Ca N P Meta

calcium and phosphate metabolism 1
CALCIUM AND
PHOSPHATE METABOLISM
Dr Jagadish S
Dept of Pedodontics
Skeleton
• Introduction.
• History.
• Distribution.
• Sources.
• Daily requirements.
• Plasma level.
• Absorption and excretion.
• Functions.
• Homeostasis.

Skeleton
• Effects of altered calcium and

phosphate level and its effect on
dental tissue.
• Calcium and phosphate in fetus.
• Calcium and phosphate in neonates.
• Conclusion.
• References.

Introduction
• Why?
The hard tissues of the body:

 Bone – 50 to 60%
 Cementum – 45 to 50%
 Dentin – 60 to 70%
 Enamel – 90 to 96%

• Metabolism
The sum total of tissue activity as considered in terms
of physicochemical changes associated with the availability
utilization and disposal of individual body constituents i.e.
Proteins, Fat, Carbohydrates, Vitamins ,Minerals Water and
the endocrine influences on these - DUNCAN
• Essential elements
An element is considered essential when its deficiency
consistently results in suboptimal physiologic function that
can be prevented or reversed by supplementation with
physiologic levels of the element - MERTZ

CLASSIFICATION OF MINERALS
MACROMINERALS: Daily requirements >100mg

• Na, K, Cl, Ca, P, Mg and S
MICROMINERALS: Daily requirements <100mg (<0.005% body wt)

• Cr, Co, Cu, Fe, I, Mn, Zn, Se, F
TRACE ELEMENTS:
• Cadmium, Nickel, Silicon, Tin, Vanadium

History
The word calcium originates from the Latin word

‘Calcis’ meaning lime.
It was discovered by sir Humphery Davy(1808).
It is a silvery alkaline earth metal.. 3.5% of
earth’s crust.

Distribution
Total calcium:1100-1200g (1.5%
of the body weight)
1% in soft
99%in bones
tissue and
and teeth
ECF
0.1% is seen
Serum 9 – 11mg/dl 0.9% is seen
in soft tissue in
C.S.F 4.5 - 5mg/dl
ECF
Muscle 70mg/dl
Nerve 15mg/dl

Calcium in plasma and interstitial fluid
The normal concentration of plasma calcium:

9 – 11 mg/dl (4.5 – 5.5 mEq/L)
Three forms of Calcium:

 Ionized Calcium
 Non ionized Calcium and
 Protein bound
Sources
 Milk – good source

 Egg, fish and vegetables – medium sources
 Cereals – small amount.
Daily requirement
 Adult – 800mg/day
 Infants (<1yr) – 350 - 550mg/day
 Children – 800 - 1200mg/day
 Pregnancy and lactation – 1200 - 1500mg/day

Absorption of calcium
Vit D
Acidic pH
Organic acids, lactose and

basic A.A
Increase in protein
Ca and phosphorus ratio of

1:1
Absorption increased by
Absorption of calcium
Absorption decreased by
Phytic acid
Oxalates
Steatorrhoea
Old age(55 – 60yrs)
High phosphate content .

Excretion of calcium
10-15%
Feces
Urine
10-15% 70-80% Sweat

Functions of calcium
 Formation and development of bones and teeth
 Blood coagulation
 Transmission of nerve impulse
 Secretion of hormones
 Mediates excitation and contraction of muscle fibers
 Activation of enzymes through calmodulin
 Maintains the integrity of intracellular substances.

Effects of increased Calcium
 Depression of the nervous system
 Sluggishness of reflex activities
 Lack of appetite
 Constipation
 Reduced ST segment and QT intervals in ECG
 Osteitis fibrosa cystica
 Deposition of crystals(kidney tubules, alveoli of lungs,
wall of arteries).
Etiologies of Hypercalcaemia
Increased GI Absorption
Increased Loss From Bone
Increased bone turnover
Decreased Bone Mineralization
Decreased Urinary Excretion

Effects of reduced Calcium
Neuromuscular
hyperexcitability
(hypocalcaemic
tetany <6mg%)
Reduced permeabity of Hyper excitability of

cell membrane. skeletal muscles
Dilatation of
heart

Etiologies of Hypocalcemia
Decreased GI Absorption:
Decreased Bone Resorption:
 Poor dietary intake of
 Low PTH
calcium
 Vitamin D deficiency
 Impaired absorption of
 Osteoblastic metastases
calcium
 Decreased conversion of vit
D to calcitriol.

