Calcium and Phosphorous metabolism 23-03-23.pptx

CALCIUM AND PHOSPHOROUS
METABOLISM
PRESENTED BY:
DR. SHAURYA NEGI
MDS-1ST YEAR
DEPARTMENT OF ORTHODONTICS
AND DENTOFACIAL ORTHOPEDICS

CALCIUM
In nature-
• Does not exist freely
• Occurs mostly in soil systems as limestone (CaCO3), gypsum
(CaSO4*2H2O) & fluorite (CaF2)
In the body –
• The most abundant mineral
• Average adult body contains approx. 1 kg
Dorozhkin SV
.CalciumOrthophosphates: Occurrence,Properties and Major Applications. BioceramicsDevelopmentand
Applications. 2014 Nov19;2014.

RECOMMENDED CALCIUM INTAKE
ClineJ.Calciumand vitamin d metabolism, deficiency, and excess.Topicsin companion animal medicine.2012
Nov 30;27(4):159-64.
DAILY REQUIREMENTS OF CALCIUM (WHO
ESTIMATE)
Adults = 800 mg/day
Infants (<1 year) = 300-500 mg/day
Children (1-16 yrs.) = 0.8-1.2 g/day
17 and above = 0.5-0.6g/day
Pregnancy and lactation = 1.5 gm/day

DISTRIBUTION
Dorozhkin SV
.CalciumOrthophosphates: Occurrence,Properties and Major Applications. BioceramicsDevelopmentand
Applications. 2014 Nov19;2014.
2.25–2.75
mmol/l
10mmol/l

FUNCTIONS OF CALCIUM
Development of
bones and teeth.
Maintenance of
excitability of nerve
and muscles.
Blood Coagulation –
factor IV
Hormone release –
Insulin, PTH,
Calcitonin
Activation of
enzymes– Lipase,
ATPase and
succinate
dehydrogenase
Action on Heart –
acts on myocardium
to prolong systole

ABSORPTION OF CALCIUM
Calcium is taken through dietary sources as calcium
phosphate, carbonate, tartrate and oxalate.
Absorbed from the gastrointestinal tract in to blood and
distributed to various parts of the body.
Mechanisms:
• SimpleDiffusion.
 Anactive transport process,involvingenergy
and calciumpump.
Nov 30;27(4):159-64.

 While passing through the kidney, large quantity of calcium
is filtered in the glomerulus.
 From the filtrate, 98 to 99% of calcium is reabsorbed in
the renal tubules in to blood and only small quantity is
excreted through urine.
Nov 30;27(4):159-64.
 In the bone, the calcium may be deposited or
resorbed depending upon the level of calcium in the
plasma.

FACTORS AFFECTING
ABSORPTION OF CALCIUM
ACTING ON
MUCOSAL CELLS
1. Vitamin D
2. Pregnancy and
growth
3. PTH
AFFECTING THE
AVAILABILITY IN GUT
1. pH of the intestine
2. Amount of dietary calcium
3.Phytic acid and Phytates
4. Oxalates
5. Fats
6. Proteins and amino acids
7. Bile salts
ClineJ.Calciumand vitamin d metabolism, deficiency, and excess.Topicsin companion animal medicine.2012Nov 30;27(4):159-64.

PREGNANCY AND GROWTH
•During later stages of pregnancy, greater amount of calcium
absorption is seen.
•50% of this calcium is used for the development of fetal skeleton
and the rest is stored in the bones to act as a reserve for lactation.
Nov 30;27(4):159-64.

VITAMIN-D
Action on Intestine
• Increases the intestinal absorption of Ca in the intestinal cells.
Nov 30;27(4):159-64.
Action on bone
• In the osteoblasts of bone, Calcitriol stimulates Ca uptake for deposition as CaPo4
Action on kidney
• Involved in minimizing the excretion of Ca through kidney by decreasing their excretion and
enhancing resorption

PARATHYROIDHORMONE
Nov 30;27(4):159-64.
Parathyroid hormone is one of the main hormones controlling Ca+2
absorption.
It mainly acts by controlling the formation of 1,25 DHCC, which is active
form of Vit. D, which is responsible for, increased Ca+2 absorption.

