VITAMIN D,
CALCIUM,
PHOSPHATE
METABOLISM
CONTENTS
1. INTRODUCTION
2. VITAMIN D
INTRODUCTION
SYNTHESIS AND REGULATION
BIOCHEMICAL FUNCTIONS
3. CALCIUM AND PHOSPHATE
INTRODUCTION
ROLE
SOURCE IN DIET
ABSORPTION & EXCRETION
REGULATION
4. APPLIED ASPECT
5. CONCLUSION
6. REFERENCES
INTRODUCTION
VITAMINS:
• "vitamin" comes from the Greek word “vita”, means
"life".
• Reqd in small quantities.
• FUNCTIONS:
(a) Resistance of the body against diseases.
(b) Stimulate and give strength to digestive and
nervous system.
(c) Convert food into energy, and repair cellular
damage.
(d) Help strengthen bones, heal wounds, and immune
system.
MINERALS:
Inorganic components in our diet.
Macro Elements Trace Elements
Calcium Iron
Iodine
Magnesium Copper
Phosphorus Manganese Zinc
• Calcification of bone Molybdenum
Sodium
• Blood coagulation Selenium
• Neuromuscular irritability Potassium Fluoride
• Acid-base equilibrium Chloride
• Fluid & osmotic balance Sulfur
INTRODUCTION
Fat soluble secosteriods.
Vitamin D2 - ergosterol – in plants PROVITAMINS
Vitamin D3 – 7-dehydrocholesterol – in animals
Sunshine vitamin.
Daily requirement - 200 IU or 5 µg
400 IU or 10 µg
SYNTHESIS
• Cholecalciferol is hydroxylated at 25th
position to 25-hydroxycholecalciferol by
specific 25-hydroxylase present in liver.
• Kidney possesses a specific enzyme, 25-
hydroxycholecalciferol 1-hydroxylase at
position 1 to produce 1,25-DHCC.
REGULATION
i. Plasma phosphorus level
ii. Plasma calcium level
BIOCHEMICAL FUNCTIONS
1. Action of calcitriol on the intestine :
• Calcitriol cytosolic receptor calcitriol
receptor complex.
• Increased formation of Calbindin, a calcium binding protein.
• This protein increases the calcium uptake by the intestine.
2. Action of calcitriol on the bone :
• Promotes mineralization of epiphyseal cartilage & osteoid matrix.
• Stimulates synthesis of osteocalcin and activity of alkaline phosphatase.
• Along with PTH, increases mobilization.
3. Action of calcitriol on the kidney :
• Stimulates reabsorption of Calcium & Phosphorus
at Distal renal tubular level.
• Calcitriol is also minimizes the excretion of
calcium and phosphate.
DENTAL IMPLICATIONS
Vitamin D deficiency: • hypoplasia of enamel
• atrophy of salivary glands
• facilitates development of dental caries
• compromise osseous healing
• increased gingival inflammation
• tooth loss
• Will not produce cathecidin
CALCIUM
Adult human contains 1.0 – 1.5kg.
99% - bones & teeth
Normal plasma level: 9.0 – 11.0mg/100ml.
Ionized (50%)
Plasma calcium exists: Protein Bound (40%)
Complexed (5 – 10%)
PHOSPHATE
In human body Phosphorus is present as phosphates
Adult body contains: 0.7 – 1.0kg.
80-85% in bones and teeth.
Normal plasma level – 4.5 – 6.0mg/100ml infants.
3.0 – 4.0mg/100ml adults.
free inorganic (40%)
Plasma phosphate exist: phosphate complexed (50%)
protein bound (10%)
ROLE OF CALCIUM IN BODY
Blood coagulation.
Action on heart.
Secretory activity of glands.
Release of certain hormones like
insulin, vasopressin, PTH.
ROLE OF PHOSPHATE
Key constituent of bone and teeth.
Regulates blood pH.
Forms phospholipids, phosphoproteins & nucleic
acid.
Formation and utilization of high energy phosphate
compounds.
Phosphorylation.
