Calcium metabolism and homeostasis is regulated by a complex interplay of hormones including vitamin D, parathyroid hormone, and calcitonin. Vitamin D promotes calcium absorption in the intestine and calcium resorption from bone. Parathyroid hormone increases calcium resorption from bone and its reabsorption in the kidneys to elevate blood calcium levels. Calcitonin decreases blood calcium levels by inhibiting bone resorption and increasing urinary calcium excretion. Together these hormones tightly control blood calcium concentrations through effects on intestinal absorption, kidney reabsorption and bone remodeling.

1. By- Anamika Singh
MDS 1st Year
Dept. Of Periodontology
Inderprastha Dental College &
Hospital
Calcium and its metabolism

2. AS DENTISTS, IT IS VITAL FOR US TO HAVE A
COMPLETE UNDERSTANDING OF THE GENERAL
METABOLISM OF CALCIUM AS IT HELPS IN THE
FORMATION AND MAINTENANCE OF THE TEETH
AND THEIR SUPPORTING BONY STRUCTURE.
INTRODUCTION

3. IMPORTANCE AND DISTRIBUTION OF Ca++ IN
THE BODY

4. Disorders of Calcium and Phosphate Metabolism in Horses, Ramiro E. Toribio,
DVM, MS, PhD, Columbus, OH, in The Veterinary clinics of North America.
Equine practice 27(1):129-47 · April 2011

5. • Total blood calcium: 8.5 to 10.3 milligrams
per decilitre (mg/dL)
• Ionized calcium: 4.4 to 5.4 mg/dl

6. 1.Contributes to hardness of bone and is a major
component of teeth.
2. Stabilises the cell membrane and their permeability.
3. Maintenance of excitability of nerve and muscles.
4. Normal skeletal and cardiac muscle contraction.
5. Blood coagulation – Ca++ is required for the conversion of
many inactive enzymes in the coagulation process.

7. Yao SG, Fine JB. The potential role of systemic calcium in
periodontal disease. Dent Open J. 2015; 2(5): 125-131

8. Milk is a good source for calcium. Calcium content of cow
milk is about 100mg/100ml.
Egg, fish &vegetables are medium source for calcium.
Cereals (wheat, rice) contains small amount of calcium.
But cereals are the staple diet in India. Therefore, cereals
form the major source of calcium in Indian diet.

10.  Several different kinds of calcium compounds are used in calcium
supplements. Each compound contains varying amounts of the
mineral calcium.
 Common calcium supplements may be labeled as:
CALCIUM CARBONATE –Calcium carbonate supplements tends to be
the best value, because they contain the highest amount of elemental
calcium (about 40% by weight). Because calcium carbonate requires
stomach acid for absorption, it's best to take this product with food.
Some well-known calcium carbonate products include Tums®,
Caltrate®, Viactiv Calcium Chews, and Os-Cal.

11.  CALCIUM CITRATE- Calcium citrate supplements are
absorbed more easily than calcium carbonate. They can
be taken on an empty stomach and are more readily
absorbed by people who take acid-reducing heartburn
medications. But because calcium citrate is only 21%
calcium, you may need to take more tablets to get your
daily requirement. Calcium citrate products include GNC
Calcimate Plus 800, Citracal® and Solgar®

12. Here are some final tips for choosing and taking calcium
supplements as found in the Harvard Special Health Report
Osteoporosis: A guide to prevention and treatment :
• Avoid products made from unrefined oyster shell, bone meal,
dolomite, or coral, as they may contain lead or other toxic
metals.
• Don't exceed the daily dose recommended by the
manufacturer—doing so increases the risk for side effects.

13. • If you take iron or zinc supplements, tetracycline antibiotics,
or levothyroxine (used to treat hypothyroidism), take them
several hours before or after taking calcium to avoid affects
potential negative interactions.
• Make sure you're also getting enough vitamin D, which
helps your body absorb calcium. If you aren't getting enough
from sunlight, your diet, or your multivitamin, you may want
to choose a calcium supplement that contains vitamin D.

14. If the calcium in diet and from supplements exceeds the
tolerable upper limit, you could increase your risk of
health problems, such as:
 Kidney stones
 Prostate cancer
 Constipation
 Calcium buildup in your blood vessels
 Impaired absorption of iron andzinc

15. Calcium absorption in the small intestine occurs by both
active & passive diffusion.
 Uptake of calcium by active transport predominates in:
duodenum jejunum
 Simple diffusion predominatesin: ileum
Most of the ingested calcium is normally eliminated in the
faeces, although the kidneys have the capacity to excrete large
amounts by reducing tubular reabsorption of calcium

16. Vitamin D –Calcitriol induces the synthesis of the carrier protein
(Calbindin) in the intestinal epithelial cells &so facilitates the
absorption of calcium.
Parathyroid hormones increases calcium transport from the
intestinal cells.
Amino acids, especially lysine &arginine increase absorption.
Lactose : enhance passive Ca uptake; its effect is valuable because of
its presence in milk.

