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CALCIUM METABOLISM

Presented by Guided by
Dr. ADITHI PRABHU Dr. JYOTI KARANI
Ist MDS DEPT OF Dr. SALONI MISTRY
PROSTHODONTICS
CONTENTS
• INTRODUCTION
• DISTRIBUTION
• FORMS OF CALCIUM
• SOURCE
• ABSORPTION AND EXCRETION OF CALCIUM
• BONE AND ITS RELATION TO EXTRACELLULAR CALCIUM
 BUFFER FUNCTIONS OF CALCIUM IN THE BONE
• HORMONAL CONTROL OF CALCIUM ION CONCENTRATION
• FACTORS INFLUENCING CALCIUM ABSORPTION
• HYPERPARATHYROIDISM
• AGE RELATED CHANGES
• CONSEQUENCES OF CALCIUM INSUFFICIENCY
• OSTEOPOROSIS
 DEFINITION
 CLASSIFICATION
 CLINICAL MANIFESTATIONS
 DENTAL MANIFESTATIONS
• PROSTHODONTIC MANAGEMENT OF OSTEOPOROTIC PATIENTS
• OSTEOPOROSIS AND DENTAL IMPLANT THERAPY
• OSTEOPOROSIS AND RESIDUAL RIDGE RESORPTION
 PROSTHODONTIC MANAGEMENT
 GENERAL CONSIDERATIONS OF OSTEOPOROTIC PATIENTS RECEIVING MEDICATION
• CONCLUSION
• REFERENCES
INTRODUCTION
Rigidity of skeleton,which
provides support and protection
for soft tissues, hardness and
fitness of the teeth

Muscle contraction, stability of


cell membranes, as an
activatory of many hormones

Beating of the heart itself


DISTRIBUTION
FORMS OF CALCIUM
Present in 3 forms
SOURCE
• Calcium is found in milk and
dairy products,
• Green leafy vegetables,
• seafood,
• almonds,
• blackstrap molasses,
• broccoli,
• enriched soy and rice milk
products, figs,
• soybeans and tofu.
RECOMMENDED DIETARY
ALLOWANCES FOR CALCIUM
ABSORPTION AND
EXCRETION OF CALCIUM
RENAL EXCRETION
• Approximately 10%
(100 mg/day) of
ingested calcium is
excreted through urine
• Around 41% of plasma
calcium is bound to
plasma proteins;
therefore not filtered by
the glomerular
capillaries
BONE AND ITS RELATION TO
EXTRACELLULAR CALCIUM
ORGANIC
MATRIX

BONE
BONE
SALTS
• 90%-95% of collagen
ORGANIC fibres (gives bone its
tensile strength)
MATRIX • Rest is ground substance

• Principally composed of
BONE calcium and phosphorus (major
crystalline salt hydroxyapatite)
SALTS • Other salts: Mg, Na, K,
carbonate ions
BUFFER FUNCTIONS OF
EXCHANGEABLE CALCIUM IN
BONES
• Increase in concentrations in
extracellular fluid calcium
and phosphate causes
immediate deposition of
exchangeable salt
• Conversely a decrease would
lead to an immediate
absorption of the salt in the
blood
• This occurs due to presence
of blood vessels in the bone
that aid in the exchange/
buffer system
HORMONAL CONTROL OF
CALCIUM ION
CONCENTRATION
EFFECTS OF PARATHYROID HORMONE
ON CALCIUM METABOLISM
 Functions:
Increase renal osteoclastic
Increasing phosphate excretion , and
resorption
of bone (occurring rapidly).
increases plasma calcium by:
Increasing intestinal absorption of
calcium (a slower response).

Increasing synthesis of 1,25-


(OH)2D3 (stimulating GIT
absorption).

Increasing renal tubular


reabsorption of calcium
ROLE OF VITAMIN D IN CALCIUM
METABOLISM
• Vitamin D has a potent effect to increase calcium
absorption from the intestinal tract
• Also has important effects on bone deposition and
absorption
FACTORS INFLUENCING
CALCIUM ABSORPTION
Lactase deficiency:

• without lactose calcium absorption is greatly reduced

in small intestine.

Low estrogen:

• Estrogen is essential for the bone-forming cells to

utilize the calcium.


