metabolism is the sum total of tissue activity as considered in terms of physicochemical changes associated with and regulated by the availability, utilization and disposal of protein, fat, carbohydrate, vitamins, minerals, water and the influences which the endocrines exert on these processes” The mineral elements constitutes only small proportion of body weight. Minerals perform several vital functions which are absolutely essential for the existance of the organism. These include calcification of bone, blood coagulation, neuromuscular irritability, acid-base equilibrium, fluid balance and osmotic regulation.

1. GUIDED BY:
Dr. BASAVAPRABHU AKKAREDDY
Dr. MAYUR BHATTAD
Dr. SUMIT RAJEWAR
Dr. ANKITA CHANDAK
PRESENTED BY :
DR. SAMRUDDHI BENGAL
1ST YEAR PG
DEPT. OF PEDIATRIC & PREVENTIVE DENTISTRY
Mineral metabolism ,
micronutrients and trace elements

2. content
INTRODUCTION
DEFINITION
CLASSIFICATON
SYSTEMIC AND LOCAL EFFECTS
CONCLUSION

3. INTRODUCTION
 The mineral elements constitutes only small proportion of body weight.
 Minerals perform several vital functions which are absolutely essential for the
existance of the organism.
 These include calcification of bone, blood coagulation, neuromuscular
irritability, acid-base equilibrium, fluid balance and osmotic regulation.

4. Metabolism-
“It is the sum total of tissue activity as considered in terms of
physicochemical changes associated with and regulated by the
availability, utilization and disposal of protein, fat,
carbohydrate, vitamins, minerals, water and the influences
which the endocrines exert on these processes”

5. CLASSIFICATION

6. MINERALS
Principle elements
(Macroelement)
60-80% of the body’s inorganic elements
1.1. Calcium
2.2. Phosphorus
3.3. Magnesium
4.4. Sodium
5.5. Potassium
6.6. Chloride
7.7. Sulphur
Trace elements
(Microelement)
Required 100mg/day.
1) Essential trace
element
Iron, Copper,
Iodine,
Manganese, Zinc,
Molybdenum,
Cobalt, Fluorine,
Selenium and
Chromium
2) Possibly
essential trace
element
Nickel,
Vanadium,
Cadmium and
Barium
3) Non-essential
trace elements
Aluminium, Lead,
Mercury, Boron,
Silver, Bismuth

7. Total calcium in human body: 1-1.5 kg
In bones - 99%
In extra cellular fluid - 1 %
Sources:-
Milk (cow's milk - 100mg/100ml)
Egg, fish, vegetables – moderate
Cereals - poor source.
Calcium

8. Daily Requirement
• Adults: 800 Mg/Day
• Children: 1200 Mg/Day
• Pregnancy And Lactation:1500 Mg/Day
• >50 Yrs : 1500 Mg/Day (To Prevent Osteoporosis)
Absorption-
 1st And 2nd Part Of Duodenum
 against Concentration gradient and requires Energy
 Requires Carrier Protein.
Shafer’s textbook of oral pathology

9. Factors promoting Ca absorption
 Parathyroid Hormone - ↑ Ca transport from intestinal cells
 Acidity- favours Ca absorption
 Amino acids - Lysine and Arginine

10. Factors Inhibiting Ca absorption
 Phytates and oxalates - form insoluble calcium oxalates
 High dietary phosphates –precipitate as calcium phosphate
 High pH - (alkaline)
 High dietary fiber

11. FUNCTIONS
1. Bones & teeth :
 formation of bone & teeth.
 Bones are reservoir for ca in the body
2. Nerve conduction:
 Transmission of nerve impulses from pre-synaptic to post-synaptic region

12. 3. Muscle contraction:
 Ca mediates excitation & contraction of muscle fibers.
 Ca interacts with troponin-c to trigger muscle contraction.
 Ca activates atpase, ↑ interaction between actin and myosin.
4. Secretion of hormones :
 Mediates the secretion of insulin, PTH, calcitonin, vasopressin etc.

13. .
5. Second Messenger:
 Ca & cyclic AMP are 2nd messengers of different hormones. Eg: glucagon
6. Membrane integrity & permeability:
 Influences transport of number of substances across the
membranous barrier.