17. Phytates — Phytates are substances found in some plant foods that can
bind calcium in the intestine and decrease its absorption.
Oxalates are present in some leafy vegetables which cause formation of
insoluble calcium oxalates.
In malabsorption syndromes , fatty acid is not absorbed , causing
formation of insoluble calcium salt of fatty acid.
High phosphate content will cause precipitation as calcium phosphate.
Absorption is also decreased with increase intake of protein & fiber in
diet.

18. 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.

19. Negative Ca2+Balance
 Is seen in women during pregnancy or lactation, where
intestinal Ca2+ absorption is less than urinary excretion and the
difference comes from the maternal bones.
Positive Ca2+balance
Is seen in growing children, where intestinal Ca2+absorption
exceeds urinary excretion and the difference is deposited in
the growing bones.

20. Calcium homeostasis is the mechanism by which the
body maintains adequate calcium levels.
Hormonal Control of Calcium Homeostasis -Gregory R. Mundy, Theresa A. Guise. The
American Association for Clinical Chemistry. Vol. 45, Issue 8, August 1999

21. The primary source of
available calcium is
trabecular bone, not cortical
bone.
The sites of trabecular bone
which supply mobile calcium
are the jaws, ribs, bodies of the
vertebrae, and the ends of the
long bones.

22. A significant finding from animal experimentation is that,
when skeletal depletion of calcium occurs as a result of
stimulation of the parathyroid gland, alveolar bone is
affected first, the ribs and the vertebrae are affected
second, and the long bones third.
Prolonged depletion results in disorganization and loss of
trabeculae, followed by cortical remodeling or structural
failure.
Studies of residual ridge resorption. The relationship of dietary calcium and
phosphorus to residual ridge resorption ; Wical and Swoope (JPD July 1974)

23. Acomplex set of interlocking mechanisms takes place in order to
allow man to survive major dietary Ca intake fluctuations. These
mechanisms are mainly controlled by the endocrine systems.
Three main hormones acting at 3 different sites are responsible
for Ca metabolism.
1.Vit. D3 - Bone.
2. Parathormone- Kidney
3. Calcitonin - Intestine

24. Physiologically active form of vitamin D is a
hormone called calcitriol or 1,25–
dihydroxycholecalciferol (1,25 – DHCC).
Increases plasma calcium concentration by
increasing the absorption of calcium from the
gastrointestinal tract.
It also increases bone resorption and enhances
the effects of PTH in the nephron to promote
renal tubular calcium reabsorption.

25. It is a powerful differentiation agent for committed
osteoclast precursors, causing their maturation to form
multinucleated cells that are capable of resorbing bone.
By these actions, 1,25(OH)2D3 provides a supply of calcium
available at bone surfaces for the formation of normal
mineralized bone.

26. • Secretion of PTH is highly dependent on the ionized calcium
concentration and represents a simple negative feedback loop.
• The serum PTH concentration decreases as the serum calcium
concentration increases, although PTH secretion is not entirely
suppressible.
• However, there is a relatively narrow range of regulation of PTH
secretion by extracellular calcium, with little further effect when
total corrected serum calcium is >2.9 mmol/L (11.5 mg/dL) or
<2.1 mmol/L (8.5 mg/dL).
PARATHYROID BONE

27. • The biological actions of PTH include :
(a) stimulation of osteoclastic bone resorption and release
of calcium and phosphate from bone,
(b) stimulation of calcium reabsorption and inhibition of
phosphate reabsorption from the renal tubules, and
(c) stimulation of renal production of 1,25(OH)2D3, which
increases intestinal absorption of calcium and
phosphate.

28. The prime function is to elevate the serum calcium
levels.
Action on kidney – increases Ca reabsorption by
kidney tubules.
Action on bone – decalcification or demineralization of
bone – increase bloodCa levels.

29. • The ionized calcium concentration is the most important
regulator of calcitonin secretion.
• Increases in ionized calcium produce an increase in
calcitonin secretion, and conversely, a fall in the ambient
calcium concentration inhibits calcitonin secretion.

