Calcium

CALCIUM AND PHOSPHORUS
METABOLISM IN GROWTH
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS

INTRODUCTION :-
Of all the minerals in our body, Calcium is present in the highest
amount. Our body’s need for calcium is also the highest of any
minerals or vitamins.
The Phosphorus is the other mineral element which is essential
for the formation and development of bone and teeth along
with Calcium.

Calcium, combined with phosphate to form hydroxyapatite, is the
mineral portion of human and animal bones and teeth.
The mineral portion of some corals can also be transformed into
hydroxylapatite.

MINERAL ELEMENTS
Minerals elements are present in animal body supplied by the diet.
Minerals elements can be classified as
1) Principal elements or Macronutrients
There are total seven essential elements-
calcium , magnesium, sodium, potassium, phosphorus, sulphur
and chlorine.

2) Trace elements
Essential trace possibly essential non essential
elements elements elements
Iron, iodine,copper nickle,tin, silicon aluminium,boron
zinc,manganese and lead and mercury
Cobalt etc….

CALCIUM :-
Calcium is essential for living organism, particularly in cell
physiology, where movement of the calcium ion Ca2+ into and
out of the cytoplasm functions as a signal for many cellular
processes.
As a major material used in mineralization of bones and shells,
calcium is the most abundantmetal by mass in many animals.

Calcium (Latin word calcis meaning "lime") was known as early as
the first century when the Ancient Romans prepared lime
as calcium oxide.
Calcium is an important component of a healthy diet and
a mineral necessary for life..

The National Osteoporosis Foundation says, "Calcium plays an
important role in building stronger, denser bones early in life
and keeping bones strong and healthy later in life.“
Approximately ninety-nine percent of the body's calcium is
stored in the bones and teeth

Normal value-
In a normal young adult there about 1100 gm. of calcium present in
the body.
It forms about 1.5 % of total body weight.
99 % of calcium is present in the bone and the rest present in plasma.
Normal blood calcium level is 9.4 mg % /100 ml.

Types of calcium :-
Calcium in plasma- is of two type.
- Ionized or diffusible calcium
- Nonionized or nondiffusible calcium
Ionized form :- Is found freely in plasma.
essential for regulate vital function like neuronal activity,
muscle contraction,cardic activity and blood coagulation..

Calcium in bones-
Small quantity of readily exchangeable calcium:-
It helps to maintain the plasma calcium level as it is removed
from the bone.
Large quantity of stable calcium:-
It helps in bone remolding since it is constantly removed and
deposited in bone.
Source of calcium:-
Rich source – Milk and Cheese
good source- Egg yolk,Nuts,Fish,Beans…

DIETARY CALCIUM RECOMMENDATIONS
Group Age mg/day
Infants 0-6 months 400
6-12 months 600
Children 1-5 years 800
6-10 years 800-1200
Adolescents and young adults 11-24 years 1200-1500
Men 25-65 years 1000
Women 25-50 years 1000
pregnant or lactating 1200-1500
Post menopausal
Receiving estrogen replacement
therapy
1000
Not receiving 1500
Men and women >65 years 1500

IMPORTANCE OF CALCIUM
Calcium along with phosphorus is essential for the formation and
development of bone and teeth.
Calcium is also required in blood coagulation process.
Calcium also regulate the neuronal activity.

It is essential for muscular contraction.
It regulates the permeability of membrane.
It is required as a activator for activate several enzymes like
ATPasse,Proteolytic enzymes.

Absorption of Calcium:-
Calcium is taken in diet as – calcium phosphate,Carbonate,Tartrate and
oxalate.
Calcium actively absorbed in upper intestine and regulated by
1,25 Dihydroxycholicalciferol(a metabolite of vit-D),which is
produced in liver and kidney in response to decrease plasma
concentration.

Calcium and phosphorus ratio of 1:2 (2:1 or 1:2 )is the most
convenient for the absorption of both.

PHOSPHORUS :-
The Phosphorus is the other mineral element which is essential for
the formation and development of bone and teeth along with
Calcium.
The crystalline salts present in bones are called “Hydroxy apatites
‘which contain Calcium and Phosphate.