14. 7. Blood coagulation:
Prothrombin to thrombin
8. Action on heart:
Ca prolongs systole.
↑ Ca concentration → ↑ myocardial contractility
9. Activation of enzymes

15. Plasma calcium
 Normal plasma / serum calcium : 9-11 mg/dl
 ionized calcium (functionally most active): 5 mg/dl
 Protein bound calcium: 4-5 mg/dl
 Complexed with phosphate/citrate/ bicarbonate: about 1 mg/dl
Shafer’s textbook of oral pathology

16. Homeostasis Of Ca
The major factors that regulate the plasma Calcium
 Calcitrol
 Parathyroid Hormone
 Calcitonin

18. Disorders of Calcium Metabolism
Hypercalcemia:
Causes:
 Hyperparathyroidism – caused by increased activity of parathyroid gland.
 Multiple myeloma.
 Paget's disease.
 Metastatic carcinoma of bone.

19. HYPOCALCEMIA
Tetany- most serious and life threatening condition.
Fall in serum ca below 7 mg/dl
Causes:
 Accidental removal of parathyroid glands
 Autoimmune disease

20. Symptoms:
 Neuromuscular irritability
 Carpopedal spasms
 Stridor
Laryngeal spasms may lead to death.
Signs:
Chovstek's sign +
Trousseau's sign +

21. Chovstek's sign
A twitch of the facial muscle following
gentle tapping over the facial nerve in
front of the ear that indicates
hyperirritability of the facial nerve

22. Trousseau's sign
A test for latent tetany in which carpal
spasm is induced by inflating A
sphygmomanometer cuff on the upper
arm to A pressure exceeding systolic
blood pressure for 3 minutes.

23. Oral manifestations
• Hypomineralized tooth integrity
• Delayed eruption pattern
• Absence of lamina dura
• Abnormal alveolar bone patterns
• Premature loss of teeth

24. • The total body phosphate - 1 kg
• 80%- bone & teeth
• 10%- muscles
• Mainly in intracellular ion- seen in all cells.
PHOSPHOROUS

25. Functions
 Formation of bone & teeth
 Production of high energy phosphates:
Atp ctp gtp
creatine phosphate
 Synthesis of nucleoside co-enzymes:
NAD and NADP
 DNA and RNA synthesis:
In phospho-diester linkage

26.  Formation of phosphate esters:
Glucose 6-phosphate, phospholipids
 Formation of phosphoprotein: casein
 Activation of enzymes by phophorylation
 Phosphate buffer system of blood:
Maintain the ph of blood at 7.4.

27. Requirement & Sources
 500 mg/day
 Milk - good source
 cereals
Nuts
Meat
Moderate Sources

28. Serum levels
 Normal adults- 3-4 mg/dl
 Children- 5-6 mg/dl
 Whole blood phosphate - 40 mg/dl
 Decrease in phosphate levels:
-Hyperparathyroidism
-rickets
Shafer’s textbook of oral pathology

29. Oral manifestations
• Incomplete mineralisation of teeth
• increased susceptibility to caries if deficient during tooth formation
• increased susceptibility to periodontal disease due to effects on
alveolar bone

30.  Chief cation of extracellular fluid.
 Total body sodium - 4000 meq
50% in bones
40% in extracellular fluid
10% in soft tissues
SODIUM

31. Biochemical Functions
 Sodium (as sodium bicarbonate) regulates the body acid base balance.
 Sodium regulates ECF volume
 Required for maintenance of osmotic pressure and fluid balance.
 Necessary for normal muscle irritability and cell permeability.

32. Daily requirement
Normal diet contains 5 - 10 gm of sodium mainly as sodium chloride
Sources:
Common salt used in cooking medium,
Bread ,whole grains , Nuts,
leafy vegetables , Egg , milk

33. Absorption
 Readily absorbed in the GI tract.
Very little <2% is found in faeces.
In Diarrhoea - large quantities of sodium is lost in faeces.

34. Excretion
 Kidney – major route of sodium excretion
 In edema - water & sodium content of the body increase.
 Diuretic drugs- excrete Na also along with water.

