Patterns and Practices in the Use of Endodontic Materials: Insights from Romanian Dental Practices

Abstract

The success of endodontic treatment depends on the correct use of materials during the cleaning and filling of the root canal system. The field of endodontics is constantly evolving with the introduction of new procedures and materials. Despite the continuous development of a wide range of chemical solutions and the introduction of new materials in endodontics, driven by the advances in state-of-the-art technologies, there is still a lack of data on how these advances are adapted to the daily practice of Romanian dentists in this field. The aim of this cross-sectional questionnaire-based study was the evaluation of current trends in endodontic practice, focusing on the materials used by dentists throughout Romania, performed by a number of dentists who graduated from universities in the Northern, Southern, Eastern, Western, and Central zones of Romania. The questions were about the irrigants used, the interim medication, the type of sealant, the filling technique, and the number of endodontic treatment sessions. The majority of participants in the research were general practitioners and endodontists, with some dentists of different specialties performing endodontic treatments in their practices. Statistical analyses were performed using DATAtab version 2024 software. The results obtained from this study provide a valuable resource and database for researchers to access a wide range of information and an apparent trend towards high-performance endodontic materials used in Romania.

1. Introduction

The main goal of root canal therapy is to prevent future infections and to control the current infection within the root canal system [1]. The field of endodontics is constantly evolving with the introduction of new procedures and materials, and there is great potential for further advancements. The exponential expansion of endodontics is significantly influenced by the scientific advances in endodontic materials. The optimal approach to debridement, cleaning, shaping, and root canal filling remains a topic of discussion. Indeed, several innovative concepts, techniques, and instruments have been developed and put into practice. It is currently impossible to eradicate intraradicular infections with mechanical instrumentation alone. Therefore, irrigants are essential as a crucial supplement in the disinfection process of root canal therapy [2,3]. Modern root canal treatment recommends comprehensive root canal debridement through mechanical preparation and chemical irrigation, following advancements in technology and knowledge. As a result, traditional root canal dressing agents have gradually become less prevalent, leading to significant changes in the medications and administration techniques used today. However, more standardization is required in root canal treatment protocols [4]. In addition to preparation and irrigation, root canal filling is a key aspect of endodontic treatment. The ultimate goal is to seal the main root canal and its accessory canals. This final step in endodontic intervention is not merely a mechanical act of hermetically sealing the root canal system; it must also exhibit marked biological characteristics. The primary objectives of filling include achieving optimal sealant levels, biocompatibility, and hermeticity. In the pursuit of the ideal endodontic filling, clinicians have developed various materials, instruments, and techniques. Therefore, a high-quality coronal filling that ensures the adhesive interface between the dental structure and the composite material is essential for protecting the tooth structure, maintaining its integrity, and enhancing the success rate of endodontic therapy [5,6]. The longevity of composite restorations also depends on excellent oral hygiene, which implies effective plaque control through appropriate techniques proven to be highly effective in removing plaque deposits [7].

In 1958, Professor Dr. Louis I. Grossman, regarded as the father of contemporary endodontics, remarked, “I seriously doubt whether there is any other space in the human body, outside the root canal, into which such a diversity of materials has been introduced over the ages” [8]. Despite continuous research and the development of new materials and techniques for achieving a “three-dimensional filling”, perfect and long-lasting sealing of the complex endodontic space remains elusive [9].

Bioceramics and epoxy resin sealers are two commonly used materials in endodontic filling. Comparative clinical investigations have yielded inconsistent findings regarding their sealing efficacy, treatment outcomes, and the occurrence of postoperative issues such as leakage, periapical inflammation, and root resorption. The performance of these sealers can be influenced by various factors, including the application technique, root canal anatomy, and the operator’s skill.