Phosphorus was discovered by German alchemist Hennig Brand in
1674 or 1675. Working in Hamburg.
Phosphorus is a component of DNA, RNA, ATP, and also the
phospholipids which form all cell membranes. It is thus an
essential element for all living cells

 It present in the blood in the form of :-
-Inorganic phosphorus - 2-5 mg /100 ml
Organic phosphorus -14-29 mg /100 ml
-phospholipids - 8-18 /100ml
Source :-
Milk,cheese,egg-yolk,meat,fish….

Daily requirement :-
Infants - 240 – 400 mg
Children - 800 – 1200 mg
Adults -800 mg.
Absorption:-
- Moderate amount of fats or acid increase absorption.
- high calcium decrease the absorption.

Importance of Phosphorus :-
It is essential for the formation and development of bone and teeth
along with Calcium.
It is required for the formation of Phospholipids,Nucelic acids, and
Phosphoproteins.
It is required for the formation of Organic phosphates.

It is required for the formation of Energy rich compounds like A.T.P.
It is required for the formation of Coenzyms such as
NADP,ADP,AMP.
It is required for the Absorption of Glucose by phosphorylation.

CALCIUM AND PHOSPHORUS METABOLISM :-
Orthodontist and dentofacial orthopedists manipulate bone. The
biomechanical response to altered function and applied loads
depends on the metabolic status of the patients.
Bone metabolism is an important aspect of clinical medicine that is
directly applicable to Orthodontics and Orthopedics.
Orthodontics is bone manipulative therapy and favourable calcium
and phosphorus metabolism is an important consideration.

As we know the Calcium along with phosphorus are the essential
major elements for the formation and development of bones and
teeth, so we can explain the metabolism of Calcium and
Phosphorus as Bone metabolism.

BONE METABOLISM :-
Orthodontics is bone manipulative therapy, and favorable calcium
and phosphorus metabolism is an important role.
Calcium homeostasis is the process by which mineral equilibrium
is maintained.

Maintenance of serum calcium levels at about 10 mg/dl is an
essential life support function.
Calcium is taken through dietary sources.It is absorbed from the
G.I.Tract in to Blood and distributed through out the body.

REGULATION OF BLOOD CALCIUM LEVEL :-
All these process are finely regulated by three hormones.
1.Parathormone
2. Vitamin-D
3.Calcitonin

PARATHORMONE :-
Secreted by the chief cells of parathyroid glands.
It is protein in nature.
Action of Parathormone :-
primary function is to maintain the blood calcium level.
It is regulated by the Calcium ion concentration in the Blood.

Parathormone acts through cyclic AMP, which acts as second
messenger.
Effect on the bone :-
Responsible for Resorption of bone or calcium . It occurs in two
phase.

Rapid flux of calcium from the bone fluid (occurs in seconds)
PTH---- Attached with receptors on the cell memb. of Osteoblast
and Osteocytes.
Hormone –Receptors complex –increase permeability of the cell
memb. For calcium ions
This increase the calcium pump mechanism allowing calcium ions
to move from these cells to plasma.

Short-term response by osteoclasts and osteoblasts (extends from
minutes to days)
In this phase the calcium resorption take place by the activation of
osteoclast.
Osteoclast----released Proteolytic enzyme ----Digest or
Dissolve the organic matrix
----- Calcium ions released and slowly move into Plasma.

Long term control of bone turnover (over weeks to months).
Long term regulation has profound effects on the skeleton.
Biomechanical factors, noncalcific hormones, and the metabolite
mechanisms dictate mass, geometric distribution and the mean age
of the bone.

EFFECT ON THE KIDNEYS :-
Increase the Reabsorption of Calcium from renal tubules along
with magnesium ions and hydrogen ions
At the same time it also increases the excretion of Phosphates from
renal tubules.

EFFECT ON GASTROINTESTINAL TRACT :-
By the formation of 1,25 dihydroxy cholecalciferol from vit-D it
increase the Absorption of Calcium. Vit- D is essentiol for that.
Ortho consideration
It increases the tooth movement and consequently influence
orthodontic treatment.

VITAMIN D – 3
Vit. D3 with parathyroid and cacitonin hormone
regulates the amount of Ca and phosphorous in human body.
Parathyroid hormone convert the vit-D in its active metabolite which
is known as
1,25 Dihydroxy cholecalciferol .

ACTION OF 1,25 DIHYDROXY CHOLECALCIFEROL
Increase the absorption of calcium from the intestine.
Increase the synthesis of calcium induced ATP in the intestinal
epithelium.
increase the synthesis of alkaline phophatase in the intestinal
epithelium.