Etiologies of Hypocalcemia
Increased Urinary Excretion:

 Low PTH
 Thyroidectomy
 Autoimmune hypoparathyroidism

Etiology of Enamel hypoplasia
• A study was conducted to determine the causes of enamel
hypoplasia and interglobular dentine.
• They have concluded that enamel hypoplasia is due to
hypocalcaemia
• Formation of interglobular dentine is due to hypophosphtaemia.
Etiology of Enamel Hypoplasia:

A Unifying Concept, J Pediatr 98:888-893. NIKIFORUK, G. and FRASER, D.(1981)

Regulation of blood Calcium level
Regulated mainly by three hormones:
 Parathyroid hormone
 1,25-dihydroxy cholecalciferol
 Calcitonin

Parathyroid Hormone
Pre-pro PTH (115 amino acids)
E.R of chief Enzymatic deletion of 25 amino acids

cells
Pro-PTH (90 amino acids)
Golgi Enzymatic deletion of 6 amino acids

apparatus
PTH (84 amino acids)

Osteolysis  Loss of Calcium
Osteoclastic bone resorption 

Loss of Calcium & Phosphate
DCT  Calcium reabsorption
PCT  Inhibit Phosphate

PTH reabsorption
Stimulates hydoxylation of
25HCC to 1,25-DHCC
1,25-DHCC
↑ Intestinal Calcium
absorption

Stimulation for PTH secretion
• Low level of Calcium in plasma.

• Maximum secretion occurs when plasma
Calcium level falls below 7mg/dl.
• When plasma Calcium level increases to
11mg/dl  ↓ PTH secretion.
• This is an exception as Calcium influx into
endocrine cells stimulates hormonal secretion.
Action on bone

PTH modulates osteoblast and ostoclast activity.
Osteoblasts produce the protein OPG

(osteoprotegerin) which binds osteoclast
rank-L receptors and down regulates
osteoclast production and maturation.
PTH decreases OPG production, allowing the

protein rank-L produced by osteoblasts, to
bind the rank-L receptors on osteoclast.

Hyperparathyroidism

the Impact of Primary Hyperparathyroidism
on the Oral Cavity
They concluded that HPT are more likely to have:
• Mandibular tori
• Widening of PDL space
• Loss of lamina dura
• Reduced cortical bone thickness at the angle of mandible.
The Journal of Clinical Endocrinology & Metabolism , doi:10.1210/jc.2005-2282 Allan D. Padbury,

Hyperparathyroidism

oral manifestations of secondary
hyperparathyroidism related to long term
hemodialysis therapy: fletcher et al.
Patients on long term hemodialysis therapy may
develop secondary hyperparathyroidsm with oral
symptoms.

Oral manifestations
Loss of lamina dura Thining of cortical bone
Spaced dentition
Hypoparathyroidism
• Decreased level of PTH Due to
Surgical removal of parathyroid gland
Congenital absence of the gland
Atrophy of the gland
• Effects:
Decreased plasma calcium level
Increased plasma phosphate level

Clinical signs & symptoms
Hyperactive reflexive
Spontaneous muscular contractions
Convulsions
Laryngeal spasm
Dental findings
– Delayed eruption
– Hypoplasia of enamel
– External root resorption and
– Root dileceration.
Activation of vit D and its Effect

Vitamin D ↑ Calcium &
↑ Phosphate
absorption
↑ Calcium
reabsorption
Weak
action
↑ Plasma
calcium &
Phosphate levels
Bone resorption calcium and phosphate metabolism 39

Vitamin D deficiency

Dental findings in Rickets
 Developmental anomalies of
enamel and dentin
 Delayed eruption
 Malallignment of teeth
 Increase caries index
 Wide predentine zone and more
interglobular dentin

Renal Rickets
 Renal tubular acidosis
 Deficient hydrogen ion production

 Loss of bicarbonates, sodium,
pottasium, calcium, magnesium and
phosphate.
 Bone changes are similar to rickets.
Osteomalacia & Osteoporosis

Tetany :
Condition when plasma calcium level falls below 6mg/dl.

Hyper excitability of nervous system.
Causes peripheral muscle spasm.
Clinical signs
 Chvostek’s sign
Contraction of ipsilateral facial muscles when tapping
facial nerve over the angle of the mandible.
 Erbs sign
Hyperexcitability of muscles to electrical stimulation

Trousseau’s sign(carpopedal spasm)
Spasm of the muscles of the upper extremity
causing flexion of wrist and thumb and
extension of fingers.
Clinically can be produced by applying pressure
with sphygmomanometer cuff on the upper arm.