Despite the ongoing advancements in state-of-the-art technologies, the availability of a wide range of chemical solutions, and the market introduction of new materials in endodontics, more data is necessary regarding how these advances align with the daily endodontic practices of Romanian dentists. The aim of this study is to analyze and document the patterns and practices employed by Romanian dentists in selecting and utilizing endodontic materials during clinical procedures. By identifying preferences, influencing factors, and trends, the research aims to contribute to a better understanding of regional practices and provide insights that can inform international collaboration, foster innovation, and bring about significant improvement in endodontic care. The study focuses on the patterns and practices of Romanian dentists while utilizing endodontic materials, providing significant insights into trends and decision-making variables. These findings advance understanding of endodontic materials, encouraging collaboration and innovation in order to improve therapeutic outcomes worldwide.

Advanced endodontic materials and techniques have been well documented in many countries [10,11], reflecting a shift towards more efficient and predictable treatment outcomes. However, there is limited evidence regarding how these advancements are implemented in daily clinical practice in Romania. This gap in data makes it challenging to evaluate the quality and consistency of endodontic care in the country and identify areas that may require additional training or resources. Although global research highlights the widespread adoption of new techniques in endodontics, studies on Romanian dental practices are scarce and do not offer a comprehensive overview of the materials and methods currently in use. For instance, bioceramic sealers and warm-filling techniques are widely adopted worldwide [12,13,14,15]. In Romania, the integration of bioceramic sealers into routine practice is limited by issues related to cost and accessibility. This study aims to assess how these global advancements are reflected in Romania’s current trends in endodontic practice.

2. Materials and Methods

This observational cross-sectional study was conducted from August 2023 to January 2024 among licensed dentists practicing in Romania. It aimed to identify the materials most frequently used in endodontic therapy by dental professionals who graduated from universities in Romania’s Northern, Southern, Eastern, Western, and Central regions. The sample was stratified to ensure proportional representation from Romania’s five geographical regions. Dentists were randomly selected from a digital platform designed for the Romanian dental community.

The sample size was determined using the Id Survey Sample Size Calculator (https://www.idsurvey.com/en/sample-size-calculator/, accessed on 1 August 2023). A questionnaire-based survey was emailed to 900 Romanian dentists, of whom 862 responded correctly, resulting in a response rate of 95.77%. Experts in the field reviewed the questionnaire to ensure content validity. The questionnaire was pilot-tested on a small group of dentists to assess its clarity and comprehensibility. Based on feedback from the pilot, we refined the wording to minimize ambiguity and improve question clarity. The survey included eleven open-ended questions on endodontic practice: types of irrigants used, interim medications applied, types of sealants employed, techniques used for filling, number of endodontic treatment sessions performed, and general data about the respondents. The open-ended questions were carefully worded to align with the specific aims of the research and to gather in-depth information about practitioners’ experiences and opinions. In addition, to reduce the variability of interpretation, responses to these questions were categorized into themes through a systematic qualitative analysis process. This allowed us to identify common trends and avoid inconsistencies in interpreting responses.

In order to be included in the study, dentists had to be graduates from a Romanian university after 1990, practice clinically in Romania, and perform more than ten endodontic treatments per month, considering in the study only practitioners who are regularly involved in endodontic procedures, as they are likely to provide the most relevant and up-to-date information.

All participants in this study were fully informed about the study’s objective, and their consent was obtained before participation. The participants’ informed consent and agreement to the handling and use of their personal information were important steps in ensuring the ethical conduct of this study.

2.1. Statistical Analysis

Descriptive analysis was performed, and frequencies of distribution were calculated in percentages; proportions were compared using chi-squared tests, with p-values < 0.05 accepted as statistically significant. Statistical analyses were performed using the software DATAtab version 2024 [16].

2.2. Demographical Data

A total of 862 dentists responded to the survey. Of the respondents, 572 were female and 290 were male. The data were recorded according to the year of graduation. Data were divided into four groups, each representing a different graduation year: Group A (1991–1998), Group B (1999–2006), Group C (2007–2014), and Group D (2015–2023). Table 1 illustrates the distribution of data between graduation year and sex. Figure 1 shows the distribution of data between sex and regional center, with the data divided into five categories: Northern, Southern, Eastern, Western, and Central zones in Romania.

The distribution of data by regional center of graduation and year of graduation is presented in Table 2.

The majority of healthcare professionals who participated in the study were general practitioners (91%) and endodontists (3%), with a presence of doctors from various other specialties as well (6%). This data is presented in Figure 2.

