CALCIUM AND PHOSPHORUS

METABOLISM
Adedotun Adewale BChD, FWACS
Oral Medicine and Oral Pathology O.A.U.T.H.C, Ile-Ife.
Introduction
• Calcium and phosphate are essential elements for normal growth and
development
• Calcium and phosphate in the form of calcium hydroxyapatite crystals
( Ca10(PO4)6(OH)2 )are present in bone and teeth.
• Dysregulation of calcium or phosphate metabolism severely hampers
normal bone and tooth development as well as causes abnormalities
in the developed bone and tooth.
• The physiology of calcium and phosphate metabolism, the function of
vitamin D and the formation of bone and teeth are tied together in a
common system.
• Parathyroid hormone(PTH) and calcitonin play a regulatory role in
calcium and phosphate metabolism.
Functions of Calcium
• The total body content of calcium in an adult is approximately 1.1 kg,
of which around 98–99% is present in bone and teeth alone.
• Functions of calcium includes:
üstability of cell membranes
ü muscle contraction
ü exocytosis in secretory cells
ü blood clotting
ü Helps in the development of bone and teeth
Sources of Calcium
• The daily requirement of calcium is around 1000 mg but more has to
be consumed because only 60% of what we take is absorbed.
• Milk, vegetables, cheese and fruits are some of the main sources of
calcium.
• During pregnancy, the calcium intake should be around 1.5 g/day, and
in lactating mothers, it should be 2 g/day for the healthy growth of the
infant.
Absorption and Excretion
• Calcium is absorbed in the duodenum.
• Phytic acid and oxalic acid decrease absorption by forming insoluble
calcium phytate and calcium oxalate.
• Factors such as vitamin D, fat, citrates, protein diet and low pH in the
gastrointestinal tract increase the absorption of calcium.
• Calcium enters the cells by passive diffusion and binds to the calcium-
binding proteins within the cell. From the cells, the calcium is passed
out by active calcium pumps on the cell membrane.
• Calcium is excreted in faeces and in urine. In the faeces, it is excreted
through the exfoliated gastrointestinal tract cells, and in the urine, it
is excreted as calcium phosphate and calcium chloride
Blood Calcium concentration
• The normal blood calcium level is maintained between 9 and 11
mg/dl.
• Blood calcium may be in a free state or may be complexed with
hydrogen carbonate and citrates and in some cases, bound to plasma
proteins
Calcium Regulation
• The blood calcium level is maintained by two hormones and vitamin
D.
1. Parathyroid hormone(PTH): Secreted by the chief cells of the
parathyroid gland
2. Calcitonin: Secreted by the parafollicular cells of the thyroid gland
3. Vitamin D: Acts like a third hormone in this regulatory process
Parathyroid hormone (Parathormone)
• The main function of the parathyroid hormone (PTH) is to increase
the blood calcium level.
• The action of PTH is both by its direct effect on bone and kidney and
by its indirect effect on intestine through vitamin D.
• The secretion of PTH varies inversely with the level of calcium in
blood. The parathyroid hormone acts in the following ways:
• Effect of PTH on kidney
(a) Increases the reabsorption of calcium
(b) Increases phosphate excretion
(c) Increases the conversion of 25-hydroxycholecalciferol to its active
form 1,25-dihydroxycholecalciferol (calcitriol) which enhances calcium
absorption in the intestine
• Effect of PTH on bone
(a) Increases osteoclastic activity on bone, thereby mobilizing calcium
from bone to plasma
(b) Decreases osteoblastic activity and new bone formation, thereby
decreasing utilization of blood calcium
• Effect of PTH on intestine
(a) Increases the absorption of calcium and phosphorus by indirectly
increasing the renal production of 1,25-dihydroxycholecalciferol
(calcitriol)
Clinical correlate (Hyperparathyroidism)
• It is characterized by increased levels of PTH in the body which results
in resorption of bone, increased absorption and reabsorption of
calcium which eventually ends in increasing the serum calcium levels
(hypercalcaemia).
• Though new bone formation commences with induced bone
resorption, at some point resorption surpasses the formation of
bone. This results in a characteristic pathology commonly affecting
the jaw bone called as Brown’s tumour of hyperparathyroidism.
• Further, very rarely can hyperparathyroidism be associated with
multiple internal resorption of tooth.
Clinical correlate (Hypoparathyroidism)
• It results in a reduced serum calcium level (hypocalcaemia).
• Hypocalcaemia leads to a neuromuscular disorder known as tetany.
Hypoparathyroidism at a very early stage of life can lead to
abnormalities in tooth development which may present as a
generalized pitting type of enamel hypoplasia
Enamel Hypoplasia
Calcitonin
• The modes of action of calcitonin are as follows:
1. When the blood calcium level increases, calcitonin reduces the
