# Patterns and Practices in the Use of Endodontic Materials: Insights from Romanian Dental Practices
## 4 Discussions  
In the past decade, the field of endodontics has undergone significant developments, resulting in notable advancements in both endodontic procedures and materials. The objective of this study was to utilize a questionnaire-based survey in order to ascertain the materials most frequently employed in contemporary endodontic therapy by a diverse range of dental professionals who graduated from universities in Romania's Northern, Southern, Eastern, Western, and Central zones. The ideal irrigant for disinfection of the root canal system should be a substance that is both bactericidal and biocompatible. It should dissolve tissue, lubricate, and remove smear layers effectively, while also removing debris, providing long-lasting results, and not altering the physical characteristics of dentin. In this study, the most commonly used irrigant was sodium hypochlorite (77%), followed by hydrogen peroxide (8.8%), ethylenediaminetetraacetic acid (EDTA) (6%), and chlorhexiidine (5.8%). Citric acid and MTAD were used in very low percentages. Historically, hydrogen peroxide was used for endodontic irrigation, but it has largely been replaced by more effective and safer solutions. Despite this, the study shows that a significant percentage (8.8%) of Romanian dentists still use hydrogen peroxide, particularly those who graduated before 2006. Hydrogen peroxide can have adverse effects, such as forming oxygen bubbles in the root canal, interfering with canal sealing, or leading to gas emboli [17]. There is limited research on the efficacy and risks of using hydrogen peroxide for endodontic irrigation. The study results indicate that since 2015, very few Romanian dentists have used hydrogen peroxide. This decline may be due to its cytotoxic nature and its reduced effectiveness against _Enterococcus faecalis_. Research on the cytotoxicity of iron oxide nanoparticles combined with hydrogen peroxide as an endodontic irrigation has shown moderate cytotoxic effects at higher concentrations (4 and 8 mg/mL) on cultured human dermal fibroblasts (HDFn) cells [18]. Additionally, hydrogen peroxide (1.5%) has demonstrated lower efficacy against _Enterococcus faecalis_ than sodium hypochlorite and chlorhexiidine, which are more effective in reducing bacterial counts [19,20]. Worldwide surveys have consistently reported sodium hypochlorite (NaOCl) is the most commonly used irrigating solution in endodontics [21,22]. Research findings provide insights into the safety and efficacy of NaOCl in endodontic procedures, as it is widely regarded for its bactericidal properties and unique ability to dissolve organic tissues [23], especially when using techniques such as the activation of irrigants or negative pressure irrigation to minimize the formation of air bubbles during endodontic therapy [24]. The results of this study reflect similar findings, with NaOCl being used by 77.03% of practitioners, showing a notable increase in its use, especially after 1999. Furthermore, a study by [PERSON] et al. on the practices of Romanian dentists revealed that 82.1% of the participants use NaOCl at a 5.25% concentration. In contrast, the remaining dentists opt for lower concentrations [25]. NaOCl dissolves organic substances through three primary reactions: saponification, neutralization of amino acids producing water and salts, and interference with microbial cell metabolism by reacting with chlorine and amino groups through chlorination [26]. Organic tissues can be effectively dissolved in solutions containing more than 2.5% NaOCl. While higher concentrations, temperatures, volumes, and longer durations enhance its bactericidal and tissue dissolution abilities, they also increase its causticity and cytotoxicity, potentially causing periapical tissue damage if accidentally extruded from the apical foramen [27]. Despite its antimicrobial and tissue-dissolving characteristics, NaOCl should be used cautiously to avoid adverse effects caused by its cytotoxicity and its unfavorable impact on dentin qualities [28].