Calcitonin and its action

OTHER HORMONES AFFECTING
CALCIUM METABOLISM
GROWTH
HORMONE
INSULIN
THYROID TESTOSTERO
HORMONE NE
PLACENTAL
ESTROGEN
LACTOGEN

Other factors:
 Plasma proteins
50% of calcium are non diffusible form bound

to proteins.
 Plasma phosphate
A reciprocal relation exists between calcium

and phosphate.

Integrated Hormonal Regulation
Calcium Deficiency
Hypocalcaemia
Negative feedback- PTH ↑ urinary phosphate
↑ PTH excretion
↓ plasma phosphate
level
1,25-DHCC (Hypophosphatemia)
↑ osteocytic &
osteoclastic bone ↑ Intestinal calcium
resorption absorption
↑ Calcitonin secretion
If excessive
↑ Renal calcium
absorption ↑ plasma calcium level
(Normal) Normal level
49
Phosphate Metabolism
History
 1st metal isolated by electrolysis – sir Humphrey
Davy(1807).
 Soft silvery-white alkali metal.
 2.5% of earth’s crust.
 7th most abundant element on earth.

Phosphorus
• Total phosphate:
500-800 gms • Normal plasma levels:
2.5-4.5 mg/dl
bones soft tissues

and teeth
Organic Inorganic
(0.5-1mg/dl)
(Adults:3-4mg/dl)
(children:5-6mg/dl)
within cells
ECF, blood
and other
fluids

52
Sources of Phosphorus
Occurs together with calcium

 Protein-rich foods such as milk,
cheese, meats, poultry, and fish.
 Cereals, legumes, nuts, soft drinks
 Milk Phosphoprotiens
 Brain, Liver, Egg yolk Phospholipid
 Muscles Phosphogen & ATP
calcium and phosphate metabolism

51
Phosphorus: Requirements
Age in years Estimated average
reqiurements
< 1 year 100-275 mg
1-3 years 380 mg
4-8 years 450 mg
9-18 years 1055 mg
19-70 years 580 mg
Dietary Reference Intakes, Food and Nutrition Board,

National Academy of Sciences-Institute of Medicine, 1997
Functions of Phosphorus
 Formation of bones & Teeth

 Production of high energy phosphate compounds
 Synthesis of nucleoside co-enzymes
 DNA and RNA synthesis

 Formation of phosphate esters
 Activation of enzymes by phosphorylation
 Phosphate buffer system in blood and saliva.

• THE PHOSPHORUS OF SALIVA, WITH SPECIAL REFERENCE
TODENTAL CARIE
GUY E.YOUNGBURG ET AL: J DENT RESEARCH
• In phosphate content, the average saliva of persons having

dentalcaries is not appreciably different from normals.
• Average values for inorganic phosphorus are: normals 17.50
mg.,dental caries 18.13 mg of phosphorus per100 cc. of
saliva.
• There is no reason to believe that the phosphorus of the
saliva plays any role in dental caries.

Daily turnover of phosphate

Phosphate absorption
Factors favoring Factors decreasing
Low calcium diet High calcium diet
Vitamin D Vitamin D deficiency
PTH
High phosphate diet Antacids- Al(OH)3
Growth hormone
During lactation.
Phosphate
regulation
58

Hyperphosphatemia
 Serum phosphorus level >5 mg/dL.
 The pathophysiology of hyperphosphatemia

involves decreased Ca++ due to increased
serum phosphorus.
 Elevated serum phosphorus levels are
associated with the progression of kidney
disease.
 27% greater risk of mortality.
Hyperphosphatemia
Causes:
 Increased intake
 Increased release from cells
 Increased release from bone
 Decreased excretion

61
Effects of Hyperphosphatemia
 Phosphate trapping
 Respiratory insufficiency
 Erythrocyte dysfunction
 Nervous Dysfunction
 Leukocyte Dysfunction
 Metabolic acidosis

59
Hypophosphataemia
Causes:
 Decreased Intake
 Increased cell uptake

 Increased Excretion
 Familial hypophosphatemia
 Chronic alcoholism & Diabetic Ketoacidosis
 Primary hyperparathyroidism
 Vit D deficiency
 Metabolic acidosis
Effects of Hypophosphataemia
 Interferes with renal tubular reabsorption of Ca, PO4,K & H2O
 Leads to rickets & Osteomalacia

 Severe case is a life threatening condition & can cause
hemolysis, muscular weakness, mental changes, decreased
myocardial contractility & respiratory failure
 Deformities of bone & teeth.
 Hypocalcified dentin, abnormal Cementum, alveolar bone
pattern & highly placed pulp horns reaching up to DEJ are
seen.
Bone and its relation to extracellular
calcium and phosphate
• Composed of 30% organic matrix and 70% of

salts.
• Bone salts are principally of calcium and
phosphate i.e hydroxyapatite.
• Ca/p ratio ------- 1.3 to 2.

