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Calcium and Phosphorous Metabolism

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Calcium and Phosphorous Metabolism CALCIUM AND PHOSPHOROUS METABOLISM -DR. SUHASINI. G P Lecturer Dept. of Oral Pathology & Microbiology Dr. Suhasini GP, Subharti Dental College, SVSU INTRODUCTION • Metabolism (Greek, Metabote= change) • Sum of the chemical and physical changes in tissue consisting of anabolism (reactions that convert small molecules into large) & catabolism (reactions that convert large molecules into small) Dr. Suhasini GP, Subharti Dental College, SVSU Functions of Calcium • Most abundant mineral • Most important inorganic cation in mineralised tissue- structural role • [Ca10(PO4)6(OH)2] in bone, dentin, cementum & enamel Dr. Suhasini GP, Subharti Dental College, SVSU Functions Formation of bone and teeth Controls secretion of glandular cells Muscle contraction Clotting of blood Neuromuscular excitability Cell-cell adhesion, cell integrity Intracellular second messenger in harmonal actions Dr. Suhasini GP, Subharti Dental College, SVSU Dietary requirements • Adults- 0.8 gms/day • Children & pregnant and lactating women- additional 1gm of Ca supplements/day • Postmenopausal women Dr. Suhasini GP, Subharti Dental College, SVSU Sources • Milk & its products • Green leafy veg (oxalic acid and phytic acid- reduces absorption) • Raagi • Egg yolk • Legumes • Nuts • Dried fish • Pan chewing with slacked lime • Drinking water Dr. Suhasini GP, Subharti Dental College, SVSU Distribution of Ca++` • Essentially distributed extracellularly • 1.2-1.4 kg in 70kg adult • 99%-skeleton • 1%- soft tissue+ body fluids Dr. Suhasini GP, Subharti Dental College, SVSU Bone Ca++ Exists in 2 forms- • Readily exchangeable form- simple exchange b/n newly deposited bone & exctracellular Ca++ • Stable form- constant formation & resorption of bone- – Controlled by PTH, calcitonin & vit.D Dr. Suhasini GP, Subharti Dental College, SVSU Blood Ca++ • Plasma, little in RBC • 9-11mg/dl- constant • In plasma- 1. Diffusible o Ionised o Non-ionised 2. Non diffusible Dr. Suhasini GP, Subharti Dental College, SVSU • Ionised diffusible form- physiologically active form • Non ionised diffusible form- in the form of complexes as citrates, phosphates n bicarbonates • Protein bound (albumin in plasma)- physiologically inactive Dr. Suhasini GP, Subharti Dental College, SVSU Calcium balance • Calcium absorption- • Active transport- against conc. gradient- duodenum • Passive diffusion- proximal jejunum & ileum • Normal secretion of HCL is necessary for optimal absorption • Achlorhydria, hypochlorhydria— decreased absorption. Dr. Suhasini GP, Subharti Dental College, SVSU LUMEN CELL BLOOD 1,25-dihydroxycholecalciferol 2+ 2+ Ca CBP Ca 2+ d ie ta ry C a + + C a C B P Na Na + 2+ Facilitated Na /C a D iffu s io n E x c h a n g e CBP = calcium binding protein 4 Dr. Suhasini GP, Subharti Dental College, SVSU Intake, Uptake and Excretion D ie t 1 0 0 0 m g CALCIUM a b s o rb s 5 0 0 m g GUT 3 5 0 m g 2+ Ca B o n e s e c re te s P o o l 5 0 0 m g 1 5 0 m g Kidney 2% filtered load 8 0 0 m g 2 0 0 m g e x c re te d e x c re te d 5 Dr. Suhasini GP, Subharti Dental College, SVSU • Positive Ca++ balance • Negative Ca++ balance Dr. Suhasini GP, Subharti Dental College, SVSU FACTORS AFFECTING Ca ABSORPTION (a) Factors affecting mucosal cells ♣ Vit D- increases absorption ♣ D2(ergocalciferol)- yeast bread ♣ D3- fish liver oils Dr. Suhasini GP, Subharti Dental College, SVSU • 1,25 dihydroxycholecalciferol- active form • Acts as a hormone • Acts by promoting synthesis of Ca binding protein (CaBP) in epithelium of intestinal villi Dr. Suhasini GP, Subharti Dental College, SVSU (b) precipitating anions • Ca soluble form- absorbed • Contents- stomach Intestine- alkaline digestive juices- pH insoluble Ca salts- absorption • Acidic conditions in small intestine- favor absorption • Phosphate & long chain fatty acids, bile & bile salts are such anions • Very high or low Ca/P ratio or too high levels of both absorption Dr. Suhasini GP, Subharti Dental College, SVSU (c) Complexing agents • Fat+ Ca – colloidal complexes- absorbed through intestinal wall (d) Carbohydrates &proteins • Disaccharide- lactose- absorption and bone calcification • Proteins- absorption (e) Hormones • Parathyroid hormone- stimulate intestinal transport • Controls formation of 1,25 dihydroxycholicalciferol • GH increases the absortion Dr. Suhasini GP, Subharti Dental College, SVSU (f) Seasonal & unexplained effects- • Max- July & august • Min- Feb & March • Emotional factors- Stress Dr. Suhasini GP, Subharti Dental College, SVSU PARATHYROID HARMONE VIT D CALCITONIN bone Action kidney on intestine Dr. Suhasini GP, Subharti Dental College, SVSU Role of PTH • Stimulates renal reabsorption of calcium • Stimulates bone resorption • Inhibits bone formation and mineralization • Stimulates synthesis of calcitriol- increased absorption from intestine Net effect of PTH ↑ serum calcium Dr. Suhasini GP, Subharti Dental College, SVSU Regulation of PTH Low serum [Ca+2] Increased PTH secretion High serum [Ca+2] Decreased PTH secretion Dr. Suhasini GP, Subharti Dental College, SVSU Role of Calcitriol • Stimulates GI absorption of calcium • Stimulates renal reabsorption of calcium • Stimulates bone resorption • (INCREASES SYNTHETIC ACTIVITY OF OSTEOBLASTS, NECESSARY FOR NORMAL CALCIFICATION • IN LARGE QUANTITIES- CAUSE RESORPTION OF BONE) Net effect of calcitriol ↑ serum calcium Dr. Suhasini GP, Subharti Dental College, SVSU Regulation of Calcitriol INTESTINE KIDNEY BONE Dr. Suhasini GP, Subharti Dental College, SVSU Calcitonin • Secreted by the type C cells(parafollicular) of thyroid. • CT reduces Ca2+ by reducing transfer of Ca2+ to the blood and inhibiting bone resorption by decreasing the osteoclastic activity • Used in the treatment of Paget’s disease & osteoporosis Dr. Suhasini GP, Subharti Dental College, SVSU Other harmones • GROWTH HARMONE-increases intestinal absorption • GLUCOCORTICOIDS-initially- inhibit osteoclstic activity- decreasing the plasma conc. Over prolonged periods- increases bone resorption and decreased bone formation • THYROID HARMONES- T3, T4- hypercalemia and hypercalciuria- osteoporosis • TESTOSTERONE-increases bone density & bone growth • ESTROGEN- inhibits osteoclastic activity, prevents osteoporosis. Dr. Suhasini GP, Subharti Dental College, SVSU APPLIED ASPECTS Dr. Suhasini GP, Subharti Dental College, SVSU Hypercalcemia • Fatigue, lethargy • Anorexia, nausea, vomitting • Constipation (muscle hypotonia) • Cardiac abnormality • Peptic ulcer • Metastatic calcification etc Dr. Suhasini GP, Subharti Dental College, SVSU Tetany • Ca++ <6mg/dl • Chvostek’s sign-tapping of facial nerve- spasm of muscles • Trousseau’s sign- application of torniquet of sphygmomanometer on arm- carpopedal spasm • Accoucher’s hand-flexion of metacarpophalangeal joints while fingers remain extended • Laryngeal stridor Dr. Suhasini GP, Subharti Dental College, SVSU Hyperparathyroidism • Primary- adenomas of PTH glands • Secondary- renal diseases, rickets, osteomalacia, acromegaly, malabsorption syndrome Dr. Suhasini GP, Subharti Dental College, SVSU Hypoparathyroidism • Postoperative • Functional • Idiopathic • Hypomagnesemia • Pseudohypoparathyroidism- PTH level high, serum Ca++ low- defect in target cell receptor or CBP Dr. Suhasini GP, Subharti Dental College, SVSU RICKETS Rickets can be caused by lack of sunlight, but also from insufficient calcium. Vitamin D linked to calcium absorption. Dr. Suhasini GP, Subharti Dental College, SVSU • RENAL RICKETS Dr. Suhasini GP, Subharti Dental College, SVSU Pathologic calcification • Dystrophic Calcification • Metastatic calcification • Calcinosis Dr. Suhasini GP, Subharti Dental College, SVSU Dystrophic Calcification • Calcification of dead and dying tissues. • The level of calcium in blood is usually normal. (There is no hypercalcemia). • In mouth- gingiva, tongue, cheek, pulp Dr. Suhasini GP, Subharti Dental College, SVSU CalcificationsPulp in pulp: calcification Three types- I. Denticles - Denticles are formed as a result of an epitheliomesenchymal interaction within the developing pulp. II. Pulp stones- pulp stones are developed around the central nidus of pulp tissue III. Diffuse linear calcifications- they exhibit areas of fine, fibrillar, irregular calcification that often parallel the vasculature. Dr. Suhasini GP, Subharti Dental College, SVSU • Classification by Hill- • 1st - Nodular type- result of calcification of hyalinized CT – perivascular, perineural, associated with fibrosis • 2nd type- Found in and around the necrotic cells • Inflammatory process Dr. Suhasini GP, Subharti Dental College, SVSU Local metabolic Trauma dysfunction Hyalinization Vascular of injured cells damage fibrosis Mineralization PULP STONE Dr. Suhasini GP, Subharti Dental College, SVSU Clinical & radiographic features denticles and pulp stones are detected on intraoral radiographs as radioopaqueHistopath enlargementsfeatures within the pulp chamber or canals May interfere• Denticles with root –consist formation of tubular leading dentin to early surrounding periodontal a destructionnest andof epithelium tooth loss , central epithelium degenerates with time and tubules undergo sclerosis. • Pulp stones –a central amorphous mass of irregular calcification surrounded by concentric, lamellar rings of regular calcified material. • Diffuse linear calcification – consist entirely of fine, fibrillar and irregular calcification that develop in the pulp chambers and canals Dr. Suhasini GP, Subharti Dental College, SVSU Metastatic calcification It is deposition of calcium salts in many tissues which may be normal. It is associated
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