30. Promotes calcification by increasing activity of osteoblasts.
Decreases bone resorption.
 Calcitonin directly inhibits osteoclastic bone resorption , and the effect
is rapid, occurring within minutes of administration.
 This inhibition is accompanied by the production of cAMP as well as
an increase in cytosolic calcium in the osteoclast and leads to
contraction of the osteoclast cell membrane.
 These effects are transient and likely have little role in calcium
homeostasis chronically, although they may be important in short-term
control of calcium loads.
Increases excretion of Ca in urine.
Thus, has a decreasing influence on blood Ca.

32. Estrogen is a hormone that plays an important role in
helping increase calcium absorption.
• Estrogen acts on both osteoclasts and osteoblasts to inhibit
bone breakdown at all stages in life.
• Estrogen may also stimulate bone formation.

33. • After menopause, estrogen levels drop and so may calcium
absorption. The marked decrease in estrogen at menopause is
associated with rapid bone loss.
• Hormone replacement therapy has been shown to increase the
production of vitamin D thus increasing calcium absorption, but
this practice is now controversial because of the risks of
increased breast cancer, strokes, blood clots, and cardiovascular
disease with hormone therapy.

34. Hypercalcemia - Increased level of Ca in the blood.
Symptoms
- Tiredeness
- Loss of appetite.
- Nausea, vomitting.
- Constipation.
-Polyuria.
-Dehydration.
-Loss of muscle tone.
-Decreased excitabilityof muscles and nerves.
IMPAIRMENTS IN BLOOD CALCIUM

35. Conditions in which it occurs
• Hyperparathyroidism.
• Acute osteoporosis.
• Vit. D intoxication.
• Thyrotoxicosis.

36. Hypocalcemia - Decreased levels of Ca in the blood.
Below 8.8mg/dL MILD TREMORS
 Less than 7.5mg/dL
TETANY
Symptoms
• Carpopedal spasm.
 This occurs in cases of –
 Insufficient Ca in the diet.
 Hypoparathyroidism.
 Insufficient vit. D in the diet.
 Increase in calcitonin levels.
HYPOCALCEMIA

37. Osteoporosis is the most common of all bone diseases in adults,
especially in oldage.
It results from diminished organic bone matrix rather than from
poor bone calcification.
In osteoporosis the osteoblastic activity in the bone usually is
less than normal, and consequently the rate of bone osteoid
deposition is depressed.

38. Characterized by demineralization of bone resulting in
progressive loss of bone mass.
Elderly persons (>60 years) of both sexes are at risk.
More predominantly in postmenopausal women.
Etiology – ability to produce calcitriol from vitamin D
is reduced withage.
Results in frequent bone fractures – major cause of
disability.

39. • The spine, hips, ribs, and wrists are common areas of
bone fractures from osteoporosis although
osteoporosis-related fractures can occur in almost any
skeletal bone.
• Osteoporosis can be present without any symptoms for
decades because osteoporosis doesn't cause symptoms
until bone fractures.

40. Therefore, patients may not be aware of their osteoporosis
until they suffer a painful fracture.
The symptom associated with osteoporotic fractures usually
is pain; the location of the pain depends on the location of
the fracture.
Repeated spinal fractures can lead to chronic lower back pain as
well as loss of height and/or curving of the spine due to
collapse of the vertebrae.

42. The condition of osteoporosis results in bone loss in the
maxillae and mandible as well as in other bones of the
body.
By the time osteoporosis is generally diagnosed, 50% to 75%
of the original bone material has been lost from the skeleton.
Increasing calcium intake by means of dairy foods and
supplementation is the method most practiced in the
prevention and treatment of osteoporosis to optimize calcium
balance.

43. The relationship of osteoporosis to alveolar and
residual ridge resportion is of justifiable concern to the
dental profession.
Although generalized bone loss is characteristic of
osteoporosis, the first sign may be alveolar bone loss,
followed by loss in the vertebrae and long bones.

45. The most recent National Institutes of Health (NIH)
proposal calls for 1000 to 1500 mg of daily calcium.
The World Health Organization (WHO)
recommendation is only 400 to 500 mg of
calcium/day.
Calcium intake in most populations around the world
is 300 to 500 mg/day without any evidence of
osteoporosis.

46. The diets of subjects with minimal bone resorption
were compared with the diets of subjects with severe
alveolar destruction.
The results indicate a positive correlation among low
calcium intake, and severe ridge resorption.