3. Results

The most frequently utilized endodontic irrigants were sodium hypochlorite (NaOCl), hydrogen peroxide (H₂O₂), chlorhexidine (CHX), ethylenediaminetetraacetic acid (EDTA), citric acid, and MTAD. The chi-square test demonstrated a statistically significant difference between the categories of the independent variable and the dependent variable graduation year (p < 0.001). This p-value is less than 0.05, indicating that the groups were significantly different in pairs in favor of NaOCl. The observed differences between groups are statistically significant at the conventional level of 0.05 (Table 3 and Figure 3).

The most commonly used interim medications were calcium hydroxide (Ca(OH)₂), antibiotic paste, and iodoform (CHI₃). A p-value of 0.006 indicates a 0.6% probability of observing the data or something more extreme if there were no actual association between the graduation year and the intracanal medications used. Since the p-value is smaller than the common threshold for a significance of 0.05, this suggests that the observed association is unlikely to have occurred by chance. Therefore, there is a significant association between the graduation year and the types of intracanal medications used, as confirmed at the traditional 5% significance level (see Table 4 and Figure 4).

Table 5 and Figure 5 demonstrate a correlation between the filling technique used and the year of graduation. The calculated p-value of 0.001 indicates a significant association. Since this p-value is well below the common significance threshold of 0.05, it suggests that the choice of filling technique is unlikely to have occurred by chance. Thus, there is a statistically significant association between the year of graduation and the filling technique chosen at the traditional 5% significance level (see Table 5 and Figure 5).

The most commonly used endodontic sealers, in descending order of usage, were sealers based on epoxy resins, calcium hydroxide, zinc oxide eugenol, and bioceramics. Table 6 and Figure 6 illustrate a correlation between the type of sealer used and the year of graduation. The calculated p-value of 0.001 indicates a significant association. Since this p-value is well below the common significance threshold of 0.05, it suggests that the sealer choice is unlikely to be due to chance. Therefore, there is a statistically significant association between the year of graduation and the type of sealer used, as confirmed at the traditional 5% significance level (see Table 6 and Figure 6).

Table 7 and Figure 7 show the number of treatments and retreatments performed by practitioners over the course of one month. The data reveals that the number of retreatments compared to treatments is inversely proportional to the year of graduation. Specifically,

• Practitioners who graduated before 2006 performed about three times fewer retreatments than treatments.

• Those who graduated between 2007 and 2014 performed about four times fewer retreatments than treatments.

• Practitioners who graduated between 2015 and 2023 performed about six times fewer retreatments than treatments.

Table 8 indicates that more than half of the study participants performed endodontic treatment in two sessions.

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 chlorhexidine (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 irrigant 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 chlorhexidine, 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 Diaconu 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].

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 Monea 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 metronidazole, 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. Vitapex possesses antibacterial properties and inhibits the reproduction of residual bacteria in the endodontic system. It promotes the healing of periapical lesions with a minimal inflammatory response in surrounding tissues [46,47].

Regarding sealants used for endodontic filling, epoxy resin-based sealers are preferred by the dentists participating in the study because of their performance in root canal treatments (35.5%). Comparative trials have demonstrated that epoxy resin-based sealers exhibit superior sealing properties, leading to better clinical outcomes for patients with chronic apical periodontitis [48]. Epoxy sealers also demonstrate effective penetration into dentinal tubules, crucial for successful endodontic treatment [49]. Despite various sealants available on the market, epoxy resin sealers maintain their physical and bioactive properties, making them a preferred choice in endodontic procedures [50].

