„ CALCIUM AND PHOSPHATE METABOLISM

CONTENTS

 INTRODUCTION
 SOURCE OF CALCIUM
 IMPORTANCE OF CALCIUM
 NORMAL VALUES
 DIFFERENT FORMS OF CALIUM
 DAILY REQUIREMENT OF CALCIUM
 ABSORPTION AND EXCRETION
 CALCIUM METABOLISM
 MAINTAINANCE OF BLOOD CALCIUM LEVEL
 PHOSPHATE AND ITS METABLOLISM
 EFFECT OF VITAMIN D
 CALCIUM AND PHOSPHATE METABOLISM DISODER
 ROLE OF CALCIUM AND PHOSPHORUS IN ORAL HEALTH
 REFERENCES

CALCIUM HISTORY

 Fom latin word “calx” or calsis meaning-”lime

 Isolated in 1808 by Sir Humphrey Davy
 Sidney Ringer demonstrated its biological significance

IMPORTANCE OF CALCIUM-

Calcium is very essential for many activities in the body such as:
 Bone and teeth formation
 Neuronal activity
 Skeletal muscle activity
 Cardiac activity
 Smooth muscle activity
 Secretory activity of the glands
 Cell division and growth
 Coagulation of blood.

NORMAL VALUE
 In a normal young healthy adult, there is about 1,100g of calcium in the body.
 It forms about 1.5% of total body weight. 99% of calcium is present in the bones and
teeth and the rest is present in the plasma.
 Normal blood calcium level ranges between 9 and 11 mg/dL.
CALCIUM IN PLASMA
Calcium is present in three forms in plasma:
 Ionized or diffusible calcium: Found freely in plasma and forms about 50% of plasma
calcium.
 It is essential for vital functions such as neuronalc activity, muscle contraction, cardiac
activity, secretions in the glands, blood coagulation, etc.
 Non-ionized or non-diffusible calcium: Present in non-ionic form such as calcium
bicarbonate. It is about 8% to 10% of plasma calcium
 Calcium bound to albumin: Forms about 40% to 42% of plasma calcium.

CALCIUM IN BONES
 Calcium is constantly removed from bone and deposite in bone. Bone calcium is present
in two forms:
 Rapidly exchangeable calcium or exchangeable calcium: Available in small quantity in
bone and helps to maintain the plasma calcium level
 Slowly exchangeable calcium or stable calcium: Available in large quantity.

SOURCE OF CALCIUM

1. Dietary Source
Calcium is available in several foodstuffs. Percentage of calcium in different food substance is:
Whole milk = 10%
Low fat milk = 18%
Cheese = 27%
Other dairy products = 17%
Vegetables = 7%
Other substances such as meat, egg, grains, sugar, coffee, tea, chocolate, etc. = 21%
2. From Bones
Besides dietary calcium, blood also gets calcium from bone by resorption.

DAILY REQUIREMENTS OF CALCIUM

1 to 3 years = 500 mg
4 to 8 years = 800 mg
9 to 18 years = 1,300 mg
19 to 50 years = 1,000 mg
51 years and above = 1,200 mg
Pregnant ladies and
lactating mothers = 1,300 mg
ABSORPTION AND EXCRETION OF CALCIUM

 Calcium taken through dietary sources is absorbed from GI tract into blood and
distributed to various parts of the body. Depending upon the blood level, the calcium is
either deposited in the bone or removed from the bone (resorption). Calcium is excreted
from the body through urine and feces.
ABSORPTION FROM GASTROINTESTINAL TRACT
 Calcium is absorbed from duodenum by carriermediated active transport and from the
rest of the small intestine, by facilitated diffusion. Vitamin D is essential for the
absorption of calcium from GI tract.