Estrogen and Androgen deficiencies:
• Estrogen appears to antagonize the effect of PTH on
bone resorption, thus an estrogen deficiency would be
expected to increase the sensitivity of bone to the
resorptive action of PTH

 Calcitonin and glucocorticoids

 High protein and low calcium diet


DECREASED ABSORPTION
INCREASED ABSORPTION
HYPERPARATHYROIDISM
PRIMARY HYPERPARATHYROIDISM
• An abnormality in the
parathyroid glands
cause inappropriate,
excess PTH secretion
• Cause is ordinarily a
tumour in one of the
parathyroid glands
SECONDARY
HYPERPARATHYROIDISM
• High levels of PTH occur as a compensation for
hypocalcemia rather than as a primary abnormality
• Can also be caused by vitamin D deficiency and
chronic renal disease in which the damaged kidney is
unable to produce active form of vitamin D

• Leads to osteomalacia (inadequate mineralization of


bones)
INVESTIGATIONS
Normal calcium levels- 9-11mg/dl

Alterations in
• serum calcium levels
• PTH levels (normal range: 10 and 65 pg/ml)
• Increased levels of alkaline phosphatase (normal
level= 53-128 U/L)
AGE RELATED CHANGES IN
CALCIUM METABOLISM
Decreased renal 1,25(OH)2D
production in response to PTH.

Decreased intestinal Ca absorption


in response to 1,25(OH)2D.

Decreased sensitivity of the


parathyroid glands to serum Ca.

Decreased bone deposition relative


to resorption
CONSEQUENCES OF CALCIUM
INSUFFICIENCY
OSTEOPOROSIS
DEFINITION
Osteoporosis has been defined by WHO in 1994 as “a
disease characterized by low bone mass and micro
architectural deterioration of bone tissue leading to
enlarged bone fragility and a consequent increase in
fracture risk”
CLASSIFICATION OF OSTEOPOROSIS

PRIMARY SECONDARY
OSTEOPOROSIS OSTEOPOROSIS
(known etiology)

Post menopausal Age related


Osteoporosis Osteoporosis
CLINICAL MANIFESTATIONS
Postmenopausal
(type I)
Age related (type II)

• Age • 51-75 • 70+


• Sex • Female • Female/male
• Fracture sites • Vertebrae(crush), • Vertebrae(wedge),
distal radius hip
• Ca absorption • Decreased • Decreased
• Serum calcitriol • Decreased • Decreased
• Serum PTH • Decreased • Increased
• Bone loss • Trabecular • Trabecular and
cortical

• Spinal fractures include loss of height, increased scoliosis or


kyphosis, significant back pain and limited range of motion
DENTAL MANIFESTATIONS
• Periodontal diseases
(interproximal bone loss
and clinical attachment
loss)
• Progressive Residual
ridge resorption
PROSTHODONTIC
MANAGEMENT OF THE
OSTEOPOROTIC PATIENT
HOW CAN WE, AS
PROSTHODONTISTS ASSESS
THESE PATIENTS?
OSTEOPOROSIS AND DENTAL
IMPLANT THERAPY
• A diagnosis of osteoporosis or osteopenia is not an absolute
contraindication to dental implant therapy.
• Final conclusions regarding the effect of osteoporosis in dental
implant therapy cannot be made at this time.
Tactile evaluation of the bone
quality and assessing the bone
mineral density
preparation of the implant site

achieving primary stability

will help predict the prognosis of implant placement.


LEKHOLM AND ZARB (1985)
CLASSIFICATION BASED ON CT
DETERMINATION OF BONE DENSITY

Kalpalatha Reddy, 2N Kumaravel, 3Anjan Kumar Shah, Assessment of Trabecular Bone Texture from
CT Images by Multiresolution Analysis and Classification Using SVM, May-August 2010;1(2):55-60
OSTEOPOROSIS AND RESIDUAL
RIDGE RESORPTION
• A term used for the diminishing quantity and quality of the
residual ridge after the teeth are extracted. (GPT-9)
• RRR after tooth loss is a well described biological reaction
• Humphries et al concluded that women above 50 years with
osteoporosis required new dentures three times more
frequently than women of same age.
• Seems to indicate that the bone mineral content status in the
jaws is lower in patients with symptomatic osteoporosis than
in healthy age and menopausal age-matched females and that
osteoporosis may produce a risk factor for severe resorption of
the residual ridges
Dr. Kamalakanth Shenoy, Dr. Rajesh Shetty, Dr. Savita Dandakeri and Dr.
Tehseen Zakir, calcium and its role in prosthodontics: a short review,
International Journal of Current Research, 10, (03), 67137-67140
DENTAL SCREENING OF
OSTEOPOROSIS
• Bone density can be assessed by using
 Linear measurements (morphometric analysis)
or
By measuring optical density of bone
(densitometric analysis)
MORPHOMETRIC ANALYSIS
• MANDIBULAR CORTICAL INDICES, including
mandibular cortical index (MCI),
 mandibular cortical width (MCW) and
panoramic mandibular index (PMI), have been
developed to assess and quantify the quality of
mandibular bone mass and to observe signs of
resorption on panoramic radiographs for
identification of osteopenia.
Klemetti et al classified
mandibular corical shape
as
C1: The endosteal margin
of the cortex is even/sharp
on both the sides.
C2: Margin with semilunar
defects (resorption
cavities) on one or both the
sides with cortical residues
1–3 layers thick.
C3: The endosteal margin
consists entirely of thick
cortical residues and is
clearly porous.
DENSITOMETRIC ANALYSIS
• DEXA (Dual Energy
X-ray
Absorptiometry)