Exchangeable calcium
 Bone contains exchangaeble ca, that is always in

equilibrium with the ca ions in the extracellular
fluids
 Small portion of this is seen in liver and GIT also
 0.4- 1 % of the total bone ca
 Provides rapid buffering mechanism

Calcium and phosphate in fetus
 About 22.5 gm of ca and 13.5gms of p is

accumulated in fetus during gestation
 The bones are relatively unossified and have mainly
a cartilagenous matrix
 X ray films will not show any ossifications untill
about the 4th month of pregnancy.

Need for Calcium and Phosphates in
neonates
 Neonate is in stage of rapid ossification of its bone
at birth
 Ready supply of ca and p throughout infancy is
needed
 Supplied ordinarily by the usual diet of milk
 Calcium absorption by GIT requires vit D
 Hence vit D deficiency in infants can develop severe
rickets in only a few weeks.
Conclusion
References
• Guyton AC, Hall JE: Human Physiology and

Mechanisms of Disease, 6th edition.
• Rhoades R A, Tanner G A: Medical Physiology,

2nd edition.
• Davidson’s Principles and Practice of Medicine

19th edition.

Referances
• Structures of Biological Minerals in Dental

Research
Journal of Research of the National Institute of
Standards and Technology
• David B Ferguson Oral Bioscience
• Shafer Textbook of Oral Pathology 5th edition.

• Robbins pathologic basis of disease.

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calcium and phosphate metabolism 1

calcium and phosphate metabolism 3

• Effects of altered calcium and

calcium and phosphate metabolism 4

The hard tissues of the body:

calcium and phosphate metabolism 5

calcium and phosphate metabolism 6

MACROMINERALS: Daily requirements >100mg

MICROMINERALS: Daily requirements <100mg (<0.005% body wt)

calcium and phosphate metabolism 7

The word calcium originates from the Latin word

calcium and phosphate metabolism 8

calcium and phosphate metabolism 9

The normal concentration of plasma calcium:

Three forms of Calcium:

 Milk – good source

calcium and phosphate metabolism 12

Organic acids, lactose and

Ca and phosphorus ratio of

Old age(55 – 60yrs)

High phosphate content .

calcium and phosphate metabolism 14

calcium and phosphate metabolism 16

calcium and phosphate metabolism 17

Increased Loss From Bone

Increased bone turnover

Decreased Bone Mineralization

Decreased Urinary Excretion

calcium and phosphate metabolism 19

Reduced permeabity of Hyper excitability of

calcium and phosphate metabolism 20

calcium and phosphate metabolism 21

Increased Urinary Excretion:

calcium and phosphate metabolism 22

hypoplasia and interglobular dentine.

• They have concluded that enamel hypoplasia is due to

• Formation of interglobular dentine is due to hypophosphtaemia.

Etiology of Enamel Hypoplasia:

calcium and phosphate metabolism 23

Regulated mainly by three hormones:

calcium and phosphate metabolism 24

Pre-pro PTH (115 amino acids)

E.R of chief Enzymatic deletion of 25 amino acids

Pro-PTH (90 amino acids)

Golgi Enzymatic deletion of 6 amino acids

PTH (84 amino acids)

calcium and phosphate metabolism 25

Osteoclastic bone resorption 

DCT  Calcium reabsorption

PCT  Inhibit Phosphate

calcium and phosphate metabolism 26

• Low level of Calcium in plasma.

calcium and phosphate metabolism 28

Osteoblasts produce the protein OPG

PTH decreases OPG production, allowing the

calcium and phosphate metabolism 29

calcium and phosphate metabolism 30

They concluded that HPT are more likely to have:

• Widening of PDL space

• Loss of lamina dura

• Reduced cortical bone thickness at the angle of mandible.

The Journal of Clinical Endocrinology & Metabolism , doi:10.1210/jc.2005-2282 Allan D. Padbury,