It promotes interstitial Ca and phosphorous absorption
Vit.D3 increases the bone mass and thus reduces fractures in
osteoporosis.
Ortho consideration
It can be assumed that they can inhibit tooth movement.

CALCITONIN :-
Peptide hormone, secreted by intra follicular or C- cells in the thyroid
gland. also called Thyrocalcitonin.
Actions of Calcitonin :-
Effect on Bone :-
It increase the deposition of calcium on bones and also suppress the
activity of osteoclasts. Even it inhibits the development of new
Osteoclasts.

It decreases the Blood Calcium level and thereby counteracts the
action of Paratharmone.
It flows in bloodstream and attracts Ca to bone, thus reducing
Serum calcium
It reduces bone resorption by reducing the no. of osteoclasts.

It is used in the treatment of Hypercalcemia and Osteoporosis.
Effect on Kidney :-
It increase the excretion of calcium through urine, by inhibiting the
reabsorption of calcium from the renal tubules.

Effect on intestine :-
It prevent the absorption of Calcium from intestine into the Blood.
Ortho consideration
It inhibit tooth movement and consequently delays
orthodontic treatment

Disease state:-
Abnormalities in Calcium and Phosphorus metabolism are mainly
associated with some Diseases.
-Hypercalcaemia
-Hypocalcaemia
-Rickets
-Osteoporosis

Calcium and Phosphorus metabolism in Growth:-
-The role of Calcium and Phosphorus metabolism is most effectively
started in post natal period..
- Bone remodeling and Bone resorption (Bone metabolism ) procedure
occurs continuously throughout life..

BONE GROWTH :-
The embryo has a cartilaginous skeleton. the conversion of cartilage
into bones is called the ossification.
At the time of birth skeleton consist of 50 % cartilage and 50 % bone.

BONE :-
Bone or osseous tissue is a specialized rigid connective tissue that
form the skeleton.
it consist of special type of cells and tough intercellular matrix of
ground substance.
through out life the bone is renewed by the process of bone
formation and bone resorption.

FUNCTION OF BONE :-
Protective function --
protect soft tissue and vital organs of the body.
Mechanical function --
Support the body and their attachment to the muscles and tendon.

Metabolic function –
Bone play an important role in the metabolism and
Homeostasis of calcium and phosphorus in body.
Hemopoietic function –
Red bone marrow is the site of production of Blood.

COMPOSITION OF BONE :-
Bone matrix – bone matrix is composed of Protein fibers called
Collagen fibers. These fibers form about 90% of bone.
- matrix is embedded in the gelatinous ground substance ,which is
formed by extracellular fluid and proteoglycans.

Bone salt – The crystalline salts present in bones are called “Hydroxy
apatites ‘which contain Calcium and Phosphate.
-Some other salts present like sodium , potassium magnesium.
- The salt of the bone strengthen the bone matrix.

BONE REMODELING :-
- Bone remolding is a process that includes bone resorption
followed by bone formation.
-Bone remodeling occurs continuously throughout life.

-Usually bone remolding takes place in group of cells called Basic
multicellular units (BMU)
-Significance of remodeling – in children the shape of bone is re
altered in relation to growth of the body.

In adults the remoldeing of bone is responsible for the maintence
of toughness of bone.This because of replacement of old matrix
by new matrix.
Bone resorption :-
It is the process that involves the destruction of entire Bone
matrix and Removal of Calcium.
The osteoclast responsible for bone resorption.

BONE FORMATION :-
The osteoblast activity or the process of bone formation
involves the synthesis of collagen and formation of matrix that
is mineralized.
Mineralization :-
The mineralization starts about 10 to 12 days after the formation
of osteoid.

First large quantity of calcium phosphate is deposited . Afterwards ,
the hydroxide and bicarbonate ions are gradually added causing
the formation of hydroxyapatite crystals.
The process is increased by the enzyme Alkaline phosphatase
secreted by osteoblast.

Growth of maxilla
The Maxilla is carried out Downward and Forward growth.

GROWTH OF MANDIBLE :-
 The Mandible is translated downwards and forwards and grows
upwards and backwards.
Chin moves downwards Mandible grows
upwards
And forwards. and backwards

ROLE OF CALCIUM AND PHOSPHORUS METABOLISM IN
ORTHODONTIC TOOTH MOVEMENT.
Orthodontic tooth movement is a unique process where a solid
object(tooth)is made to move through a solid medium (bone)
When force is applied on a tooth to bring about orthodontic movement ,
it result in formation of
-Area of pressure in the direction of the tooth movement.
-Area tension form in the opposite direction.