Calcium hydroxide-based sealants rank second in this study (23.5%). These sealers are widely used in root canal treatments due to their antimicrobial properties [51]. Resinous endodontic sealers containing calcium hydroxide have shown promising results in biocompatibility, antibacterial effects, and promotion of biomineralization and collagen maturation. They are effective against Enterococcus faecalis [52]. Furthermore, compared with bioceramic sealers, calcium hydroxide sealers have demonstrated superior pH, calcium ion release, and antibacterial effects against E. faecalis [52]. Zinc oxide eugenol sealers rank third among the preferences of doctors participating in the study (19.9%), approximately half as often as epoxy resin and nearly equal to calcium hydroxide-based sealers. Sealers utilizing zinc oxide eugenol (ZOE) have been widely and successfully used for many years. Various brands and formulations exist, with zinc oxide as the primary component. Originally, eugenol served as the liquid component in Grossman’s original composition, alongside sodium borate (anhydrous), bismuth subcarbonate, hydrogenated resin, zinc oxide, and barium sulfate [53,54]. Even today, new zinc oxide eugenol sealers like EssenSeal have emerged, described by Gaeta et al. as a reliable alternative for root canal sealing [55].

In many developed countries, bioceramic sealers have become standard in endodontics due to their superior properties that enhance the success of root canal treatments. These sealers are known for their biocompatibility, excellent sealing ability, and potential to improve root strength post-filling [56]. They also exhibit antibacterial properties, which are crucial in preventing reinfection of the root canal system [57]. Moreover, bioceramic sealers can augment the bioactivity of the dentin interface, facilitating hydroxyapatite production and enhancing the sealing and integration properties of the material [58]. Their use is also gaining momentum in developing regions, where improvements in dental technology and materials are becoming more accessible. However, cost and availability remain limiting factors in some areas. The global trend towards bioceramic sealers reflects a shift towards more predictable and efficient treatment outcomes in endodontics, with these materials being widely regarded as a key innovation in modern root canal therapy [13,59,60]. The use of bioceramic sealers in clinical practice varies among studies. This study shows that endodontic sealers are used on a much smaller scale than global trends, despite their proven advantages in improving treatment outcomes. Only 13.3% of participants preferred bioceramic sealers, ranking last. A survey in Bulgaria indicated that most dentists do not find bioceramic sealers necessary for endodontic treatments [61]. However, clinical studies have reported a high success rate of 99% when using bioceramic sealers with warm gutta-percha filling techniques [15]. An online questionnaire revealed that 51.70% of dentists use bioceramic sealers, citing improved properties as the primary reason [62]. The study also highlighted differences in bioceramic sealer application between general dental practitioners and endodontic specialists, underscoring the need for standardized usage guidelines [12]. In Diaconu et al.’s study [25], another study on the current practices of dentists in Romania, it is mentioned that when questioned about the use of bioceramics in their daily practice, 61% of respondents with postgraduate training in endodontics preferred the use of bioceramics for filling root canals [25]; however, in our study, the percentage of dentists with practice limited to endodontics is very small. Although it belongs to the category of biomaterials, being biologically compatible, mechanical, functional, and corrosion-resistant and quickly adapting to clinical and laboratory technologies [5], clinicians face challenges with bioceramic sealers due to difficulties in removal during nonsurgical retreatments, variable clinical practices, and limited evidence supporting their use [63,64,65].

Regarding filling techniques, participants in the study overwhelmingly prefer warm techniques (74.13%) over cold techniques (25.87%). This preference aligns with literature findings, as warm thermoplastic filling materials offer superior dentinal adaptation and a more uniform seal than traditional cold lateral condensation methods [66]. Warm gutta-percha techniques also result in fewer voids during filling and superior outcomes in apical sealing, adaptation to root canal morphology, and reduced void formation [67].

There is no conclusive evidence in endodontics favoring single-visit versus multiple-visit root canal treatments. Both approaches demonstrate similar effectiveness and complication rates [68]. Single-visit endodontics can be particularly effective for cases of irreversible pulpitis when carefully selected and following established protocols [69]. If periodontal pathology is also present, the treatment could be extended as needed, combining nonsurgical periodontal therapy with a 7-day course of antibiotics [70]. The decision between single or multiple visits should consider factors such as case complexity, patient comfort, and treatment success rates, emphasizing the importance of individualized treatment planning in Romanian endodontic practices. More than half of the participants in this study were observed to perform endodontic treatment in two separate sessions.

