GOOD MORNING

Calcium and
phosphorus
metabolism
 OUTLINE
• INTRODUCTION
• Minerals
• Calcium
– Functions
– Sources and Distribution
– Dietary requirements
– Uses
• Phosphorus
– Functions
– Sources
– Dietary Requirements
• Absorption of calcium and phosphorus
• Regulation of absorption
• Disorders of calcium and phosphorus metabolism
• conclusion
 Introduction

• The 14 minerals - Calcium, Phosphorus, Magnesium,

Sodium, Potassium, Chloride, and Sulfur, Iron,
Manganese, Copper, Iodine, Zinc, Fluoride, and
Selenium.
• These 14 essential minerals are crucial to the growth and
production of bones, teeth, hair, blood, nerves, skin,
vitamins, enzymes and hormones; and the healthy
functioning of nerve transmission, blood circulation,
fluid regulation, cellular integrity, energy production and
muscle contraction.
• Minerals are neither animal nor vegetable; they are inorganic

• Types of Minerals

• There are two types of minerals:

– Macro minerals and Trace minerals

• The macro mineral group- Calcium, Phosphorus, Magnesium,

Sodium, Potassium, Chloride, and Sulfur
• Trace minerals includes Iron, Manganese, Copper, Iodine, Zinc,
Fluoride, and Selenium.
• Calcium is the most abundant mineral in the human body and has
several important functions.
• The three major regulators of blood calcium are parathyroid
hormone (PTH), vitamin D, and calcitonin
 CALCIUM

• Calcium Status
Atomic Number: 20
Atomic Symbol: Ca
Atomic Weight: 40.08
Electron Configuration: [Ar]4s2
Atomic Radius: 197.3 pm
Melting Point: 842 0C
Boiling Point: 1484 0C
Oxidation State: 2
Plasma calcium :
Normal level -8.6-10.6 mg/dl
i. 50% - present as ionized
form
ii. 40% - bound to proteins
i.e. albumin
iii. 10% - complexed calcium
–calcium citrate,
bicarbonate and phosphate.

• Ca X P in serum
children – 50 and adults 30-40.

• Calcium: Phosphate ratio in

diet:

During growth – 1:1

After cessation of growth- 1: 2.
 Recommended Daily Intake

• Infants- 600-900mg
• Adults- 400-500mg
• Pregnancy and lactation-1000-1200mg

Extra calcium is needed in

Menopausal Woman
Amenorrheic Women and the Female Athlete Triad
Lactose Intolerant Individuals
Vegetarians
 FUNCTIONS OF CALCIUM
• Functions of calcium:
– Hormone secretion
Hormone action :
– Ca+2 acts as second messenger, in the action of hormones
– Neuromuscular transmission
– Muscular contraction
– CBP- Calmoduli,Troponin and calbindin
– It is essential for the clotting of blood -. It helps in the
formation of activated forms of factor IX, X, II and in the
formation of prothrombin activator.
– Formation of bone and teeth
– It regulates the permeability of the capillary walls.
– cell division, mitosis and fertilization
– endocytosis, exocytosis, cellular motility
 RICH SOURCES OF CALCIUM

• Dairy Products, such as Milk, Cheese, and Yogurt

• Canned Salmon and Sardines with Bones
• Leafy Green Vegetables, such as Broccoli, Spinach
• Calcium-Fortified foods - from Orange juice to Cereals and Crackers
Ice Cream, Oysters, Ricotta.

CALCIUM BALANCE:
It is the net gain or loss of calcium by body over a specific period of
time.
Amount absorbed = Amount ingested - Amount egested in faeces
Amount retained = Amount absorbed – Urinary calcium( excreted)
 PHOSPHORUS
• Phosphorus is the second most abundant mineral in the body and 85% of it is
found in the bones.
• Non metallic element - blood, muscles, nerves, bones, and teeth
component of adenosine tri-phosphate
Functions
hydroxyapatite. Phospholipids
major structural components of cell membranes.
• energy production and storage - ATP
• Nucleic acids (DNA and RNA),
• enzymes, hormones, and cell-signaling molecules
• buffers.
• (2,3-DPG) binds to hemoglobin
Phosphate buffer system

