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Gutta percha

This document provides an overview of gutta percha, including its discovery, historical uses, sources, evolution in dentistry, composition, chemistry, phases, properties, and commercial manufacture. Gutta percha is a natural polymer that has been used in dentistry as a root canal filling material since the 19th century due to its biocompatibility and ability to adapt to canal walls and provide a fluid-tight seal at the apex. It exists in alpha and beta crystalline forms that impact its viscosity and handling properties for different obturation techniques.

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Gutta Percha By Dr.Anoop.V.Nair, PG, Dept of Cons & Endo, KVGDC
Contents  Introduction  Discovery & historical uses  Sources  Evolution in dentistry  Composition  Chemistry  Phases  Properties  Commercial manufacture  Available forms  Techniques to use  Immuno cross reactivity  Disinfection- how?  References
An introduction The primary objectives of Operative Endodontics-  total debridement of the pulpal space  development of a fluid–tight seal at the apical foramen  total obturation of the root canal. Earlier root canal filling materials- Amalgam, Asbestos, Balsam, Bamboo, Cement, Copper, Gold Foil, Iron, Lead, Oxy- Chloride of Zinc, Paraffin, Pastes, Plaster of Paris, Resin, Rubber, Silverpoints,Tin foil etc. Among all these materials tried, none of them met the requirements of an ideal obturating material. The search for a suitable Root canal filling material ended with the discovery of “Gutta-percha”.
Discovery Gutta-percha is a name derived from two words.  “GETAH”- meaning gum  “PERTJA”- name of the tree in Malay language  used in crude form by the natives of Malaysian archipelago for making knife handles, walking sticks and for various other purposes. TAXONOMY Kingdom: Plantae Subkingdom:Tracheobionta Superdivision: Spermatophyta Division: Magnoliophyta Class: Magnoliopsida Subclass: Dilleniidae Order: Ebenales Family: Sapotaceae Genus: Isonandra Species
 The first person to discover this material was John Tradescant, who brought this material after his travels from far-east in 1656, he named this material as “Mazer wood”.  But the honour of introduction of this material goes to Dr. William Montogmerie (1843), who was a medical officer in Indian service.  He first came across gutta percha in Singapore in 1822.  His interest in the latex was sparked off by the use of gutta percha by workers to made handles for their machetes.  Montgomerie also observed that knife handles and medical devices could be made from the substance.  He was the first to appreciate the potential of this material in medicine and for which he was awarded the gold medal by the Royal society of arts, London in 1843.
Other uses  First Guttapercha patent was taken by Alexander, Cabriol and Duclos for a laminate consisting of three layers called “Gutta-percha fabric”.  In 1845 Hancock and Bewley formed the Gutta-percha company in United Kingdom.  Jewels and ornaments made of it as they were considered to be precious materials at that time.
 Cyprus Field & Werner Siemens - underwater communication through telegraph wires insulated with gutta percha Insulating underwater cable wires- 1866,Trans-atlantic telegraph cable, helped the whole world by revolutionizing communication.  It was nearly a 100 years later that gutta percha was replaced by polyethylene as the material to insulate cable wires.  Liquor gutta percha fortior is used as a thin cover on linen materials to prevent them from getting stained or soiled.  Pure or clear gutta is used in silk painting.