This study complements the findings of the endodontic materials research by showcasing the broader trends in material selection across the endodontic field. By identifying preferences, influencing factors, and trends, this research and the study of Olariu et al. [71] and Diaconu et al. [25] seek to contribute to a better understanding of regional practices and provide insights that can improve international collaboration and significantly innovate and advance dental care. These studies contribute to the growing shift towards more advanced materials, providing valuable data for manufacturers, educators, and policymakers in the dental field. They underscore the evolving landscape of dental materials in Romania, pointing to challenges and opportunities for improving treatment outcomes and reflecting global trends in dental material innovation [25,71].

The study’s limitations include the potential for sample bias; when analyzing the results, it is essential to recognize the limitations inherent in cross-sectional surveys, such as possible biases arising from questionnaires. One key aspect to consider is the need for diverse representation in the sample, which can help ensure a comprehensive understanding of contemporary dental practices. Emerging trends, such as the increasing reliance on CBCT (Cone Beam Computed Tomography) examination and the use of magnification tools, hold significant potential for advancing the precision and scope of endodontic procedures. These developments could form the basis of a broader study, allowing for a detailed exploration of their impact on diagnostic accuracy and clinical outcomes. Despite these constraints, such surveys offer valuable insights, enabling professionals to keep pace with evolving endodontic materials and techniques.

5. Conclusions

This study concludes a trend towards high-performance endodontic materials in Romania, mirroring global preferences. Sodium hypochlorite is the preferred irrigant, while chlorhexidine is less frequently used. Epoxy resin sealers dominate endodontic procedures, whereas bioceramic sealers are currently employed in a minority of root canal fillings, which contrasts with international trends. Thermoplasticized gutta-percha is favored for filling techniques. Calcium hydroxide remains the primary choice for interim medication.

The findings from this research provide a valuable repository of data on preferred endodontic materials in Romania, for further use by researchers. This study offers valuable insights into current preferences of Romanian dentists regarding endodontic materials, highlighting trends in using various sealers, irrigants, and filling techniques. The findings can inform future research and guide clinicians in selecting the most suitable materials for effective root canal treatments. Additionally, these insights can be applied in educational settings to enhance training programs and help dental practitioners stay updated with evolving trends in endodontics. These programs could bridge the gap between research findings and clinical application, empowering practitioners to adopt innovative techniques confidently and effectively. Furthermore, the data could help manufacturers and suppliers to better understand market needs and refine their product offerings. To strengthen the evidence base, longitudinal studies should be conducted to evaluate various materials’ long-term durability and biocompatibility. Furthermore, comparative studies on contemporary materials would provide essential insights to assist clinicians in selecting the most appropriate options for diverse clinical scenarios.

Author Contributions

Conceptualization, D.M., I.V. and M.-M.M.; methodology, I.O.; software, I.V.; validation, R.A.P. and D.E.P.; formal analysis, R.A.P. and D.E.P.; investigation, D.M., I.V. and I.O.; resources, M.-M.M., D.M. and I.O.; data curation, I.O.; writing—original draft preparation, D.M. and I.V.; writing—review and editing, R.A.P. and D.E.P.; visualization, I.O.; supervision, D.M. and R.A.P.; project administration, D.M. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study was conducted by the Declaration of Helsinki. The study has been approved by the Ethics Committee of Victor Babes University of Medicine and Pharmacy in Timisoara, Romania, approval code: No. 73/02.10.2023.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical reasons.

Conflicts of Interest

The authors declare no conflicts of interest.

Footnotes

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Figures and Tables

Figure 1. Data distribution by sex and regional center of graduation.

Figure 2. Data distribution by specialty and graduation year.

Figure 3. Endodontic irrigants utilized according to the year of graduation.

Figure 4. Association between graduation year and intracanal medication used.

Figure 5. Association between graduation year and filling techniques.

Figure 6. Sealer used by graduation year.

Figure 7. Number of treatments and retreatments performed per month by practitioners.

Table 1

Data distribution by sex and graduation year.

	A		B		C		D		Total
	n	%	n	%	n	%	N	%	n	%
F	42	4.87%	168	19.49%	178	20.65%	184	21.35%	572	66.36%
M	20	2.32%	68	7.89%	98	11.37%	104	12.06%	290	33.64%
Total	62	7.19%	236	27.38%	276	32.02%	288	33.41%	862	100%

Table 2

Data distribution by graduation year and regional center of graduation.