CONCEPT OF CALCIUM BALANCE
This term is used to describe the amount of Ca++ either stored or lost by the body
over a specific period of time.
When the assimilation of calcium from dietary sources is less than the metabolic
requirements and the obligatory losses , then calcium is withdrawn from the
skeleton to maintain the critical concentration of the element in the blood and tissue
fluids.

PHOSPHOROUS
DISTRIBUTION OF
PHOSPHOROUS IN THE
BODY
The human body contains
1000 gms of PO4out of
which 85% (850g) is in the
bone.
Remaining phosphorous is
present in the liver,
pancreas and brain.

DAILY REQUIREMENTS OF PHOSPHOROUS
The recommended dietary allowance (RDA) of phosphate is based on the
intake of calcium
For adults,
Ca : P is 1 : 1 (Recommended ratio)
i.e. 950 mg/day
For infants,
2 : 1 (Recommended ratio)
based on ratio found in human milk

FUNCTIONS OF PHOSPHATE
Development of bone and teeth.
Important constituent of high energy phosphate compounds like ATP, creatine phosphate,
cyclic AMP, hexose phosphate, phospholipids, nucleotides.
Helps in the regulation of glycolysis.
Phosphorylation of lipids and sugar i.e. absorption, transportation and metabolism.
Essential for formation of phospholipids, phosphoproteins and nucleic acids (DNA and RNA)
ClineJ.Calciumand vitamin d metabolism, deficiency, and excess.Topicsin companion animal medicine.2012 Nov 30;27(4):159-64.

HORMONAL CONTROL OF CALCIUM &
PHOSPHATE METABOLISM
• Three hormones regulate calcium and phosphate metabolism.
Nov 30;27(4):159-64.
 Vitamin D
 PTH
 Calcitonin

VITAMIN D
Boudal, Ayah & Attar, Suzan. (2012). Vitamin D and Autoimmune Disease. 10.5772/26932.

ACTIONS OF PTH
Cline J. Calcium and vitamin d metabolism, deficiency, and excess. Topics in companion animal
medicine. 2012Nov 30;27(4):159-64.
The main function is to increase the level of Ca in plasma within the critical
range of 9-11 mg.
Inhibits renal phosphate reabsorption in the proximal tubule and therefore
increases phosphate excretion
Parathormone increases renal Calcium reabsorption in the distal tubule, which
also increases the serum calcium.
Net effect of PTH ↑ serum calcium
↓ serum phosphate

CALCITONIN
https://www.pathologyoutlines.com/topic/chemistry

ACTION OF CALCITONIN
Nov 30;27(4):159-64.
 Net effect of calcitonin- DECREASES Serum Ca
 Target site- Bone (osteoclasts)
 decreased ability of osteoclasts to resorb bone
• Calcitonin is a Physiological Antagonist to PTH with respect to
Calcium.
• With respect to Phosphate it has the same effect as PTH i.e.
Decreases plasma Phosphate level

EXCRETION OF CALCIUM
Ca is excreted both in the faeces (90%) and in the urine
Calcium of the urine is excreted as Calcium chloride and Calcium phosphate.
 The approximate daily turnover rates of Calcium in an adult are as follows:
Intake :1000mg
Intestinal absorption :350mg
Secretion in GI juices :250mg
Net absorption over secretion :100mg
Loss in the faeces :200mg
Excretion in the urine :100mg

Phosphorus is excreted primarily through the urine.
Almost two thirds of total phosphorus that is excreted is found in the urine as
phosphate of various cations.
Phosphorus found in the faeces is the non absorbed form of phosphorus
EXCRETION OF PHOSPHOROUS

A decrease in total plasma calcium concentration below 8.8
mg/dL (2.20 mmol/L) in the presence of normal plasma protein
concentration.
EmkeyRD,EmkeyGR.Calcium metabolism and correcting calcium deficiencies. Endocrinology and
metabolism clinics of North America. 2012 Sep30;41(3):527-56.
HYPOCALCEMIA
DISORDERS OF CALCIUM METABOLISM