SOURCES OF CALCIUM
Best source:
Hard cheese Fair source:
Milk String beans
Dark green Eggs
leafy Bread
vegetables
RDA OF CALCIUM:
Good source: Average adult - 800 mg/ day Infants:
Broccoli <1yr - 360-540mg
Baked beans
1-10yr - 800mg
Dried legumes
11-18yr -1200mg
Dried figs
During pregnancy & lactation-1200mg/
day
SOURCES OF PHOSPHATE
Rich source Moderate sources
Milk Cereals
Fish Pulses
Poultry Nuts
Eggs Legumes
Meat
RDA OF PHOSPHATES
Adults-800-1200mg/day
Infants-240mg/day
During pregnancy & lactation-1200mg/
day
CALCIUM & PHOSPHATE ABSORPTION
AND EXCREATION
• Calcium is absorbed from the small intestine.
• About 70% - 90% of daily intake of calcium is excreted.
• Phosphate is absorbed mainly from jejunum.
• Influenced by Vit D, Ratio of Ca:P & PTH.
• Almost 2/3rd of the total phosphate is excreted in the urine.
FACTORS AFFECTING CALCIUM ABSORPTION
FACTORS INCREASING FACTORS DECREASING ABSORPTION
ABSORPTION
• Calcitriol (D3) • Oxalates & phytates – form Ca salts
• PTH • High dietary fibers
• Acidity (Low PH) • Excess Phosphates & Magnesium
• Protein rich diet • Diet rich in fats – Ca soaps
• Growth Hormone • Chronic renal failure
• Pregnancy, Lactation • Glucocorticoids
• Milk sugar (Lactose)
REGULATION OF
PLASMA CALCIUM
LEVELS
1. In case of hypocalcemia:
• Activates 25-hydroxy-
cholecaliferol 1-hydroxylase.
• Mobilization of Ca and P.
• Renal tubular reabsorption.
2. In case of
hypercalcemia:
• Thyroid Para-
follicular cells (C -
cells)
REGULATION OF PLASMA PHOSPHATE LEVEL
APPLIED ASPECT
OSTEOPOROSIS
• WHO defines osteoporosis as a bone density that
falls 2.5 standard deviations (SD) below the mean
for young healthy adults of the same sex— also
referred to as a T-score of –2.5.
• Male to female ratio 1:4.
• More common in post menopausal women.
ETIOLOGY:
CLINICAL ORAL MANIFESTATIONS:
MANIFESTATIONS:
1. Fracture after minor trauma may be
first indication.
2. Stiffness, Weakness.
3. Back pain: Episodic, acute , low
thoracic/high lumbar pain.
4. Decrease in height
5. Kyphosis
6. Dowager’s hump
7. Early satiety
Dervis E. Oral implications of osteoporosis. Oral surgery, oral medicine, oral pathology,
oral radiology, and endodontology. 2005 Sep 1;100(3):349-56.
TREATMENT:
1. Physical therapy program of gentle exercise and activity.
2. Lifestyle modification.
3. Drug therapy to slow disease progress
4. Supportive devices
5. Surgery
RICKETS
• Characterized by bone deformities due to incomplete
or under-mineralization of bones.
• In rickets, the plasma level of calcitriol is decreased
and alkaline phosphatase activity is elevated.
Rickets during the time of tooth formation is the
most common cause of enamel hypoplasia.
Shelling & Anderson - in rachitic children: 43% of
teeth showed hypoplasia.
CLINICAL FEATURES
ORAL MANIFESTATIONS:
• Enamel hypoplasia of primary teeth.
• Tooth loss at a young age.
• Recurrent abscesses.
• Delayed eruption and development.
OSTEOMALACIA
Demineralization of preformed
bones.
Women with multiple
pregnancies, lactating mothers.
Minimal exposure to sunlight. Clinical features:
Increased alkaline phosphatase • Bone pain and tenderness
& PTH. • Peculiar waddling or
“penguin”gait
• Tetany
• Greenstick bone fractures
• Myopathy
Oral manifestation:
• Delayed enamel & dentin
formation
• Thin or absent trabeculae
• Loosened teeth
• Weakened jaw bones
RENAL RICKETS
Chronic renal failure
Calcidiol not converted to calcitriol in kidney.
Leads to hypocalcemia stimulates PTH bone resorption
Hypocalcemia & hyperphosphatemia.
Administration of oral or IV 1, 25-DHCC.
HYPERVITAMINOSIS D
Early symptoms include nausea, vomiting, anorexia, thirst, diarrhoea,
stupor.
Marked increase in plasma calcium level.
Causes calcification of soft tissues & organs.
Renal stones of calcium oxalate & renal failure.
Generalised osteoporosis.
HYPOCALCEMIA TETANY
• Plasma Ca2+ <7.5 mg/100ml.