• Computer Assisted
Densitometric Image
Analysis (CADIA)
PROSTHODONTIC MANAGEMENT
• Mucostatic or open mouth impression
techniques, selective pressure
impression technique, should be
employed to reduce mechanical forces
while impression making.
• Semi anatomic or non-anatomic teeth
with narrow buccolingual width should
be selected.
• Optimal use of soft liners, extended
tissue intervals by keeping the dentures
out of mouth for 10 hours a day can be While fabricating removable
advised. dentures, the main area of focus
• While fabricating fixed partial denture should be on reduction of the
in periodontally compromised forces on residual ridge.
abutments it may accelerate the bone
loss in osteoporotic patients. So, the
fabrication of FPD should follow
treatment of osteoporosis rather than
preceding it.(Bandela et al., 2015)
GENERAL CONSIDERATIONS IN
OSTEOPOROTIC PATIENTS
RECEIVING MEDICATION
(BISPHOSPHONATE THERAPY)
Faiman B, Pillai AL, Benghiac AG, Bisphosphonate-related osteonecrosis of the jaw: historical,
ethical, and legal issues associated with prescribing, 2013 Jan;4(1):25-35.
RECOMMENDATIONS
INTRUCTED TO PATIENTS
DIETARY RECOMMENDATIONS
CALCIUM AND VITAMIN D
SUPPLEMENTATION WHEN REQUIRED
• CAL-D, CALBO-D, CADMIN
:Calcium carbonate
USP 1250mg equivalent
to 500mg elemental calcium
and vitamin
D3 (cholecalciferol)
CONCLUSION
• Disturbances in calcium intake and excretion result in
deranged metabolism accounting for abnormal serum
levels.
• Thus, an understanding of the basic mechanism of
calcium metabolism and pathophysiology of various
related disorders is helpful in guiding therapeutic
decisions.
• The prosthodontist, by identifying the features would be
at an advantage enabling to refer patient for bone
density screenings for early diagnosis and subsequent
treatment of disease.
• A healthy diet, regular exercises and medications can
help in preventing bone loss or strengthening already
weak bones.
REFERENCES
• Hall, J. E., & Guyton, A. C. (2011). Guyton and Hall textbook of medical physiology. Philadelphia, PA:
Saunders Elsevier
• Dr. Kamalakanth Shenoy, Dr. Rajesh Shetty, Dr. Savita Dandakeri and Dr. Tehseen Zakir, calcium and
its role in prosthodontics: a short review, International Journal of Current Research, 10, (03), 67137-
67140
• Harvey James Armbrecht, Age-related Changes in Calcium Homeostasis and Bone Loss
• Atwood D.A. Reduction of residual ridges: A major oral disease entity. J Prosthet Dent 1971; 26: 266-
279
• Dr. Ajay Gupta MDS, Residual ridge resorption : a review
• Bhupender Yadav, Manisha Jayna, Harish Yadav, Shrey Suri, Shefali Phogat, and Reshu Madan et al,
Comparison of Different Final Impression Techniques for Management of Resorbed Mandibular Ridge:
A Case Report, Article ID 253731, 6 pages doi.org/10.1155/2014/253731
• vinod bandela, bharathi munagapati,rajeev k reddy karnati,giridhar reddy sirupa venkata,and
simhachalam reddy nidudhur , osteoporosis: its prosthodontic considerations - a review, 2015 december,
doi: 10.7860/jcdr/2015/14275.6874
• Esin Hastara ,H. Huseyin Yilmazb,Hikmet Orhan, Evaluation of mental index, mandibular cortical index
and panoramic mandibular index on dental panoramic radiographs in the elderly, 2011 Jan;5(1):60-7
• AkiraTaguchi, Panoramic radiographs for identifying individuals with undetected osteoporosis, 2009
September, 109-120
• Kalpalatha Reddy, 2N Kumaravel, 3Anjan Kumar Shah, Assessment of Trabecular Bone Texture from
CT Images by Multiresolution Analysis and Classification Using SVM, May-August 2010;1(2):55-60
• Venkatakrishnan C. J, Bhuminathan S, Chandran C. R, Poovannan S. Dental Implants In Patients With
Osteoporosis – A Review. Biomed Pharmacol J 2017;10(3)
THANK YOU