 Its introduction simplified the manufacture of golf balls.  Earlier they were made of wood, leather and feathers and the procedure was cumbersome. It was introduced as hand moulded one by James Patterson in 1845.  This change was instrumental in seeing the game grow immensely. The era of Gutta-percha golf balls lasted from 1845-1900, till the introduction of natural rubber in its manufacture.  In medicine, they were used as splints for holding fractured joints and manufacture of handles of forceps, catheters etc.  It was earlier used to control hemorrhage in extracted socket wounds.  They were also used for skin diseases by the dermatologists, particularly against Small pox, Erysipelas, Psoriasis and Eczema. ‘Gutty’
 Dried coagulated extract of plants of Palaquium, Blanco genus of Sapotaceae family.  These trees are natural inhabitants of South East Asia, particularly Malaysian and Indonesian archipelago  The concrete juices of Isonandra gutta, Palaquium gutta and Dichopsis gutta are the main trees from where, we obtain Gutta-percha material.  These Gutta-percha yielding trees are medium to tall trees, in which a series of cuts (concentric or v- shaped cuts) are made to obtain the juice.  The leaves of these trees also contribute to a minimal extent in Gutta-percha production. Sources
 In India the species of this genus is very scanty.  The species found are Palaquium obavatum, Palaquium polyanthum, Palaquium ellipticum and palaquium gutta trees in Assam and Western ghats.  Palaquium gutta was recently introduced and planted in Botanical gardens, Bangalore.  Indigenous plantation of these trees can be done like rubber gardening and there is an encouraging prospect.  Among the various trees, Palaquium oblongifolium is suited for plantations, but yield low amount of Gutta.  Among them, the important one is Guttabalata or Surinam Gutta-percha, obtained from Mimusops globsa (Bullet tree), South America.  It contains more resin proportions than true Gutta.  The other substitutes are from Butyrospermum park (Sheabutter tree of West Africa), Dyera costulata (of Malaya and Borneo), Maytenus phyllanthoides (Mexico), Calatropis giganlea (Madar tree of India) and Manilkara species (inferior balata-SouthAmerica) INDIGENOUS SOURCES
EVOLUTION Gutta-percha was first introduced to dentistry as a temporary filling material by Edwin Truman.  1847 - Hill Developed “Hill’s-stopping” a restorative material, a mixture of bleached Guttapercha and carbonate of lime and quartz.  1867 - Bowman was the first to use Guttapercha for root canal filling.  1883 - Perry used pointed gold wire wrapped with soft Gutta-percha, rolled and packed it into the canal.  1887 - S.S White Company was the first to start the commercial manufacture of Gutta- percha points.  1893 - Rollins used Gutta-percha with pure oxide of mercury into root canal filling.  1914 - Callahan introduced softening and dissolution of Gutta-percha with the use of rosins in obturation.  1959 – Ingle and Levine were the first persons to propose standardization of root canal instruments and filling materials and at their behest, standardized Gutta-percha was introduced to the profession in 1959 after 2nd International Conference of Endodontics at Philadelphia.  1976 - A group evolved into the present day International standards organization (ISO) for approval of specification of root canal instruments and filling materials.  ADA specification for obturating Gutta percha points is No.78.
 Gutta-percha is aTrans- isomer of poly isoprene.  Its chemical structure is 1, 4, trans–poly isoprene.  Since its molecular structure is close to that of natural rubber, which is a cis- isomer of poly isoprene, it has a number of similarities but a difference in form makes its mechanical properties to behave more like crystalline polymers.  In crude form its composition is GUTTA--------- 75-82% ALBAN--------- 14-16% FLUAVIL------- 4-6% and also contains Tannin, salts and saccharine substance. CHEMISTRY & COMPOSITION
Dental gutta percha composition:  matrix gutta percha: 20%  filler zinc oxide: 66%  radiopacifier heavy metal sulfates: 11%  plasticizer waxes and/or resins: 3%
 Chemically pure Gutta-percha exists in two distinctly different crystalline forms (α and β), that can be interconvertible  Natural gutta percha from tree- α form  However the most commercial available product is in β form  During the process of manufacture, if the cooling is done rapidly, ‘β’ form results. If it is cooled slowly, less than 0.5°c/hr, ‘α ’ form results. Another unstable form (γ) exists, which is amorphous in nature.  α ---- runny, tacky and sticky (lower viscosity)  β ---- solid, compactible and elongatible (higher viscosity)  γ ----- similar to a (unstable)  Transitions between low and high melting polymorphs of Gutta-percha are reversible, cyclic phenomena PHASES