47. CALCIUM INTAKE IN RELATION TO PERIODONTAL
DISEASE
• The Danish Monica study (Monitoring Trends and Determinants in
Cardiovascular Disease) is a prospective observational study from
1982-1983 to 1993-1994 conducted under the auspices of the World
Health Organization (WHO) drawing from men and women (30-60
years old) living in Copenhagen County drawn from the National
Central Person Registry (CPR).

48. (MONICA cohort study)
• They found that dairy calcium intake was associated with
a decreased risk of tooth loss in both men and women.
• In men this was still true after several adjustments such as
age, education, smoking, alcohol, but in women it was
only statistically significant after an adjustment for
Lactobacillus count.

49. • Another study by these researchers was a cross-sectional study
looking to see whether calcium intakes from dairy and non-dairy
sources and absolute intakes of various dairy products were
associated with periodontitis.
• They found that intakes of calcium and dairy foods were significantly
and inversely associated with periodontitis while intakes of non-dairy
calcium were not associated with periodontitis.
• These findings agree with earlier studies by Al-Zahrani MS and
Shimazaki Y et al.

50. • Al-Zahrani MS found that intakes of dairy foods was inversely and
significantly associated with periodontitis where periodontitis was
defined as pocket depth ≥4 mm and attachment loss ≥3 mm.
• Shimazaki Y, et al. found that an increased intake of lactic
acid/fermented foods was significantly associated with lesser
mean pocket depth and attachment loss but no significant
associations were found with intakes of cheese, milk and other
dairy foods

51. • A cross-sectional study found that higher intakes of calcium
and dairy servings are associated with lower plaque scores
when vitamin D intakes are ≥6.8 μg/d.
• They believe that the better vitamin D intakes facilitate
beneficial effects of higher calcium intakes, most likely by the
enhancement of calcium absorption
Adegboye ARA, Christensen LB, Holm-Pedersen P, Avlund K, Boucher BJ,
Heitmann BL. Intakes of calcium, vitamin D, and dairy servings and dental
plaque in older Danish adults. Nutrition Journal. 2013; 12: 61-65

52. • This group of investigators performed another study investigating
whether intakes of calcium, vitamin D, casein and whey were
associated with periodontitis and the possibilities of interactions
between them in relation to periodontitis.
Adegboye ARA, Boucher BJ, Kongstad J, Fiehn N-E, Christensen LB,
Heitmann BL. Calcium, vitamin D, casein and whey protein intakes and
periodontitis among Danish adults. Public Health Nutrition. 2015; (4):

53. • They found that after adjusting for age, gender, education,
smoking, sucrose intake, alcohol consumption, number of teeth,
daily brushing, regular visits to the dentist and chronic illness that
higher intakes of calcium, whey protein and casein were
individually associated with a lower occurrence of severe
periodontitis, but vitamin D intake was not directly associated
with periodontitis

54. • A longitudinal study in Japan among the elderly, found a lower
serum calcium/magnesium (Ca/Mg) ratio was significantly
associated with periodontal disease progression in smokers over 6
years.
• They had looked both into serum calcium and the Ca/Mg ratio. The
serum calcium was significantly lower in smokers compared to the
non-smokers. A high Ca/Mg ratio was significantly associated with
fewer periodontal disease events
Yoshihara A, Iwasaki M, Miyazaki H. Mineral content of calcium and
magnesium in the serum and longitudinal periodontal progression in
Japanese elderly smokers. J Clin Periodontol. 2011; (38): 992-997

55. • A Study from India looked for any influence of calcium and
vitamin D supplementation in periodontitis treatment
outcome in otherwise healthy subjects whose serum
calcium and vitamin D levels are in the normal range.
Perayil J, Menon KS, Kurup S, et al. Influence of vitamin D & calcium
supplementation in the management of periodontitis. J Clin Diagn Res. 2015;
9(6): ZC35-ZC38

56. • It was a non-randomized clinical trial, where both groups received full
mouth prophylaxis, subgingival scaling, root planning and curettage and
then one group also received 500 mg calcium and 250 IU vitamin D
supplementation for 3 months.
• Both groups showed significant change in the periodontal parameters and
bone density after 3 months with highly significant results for the
supplementation group.
• These results strongly recommend that calcium and vitamin D can be given
as an adjunct to scaling and root planning for better periodontal outcomes
and that vitamin D and calcium supplementation has a got a slight positive
effect in the periodontal treatment.

57. • Calcium in the human bodies found in the bones and
teeth. Periodontal disease affects the alveolar bone that
supports the teeth.
• The disease is a complex relationship between host,
bacterial, behavioral and environmental factors.
• The intake of food and nutrients, such as calcium has
been shown to play a role in this complex relationship
CONCLUSION

58. THANK YOU