calcium metabolism in orthodontics

1. Presented by
Dr. Amit Kumar

2. Calcium metabolism
Contents
Introduction
Importance and distribution in body
Daily requirement
Sources
Absorption and excretion
Concept of homeostasis
Applied anatomy
References

3. Calcium metabolism
MINERAL ELEMENTS Minerals elements are present in
animal body supplied by the diet. Minerals elements can be
classified as
1. Principal elements or Macronutrients There are total
seven essential elements- calcium , magnesium, sodium,
potassium, phosphorus, sulphur and chlorine.
2. Trace elements Essential trace elements are Iron, iodine,
copper, nickel, tin, silicon aluminum, zinc, manganese,
lead, mercury and Cobalt etc.

4. Calcium metabolism
Calcium, combined with phosphate forms hydroxyapatite
the mineral portion of human bones and teeth.
Remodeling is a coupled sequence of catabolic and anabolic
events to support calcium homeostasis and repair damaged
mineralized tissues.(Harold frost)
Cortical bone remodeling occurs by cutting and filling cones
also referred as BONE MULTICELLULAR UNIT

5. Calcium metabolism
Bone modeling
1- surface specific change in
shape and size
2-occurs during growth
decrease after maturity
3-functional process
4-in OTM both modeling and
remodeling occurs
5-resorption and deposition are
not coupled
Bone remodeling
1-Stochastic –remodels
uniformly throughout the
body
•Provides metabolic calcium
And decrease calcium is
increased by cutting and
filling cone process
2-Targated bone remodeling
occurs at specific types of
injury (bone implant
interface)

6. Modeling and remodeling

7. The A-R-F SEQUENCE(151 days)

8. The overall concept of bone adaptation associated with
drift of a long bone is quite similar to alveolar process
adaptation during OTM

9. Enamel, dentin and acellular cementum are unique
structure and does not shows remodeling.
Cellular cementum has the adaptation and repair tissue
that helps maintain dental functions over a lifetime
Dr.Reiten’s studies of human teeth demonstrated that
root resorption lesions are similar to the resorptive phase
of the remodeling cycle in trabecular bone
Orthodontically induced root resorption will
subsequently repair with cellular cementum following
the A-R-F SEQUENCE

10. Reitan also said that interrupted force tends to results in
less root resorption because resorption cavities tends to
repair with cellular cementum in 5-8 weeks
Kimura and coworker concluded that “odontoclast”of
root resorption have an intravascular origin similar to
the osteoclast of bone remodeling
Therefore it appears that root resorption is a “portion of
turnover process” to replace the damaged root structure

11. Complete understanding of the general metabolism
of calcium helps in the formation and maintenance
of the teeth and their supporting bony structure.
CALCIUM METABOLISM :- Orthodontist and
Dentofacial orthopedists manipulate bone. The
biomechanical response to altered function and applied
loads depends on the metabolic status of the patients and
favorable calcium and phosphorus metabolism is an
important consideration in treatment .

12. ✓ Approximately 99% of the total body weight of
calcium is present in the skeleton.
✓The remaining 1% is found in the cell
membranes and extracellular fluid.
✓It is this small percentage of calcium that is vital
to all life processes.

13. TYPES OF CALCIUM : in plasma
Ionized or diffusible calcium – :- (free ionized) Is found
freely in plasma. essential for regulate vital function
like neuronal activity, muscle contractions, cardiac
activity and blood coagulation
Complex ionized (calcium oxalate)
Nondiffusible - complex of calcium and albumins ( not
a part of cellular process)

14. 1.Contributes to hardness of bone and is a major
component ofteeth.
2. Stabilises the cell membrane and their permeability.
3. Maintenance of excitability of nerve and muscles.
4. Normal skeletal and cardiac muscle contraction.
5. Blood coagulation – Ca++ is required for the
conversion of many inactive enzymes in the
coagulation process.

15. Infants (< 1year) = 300-500 mg/day
Children (1– 18years) = 0.8-1.2 g/day
Adult men and women = 800 mg/day
Pregnancy and lactation= 1.0-2gm/day

16. Milk is a good source for calcium. Calcium content of cow
milk is about 100mg/100ml.
Egg, fish &vegetables are medium source for calcium.
Cereals (wheat, rice) contains small amount of calcium.
But cereals are the staple diet in India. Therefore, cereals
form the major source of calcium in Indian diet.