• For each gram decrease of albumin from normal
(i.e., 4.0 mg/100ml), [Ca2+] decreases by 0.8
mg/100ml.
CAUSES OF HYPOCALCEMIA
• Hypoparathyroidism
• Vitamin D deficiency
• Chronic liver disease and renal
failure
• Medullary carcinoma of thyroid
• Rickets, osteomalacia, osteoporosis
CLINICAL FEATURES: ORAL MANIFESTATIONS:
1. Delayed eruption
2. Root dilacerations
3. Microdontia
4. Dental caries
TREATMENT:
Calcium gluconate contains 90 mg of elemental calcium per 10
mL ampule, and usually 1 to 2 ampules (180 mg of elemental
calcium) diluted in 50 to 100 mL of 5% dextrose is infused over
10 minutes.
Oral calcium and vitamin D or an activated vitamin D metabolite
such as calcitriol
HYPOPHOSPHATASIA:
<2mg/100ml in rickets.
Def. of enzyme alkaline phosphatase.
C/F:
Childhood Adult
Infantile form Severe Spontaneous fracture
Loss of primary teeth
rickets Bone
Increased infection Growth
abnormalities Failure
retardation Rachitic like
to thrive
deformation, lung., renal, GI
disorders
Oral manifestations:
Premature loss of primary teeth
Gingivitis
Radiographic features:
Hypocalcification Large
pulp chambers Alveolar
bone loss
HYPERCALCEMIA
• serum Ca2+ >12 mg/100ml in an individual with normal
serum albumin concentration.
CAUSES : Increased absorption
Vitamin D excess
Elevated PTH
Increased bone resorption
Decreased urinary excretion
Paget’s disease and multiple myeloma
CLINICAL FEATURES:
MANAGEMENT OF HYPERCALCEMIA
HYPERPHOSPHATEMIA
• serum phosphorous is >4.5mg/100ml.
• Increased serum P & decreased PTH
EFFECTS OF
HYPERPHOSPHATAEMIA
CAUSES:
Hypoparathyroidism 1. Rhabdomyolysis
Renal failure 2. Cardiamyopathy
Diabetes mellitus 3. Respiratory insufficiency
Acromegaly 4. Erythrocyte dysfunction
5. Nervous dysfunction
6. Skeletal dysfunction
7. Metabolic acidosis.
PERIODONTAL DISEASE DUE TO DIETARY CALCIUM
DEFICIENCY AND/ OR DIETARY PHOSPHOROUS
Henrickson suggested:
High incidence of periodontal disease in natives of India-attributed in part to their
low dietary calcium & phosphate intake.
Labile for Resorption- Alveolar bone
Vertebrae
Ribs
Long bones
Nutrition and Immunology: Principles and Practice edited by M. Eric Gershwin, J. Bruce German, Carl L. Keen
CONCLUSION
• Vitamines are organic components while minerals are inorganic components that
are required in our diet for growth and maintenance of good health.
• Vitamin D regulates the plasma calcium and plasma phosphate levels.
• These elements are interconnected with each other, hence, deficiency of any one
would lead to imbalance in body.
• Vitamin D is considered a calciotropic hormone while cholecalciferol is a
prohormone.
• Calcium & phosphate are key elements required in the metabolism of bone
and bone health.
• Deficiency would lead to osteoporosis, rickets, osteomalacia.
• People with lower vitamin D levels had more attachment loss.
• Pregnant women with PD had lower vitamin D levels and were twice as
likely to have vitamin D insufficiency
REFERENCES
1. Guyton’s Textbook of Medical Physiology; 8th edition.
2. Biochemistry by Dr. U Satyanarayana 3rd edition.
3. Textbook of biochemistry with biochemical significance by Prem Prakash
Gupta.
4. Ferguson, John H. (1936). THE BLOOD CALCIUM AND THE CALCIUM
FACTOR IN BLOOD COAGULATION. Physiological Reviews, 16(4), 640–
670.
5. Bolat M, Chiriac MI, Trandafir L, Ciubara A, Diaconescu S. Oral
manifestations of nuritional diseases in children. Romanian Journal of Oral
Rehabilitation. 2016 Apr 1;8(2):56-60.
6. Mizumoto T. Effects of the calcium ion on the wound healing process.
[Hokkaido igaku zasshi] The Hokkaido journal of medical science. 1987
Mar;62(2):332.
