally, it neutralizes bacterial endotoxins on root dentin and promotes tissue repair by reducing inflammatory acidic chemicals [39; 40]. Ca(OH)\({}_{2}\) also supports the healing of periapical hard tissues and the development of mineralized tissues [41; 42]. However, its effectiveness as an intracanal medication is limited against specific pathogens such as _E. faecalis_ and _Candida albicans_[43]. As for interim medication, calcium hydroxide remains the most commonly used (67%), with antibiotic paste ranking second, utilized more than six times less frequently by dentists in the study (10%). Other studies also indicate that antibiotics as interim endodontic medication are not widely employed due to their limited effectiveness and the potential for bacterial resistance. Triple antibiotic paste, combining metronidazoleazole, minocycline, and ciprofloxacin, is recognized for its effective antimicrobial treatment and is commonly used in regenerative endodontic procedures [44; 45]. According to this study, iodoform is used significantly less frequently than calcium hydroxide as interim medication (6.4%). Literature on this subject is scarce, with few references, particularly regarding Vitapex paste, a mixture of calcium hydroxide, iodoform, and polysiloxane oil.