17. Several different kinds of calcium compounds are used
in calcium supplements. Each compound contains
varying amounts of the mineral calcium.
Common calcium supplements may be labeled as:
Calcium carbonate - Tums®and Caltrate®
Calcium citrate- Citracal® and Solgar®

18. If the calcium in diet and from supplements exceeds
the tolerable upper limit, could increase the risk of
health problems, suchas:
➢ Kidney stones
➢ Prostate cancer
➢ Constipation
➢ Calcium buildup in bloodvessels
➢ Impaired absorption of iron andzinc

19. Calcium absorption in small intestine occurs by both
active &passivediffusion.
➢ Uptake of calcium by active transport predominates in:
duodenum jejunum;
➢ Simple diffusion predominatesin: ileum
Most of the ingested calcium is normally eliminated in the
feces, although the kidneys have the capacity to excrete
large amounts by reducing tubular reabsorption of calcium

20. VitaminD –Calcitriol induces the synthesis of the carrier
protein
(Calbindin) in the intestinal epithelial cells &so
facilitates the absorption of calcium.
Parathyroid hormones(catabolic effect)
increases calcium transport from the intestinal
cells.
Amino acids, especially lysine &arginine increase
absorption.
Lactose : enhance passive Ca uptake; its effect is valuable
because of it presence inmilk.

21. Phytates — Phytates are substances found in some plant
foods that can bind calcium in the intestine and decrease its
absorption.
Oxalates are present in some leafy vegetables which cause
formation of insoluble calcium oxalates.
In malabsorption syndromes , fatty acid is not absorbed ,
causing formation of insoluble calcium salt of fatty acid .
Absorption is also decreased with increase intake of
protein & fiber in diet.

22. This term is used to describe the amount of Ca++
either stored or lost by the body over a specific period
of time.
When the assimilation of calcium from dietary sources
is less than the metabolic requirements and the
obligatory losses , then calcium is withdrawn from the
skeleton to maintain the critical concentration of the
element in the blood and tissue fluids.

23. Calcium homeostasis is the mechanism by
which the body maintains adequate calcium
levels.
Positive Ca2+ balance
Is seen in growing children, where intestinal
Ca2+ absorption exceeds urinary excretion
and the difference is deposited in the
growing bones.

24. Negative Ca2+ balance
Is seen in women during pregnancy or
lactation,
where intestinal Ca2+ absorption is less than
urinary excretion and the difference comes from
the maternal bones.

25. The primary source of available calcium is trabecular
bone, not corticalbone.
The sites of trabecular bone which supply mobile
calcium are the jaws, ribs, bodies of the vertebrae, and
the ends of the long bones.

26. A significant finding from animal experimentation is
that, when skeletal depletion of calcium occurs as a
result of stimulation of the parathyroid gland, alveolar
bone is affected first, the ribs and the vertebrae are
affected second, and the long bones third.
Prolonged depletion results in disorganization and
loss of trabeculae, followed by cortical remodeling or
structural failure.

27. Acomplex set of interlocking mechanisms takes place
in order to allow man to survive major dietary Ca
intake fluctuations. These mechanisms are mainly
controlled by the endocrine systems.
Three main hormones acting at 3 different sites are
responsible for Ca2+metabolism.
1.Vit. D3 - Bone.
2. Parathormone - Kidney
3. Calcitonin - Intestine

29. Physiologically active form of vitamin D is a hormone
called calcitriol or 1,25– dihydroxycholecalciferol
(1,25 – DHCC).
It stimulates Ca uptake thus increasing the blood
calcium levels.

31. The prime function is to elevate the serum calcium
levels.
Action on kidney – increases Ca reabsorption by
kidney tubules.
Action on bone – decalcification or demineralization
of bone – increase bloodCa levels.

32. Promotes calcification by increasing activity of
osteoblasts.
Decreases bone resorption.
Increases excretion of Ca in urine.
Thus, has a decreasing influence on blood Ca.

33. Estrogen is a hormone that plays an important role in
helping increase calciumabsorption.
After menopause, estrogen levels drop and so
decreases calcium absorption.
Hormone replacement therapy has been shown to
increase the production of vitamin D thus increasing
calcium absorption.

35. Mechanism of coordination of
osteoblastic and clastic activity

36. Effect of parathyroid on the bone and
bone cells

37. Metabolic control
The balance of bone resorption and formation at any
point in time controls the net balance of ionic calcium
released into the extracellular fluid

38. Hypercalcemia - Increased level of Ca in the blood.
Symptoms
- Tiredeness
- Loss of appetite.
- Nausea, vomitting.
- Constipation.
Conditions in which it occurs
- Hyperparathyroidism.
- Acute osteoporosis.
- Vit. D intoxication.
- Thyrotoxicosis.
-Polyuria.
-Dehydration.
-Loss of muscle tone.
-Decreased excitability of
muscles and nerves.

