CHAPTER 8 MINERALS ESSENTIAL FOR CALCIFIED STRUCTURES Copyright © 2010, 2005, 1998 by Saunders, an...

CHAPTER 8CHAPTER 8

MINERALS ESSENTIAL MINERALS ESSENTIAL FOR CALCIFIED STRUCTURESFOR CALCIFIED STRUCTURES

Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 22

Bone Mineralization and GrowthBone Mineralization and GrowthCalcified structures include bones and Calcified structures include bones and

teethteethCollagen and bone undergo constant Collagen and bone undergo constant

remodelingremodelingOrganic matrix of bone is 90%–95% collagen Organic matrix of bone is 90%–95% collagen

fibersfibers Formation of collagen requires protein,Formation of collagen requires protein,

vitamin C, iron, copper, and zinc vitamin C, iron, copper, and zinc Once collagen is formed, mineralization beginsOnce collagen is formed, mineralization begins

Calcium, phosphorus, magnesium, sodium, potassium, Calcium, phosphorus, magnesium, sodium, potassium, and carbonate ions form mineral matrixand carbonate ions form mineral matrix

Calcium reserve: 0.4%–10% of total bone Calcium reserve: 0.4%–10% of total bone calcium in shapeless (calcium in shapeless (amorphous)amorphous) form form

From Bath-Balogh M, Fehrenbach MJ: From Bath-Balogh M, Fehrenbach MJ: Illustrated Dental Embryology, Histology, Illustrated Dental Embryology, Histology, and Anatomy, ed 2. St. Louis: Saunders, and Anatomy, ed 2. St. Louis: Saunders,

2006.2006.


Formation of TeethFormation of TeethCrystalline structure of enamel is Crystalline structure of enamel is

one of the most insoluble and one of the most insoluble and resistant proteins knownresistant proteins knownComparable to hardness of quartzComparable to hardness of quartz

Dentin contains the same Dentin contains the same constituents as bone, but its constituents as bone, but its structure is more densestructure is more dense

Cementum is another bone-like Cementum is another bone-like substance, but because contains substance, but because contains fewer minerals, is softer than bonefewer minerals, is softer than bone

From Nanci A: Ten Cate’s Oral Histology, ed From Nanci A: Ten Cate’s Oral Histology, ed 7. St. Louis: Mosby, 2008. 7. St. Louis: Mosby, 2008.


Introduction to MineralsIntroduction to MineralsMinerals are inorganic elements that have many Minerals are inorganic elements that have many

physiological functionsphysiological functionsInorganic elements in body account for only Inorganic elements in body account for only

about 4% of total body weight, or 6 lb for a 150-lb about 4% of total body weight, or 6 lb for a 150-lb personperson

Minerals subdivided into two categoriesMinerals subdivided into two categoriesThose required in larger amounts (major minerals)Those required in larger amounts (major minerals)Those required in smaller amounts (micronutrients or Those required in smaller amounts (micronutrients or

trace elements) trace elements)


Physiological Roles: CalciumPhysiological Roles: CalciumMost abundant mineral in theMost abundant mineral in the

body (~1200 g)body (~1200 g)99% in teeth and bones99% in teeth and bonesFunctionsFunctions

Bone healthBone healthBlood clottingBlood clottingTransmit nerve impulsesTransmit nerve impulsesMuscle contraction and relaxationMuscle contraction and relaxationMembrane permeabilityMembrane permeabilityActivate certain enzymesActivate certain enzymesSalivary calcium acts as bufferSalivary calcium acts as buffer

From Fehrenbach MJ, Herring SW: Illustrated Anatomy of the From Fehrenbach MJ, Herring SW: Illustrated Anatomy of the Head and Neck, ed 3. St. Louis: Saunders, 2007.Head and Neck, ed 3. St. Louis: Saunders, 2007.