α and β ALPHA FORM BETA FORM Brittle at room temperature Stable and flexible at room temperature Becomes gluey, adhesive and highly flowable when heated ( low viscosity) Becomes less adhesive and flowable when heated ( high viscosity) Thermoplasticized gutta percha for warm condensation obturation technique are in alpha form Gutta percha points used for cold condensation obturation techniques are in beta form Gutta percha exhibits two crystalline transformations when heated from room temperature to 1000 Centigrade. These transformations can be summarized as follows: •Beta to alpha: occurs between 42-49 ( this phase transformation is reversible) •Alpha to amorphous: occurs between 53-59
Properties  Biocompatibility: highly biocompatible; does not react with body fluids, inert irrespective of alkaline or acidic medium, does not initiate allergic host response.  Dimensional stability: expansion or shrinkage of material occurs only during phase transformations.  Ductility and malleability: depending on existing phase, material may be ductile or malleable.  Melting point: approximate value is around 600C, starts softening  Ease of handling: gutta percha used for endodontic obturation purposes are in both alpha and beta forms, both of which are easy to manipulate. When required gutta percha can be easily removed from root canal.  Adaptation to root apex: apical seal is of prime importance in obturation, which is achieved by using gutta percha, either in cones or warm, thermoplasticized form.
 Materials expand, when heated from β to α orΥ phases (1-3%).  When cooled down, shrinkage also takes place and it is greater than degree of expansion and differs by as much as 2%.  Aging of Gutta-Percha cones results in brittleness.  The encylopedia brittanica states that oxidation of Gutta-percha cones causes brittleness.  Aged brittle cones can be made reusable by a rejuvenation process of heating – quenching treatment.  The cones are immersed in hot tap water (>55º C) for one or two seconds and then immediately immersed in cold tap water (< 20º C) for several seconds.
COMMERCIAL MANUFACTURE Coagulation  The sap that oozes out is collected and put into a pot and boiled with little water.  It is boiled and then kneaded under running water.  Chemical method of coagulation is by addition of alcohol and creosote mixture (20:1), ammonia, limewater or caustic soda
Obach’s technique  The obtained pulp is mixed with water and heated to 75°c to release the Gutta-percha threads and then cooled to 45°c.  The flocculated Guttapercha called “yellow Gutta” contains 60% poly isoprene and 40% contaminants (resin, protein, dirt and water).  Yellow Gutta is mixed with cold industrial gasoline at below 0°c temperature.  This treatment not only flocculates the Gutta-percha but also dissolves resins and denatures any residual proteins.  After removal of cold gasoline, de-resinated Gutta threads are dissolved in warm water at 75°c and dirt particulate is allowed to precipitate.  Residual greenish yellow solution is bleached with activated clay, filtered to remove any particulate and then steam distilled to remove the gasoline.  “Final ultra pure” Gutta-percha has gasoline scent, before it is modified with fillers into its final commercial product formulation.
CURRENT FORMS i. Solid core gutta percha points: Available as standardized and non- standardized points ( beta phase).  Standardized points: these are manufactured in coherence to instrument taper and apical gauge. Increased zinc oxide content adds to stiffness.  Non standardized points: these are manufactured in variable taper, not necessarily in accordance with a particular instrument. The tip of point is adjusted with an apical gauge to best fit and seal the apex. Flexibility is enhanced due to low content of zinc oxide.  Both standardized and non standardized gutta percha points are used with cold lateral condensation with warm vertical compaction.
ii.Thermoplasticized gutta percha: Usually available in injectable form (alpha phase).  Thermoplaticized gutta percha systems provide special heaters which heats the gutta percha till the temperature when it flows.  For obturation the apical seal is achieved with the plugging of master cone and then the gutta percha is backfilled.