VitaminDdeficiency
Idiopathichypoparathyroidism
Renaltubulardisease
Magnesium depletion
CAUSES OF HYPOCALCEMIA
Acutepancreatitis
Hypoproteinemia
Hyperphosphatemia

CHVOSTEK’S SIGN
TROUSSEAU’S SIGN ACCOUCHER’S HAND
TETANY

Severe
symptomatic cases
Intravenous
Calcium
gluconate
Asymptomatic
cases
Calcium
carbonate
Vitamin D
TREATMENT

Emergency treatment
 calcium gluconate iv 0.23 mmol Ca/ml
Dose : 10ml iv in first instance
 Oral calcium tablets
- Calcium gluconate 90mg/tab
- Sandoz calcium 135mg /tab
 Long term treatment: vitamin D therapy

CAUSES
•Excessive PTH production
- Primary Hyperparathyroidism
- Tertiary Hyperparathyroidism
•Excessive 1,25(OH)2D production
-Granulomatous diseases (Sarcoidosis, Tuberculosis)
- Lymphomas
-Vitamin D intoxification
Elevated serum calcium level up to 12- 15
mg/dl
HYPERCALCEMIA

SIGNSAND SYMPTOMS (HYPERCALCEMIA)
Trouble concentrating
 Depression
 Peptic ulcer disease
 Nausea
 Anorexia
Constipation
Pancreatitis
Polyuria

Total calcium measurements……………… (Raised)
Plasma phosphate………………………….(Lowered)
Alkaline Phosphatase………………………(Raised)
INVESTIGATIONS

TREATMENT
Emergency treatment:
 500ml of mono and dihydrogen phosphate solution should be infused
over 4 to 6 hours.
Long term phosphate treatment:
 Oral phosphate is given as diphosphate.
 Dose 100 to 300ml per day in divided doses
Phosphate sandoz tablet Dose: 1-6 tab daily

VITAMIN D DEFICIENCY DISORDERS
RICKETS OSTEOMALACIA

 Children between 6 months to 2 years of age.
 Affects long bones
 Lack of calcium causes failure of mineralization resulting
into formation of cartilagenous form of bone.
Most critical that gets affected is the center endochondral ossification at
the epiphyseal plates.
EmkeyRD,EmkeyGR.Calciummetabolism and correcting calcium deficiencies.Endocrinologyand
metabolism clinicsof North America. 2012 Sep30;41(3):527-56.
RICKETS

CLINICAL FEATURES(RICKETS)
EmkeyRD,EmkeyGR.Calcium metabolism and correcting calcium deficiencies. Endocrinology and metabolism clinics of North
America. 2012 Sep30;41(3):527-56.

 Developmental abnormalities
of dentin and enamel
 Delayed eruption
 Misalignment of teeth in the
jaw
 High caries index
 Enamel hypoplasia
ORAL MANIFESTATIONS

 Oral therapy:
• Vitamin D- 0.5-1g/day for children 2-4 yrs
• 1-4g/day for children > 4 yrs
 Corrective osteotomy for deformed limbs
TREATMENT

OSTEOMALACIA
 Also known as ADULT RICKETS
 Softening of bones due to defective mineralization (Ca and PO4).
 Main cause is – Vit. D deficiency

 Pain and Chronic fatigue, starting insidiously.
 Proximal muscles weakness.
CLINICAL FEATURES (OSTEOMALACIA)

DISORDERS OF PHOSPHOROUS
METABOLISM
HYPOPHOSPHATEMIA
HYPERPHOSPHTEMIA

HYPOPHOSPHATEMIA
Serum phosphate concentration < 2.5 mg/dL (0.81 mmol/L)
CAUSES
Reduced renal tubular phosphate rebsorption
Primary hyperparathyroidism
Secondary hyperparathyroidism
Tumor induced Osteomalacia

Muscle pain and weakness
Respiratory muscle weakness
Cardiac arrhythmias
Confusion, convulsions
Haemolysis
Hypercalciurea
Hypermagnesuria
CLINICAL FEATURES

Abnormally high serum phosphate levels (>1.4mmol/l)
CAUSES :
 Renal insufficiency
 Hypoparathyroidism
-Developmental
-Autoimmune
-After neck surgery or radiation
HYPERPHOSPHATAEMIA