RequirementsRequirements: Calcium: Calcium

AIAI9–13 yo boys and girls9–13 yo boys and girls

1300 mg/day1300 mg/day

19–50 yo men and women19–50 yo men and women 1000 mg/day1000 mg/day

51–70+ yo men and women51–70+ yo men and women 1200 mg/day1200 mg/day

Only 1 in 4 Americans meets AIOnly 1 in 4 Americans meets AI

for calciumfor calcium


Requirements: CalciumRequirements: CalciumCurrent levels of intakeCurrent levels of intake

Males ages 9 and older Males ages 9 and older Average intake ~925 mg/day (71% of AI)Average intake ~925 mg/day (71% of AI)

Females ages 9 and olderFemales ages 9 and older Average intake ~657 mg/day (51% of AI)Average intake ~657 mg/day (51% of AI)

AI for those with self-diagnosed lactose intolerance AI for those with self-diagnosed lactose intolerance ~320 mg/day (25% of AI)~320 mg/day (25% of AI) At high risk of inadequate intakes to buildAt high risk of inadequate intakes to build

peak bone mass and prevent osteoporosispeak bone mass and prevent osteoporosis


Calcium-to-Phosphorus RatioCalcium-to-Phosphorus RatioSerum levels of calcium and phosphorus Serum levels of calcium and phosphorus

inversely relatedinversely relatedIf calcium level goes up, phosphorus level goes downIf calcium level goes up, phosphorus level goes down

Ideal calcium/phosphorus ratio for adults is 1:1Ideal calcium/phosphorus ratio for adults is 1:1Excessive intake of phosphorus compared with Excessive intake of phosphorus compared with

calcium reduces serum calcium concentrationcalcium reduces serum calcium concentration

Calcium requirements are increased when Calcium requirements are increased when dietary phosphate is high as in the typical dietary phosphate is high as in the typical American dietAmerican diet


Absorption: CalciumAbsorption: CalciumAbsorption regulated by hormones (parathyroid, Absorption regulated by hormones (parathyroid,

estrogen, glucocorticoids, thyroid) estrogen, glucocorticoids, thyroid) Best absorbed when consumed in smaller Best absorbed when consumed in smaller

amounts and ingested several timesamounts and ingested several times

during the dayduring the dayFactors decreasing absorption:Factors decreasing absorption:

Oxylates and phytates in grains,Oxylates and phytates in grains,

vegetablesvegetablesReduced gastric acidityReduced gastric acidityExcessive fiberExcessive fiberLow-protein, low-phosphorus dietsLow-protein, low-phosphorus diets

From Thibodeau GA, Patton KT: Anatomy & From Thibodeau GA, Patton KT: Anatomy & Physiology, ed 6. St. Louis: Mosby, 2007.Physiology, ed 6. St. Louis: Mosby, 2007.


Sources: CalciumSources: CalciumMilk and dairy productsMilk and dairy products

Preferred sources of calcium because of high calcium, Preferred sources of calcium because of high calcium, lactose, and other nutrient content that enhances lactose, and other nutrient content that enhances calcium absorptioncalcium absorption

Fortified soy and rice milkFortified soy and rice milkOther fortified foods (orange juice)Other fortified foods (orange juice)SupplementsSupplements

Limited bioavailabilityLimited bioavailabilityBetter absorbed when taken with foodBetter absorbed when taken with foodCalcium citrate malate, calcium lactate, calcium citrate, Calcium citrate malate, calcium lactate, calcium citrate,

and calcium sulfate have high absorption ratesand calcium sulfate have high absorption rates


Hyperstates: CalciumHyperstates: CalciumHypercalcemia-excess calcium levels in the bloodHypercalcemia-excess calcium levels in the blood

Caused by:Caused by: HyperparathryoidismHyperparathryoidism Overdoses of cholecalciferolOverdoses of cholecalciferol Vitamin D poisoningVitamin D poisoning