GUTTA PERCHA Standardized points Non standardized points Thermoplaticized Phase Beta Beta Alpha Trade names Denstply, Sure endo Sure endo, Omega Obtura II, Ultrafill, System B Obturation technique to be used Cold lateral condensation with warm vertical compaction Cold lateral condensation with warm vertical compaction Warm gutta percha with injectable technique
Gutta percha and a 3 dimensional seal  The objective of root canal filling procedures, should be the total three dimensional filling of the root canals and all accessory canals.  Gutta percha cones may be used with a cementing material, or they may be rendered plastic with various solvents and used without root canal cement.
Solvent techniques  Gutta percha may be dissolved in various solvents, such as chloroform, oil of eucalyptus, or xylol. CHLOROPERCHA  When dissolved in chloroform, a paste of chloropercha is formed, the thickness of which is determined by the amount of solvent used and by the amount which evaporates in the course of the filling procedure.  At the beginning of the filling visit, several pieces of gutta percha are cut into a dappen dish and stirred with a small amount of chloroform.  The dappen dish should be covered with a glass slab to minimize evaporation of the chloroform as the gutta percha dissolves into it while the dentist is selecting his master gutta percha cone.
 A small amount of chloropercha is streaked onto the walls of the dry root canal with a fine root canal spreader or other suitable instrument.  The apical third of the master cone is dipped into the chloropercha paste, and the entire master cone is gently repositioned into the canal.  The material in the canal is now forced laterally with root canal spreaders, making room for additional gutta percha cones which are added repeatedly in sufficient number to provide a dense root canal filling.  Each piece of gutta percha blends with the gutta percha and chloropercha already in the canal to form a homogeneous mass which conforms quite adequately to the configuration of the root canal system.  The lateral pressure on the plastic gutta percha– chloropercha mixture automatically imparts a small vertical component of pressure, owing to the shape of most prepared canals.  The entire mass moves apically during lateral condensation with any solvent technique.
Callahan–Johnson diffusion technique- the root canal system is flooded with 95 percent ethyl alcohol and then dried with paper points. The alcohol flooding and drying removes some organic and most aqueous material from the walls of the canals. The canals are flooded again, now with a chlororosin solution. The chlororosin solution spreads extensively into inaccessible eccentricities in the root canal and into accessory canals as well. This solution acts as a solvent both for a previously prepared master cone and for fatty organic material, so that when the master cone and additional cones are added in the condensation procedures, dissolved gutta percha will diffuse effectively into otherwise inaccessible portions of the root canal system.
Nygaard–Ostby technique is a variation of the Callahan–Johnson method, where finely ground specially prepared gutta percha particles are spatulated with chloroform to produce the necessary paste which will be used in conjunction with the master gutta percha cone.  This method is reported to reduce greatly both apical excess and the shrinkage in the final filling.
LATERAL CONDENSATION /COMPACTION  The advantage of this method over the solvent techniques is that positive dimensional stability of the root canal filling can be anticipated, and there is less likelihood of carrying filling material beyond the root apex.  One disadvantage is that at no time is a homogeneous mass developed.  The final filling consists of a large number of separate gutta percha cones tightly pressed together and joined by frictional grip and the cementing substance only.  It is the gradual setting of the root canal cement which gives the digital illusion of homogeneity as the lateral condensation procedure continues  Only at the point where the coronal excess is removed with a hot instrument is true homogeneity established.  lateral condensation produces the densest filling in the middle and coronal thirds of the tooth, and the apical seal is little improved as additional cones are added.  It offers the distinct advantages of greater lemgth control and greater patient comfort, and has been successfully employed by large numbers of dentists for many years.  May not fill canal irregularities as well as warm vertical compaction or thermoplastic techniques
WARMVERTICAL COMPACTION  Introduced by Schilder  The use of warm gutta percha with vertical condensation permits great density to be created in the apical portion of the filling.  No other technique provides for the filling of accessory canals and foramina with such frequency as warm gutta percha used in conjunction with vertical condensation.  To employ the warm gutta percha technique, the root canal must be shaped so that a continuously tapering funnel is created with its narrowest diameter at the periodontal ligament and its widest diameter at the coronal opening or access cavity.  However this funnel may curve, it must be progressively wider coronally.  This continuous taper permits the introduction into the canal of a graded series of pluggers with which the gutta percha is wedged apically.  Disadvantage include slight risk of vertical root fracture because of compaction forces, less length control and potential for extrusion of material into periradicular tissues.