35. Normal Values
 In plasma 136-145 mEq/L
 In cells 35 mEq/L
Mineralocorticoids influence Na metabolism in adrenocortical insufficiency
↓ Plasma na
↑ Urinary excretion of na
Shafer’s textbook of oral pathology

36. Hypernatremia
 Cushing's disease
 Prolonged cortisone therapy
 In dehydration - water predominantly lost, the blood volume decreased
with apparent ↑ conc. of sodium

37. Hyponatremia
 Vomiting
 Diarrhoea
 Burns
 Addison's disease (adrenal insufficiency)
 In severe sweating, na is lost considerably
- muscle cramps & headache.

38. Oral manifestations
• Mucosal pigmentation
• Tongue discoloration
• Xerostomia
• dry lips
• Gingival bleeding
• Oral candidiasis

39.  Principal intracellular cation
 Total body potassium - 3500 mEq
 Required for regulation of acid base balance and water balance in cells.
 Maintains intracellular osmotic pressure.
 Required for transmission of nerve impulse.
POTASSIUM

40.  Enzyme - pyruvate kinase (of glycolysis) depend on K+ for optimal activity.
 Adequate intracellular concentration of K+ is necessary for proper
biosynthesis of proteins by ribosomes.
 Extracellular K+ influences cardiac muscle activity.

41. Dietary requirement
 3-4 g/day
 Sources:
Banana, potato, Orange,
beans, Pineapple, chicken & liver
Tender coconut water- rich source

42. Absorption & excretion
 Absorption: From GI tract very efficient (90%)
In diarrhoea - good proportion of K+ is lost in faces
 Excretion: Through urine
Aldosterone ↑ excretion of potassium.

43. Normal values
In plasma - 3.4 - 5.mEq/L
Child: 3.4-4.7 mEq/L.
Either high or low concentrations are dangerous since K+ affects contractility
of cardiac muscle
Shafer’s textbook of oral pathology

44. Hypokalemia
 Over activity of adrenal cortex (cushing's syndrome)
 Prolonged cortisone therapy
 Prolonged diarrhoea & vomiting
 Diuretics used for CCF may cause K* excretion
Symptoms- irritability, muscular weakness, tachycardia, Cardiomegaly & cardiac
arrest

45. Hyperkalemia
 Renal failure
 Adrenocortical insufficiency (addison's disease)
 Diabetic coma
Symptoms - Depression of CNS
- Mental confusion
- Numbness
- Bradycardia, Cardiac arrest

46.  Adult body contain 20 gm of Mg , 70% of which is found in bones
in combination with calcium and phosphorus.
 Remaining 30% found in soft tissue and body fluids.
MAGNESIUM

47. Biochemical functions
1. Magnesium is required for the formation of bones and teeth.
2. It serves as a cofactor for several enzymes requiring ATP eg. Hexokinase, glucokinase,
phosphofructokinase, adenylate cyclase.
3. It is necessary for proper neuromuscular function. Low levels of magnesium lead to
neuromuscular irritability.
Dietary requirements-
Adult man - 350 mg/day
Adult woman - 300 mg/day
Children- 130-240 mg/day

48. Sources -
Cereals, nuts, beans, vegetables (cabbage, cauliflower)
meat, milk & fruits
Serum magnesium
 Normal serum concentration of Mg is 2-3 mg/dl.
Shafer’s textbook of oral pathology

49. Deficiency
1. Magnesium deficiency causes neuromuscular irritation, weakness and
convulsions. These symptoms are similar to that observed in tetany (Ca
deficiency) which are relieved only by Mg.
2. Malnutrition, alcoholism and cirrhosis of liver may lead to mg deficiency.
3. Low levels of Mg may be observed in uremia, rickets and abnormal pregnancy.

50. Oral manifestations
• Alveolar bone fragility
• gingival hypertrophy

51. Chlorine is a constituent of sodium chloride. Hence, the metabolism of chlorine and
sodium are related.
Biochemical functions
1. Chloride is involved in the regulation of acid- base equilibrium, fluid balance and
osmotic pressure.
2. Chloride is necessary for the formation of HCL in the gastric juice.
3. The enzyme salivary amylase is activated by chloride.
CHLORINE

52. Dietary requirements –
 The daily requirement of chloride as nacl is 5-10 g.
sources -
 Common salt as cooking medium, fish,
whole grains, vegetables, eggs and milk.