• Composed of HPO4, H2PO4

• More effective buffer in tubular
fluid.
• Pk -6.8
• It functions near its most effective
range of pH of urine.
• Only 30-40mEq/day is available
for buffering .
 The Recommended Dietary Allowance (RDA)

Life Stage Age Males(mg/day) Females

Infants 0-6 months 100 100
Infants 7-12 months 275 275
Children 1-3 years 460 460
Children 4-8 years 500 500
Adolescents 14-18 years 1,250 1,250
Adults 19 years and older 700 700
Pregnancy 19 years and older 700
Breast-feeding 18 years and younger 1,250
Breast-feeding19 years and older 700
 PHOSPHORUS RICH FOODS

• Food Serving Phosphorus (mg)

Milk, 8 ounces 247
Yogurt, plain nonfat 8 ounces 385
Cheese, 1 ounce 131
Egg 1 large, cooked 104
Chicken 3 ounces, cooked* 155
Fish, salmon 3 ounces, cooked* 252
Bread, whole wheat 1 slice 57
 BONE GROWTH AND CALCIUM METABOLISM
• Bone – organic-collagen.glycoproteins,phosphoprus
inorganic-hydroxyapatite crystals.-strength and hardness.
• Outer cortical layer and inner cancellous structure.
• Cancellous bone – trabaculae
• Osteoblasts, osteoclasts and osteocytes.

• BONE REMODELLING
– Osteoblasts secret interleukins osteoclasts

Estrogen-inhibits acids proteases

osteoclastic activity
collagen lysis cavity formation
Glucocorticoids -inhibits Ostoblasts
Osteoblastic activity Alkaline
phosphatase
new bone formation
BONE GROWTH AND CALCIUM METABOLISM

Growth of epiphyseal plate

IGF-1,tyroid,vitD,Growth
harmone.

OSSIFICATION
Cartilagenous ossification
Membranous ossification
ABSORPTION OF CALCIUM AND PHOSPHORUS

• Ca+2 is poorly absorbed from intestine.

• Vitamin D and PTH promotes absorption
• Slight acidity or neutral pH is needed for Ca
absorption
• Active transport – Where Ca absorption
occurs against
Ca concentration and is dependent on 1,25
(OH)2 cc.-Duodenum
Passive diffusion occurs lower down in the
small intestine and accounts only for 15%.

• Renal excretion of calcium and phosphorus

CALCIUM METABOLISM
 Factors affecting absorption :
• pH of intestinal contents
acidic pH – favors absorption
alkaline medium - lowered
• Composition of diet :
High protein diet favors absorption
Fatty acids – decreases calcium absorption
Sugars and organic acids
Citric acid also increases absorption- chelator
Phytic acid forms insoluble calcium salts
Minerals : Excess phosphates lowers calcium absorption, high
magnesium content decreases Ca absorption
• Health status
• Hormonal control : PTH, calcitonin, Vit-D, glucocorticoids
decrease the intestinal transport of calcium.
 Sex harmones:
•
Increase intestinal absorption
–
Stimulate mineralization
–
Decrease renal excretion
–
Thyroid harmones:
•
Hyperthyroidism-increased bone resorption
–

Factors regulating absorption

• Three tissues-
–
Three harmones-
–
Three cells -
–
VITAMIN D
• Requirements
RDA – infancy through puberty -10 mcg of cholecalciferol/400 IU
Adults- 7.5 mcg
> 25 – 5 mcg
Pregnancy and lactating – increase by 5 mcg.
 Actions of Vitamin D
• Intestinal calcium absorption
• Intestinal phosphorus absorption
• Decreases Renal Calcium and Phosphorus excretion

• Effect of Vitamin D on Bone and its relation to Parathyroid

harmone
Bone absorption and Bone deposition
Smaller quantities – bone calcifications.
• VITAMIN DEFFICIENT RICKETS
Bones and Teeth
1. cessation of calcification of epiphyseal disks
2. Osteiod lay down
3. Children-bowing of legs, pigeon breast deformity, harrison’s groove
4. Developmental anomalies of dentin and enamel, delayed eruption.