CONTINUOUS WAVE COMPACTION TECHNIQUE  Employs an electric heat carrier, the System B unit, and stainless steel pluggers ( tapered .04, .06, .08, .010, .12), with 0.5 mm diameter.  Recommended temperature setting for system B is 200 o C.  But studies have shown that external temperature never exceeded critical 10 o c rise with any tip config or temp setting.  After selecting master cone, plugger is inserted to fit within 5 to 7 mm of the canal length, deeper placement may enhance flow of GP.  Unit is set to 200 o C, plugger inserted activated, compaction done by cold plugger againstGP in the canal orifice.  Firm pressure is applied and heat is activated within the device.  Plugger moved rapidly to within 3 mm of binding point.  Heat inactivated while firm pressure maintained, on the plugger for 5 to 10 seconds.  After GP cooled, a 1 sec application of heat separates plugger from GP and is removed.
WARM LATERAL COMPACTION  Endotec II-(Medidenta) advantage of length control of lateral compaction and incorporating a warm GP technique.  Produces a fusion of the GP into a solid homogenous mass  Endotwinn (Hu Friedy) ability to vibrate the electronically heated tip.  Studies have shown warm lateral compaction, using both heat and vibration, warm vertical compaction produced better replication of defects than cold lateral compaction.  EL Downpak (Hu Friedy) variation of Endotwinn, used with warm lateral and warm vertical compaction.
THERMOPLASTIC INJECTION TECHNIQUES  Heating GP outside the tooth and injecting the material into the canal.  OBTURA II,OBTURA III,CALAMUS, ELEMENTS, HOTSHOT, ULTAFIL 3D
CARRIER BASED GUTTA PERCHA  Thermafill, Profile GT obturators, GT series X Obturators, Protaper universal obturators.  Metal core and coating of GP, heated over open flame  Central core provided rigid mechanism to facilitate placement of GP  Disadvantage was that metallic core made placement of post challenging and retreatment procedures were difficult.  GP often stripped from carrier leaving only the carrier as the obturating material in the apical area of the canal.  Now Plastic core with alpha phaseGP and heating device to control temperature available.
IMMUNO CROSS REACTIVITY  GUTA PERCHA and NATURAL RUBBER LATEX (NRL), are from different trees of the same botanical family  Raw GP contains the rubber molecule trans-polyisoprene  NRL contains cis-polyisoprene intermingled with a variety of latex-allergen proteins  Dental latex materials can cause immediate hypersensitivity (type I allergy) in dental professionals and patients.  Type I reactions from NRL which include ocular, nasal, pulmonary, gastrointestinal, cardiovascular and genitourinary symptoms products can be localized and systemic
 Gazelius et al. and Boxer et al. speculate that because gutta percha and NRL are both rubber-like materials from the same family of trees, a potential cross-reactivity between NRL and gutta percha allergens in latex- allergy patients exists.  Two case reports were published alleging that gutta percha induced an allergic response in NRL-sensitized patients  Costa et al. investigated the cross-reactivity between gutta percha, gutta balata, and NRL using a competitive radioallergosorbent test (RAST) inhibition assay.  These results demonstrated that the raw or manufactured gutta percha points did not show detectible cross reactivity.  However, raw gutta balata extracts cross-reacted with NRL-specific IgE antibody.  Using the RAST inhibition and the immunoblot inhibition assays, Hamann et al. demonstrated that there is no cross-reactivity between gutta percha points and NRL, but raw gutta percha cross-reacted with serum from patients with type 1 NRL allergy.