53. Plasma chloride -
 The normal plasma concentration of chloride is 95-105 mEq/l.
 CSF contains higher level of cl (125 mEq/l).
Excretion -
 There is a parallel relationship between excretion of chloride and sodium.
 The renal threshold for cl is about 110 mEq/l.

54. Disease states-
1. Hypochloremia: A reduction in the serum chlorine level may occur due to
vomiting, diarrhoea, respiratory alkalosis, addison's disease and excessive
sweating.
2. Hyperchloremia : an increase in serum chlorine concentration may be due to
dehydration, respiratory acidosis and cushing's syndrome.

55. Introduction -
 Total body iron content: 3-5 gm
 Iron is present in almost all cells
 Heme containing proteins: HB, myoglobin, cytochromes, cytochrome oxidase,
catalase, peroxidase, xanthine oxidase & TRP pyrrolase
 75% of total Fe is in Hb & 5% in myoglobin.
 Non-heme iron containing proteins: ferritin, transferrin, hemosiderin,
lactoferin & neutrophil
IRON

56. Biochemical functions -
Tissue respiration:
Iron can change readily between ferrous and ferric states and function in electron
transfer .
Transport of gases:
 Able to bind with molecular O₂ and CO₂.
 The main function is to coordinate the o₂ molecule into heme of haemoglobin,
so that it can be transported from the lungs to the tissues.

57. Oxidative reactions:
 Component of various oxidoreductase enzymes
-vital role in oxidative reactions.
Immune response:
Required for effective activity of lysosomal enzyme peroxidase - helps in
phagocytic and bactericidal activity of neutrophils.

58. Requirement is high in women
 20-40 mg - blood loss in each menstrual cycle.
 Daily demand to 3-4 mg in pregnant & lactating women.
 900 mg during pregnancy.
 Delivery feeding diversion of iron to foetus
Shafer’s textbook of oral pathology

59. REQUIREMENT
Children: 10 mg/day
Adults:
Males - 10-12 mg/day
Women
Premenopausal: 18mg /day
Postmenopausal: 10 mg/day
pregnant & lactating: 40mg/day
Shafer’s textbook of oral pathology

60. SOURCE
 Good sources: - leafy vegetables (20mg/100g)
- Pulses (10mg/100g)
- Cereals (5mg/100g)
- Liver (5mg/100g)
- Meat (2mg/100g)
- Fish, dried fruits, jaggery and iron cookware
 Poor sources: - milk (0.1 mg/100 ml)
- wheat
- Polished rice

61. ABSORPTION
 Ferric ions are reduced with the help of gastric HCI, ascorbic acid
 Ca, Cu, Zn inhibit absorption.
 Phytates , oxalates & phosphates in the diet reduce absorption by
forming insoluble iron salts.

62. EXCRETION
 One-way element (very little of it is excreted)
 Almost no iron is excreted through urine
 Any type of bleeding will cause the loss
Normal level in plasma - 50-175 μg/dl

63. DEFICIENCY
 Iron deficiency anemia is the most common nutritional deficiency diseases.
 Characterized by microcytic hypochromic anemia (blood hb <12 g/dl)
 Oral manifestation:
 Salivary gland dysfunction
 Very red painful tongue with a burning sensation,
 Dysphagia
 Angular cheilosis

64. IRON DEFICIENCY ANEMIA
Clinical Manifestations:
 Achlorhydria
 Impaired attention, irritability, lowered memory
 Koilonychia (spoon nails)
 Slow growth and development in children
 Poor appetite
 Fatigue
 Children show unusual cravings for non nutritive substances like ice, dirt,
paint or starch
 Frequent infections

65. CAUSES
 Hookworm infection
 Nephrosis
 Repeated pregnancy
 Lack of absorption
 Nutritional deficiency
 Chronic blood loss (piles, peptic ulcer, uterine hemorrhage)

66. causes of iron deficiency in children include
 insufficient intake together with rapid growth
 low birth weight
 gastrointestinal losses related to excessive intake of
cow's milk.

67. TOXICITY
HEMOSIDEROSIS
 Occurs in persons receiving repeated blood transfusion (in hemophilia,
hemolytic anemia).
 Common in bantu tribe, because of staple diet and their habit of cooking
foods in iron vessels.