EXCRETION

 While passing through the kidney, large quantity of calcium is filtered in the glomerulus.
From the filtrate,
 98% to 99% of calcium is reabsorbed from renal tubules into the blood. Only a small
quantity is excreted through urine.
 Most of the filtered calcium is reabsorbed in the distal convoluted tubules and proximal
part of collecting duct. In distal convoluted tubule, parathormone increases the
reabsorption. In collecting duct, vitamin D increases the reabsorption and calcitonin
decreases reabsorption. About 1,000 mg of calcium is excreted daily. Out of this, 900 mg
is excreted through feces and 100 mg through urine.

REGULATION OF BLOOD CALCIUM LEVEL

Blood calcium level is regulated mainly by three

hormones (Figs 68.5 and 68.6):
1. Parathormone
2. 1,25-dihydroxycholecalciferol (calcitriol)
3. Calcitonin.

 Parathormone
 Parathormone is a protein hormone secreted by parathyroid gland and its main function is
to increase the blood calcium level by mobilizing calcium from bone (resorption) (See
above for details).

 1,25-dihydroxycholecalciferol – Calcitriol
 Calcitriol is a steroid hormone synthesized in kidney. It is the activated form of vitamin
D. Its main action is to increase the blood calcium level by increasing the calcium
absorption from the small intestine.

 Calcitonin
 Calcitonin secreted by parafollicular cells of thyroid gland. Thyroid gland is a calcium-
lowering hormone. It reduces the blood calcium level mainly by decreasing bone resor
EFFECTS OF OTHER HORMONES

 In addition to the above mentioned three hormones, growth hormone and glucocorticoids
also influence the calcium level.
 Growth hormone
 Growth hormone increases the blood calcium level by increasing the intestinal calcium
absorption. It is also suggested that it increases the urinary excretion of calcium.
However, this action is only transient.
 Glucocorticoid- Glucocorticoids (cortisol) decrease blood calcium by inhibiting intestinal
absorption

PHOSPHATE METABOLISM
 Phosphorus (P) is an essential mineral that is required by every cell in the body for
normal function. Phosphorus is present in many food substances, such as peas, dried
beans, nuts, milk, cheese and butter. Inorganic phosphorus (Pi) is in the form of the
phosphate (PO4). The majority of the phosphorus in the body is found as phosphate.
Phosphorus is also the body’s source of phosphate. In body, phosphate is the most
abundant intracellular anion.

IMPORTANCE OF PHOSPHATE

1. Phosphate is an important component of many organic substances such as, ATP, DNA, RNA
and
many intermediates of metabolic pathways
2. Along with calcium, it forms an important constituent of bone and teeth
3. It forms a buffer in the maintenance of acid-base balance.

NORMAL VALUE

 Total amount of phosphate in the body is 500 to 800 g. Though it is present in every cell
of the body, 85% to 90% of body’s phosphate is found in the bones and teeth. Normal
plasma level of phosphate is 4 mg/dL.
REGULATION OF PHOSPHATE LEVEL

Phosphorus is taken through dietary sources. It is absorbed from GI tract into blood. It is also
resorbed from bone. From blood it is distributed to various parts of the body. While passing
through the kidney, large quantity of phosphate is excreted through urine.

Blood phosphate level is regulated mainly by three hormones:

1. Parathormone

2. Calcitonin

3. 1,25-dihydroxycholecalciferol (calcitriol).

1. Parathormone

 Parathormone stimulates resorption of phosphate from bone and increases its urinary
excretion. It also increases the absorption of phosphate from gastrointestinal tract through
calcitriol. The overall action of parathormone decreases the plasma level of phosphate.

2. Calcitonin

 Calcitonin also decreases the plasma level of phosphate by inhibiting bone resorption and
stimulating the urinary excretion.

3. 1,25-Dihydroxycholecalciferol – Calcitriol

 Calcitriol hormone increases absorption of phosphate from small intestine.

EFFECTS OF OTHER HORMONES

In addition to the above mentioned three hormones, growth hormone and glucocorticoids also
influence the phosphate level.