 Kang PB et al. studied the postulated immuno cross-reactivity between proteins derived from raw gutta percha (RGP), gutta percha point (GPP) and natural rubber latex (NRL).  Antigenicity and cross-reactivity of proteins were determined by the FITkit (FITBiotech, Finland) and ELISA inhibition assays.  Antigenicity of proteins derived from RGP or GPP was not demonstrated.  Except for NRL glove extracts, neither extracts from RGP or GPP were reactive in ELISA inhibition assay.  Significance. There is no immunologic cross-reactivity in vitro between proteins derived from RGP or GPP, and from NRL gloves.Thus, therapeutic use of GPP is unlikely to initiate adverse immuno-reactivity in individuals previously sensitized to NRL proteins. The immuno cross-reactivity of gutta percha points Peter B. Kang∗, Kristy Vogt, Stephen E. Gruninger, Milton Marshall, Chakwan Siew, Daniel M. Meyer Dental materials 23 ( 2007 ) 380–384
Disinfection  GP can be contaminated by handling, aerosols and physical sources during the storage process. Why disinfection of GP?  To fill the root canal system were free from pathogenic microorganisms  Penetration of bacteria into the blood stream of systemically compromised patients should be avoided because of the risk of infective endocarditis  Owing to the thermoplastic characteristic of gutta-percha cones, they can not be sterilized by the conventional process in which moist or dry heat is used because this may cause alteration to the gutta-percha structure. Therefore, a rapid chairside chemical disinfection is needed.
 Polyvinylpyrrolidone-iodine, ethyl alcohol, sodium hypochlorite, hydrogen peroxide, quaternary of ammonium, glutaraldehyde, and chlorhexidine liquid.  The time for these substances to kill microorganisms ranges from a few seconds to substantial periods of time. Why do we need a quick decontamination method?  It is difficult to know beforehand how many accessory cones will be used during lateral condensation.  5.25% NaOCl is an effective agent for a rapid disinfection of gutta-percha cones.  CHX was not effective in eliminating Bacillus subtilis spores on gutta-percha cones after 72 h of contact with the disinfecting substance. Disinfection of gutta-percha cones with chlorhexidine and sodium hypochlorite Brenda Paula Figueiredo de Almeida Gomes et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:512-7
FUTURE  The rapid strides taking place in dental materials science has lead to the introduction of newer materials and techniques with improved physical and mechanical properties. This surge in newer alternatives has lead to the phasing out of older obsolete materials. This brings to the question whether Gutta-percha is indispensable?  Gutta-percha’s unique property of inertness, better sealing ability and the ability to do re-treatment in case of failure, make it an indispensable obturating material currently.
 Gutta-percha has over the years have been modified in several ways to accommodate the growing trends in endodontics and achieve its mission by simplifying the techniques, achieving optimal seal with a better adaptation to the dentinal walls and a less time consuming process.  In this continual process, newer products like self lengthed marked Gutta- percha have been developed and are in line for clearance of patency.  In future, for Gutta-percha to remain indispensable certain property modifications are required such as increased stability, better flow properties, better intra-canal adaptation with reduced shrinkage and an inherent antibacterial efficacy without dissolution.
REFERENCES  COHEN’S PATHWAYS OFTHE PULP- 10TH edition  Schilder H. Filling root canals in three dimensions- JOE — Volume 32, Number 4, April 2006  Disinfection of gutta-percha cones with chlorhexidine and sodium hypochlorite.Gomes BPFA et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:512-7  The immuno cross-reactivity of gutta percha points Kang BP. Dental materials 23 ( 2007 ) 380–384  Gutta percha: An untold story. Prakash R, GopiKrishnaV, Kandaswamy D. Endodontology 32-36  Comparison of 6 different gutta-percha techniques (part II):Thermafil, JS Quick-Fill, Soft Core, Microseal, System B and lateral condensation. Nimet Genc¸og˘lu.ORAL SURGERY ORAL MEDICINEORAL PATHOLOGY Volume 96, Number 1
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