68. Hemochromatosis
Primary hemochromatosis :
 Genetic disorder - excessive storage of iron in tissues → tissue damage.
Secondary hemochromatosis:
 Repeated blood transfusions
 Excessive oral intake of iron
Eg. As in african bantu tribes

69. Bronze Diabetes
 Deposition of iron
 Liver cell death - Cirrhosis
 Pancreatic cell death - Diabetes
 Deposits under the skin cause yellow-brown discoloration – Hemochromatosis
the triad of cirrhosis, diabetes and hemochromatosis - Bronze diabetes

70. Oral manifestations of iron deficiency
• Bad breath
• Excessive plaque
• Burning mouth
• Loss of taste and smell
• Delayed wound healing
• Increased susceptibility to periodontal diseases
• Xerostomia
• candidiasis

71.  Total body iodine 25-30 mg (80% in thyroid gland)
Requirements:
 Children: 40-120 μg /day
 Adults: 100-150 µg/day
 Pregnant women: 175 µg/day
IODINE
Shafer’s textbook of oral pathology

72. Commercial source: Sea weeds
Other sources: drinking water,
vegetables, fruits, iodized salt
Absorption: small intestine
 Only 30% of iodine in food is absorbed
 Goiterogenous substances prevent absorption of iodine

73. Storage -
Iodothyroglobulin
Excretion:
mainly through urine and also through bile, saliva and skin
Plasma: 4-10 μg /dl
Deficiency:
Children: Cretinism
Adults: Goiter, Hypothyroidism, Myxedema

74.  Total body Zn: 2 gm (99% is intracellular)
(60% in skeletal muscle)
(30% in bones)
 Prostate gland contains 100 μg/g
 & liver 50 μg/g
Sources: grains, beans, nuts, cheese,
eggs, milk, meat & shell fish
Absorption: duodenum
Storage: in liver with a specific protein, metallothionine.
ZINC
Shafer’s textbook of oral pathology

75. Biochemical functions
 Cofactor for more than 300 enzymes
Eg: carboxy peptidase, carbonic anhydrase, ALP, LDH, ADH, superoxide
dismutase & glutamate dehydrogenase.
 Participate in the metabolism of carbohydrates, lipids, proteins
& nucleic acids.

76.  Stabilizes insulin, when stored in ẞ- cells of pancreas.
 Promotes the synthesis of retinol binding protein.
 Gusten a zn containing protein in saliva, is important for taste sensation.
 Role in growth, reproduction & wound healing

77. Requirement
 Children: 5-10 mg/day
 Adults: 10-15 mg/day
 Pregnancy & lactation: : 15-20 mg/day
 Deficiency - Hypogonadism
- Growth Failure
- Impaired Wound Healing
- Decreased taste and smell acuity
 Plasma: 50-150 mg/dl

78. Total body Cu is 100 mg; quantitatively this is next to iron and zinc
It is seen in muscles, liver, bone marrow, brain, kidney, heart and hair
Cu Containing Enzymes:
Ceruloplasmin, cyt. Oxidase, cyt. C, tyrosinase, lysyl oxidase, ALA synthase,
monoamine oxidase, cytosolic superoxide dismutase, uricase and phenol oxidase
COPPER

79. Requirement and Sources
 Infants & children: 1.5-3 mg/day
 Adults: 2-3 mg/day
Sources:
 Cereals, meat, liver, kidney, egg yolk,
nuts and green leafy vegetables
 Milk is a poor source
Shafer’s textbook of oral pathology

80. Absorption
 Mainly from duodenum and is mediated by a Cu binding protein
(metallothionein)
 Only about 10% of dietary cu is absorbed
 Rate of absorption is reduced by phytates, Ca, Fe, Zn in the intestines.
Storage: liver & bone marrow
Transport: albumin

81. Excretion – bile
 Urine doesn't contain Cu in normal circumstances
Plasma copper: 100-200 μg/dl
 95% is tightly bound to Ceruloplasmin.
 Small fraction (5%) is loosely held to histidine residues of albumin.
 Normal serum conc. of ceruloplasmin: 25-50 mg/dl

82. Deficiency
• Microcytic normochromic anemia
• Fragility of arteries,
• deminiralization of bones,
• demyelination of neural tissue,
• myocardial fibrosis,
• hypopigmentation of skin,
• greying of hair

83. Minke's kinky hair syndrome:
results from defective cross linking
of connective tissue due to Cu deficiency

84. Wilson's hepatolenticular degeneration
Rare (1 in 50,000)
Occurs due to Cu toxicity
 hepatic cirrhosis
 brain necrosis
 renal damage
 Chronic toxicity may lead to diarrhoea and blue-green
discoloration of saliva.