	Graduation Year
	A		B		C		D		Total
	N	%	n	%	n	%	N	%	n	%
East	10	1.16%	36	4.18%	56	6.5%	38	4.41%	140	16.24%
South	16	1.86%	62	7.19%	82	9.51%	76	8.82%	236	27.38%
West	24	2.78%	76	8.82%	74	8.58%	78	9.05%	252	29.23%
Center	10	1.16%	34	3.94%	36	4.18%	66	7.66%	146	16.94%
North	2	0.23%	28	3.25%	28	3.25%	30	3.48%	88	10.21%
Total	62	7.19%	236	27.38%	276	32.02%	288	33.41%	862	100%

Table 3

Irrigants used according to the year of graduation.

	Graduation Year
	A	B	C	D	Total
	n	n	n	n	n
NaOCl	20	172	218	254	664
H2O2	32	22	14	8	76
CHX	6	16	16	14	52
EDTA	4	16	18	12	50
Acid citric	0	6	2	0	8
MTAD	0	2	0	0	2
Other	0	2	8	0	10
Total	62	236	276	288	862

Chi-square test; p < 0.001.

Table 4

Association between graduation year and intracanal medication used.

	Graduation Year
	A		B		C		D		Total
	n	%	n	%	n	%	n	%	n	%
Other	6	0.7%	36	4.18%	60	6.96%	40	4.64%	142	16.47%
Antibiotic paste	24	2.78%	26	3.02%	24	2.78%	14	1.62%	88	10.21%
Ca(OH)2	25	2.9%	158	18.33%	178	20.65%	216	25.06%	577	66.94%
CHI3	7	0.81%	16	1.86%	14	1.62%	18	2.09%	55	6.38%
Total	62	7.19%	236	27.38%	276	32.02%	288	33.41%	862	100%

Chi-square test; p < 0.001.

Table 5

Filling techniques used according to graduation year.

	Graduation Year
	A		B		C		D		Total
	n	%	n	%	n	%	N	%	n	%
Cold techniques	47	5.45%	66	7.66%	76	8.82%	34	3.94%	223	25.87%
Warm techniques	15	1.74%	170	19.72%	200	23.2%	254	29.47%	639	74.13%
Total	62	7.19%	236	27.38%	276	32.02%	288	33.41%	862	100%

Chi-square test, p < 0.001.

Table 6

Sealer used by graduation year.

	Graduation Year
	A		B		C		D		Total
	n	%	n	%	n	%	N	%	n	%
Zinc oxide eugenol	22	2.55%	52	6.03%	56	6.5%	42	4.87%	172	19.95%
Epoxy resin	10	1.16%	94	10.9%	100	11.6%	102	11.83%	306	35.5%
Ca(OH)2	21	2.44%	52	6.03%	56	6.5%	74	8.58%	203	23.55%
Other	8	0.93%	14	1.62%	26	3.02%	18	2.09%	66	7.66%
Bioceramic sealer	1	0.12%	24	2.78%	38	4.41%	52	6.03%	115	13.34%
Total	62	7.19%	236	27.38%	276	32.02%	288	33.41%	862	100%

Chi-square test, p < 0.001.

Table 7

Number of treatments and retreatments performed per month by practitioners.

		Frequency	Mean	Std. Deviation	Maximum
Number of endodontic treatments per month	D	288	24.7	22.26	150
	C	276	33.96	36.77	250
	B	236	28.72	31.87	200
	A	62	24.65	26.48	120
Number of endodontic retreatments per month	D	288	8.17	12.98	100
	C	276	11.57	16.01	100
	B	236	7.22	9.12	50
	A	62	4.23	4.56	20

Table 8

Single-visit/multiple-visit endodontic treatments.

Graduation Year
Number of Visits	A	B	C	D	Total
1	24	84	126	138	372
2	32	132	134	142	440
3	6	20	16	8	50
Total	62	236	276	288	862

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