• OSTEOMALACIA
1. Flat bones and diaphyses
2. Post menopausal women
3. Losers zone are milkmans fracture
4. severe periodontitis
5. Treatment: Dietary enrichment of Ca, harmonal therapy
• VITAMIN D-RESISTANT RICKETS
1. Renal tubular defects
2. Inability to reabsorb some elements.
3. X- linked dominant defect in renal phosphate metabolism.
4. Hypophosphatemia

5. Globular and hypo calcified dentin

6. Pulp horns are elongated and extended high

Treatment : decreased vit D + oral phosphate

• RENAL RICKETS
1. Inability of kidneys to synthesize 1-a-hydroxylase
2. Calcium absorption is impaired-increase in fecal calcium
excretion
3. Treatment: administration of 1-a-OH-cholecalciferol

HYPERVITAMINOSIS D:
1. Feeling of well-being
2. Improved appatite
3. Digestive disturbances, fatigue weakness
4. Increased flow of urine containing calcium and phosphorus
PARATHYROID HARMONE
• The major hormone for
regulation of the serum [Ca2+]
• Synthesized and secreted by
the chief cells of the
parathyroid glands.
• PTH-rp-produced by different
genes
• both elevates calium level
• Also binds with PTH receptors
 Biological Activity of PTH

• BONE
– PTH stimulates bone osteoblasts to increase growth &
metabolic activity
– PTH stimulated bone resorption releases calcium &
phosphate into blood
• KIDNEY
– PTH increases reabsorption of calcium & reduces
reabsorption of phosphate
– Net effect of its action is increased calcium & reduced
phosphate in plasma
• INTESTINE
– Increases calcium reabsorption via vitamin D
–
Secretion of PTH

• controlled by the serum [Ca2+] by negative feedback

• mild decreases in serum [Mg2+] also stimulate PTH secretion.

• severe decreases in serum [Mg2+] inhibit PTH

secretion and produce symptoms of hypo parathyroidism.

• the second messenger for PTH secretion by the

parathyroid gland is cyclic AMP.

• Estimation: two sides immuno radiometric assay

• Degradation: kupffer cells of liver

HYPOPARATHYROIDISM
• Reduced amount of PTH
• Surgical removal of parathyroid glands
• Autoimmune destruction of parathyroid tissue
• DiGeorge syndrome and endocrine –candidiasis syndrome
CLINICAL FEATURES
• Hypocalcemia
• Pitting of enamel hypoplasia
• Failure of tooth eruption
Treatment : oral diseases of ergocalciferol.

PSEUDOHYPOPARATHYROIDISM TYPE IA –ALBRIGHT’S

HEREDITARY OSTEODISTROPHY
• Result of defective G protein in kidney and
bone, which causes end-organ resistance to PTH.
• hypocalcemia and hyperphosphatemia
HYPERPARATHYROIDISM
• Excss production of PTH
• Primary hyperparathyroidism:
– Uncontrolled production of PTH
– Parathyroid adenoma
• Secondary hyperparathyroidism:
– Chronic renal diseases
• Clinical features
• Triad of signs and symptoms-stones,bones, and abdominal groans
• Treatment:
• hyperplastic tissue removed surgically
• Restriction of phosphate diet
• Use of phosphate binding agents
• calcitriol
• Calcitonin is a peptide Calcitonin
hormone secreted by the
parafollicular or “C” cells
of the thyroid gland
• It is synthesized as the
preprohormone &
released in response to
high plasma calcium
• Calcitonin acts on bone
osteoclasts to reduce
bone resorption.
• Net result of its action is a
decline in plasma calcium
& phosphate
Summary:

• PTH & calcitonin release are regulated by plasma Ca levels

• Bone Ca & phosphate serve as a ready reserve for
maintenance of plasma levels
• Bone, kidney & intestine participate in the regulation of
plasma calcium
• PTH, Vitamin D, & calcitonin balance plasma [Ca++] for
bone synthesis, muscle contraction, & cell signaling
• Endocrine diseases result from pathway or glandular hypo or
hyper secretion
 Etiologies of Hypercalcemia