1. Growth hormone

Growth hormone increases the blood phosphate level by increasing the intestinal phosphate
absorption.

2. Glucocorticoids -Glucocorticoids (cortisol) decreases blood phos phate by inhibiting

intestinal absorption.
CALCIUM AND PHOSPHATE METABOLISM DISORDERS
Can be studied under following heading

 hypercalcemia

 hypoclacemia

 hyperphosphatemia

 hypophosphatemia

HYPERCALCEMIA

CLINICAL FEATURES

 polyurea

 polydipsia

 renal colic

 lethargy

 anorexia

 renal calculi

 peptic ulceration

ORAL MANIFESTATIONS

 jaw bone demineralization

 loss of lamina dura

 osteitis fibrosa cystica

 localized swelling( mandible- cystic)

 pepperpot apparance o skull in lateral cehalogram

 cystic changes

TREATMENT

 rehydration with normal saline

 bisphophonates

 addtitonal rapid therapy in very serious condition

HYPOCALCEMIA

CLINICAL FEATURES

 tetany

 carpal spasm

 trousseu sign

 chvotek’s sign

 erb’s sign
TREATMENT

-intravenous calcium gluconate

HYPERPHOSPHATEMIA

 seen in chronic renal failure

 metastatic calcification
 secondary stimulation of
 parathyroid glands
 pruritis

HYPOPHOSPHATEMIA

 muscle pain, weakness

 respiratory muscle weakness
 cardiac arrythmia
 confusin, convulsion, coma
 hemolysis

VITAMIN D DEFICIENCY

CHILDREN (RICKET)

 DENTAL ABNORMALITY

 development abnormality of enamel and dentin

 delayed eruption
 malalignment of teeth
 higher caries index
 increased amount of interglobular dentin\

ADULT(OSTEOMALACIA)

severe periodontitis
ROLE OF CALCIUM IN ORAL HEALTH
MINERALIZED TOOTH STRUCTURE

 Calcium helps to maintain the mineral composition of teeth, which are subject to both
demineralisation and remineralisation dependent on a number of dietary factors and
the Ph of the oral environment.
 Enamel demineralisation takes placecbelow a pH of about 5.5 (the critical pH). The
critical pH is inversely related to both the calcium and phosphate concentration of
plaque and saliva, which are influenced by diet.
 The concentration of calcium in plaque influences demineralisation of tooth enamel
and thus, risk of caries. The greater the concentration of calcium, the lower is the rate
of demineralization and risk of dental decay.

PRE-ERUPTIVE EFFECTS OF CALCIUM

 Mineralization of primary teeth begins around 4 months in utero and of permanent teeth
around birth, and continues till 6 to 13 years of age.

 During formation, the enamel, dentin and cementum and cementum have vascularsystem
to supply nutrients for mineralization, but this system is severed at the time of eruption.

 As a result, the time when an imbalance in calcium nutrition will have its major effect on
tooth structure is during gestation and childhood.

ROLE OF CALCIUM IN THE ORAL HEALTH OF GERIATRIC PATIENT

 It is incumbent upon the dentist to provide the patient with the nutritional information for
optimal oral health, as factors which are good for prevention of oral disease will also be
equally good for prevention of general illness.

 Unlike other nutrients, the calcium needs for older patients are less as than they were in
young age.

 There should be emphasis on good quality protein foods and a generous selection of
vegetables and fruits and less emphasis on fats, starches, and sugars to avoid an excess of
calories.

 For the individual geriatric new denture wearer each diet prescription should be based on
an analysis and evaluation of his individual food habits and actual food intake.
ROLE OF CALCIUM DEFICIENCY IN THE PROGRESS OF PERIODONTAL
DISEASES

 A reduction of bone mineralization aggravates pathological periodontal changes resulting

in less support for the teeth.

 Decline in dietary intake of calcium and calcium phosphorus ratio may enhance the
appearance of both these conditions by increasing bone resorption.