CLINICAL FEATURES
Tetany
Seizures
Pulmonary or cardiac calcifications
Flaccid paralysis
Muscular weakness
Tachycardia
Nausea
Abdominal cramps

BONE IS BOTH AN ORGAN AND A TISSUE
BONE AS A TISSUE: Bone tissue
(or osseous tissue) is a type of connective
tissue. Osseous tissue consists primarily
of osteoblasts which makes the proteins and
molecules needed to form the fibers and the
ground substance which makes up the
extracellular matrix.
BONE AS AN ORGAN: When we refer to
bones as an organ, we include not only the
osseous tissue, but also the cartilage, nervous
tissue, the epithelial tissue (in the form of blood
vessels) and the fibrous connective tissue that
functions together as a unit.

DENTAL CONSIDERATIONS
Delayed teething and early childhood caries are the more dominant dental
abnormalities among children with calcium metabolism disorders.
Mohebbi, Ali. (2018). Prevalence of dental abnormalities in different calcium metabolism disorders in a

In Osteoporotic patients particular attention must be given to accurate
impressions. In addition, the use of monoplane teeth in the dentures of
these patients may be advocated to minimize vertical and horizontal
forces.
• Increased Residual Ridge Resorption (RRR).
• 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 suffering from calcium metabolic disorders required new
dentures three times more frequently than women of same age

Some investigators have
suggested that in addition to
faster teeth movement,
localized administration of
vitamin D enhances tooth
position stability
Bone remodeling,
following the
application of
orthodontic forces,
includes resorptive
and bone formation
phases at the alveolar
process.
Researchers have
shown that vitamin D,
parathyroid hormone,
and calcitonin regulate
calcium and
phosphorus levels.
In various studies,
vitamin D stimulated
bone resorption by
inducing the
differentiation of
osteoclasts from their
precursors and
increasing the
activity of existing
osteoclasts.

REFERENCES
• Cline J. Calcium and vitamin d metabolism, deficiency, and excess. Topics in companion animal medicine. 2012 Nov 30;27(4):159-64.
• Harrison MR, Edwards PP, Klinowski J, Thomas JM, Johnson DC, Page CJ. Ionic and metallic clusters of the alkali metals in
zeolite Y. Journal of Solid State Chemistry. 1984 Oct 31;54(3):330-41.
• Dorozhkin SV. Calcium Orthophosphates: Occurrence, Properties and Major Applications. Bioceramics Development and
Applications. 2014 Nov 19;2014.
• Reid IR, Bristow SM, Bolland MJ. Calcium supplements: benefits and risks. Journal of internal medicine. 2015 Oct 1;278(4):354-68.
• Emkey RD, Emkey GR. Calcium metabolism and correcting calcium deficiencies. Endocrinology and metabolism clinics of North
America. 2012 Sep 30;41(3):527-56.
• Guyton. Textbook of medical physiology,8th edition
• Harrisons. Textbook of medicine
• U. Satyanarayana. Biochemistry
• Mohebbi, Ali. (2018). Prevalence of dental abnormalities in different calcium metabolism disorders in a group of Iranian children.
• https://www.scientistcindy.com/bones-and-skeletal-tissues.html
• Carpenter TO. Primary Disorders of Phosphate Metabolism. [Updated 2022 Jun 8]. In: Feingold KR, Anawalt B, Blackman MR, et al.,
editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.
• Keerthana, P., Mukhopadhyay, M., Verma, S., Chitra, P. Effect of Altered Calcium Metabolism on Orthodontic Tooth
Movement: a Systematic Review. Iranian Journal of Orthodontics, 2022; 17(1): 1-12. doi: 10.22034/ijo.2022.549955.1051
• Boudal, Ayah & Attar, Suzan. (2012). Vitamin D and Autoimmune Disease. 10.5772/26932.
• Ronald B. Brown. Dysregulated Phosphate Metabolsim, Periodontal disease and Cancer: Possible Global Health Implications. Dent J.
2019

Calcium and Phosphorous metabolism 23-03-23.pptx

Calcium and Phosphorous metabolism 23-03-23.pptx

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Calcium and Phosphorous metabolism 23-03-23.pptx