Increased GI Absorption
Decreased Bone Mineralization
Milk-alkali syndrome
Elevated calcitriol Elevated PTH
Vitamin D excess
Aluminum toxicity
Increased Loss From Bone/ Increased net
bone resorption
Elevated PTH
Hyperparathyroidism Decreased Urinary Excretion
Malignancy Thiazide diuretics
Osteolytic metastases
PTHrP secreting tumor Elevated calcitriol
squamous cell bronchogenic carcinoma.
Elevated PTH
Increased bone turnover
Paget’s disease of bone
Hyperthyroidism
• Treatment:isotonic saline 6-8 lt/day
• Corticosteroids: Prednisone 40-80 mg/day in patients with sarcaidosis,
lymphoma are hypervitaminoses D.
• biphosphonates (ctidronate, pamidronate) inhibits osteoclastic resorption.
• Gallium nitrate
 Etiologies of Hypocalcemia

Decreased GI Absorption
Poor dietary intake of calcium
PTH resistance
Impaired absorption of calcium
Vitamin D deficiency (pseudohypoparathyroidism
Decreased conversion of vit. D to )
calcitriol Vitamin D deficiency /
Liver failure low calcitriol
Renal failure
Low PTH Increased Urinary Excretion
Decreased Bone Resorption /
Increased Mineralization
Low PTH
Low PTH (hypoparathyroidism)
 • Clinical signs of hypocalcemia
CHVOSTEK’S SIGN
• Elicitation: Tapping on the face at a point
just anterior to the ear and just below
the zygomatic bone
• Postitive response: Twitching of the
ipsilateral facial muscles, suggestive of
neuromuscular excitability caused by
hypocalcemia
TROUSSEAU’S SIGN
• Elicitation: Inflating a
sphygmomanometer cuff above systolic
Hypocalcemic tetany in the hand, called
carpopedal spasm
blood pressure for several minutes
• Postitive response: Muscular contraction
including flexion of the wrist and
meta carpophalangeal joints
• Diagnosis:
serum phosphate and alkaline phosphatase levels are increased –
vit D defficiency
blood urea nitrogen , creatinine increased in renal diseases.
• Treatment
In severe tetany - Acute cases, calcium chloride – 10% - 10-30 ml IV not
to exceed 1 ml/min.

• Dental manifestations of hypocalcimia :

Enamel hypoplasia, widened pulp chambers, pulp stones, shortened roots,
delayed eruption and hypodontia
 Etiologies of Hypophosphatemia
Decreased GI Absorption
Decreased dietary intake (rare in
isolation)
Diarrhea / Malabsorption
Phosphate binders (calcium
acetate, Al & Mg containing
antacids)
Decreased Bone Resorption /
Increased Bone Mineralization
Vitamin D deficiency / low
calcitriol
Hungry bones syndrome
Osteoblastic metastases
Increased Urinary Excretion
Elevated PTH (as in primary
hyperparathyroidism)
Vitamin D deficiency / low
calcitriol
Fanconi syndrome
Internal Redistribution (due to acute
stimulation of glycolysis)
Refeeding syndrome (seen in
starvation, anorexia, and
alcholism)
During treatment for DKA
 Etiologies of Hyperphosphatemia

Increased GI Intake
Fleet’s Phospho-Soda

Decreased Urinary Excretion

Renal Failure
Low PTH (hypoparathyroidism)

Cell Lysis
Rhabdomyolysis
Tumor lysis syndrome
 Etiologies of Hypophosphatemia

Decreased GI Absorption
Decreased dietary intake
Phosphate binders

Decreased Bone Resorption

Vitamin D deficiency / low calcitriol
Hungry bones syndrome

Increased Urinary Excretion

Elevated PTH (as in primary hyperparathyroidism)
Vitamin D deficiency
Internal Redistribution (due to acute stimulation of glycolysis)
Refeeding syndrome
• Conclusion
Understanding bone physiology is
important in orthodontic interventions
involving manipulation of bone by the
dentist should be carried out only when the
patient is in positive calcium balance
• REFERENCES
Textbook of medical physiology tenth edition
GUYTON & HALL
Clinical Oral Physiology –Timothy s miles,
Concise medical physiology- Chaudhuri
Principles & Practice of medicine –Davidson ,
6th edition