 This type of bone loss affects the bones in descending order- jaw bones (mainly alveolar
bones), cranial bones, ribs, vertebrae and long bones.

 Alveolar bone has the highest rate of renewal and is affected first and consequently is the
most severely affected in the long term.

 Studies have shown that increased calcium intake improves the suffering of inflammatory
processes and tooth mobility in patients having gingivitis. Insufficient dietary intake of
calcium results in more severe gingival and periodontal diseases.

EFFECTS OF CALCIUM WITH VITAMIN D SUPPLEMENTATION ON ALVEOLAR

RIDGE RESORPTION

 Studies have reported that subjects receiving a 1gm calcium supplement daily for 12
months showed an increase in bone density in the mandible of approximately 12.5%.

 Adequate vitamin D is absolutely essential for absorption and metabolism of calcium.6

Vitamin D deficiency is common in patients not exposed to significant amounts of
natural sunlight.

 Mean alveolar bone loss for patients receiving the supplement was 36% lessthan that for
patients receiving a placebo medication in a l-year double-blind study.

OSTEOPOROSIS
Definition: Osteoporosis has been defined by WHO in 1994 as “a disease characterized by low
bone mass and microarchitectural deterioration of bone tissue leading to enlarged bone fragility
and a consequent increase in fracture risk”.

Classification: Osteoporosis is classified as

1. primary osteoporosis (having unknown cause)

2. secondary osteoporosis (having traceable etiology). Primary osteoporosis is further classified

as

Type – I Post-menopausal (between 50-70 years of age)

Type – II Age related (more than 70 years of age affecting both trabecular and cortical bone)

Osteoporosis can also be classified as-

1. localized

2. generalized osteoporosis.

Clinical features:. The dental

manifestations includes: the cortex at the mandibular angle gets
distinctly thinner and cannot be seen well at the anterior margin of ramus and in the maxilla it is
minimal along the alveolar crest.

DENTAL SCREENING OF OSTEOPOROSIS:

 Mandibular and maxillary radiographs

 Bone density may be assessed by a prosthodontist using linear measurements
(morphometric analysis) or by measuring optical density of bone (densitometric
analysis),
 The Gonial Index measures the mean thickness of the inferior mandibular cortex at the
angle of the mandible.
 The Panoramic Mandibular Index (PMI) given by Benson BW et al., in 1991 is the ratio
of the thickness of mandibular cortex below the mental foramen, to the distance between
the inferior border of mental foramen and the inferior mandibular cortex
 In Mandibular Cortical Thickness (MCT) measurement, a line is drawn on the panoramic
radiograph through the middle of the mentalforamen and perpendicular to a tangent to the
lower border of the mandible similar to PMI.
 Taguchi et al., suggested that the Mandibular Cortical Index (MCI) developed by
Klemetti in 1994, was appropriate for screening [25,26] wherein the inferior cortical
margin is examined with a loupe at 4X magnification and classified as follows
 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.
 Haster et al., further classified MCI based on gender as:
 C1: seen in men, C2: seen frequently in men and C3: seen only in females.

DENTAL CONSIDERATIONS IN OSTEOPOROSIS:

 Some studies have experimentally concluded that in post menopausal women BMD is
related to interproximal bone loss and pointed at osteopenia as a possible risk factor for
periodontal disease.

 Women with low BMD & high calculus apposition had greater clinical gingival
attachment loss than in women with normal BMD & similar calculus apposition.
  Serum estroidal supplementation reduces gingival inflammation and attachment loss
which is the cause for early loss of teeth in early menopausal osteoporotic women.

 Taguchi et al., suggested that the loss of posterior teeth may be with a decrease not only
in alveolar bone height, but also alveolar BMD.

OSTEOPOROSIS AND RESIDUAL RIDGE RESORPTION (RRR):

 RRR after tooth loss is a well described biological reaction.

 A decrease in biomechanical loading on bone reduces the stresses within the bone and
results in resorption within the bone and its periosteal surface.