number of active osteoclasts and inhibits bone resorption, thereby
reducing the amount of calcium mobilized to blood.
2. It prevents the distal tubular reabsorption of calcium, thereby
increasing the excretion of calcium and reducing the blood calcium
level.
Vitamin D
• The most active metabolite of vitamin D is calcitriol, which is formed in the
kidney and is considered a hormone.
• The active form of vitamin D is formed from vitamin D2 or ergocalciferol
and vitamin D3 or cholecalciferol. Vitamin D3 is made in the skin when 7-
dehydrocholesterol reacts with ultraviolet light.
• Ergosterol is derived from diet.
• Cholecalciferol is hydroxylated in the liver to form 25-
hydroxycholecalciferol. This reaction is catalysed by the microsome enzyme
present in the liver, hepatic 25-hydroxylase.
• It is further transported to the proximal tubules of the kidneys, where it is
hydroxylated to form calcitriol (1,25-dihydroxycholecalciferol).
• This product is the active form of vitamin D, which mediates most of the
physiologic actions of the vitamin.
• Calcitriol is responsible for all the effects of vitamin D on calcium
metabolism. Calcitriol increases the blood calcium level by its effect
on the intestine, kidneys and bone. The functions of calcitriol are as
follows:
1. Calcitriol increases the formation of calcium binding proteins, which
in turn cause increased absorption of calcium from the intestine and
also enhance calcium transport.
2. Calcitriol increases osteoclastic activity and increases mobilization of
calcium from bone to blood.
3. Calcitriol increases renal reabsorption of calcium and decreases
phosphate reabsorption.
Clinical Correlate (Rickets)
• This is a condition which affects children with calcium, phosphate and
vitamin D deficiency.
• Malformed teeth and bone abnormalities are seen in this condition.
Other Hormones involved in calcium metabolism
1.Growth hormone: It increases absorption of calcium from intestine
and also enhances protein synthesis in bone.
2. Insulin: It is an anabolic hormone that favours bone formation.
3. Sex hormones: They increase calcium absorption, decrease calcium
excretion and enhance bone mineralization. Oestrogen has a direct
effect in reducing bone resorption.
4. Prolactin: It increases calcitriol production, thereby increasing
calcium absorption during the lactating period.
5. Thyroid hormone: An increase in the levels of thyroid hormone is
accompanied by osteoporosis and hypercalciuria
Phosphate
• The total body content of phosphate is 320 mmol/kg. Eighty-five
percent of the body’s phosphate content is present in the bones and
teeth; the rest is widely distributed in the cells.
• Functions include:
1.Development of bone and teeth
2.Metabolism of fat and carbohydrate (phosphorylation)
3. Formation of adenosine triphosphate (ATP)
4. Formation of nucleic acids
Intake, Absorption, Excretion
• The RDA of phosphate is around 550 mg/day but has to be increased
in pregnant and lactating females (around 1,000 mg/day). Some of
the rich sources of phosphate are milk, meat, fruits and vegetables.
• Phosphate is absorbed in the duodenum. The presence of calcitriol
increases phosphate absorption. Excess of iron, calcium and
aluminium retards phosphate absorption.
• Phosphorus is mainly excreted in the urine as phosphates of various
cations. Faecal phosphates are excreted in the form of calcium
phosphate.
• Ninety percent of phosphates are reabsorbed in the proximal
convoluted tubule. Parathormone decreases renal tubular
reabsorption of phosphates.
Blood Phosphorus Concentration

• The normal blood level of phosphorus is 2–4 mg/dl in adults.

Related tooth structure
• Enamel makes up the outer layer of the crown of the tooth. It is
composed of hydroxyapatite embedded in a tight meshwork of
protein fibers similar to keratin in hair.
• The crystalline structure makes the enamel hard, whereas the protein
which is completely insoluble provides resistance to enzymes, acids
and other corrosive substances.
• Dentine is the next layer. It is composed of hydroxyapatite crystals
embedded in a strong meshwork of collagen fibers, a structure similar
to bone. It has no cellular components.
• Nourishment is provided by odontoblasts cells which line the inner
surface of the dentine along the wall of the pulp cavity.
Summary
1. Bone and teeth contain the maximum amount of calcium and
phosphate in the form of calcium hydroxyapatite crystals.
2. The normal blood calcium level is maintained between 9 and 11
mg/100 mL.
3. The parathyroid hormone increases osteoclastic activity of the bone,
thereby mobilizing calcium from bone to plasma. Calcitonin does the
exact opposite.
4. The active form of vitamin D is calcitriol. Calcitriol by its effect on the
intestine, kidneys and bone increases the blood calcium level.
5. Phosphate helps in the formation of adenosine triphosphate (ATP)
and nucleic acids.