Bone resorption take place at the Pressure side.
Bone deposition take place at the Tension side.
Optimum orthodontic force :- Is one which moves teeth most
rapidly in the desired direction, with the least possible damage to
tissue and with minimum patient discomfort.

Optimum force is equivalent to the capillary pulse pressure which
is 20-26 gm/sq.cm of root surface.
phases of tooth movement.
1. Initial phase
2. Lag phase
3. Post lag phase

Journal of Bone and Mineral Metabolism, 2004
Masayoshi Kawakami and Teruko Takano-Yamamoto
Local injection of 1,25-dihydroxyvitamin D3 enhanced bone formation
for tooth stabilization after experimental tooth movement in rats
The present investigation evaluated the effect of 1,25-dihydroxyvitamin
D3 (1,25(OH)2D3) on alveolar bone formation during tooth movement
in rats
Orthodontic elastics were inserted between the maxillary first and second
molars on bilateral sides in male rats

1,25(OH)2D3 was injected locally, at the concentration of 10–10 M, once
every 3 days in the sub mucosal palatal area of the root bifurcation of
the molar on the right side.
Histomorphometric analysis revealed that tooth movement without
application of 1,25(OH)2D3 decreased the mineral appositional rate
(MAR) on the compression area at 7 days.
Repeated injections of 1,25(OH)2D3 in the orthodontically treated
animals distinctly stimulated alveolar bone formation on the mesial
side at 14 days. There was a significant increase in MAR associated
with elevated osteoblast surface value on the tension surface.

These findings suggest that local application of 1,25(OH)2D3 enhances
the reestablishment of supporting tissue, especially alveolar bone of
teeth, after orthodontic treatment.

Source: AJO-DO on CD-ROM (Copyright © 1998 AJO-DO), Volume 1984 May (424 - 430): Root resorption and tooth
movement in orthodontically treated, calcium-deficient, and lactating rats - Goldie and King
A study had been done by Goldie and King on , Root resorption and
tooth movement in orthodontically treated, calcium-deficient, and
lactating rats.
A 60-gm orthodontic force designed to tip maxillary molars mesially was
applied for varying times.
Since the appliance force was similar for both groups.

The increased rate of tooth movement in the test animals can be
attributed to increased bone metabolism and decreased bone
density.
This study confirms earlier findings that lactation, coupled with a
calcium-deficient diet, will produce
decreased bone density through secondary hyperparathyroidism.

Increased tooth movement was also found to correlate directly with
increased bone turnover and decreased bone density.
Morphometric data indicated that animals stressed with lactation and
dietary calcium deficiency had significantly less root resorption in the
time course of this experiment.
.

These findings suggest that tooth movement and root resorption
may be dependent upon bone density and calcium metabolism in
alveolar bone.

Quintessence Int. 2001 May;32
Tyrovola JB, Spyropoulos MN
Effects of drugs and systemic factors on orthodontic treatment.
Orthodontic tooth movement and bone remodeling activity are dependent
on systemic factors such as nutritional factors, metabolic bone
diseases, age, and use of drugs
Systemic hormones such as estrogen, androgen, and calcitonin are
associated with an increase in bone mineral content, bone mass, and a
decrease in the rate of bone resorption. Consequently, they could
delay orthodontic tooth movement

On the contrary, thyroid hormones and corticosteroids might be involved
in a more rapid orthodontic tooth movement during orthodontic
therapy and have a less stable orthodontic result.
Drugs such as bisphosphonates, vitamin D metabolites, and fluorides can
probably cause a reduction of tooth movement after the orthodontic
force is applied.

Nonsteroidal anti-inflammatory drugs have also been shown to reduce
bone resorption.
Long-term administration of these drugs may therefore delay the
necessary bone response to respective tooth-borne pressure and should
not be administered for long periods of time to patients undergoing
orthodontic tooth movement.
The use of the above drugs should be considered by every dentist in
evaluating the treatment time and in planning treatment when tooth
movement is attempted.

CONCLUSION
Calcium and phosphorus are essential elements required for
maintaining the integrity of the skeletal system and they assist in
mineral metabolism as well. Their importance in orthodontics can
never be denied.

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Calcium

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