 The single case control study seems to indicate that the BMC 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 maxillary residual ridge, ridge, while this relationship is not clear cut in the mandible.

OSTEOPOROSIS AND IMPLANT SUPPORTED OVERDENTURES

 Overdentures supported by implants improve the masticatory force, and thus the loading
on the mandibular bone compared to that of conventional full dentures.

 Hutton et al., performed a multinational and multicentre study involving 133 persons
treated with implant supported overdentures in the mandible and/or maxilla .

 The results indicate that persons with inferior bone quality (very thin cortical bone with
low density cancellous bone of poor strength) and pronounced alveolar ridge resorption at
the implant site show the highest risk of implant failure.

PROSTHODONTIC MANAGEMENT:

 Humphries et al., conducted a study on bone resorption of mandibular alveolar bone in

elderly edentulous adults and they concluded that women above 50 years with
osteoporosis required new dentures three times more frequently than women of same age.

 Reducing the stresses on the bone by modifying the treatment plan with specific
precautions is considered in these patients .

 Curtis et al., reported that largest amount of resorption has been shown to occur in the
mid lateral aspects of the body of the mandible, while less resorption occurred anteriorly.

 It was also reported that the clinical height of the region distal to the mental foramen was
more closely correlated with the general bone loss status than the anterior region [.
  While fabricating the removable dentures the main area of focus should be on reduction
of the forces on residual ridge.

 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 advised.

 While fabricating fixed partial denture in periodontally compromised abutments it may

accelerate the bone loss in osteoporotic patients. So, the fabrication of FPD should follow
treatment of osteoporosis rather than preceding it.

TREATMENT AND PREVENTION BY NUTRITIONAL SUPPLEMENTATION

 The intake of foods containing large amounts of phosphorus makes total dietary control
of the calcium-phosphorus ratio ineffective.

 So, nutritional supplementation of the diet is logical and convenient alternative. A

supplementation of 750 to 1,000 mg per day calcium and 375 IU vitamin D is suggested.

 Vitamin D supplementation in patients with coronary disease, impaired renal function,

and atherosclerosis is cautioned.

REVIEW OF STUDY

THE PURPOSE OF THIS STUDY: was to test the hypothesis that a daily calcium and vitamin
D supplement would tend to reduce the rate and extent of alveolar bone resorption following
extractions of teeth.

Throughout the study period of 1 year, each subject received a medication in tablet form. Half of
the subjects took three tablets daily of a supplement which provided a total of 750 mg of calcium
(calcium carbonate from oyster shell) and 375 USP units of vitamin D, (Ergocalciferol) each day.
Half of the subjects took the same number of tablets of a placebo preparation consisting of
lactose and methyl cellulose.

Radiographic examination Panoramic radiographs of each patient’s jaws were made before
extractions, a few days after extractions, and at approximately 3-month intervals until the final
radiographs.

RESULT: A significant reduction in the severity of alveoiar bone resorption in the supplement
group is revealed.
The differences ranged from 34% less in the maxillae to 39% less in the mandible, with an
average difference of 36% less

REFERENCES

1.GUYTON AND HALL TEXTBOOK OF MEDICAL PHYSIOLOGY, 4TH EDITION

2. SEMBULINGAM K . ESSENTIALS OF MEDICAL PHYSIOLOGY, 10TH EDITION

3. GANONG’S REVIEW OF MEDICAL PHSYILOGY-23RD EDITON

4. EFFECTS OF A CALCIUM AND VITAMIN D SUPPLEMENT ON ALVEOLAR RIDGE

RESORPTION IN IMMEDIATE DENTURE PATIENTS- KENNETH

5. OSTEOPOROSIS: ITS PROSTHODONTIC CONSIDERATIONS - A REVIEW BY DR.

VINODBANDELA1 et al.

6. CALCIUM AND ORAL HEALTH: A REVIEW BY DR. MANU RATHEE et al