39. Hypocalcemia - Decreased levels of Ca in the blood.
Below 8.8mg/dl mild tremors
Less than 7.5mg/dl tetany
Symptoms
- Tetany (Carpopedal spasm).
This occurs in cases of –
- Insufficient Ca in the diet.
- Hypoparathyroidism.
- Insufficient vit. D in the diet.
- Increase incalcitonin levels.

40. Osteoporosis is the most common of all bone diseases in adults,
especially in oldage.
It results from diminished organic bone matrix rather than from
poor bone calcification.
In osteoporosis the osteoblastic activity in the bone usually is
less than normal, and consequently the rate of bone
osteoid deposition is depressed.

41. Characterized by demineralization of bone resulting in
progressive loss of bone mass.
Elderly persons (>60 years) of both sexes are at risk.
More predominantly in postmenopausal women.
Etiology – ability to produce calcitriol from vitamin D
is reduced withage.
Results in frequent bone fractures – major cause of
disability.

42. The spine, hips, ribs, and wrists are common areas of
bone fractures from osteoporosis although
osteoporosis-related fractures can occur in almost any
skeletal bone.
Osteoporosis can be present without any
symptoms for decades because osteoporosis
doesn't cause symptoms until bone fractures.

43. Therefore, patients may not be aware of their
osteoporosis until they suffer a painful fracture.
The symptom associated with osteoporotic
fractures usually is pain; the location of the pain
depends on the location of the fracture.
Repeated spinal fractures can lead to chronic lower
back pain as well as loss of height and/or curving
of the spine due to collapse of the vertebrae.

44. Studies have shown that nutritional supplementation
can yield impressiveresults.
Albanese used a supplement of 750 mg of calcium per
day over a 3-year period and found that the
supplemented patients showed cessation of bone loss
or an increase of up to 12%in bone density when
compared to a test group showing continued bone
loss.

45. The current recommended dietary allowance (RDA) is
800 mg ofcalcium/day,
The most recent National Institutes of Health (NIH)
proposal calls for 1000 to 1500 mg of daily calcium.
The World Health Organization (WHO)
recommendation is only 400 to 500 mg of
calcium/day.
Calcium intake in most populations around the
world is 300 to 500 mg/day without any evidence
of osteoporosis.

46. Bone remodeling in orthodontics
OTM is a mechanically mediated inflammatory process.
The superimposition of a therapeutic load on function
induces the alveolar process to adapt in size, position
and architecture .
Catabolic modeling will leads to bone resorption in the
path of movement .
Anabolic modeling is the bone formation within the
widened PDL

47. Calcium metabolism and tooth
movement
Ronald j. midgett concluded in his study on beagle dogs that
decrease in calcium diet will leads to increase in parathyroid
hormone and subsequently will leads to increase in tooth
movement due to decreased bone density
Fan li and colleagues finds that short term parathyroid
hormone injections might be a potential method for
accelerating OTM by increasing the alveolar bone turn over
rate

48. Calcium metabolism and tooth
movement
Efstratios poumpros concluded in his study that thyroxin
administration seems to lower the frequency of root
resorption in maxillary incisors of rats.
So the administration of thyroxin can be considered in
patients with low thyroxin level
Mohsin shirazi finds the renal deficiency is associated with
elevated level of (PTH) which will enhance the bone
remodeling of the alveolar process and increase in OTM

49. Calcium metabolism and tooth
movement
Hellsing E. stated that the OTM will be enhanced in
preganancy

50. 1. W. Eugene Robetrs, Jaffery A
RobertsRemodeling of mineralized tissue par1;
The Frost legacy seminar in orthodontics vol 12
no4 December 2006
2. W. Eugene Robetrs, Jaffery A RobertsRemodeling
of mineralized tissue par11; Control and
pathophysiology seminar in orthodontics vol 12
no4 December 2006
3. Ronald j. midgett The effect of altered bone
metabolism on orthodontic tooth movement Am j.
orthodontics September 1981 vol 80

51. 4.Efstratios poumpros Thyroid function and root
resorption The Angle ortodontist vol. 64 1994
5. Mohsin shirazi the effect of chronic renal
insufficiency on orthodontic tooth movement angle
orthodontist vol71 no6,2001