85. Oral manifestations of Cu deficiency
• Increased tissue fragility
• Decreased trabeculae of alveolar bone
• Decreased tissue vascularity

86.  Least abundant and most toxic of essential elements
Sources-
 Plants , meat & sea foods
Requirements-
 Children: 10-30 μg/day
 Adult male 40-70 μg/day
 Female: 45-55 μg/day
 Pregnancy & lactation: 65-75 μg/day
SELENIUM
Shafer’s textbook of oral pathology

87. Biochemical functions
 Acts as a nonspecific intracellular antioxidant by providing protection
against peroxidation in tissues and cell membranes.
 Complementary to vit. E; availability of vit. E reduces the Se
requirement.
 protects from developing liver cirrhosis.

88. Plasma Se
 Normal value- 13 μg/dl
 Most of the Se in blood is a part of glutathoine reductase
 Inside the cells, it exists as selenocysteine and selenomethionine.
 Absorption: duodenum
 Se is carcinogenic in animals, its oncogenic influence in man is not established.

89. Oral manifestations
• Metallic taste in mouth
• Has antibacterial effect on S. mutans so it decreases cariogenicity of
plaque

90. Deficiency
 Marginal deficiency; when soil content is low.
 In animals; hepatic necrosis, retarded growth, muscular degeneration &
infertility.
 In humans; congestive cardiomyopathy .

91. Toxicity
• selenosis (900 μg/day) hair loss,
• dermatitis,
• irritability,
• purple streaks in nails,
• falling of nails,
• diarrhoea
• garlicky odour in breath (dimethyl selenide).

92. Pediatric considerations
• Every year approximately 1.7 million children die as a result of
diarrhea and dehydration.
• In May 2004. WHO/UNICEF issued a joint statement recommending
the use of zinc, an essential micronutrient for human growth
development and maintenance of the immune system and a new
formulation oral rehydration solution (ORS), with reduced levels of
glucose and salt, as a two-pronged approach to improved case
management of acute diarrhoea in children.
shobha tondon 3rd edition volume 1

93. • In a number of clinical trials, zinc supplementation was observed not
only to significantly reduce the incidence of diarrhoea, but also there
was a lower incidence of pneumonia.
• Moreover, in acute diarrhoea trials, zinc supplemented children had a
15% lower probability of continuing diarrhoea on a given day and in
persistent diarrhoea trials, there was a 24% lower probability of
continuing diarrhoea.
shobha tondon 3rd edition volume 1

94. • Systemic Effect of Micronutrients
Teeth are protected from chemical or mechanical attacks by the hard tooth
tissue, consisting of dental enamel, dentin and the root cementum.
Nutrients can only influence the hard tooth tissue systemically during its
original formation, i.e. before eruption of the teeth.
As the teeth develop an organic matrix is generated, which is
subsequently mineralized with calcium and phosphate.
shobha tondon 3rd edition volume 1

95. • During matrix generation, extreme mineral deficits can cause
structural changes in the dental enamel, e.g., pits or
indentations.
• Insufficient nutrient supplies during mineralization of the
enamel can lead to opaque whitish spots on the upper part of
the tooth.

96. • Local Effect of Micronutrients
• Once the teeth have erupted, they can only be affected locally by
micronutrients.
• The enamel undergoes continuous process of demineralization and
remineralization. Acid-forming bacteria like Streptococcus mutans,
mainly responsible for caries, as well as acids from food stuffs, dissolve
mineral from tooth enamel, thus making it softer.
• calcium in saliva or in food, as well as in toothpaste and other dental
hygiene products can remineralize and harden enamel again
shobha tondon 3rd edition volume 1

97. CONCLUSION
• The importance of micronutrients for body composition is must as far as oral
health is concened.
• Nutrition does not only play a role in preventing the formation of plaque and
development of caries, a balanced diet facilitate remineralization and
ossification promoting healing and resistant to infection.