Excessive calcium intake results in:Excessive calcium intake results in:Dizziness, flushing, nausea/vomiting, severe Dizziness, flushing, nausea/vomiting, severe

constipation, kidney stone formation, irregular constipation, kidney stone formation, irregular heartbeat, tingling sensations, xerostomia, fatigue and heartbeat, tingling sensations, xerostomia, fatigue and high blood pressure high blood pressure

May inhibit iron and zinc absorptionMay inhibit iron and zinc absorption


Hypostates: CalciumHypostates: Calcium

RicketsRicketsAbnormal ossification fromAbnormal ossification from

vitamin D, calcium deficiencyvitamin D, calcium deficiencyOsteoporosisOsteoporosis

““Osteoporosis is a disease of adolescence”Osteoporosis is a disease of adolescence” 90% of peak bone mass is attained by age 16.9 90% of peak bone mass is attained by age 16.9 ++ 1.3 yr and 1.3 yr and

99% by age 26.2 99% by age 26.2 ++ 3.7 yr 3.7 yr BMD associated with fractures in elder years, but also may BMD associated with fractures in elder years, but also may

predict fractures in childrenpredict fractures in children Inadequate calcium intake in early life accounts for as much as Inadequate calcium intake in early life accounts for as much as

50% of difference in hip fracture rates in postmenopausal years50% of difference in hip fracture rates in postmenopausal years

From Kumar V, Abbas AK, Fausto N: Robbins and From Kumar V, Abbas AK, Fausto N: Robbins and Cotran Pathologic Basis of Disease, ed 7. Cotran Pathologic Basis of Disease, ed 7.

Philadelphia: Saunders, 2005.Philadelphia: Saunders, 2005.


Hypostates: CalciumHypostates: CalciumReduction in total skeletal mass is directly related to Reduction in total skeletal mass is directly related to

reduction in mandibular bone density in women with reduction in mandibular bone density in women with osteoporosis osteoporosis

Postmenopausal women who lost teeth also lost bone Postmenopausal women who lost teeth also lost bone mineral of the whole body and femoral neck at greater mineral of the whole body and femoral neck at greater rates than those who retained their teethrates than those who retained their teeth Systemic bone loss appears to be a predictor of tooth loss in Systemic bone loss appears to be a predictor of tooth loss in

dentate postmenopausal womendentate postmenopausal womenInadequate calcium intake and periodontal diseaseInadequate calcium intake and periodontal disease

Study of NHANES data suggests a 56% Study of NHANES data suggests a 56% risk of periodontal risk of periodontal disease with calcium intakes disease with calcium intakes 500 mg/day 500 mg/day

27% greater risk for those women consuming from 500 to 27% greater risk for those women consuming from 500 to 800 mg/day of calcium800 mg/day of calcium


Physiological Roles:Physiological Roles:PhosphorusPhosphorus

Phosphorus: second most abundant mineral in Phosphorus: second most abundant mineral in the body; about 85% in the skeleton and teeth the body; about 85% in the skeleton and teeth

FunctionsFunctionsFormation of bones and teethFormation of bones and teethMuscle contraction and nerve activityMuscle contraction and nerve activityComponent of phospholipids in cell membranes, DNA, Component of phospholipids in cell membranes, DNA,

and RNAand RNAEnergy metabolism (ADP)Energy metabolism (ADP)Buffer for the bodyBuffer for the body


Requirement and Source:Requirement and Source:PhosphorusPhosphorus

RDARDAMen and women: 700 mg/dayMen and women: 700 mg/day

SourcesSourcesAbundant in foods—deficiency rareAbundant in foods—deficiency rareBest sources are milk products and meatsBest sources are milk products and meatsFood additive in baked goods, cheese, processed Food additive in baked goods, cheese, processed

meats, and soft drinksmeats, and soft drinks


Hyperstates: PhosphorusHyperstates: Phosphorus

Hyperphosphatemia Hyperphosphatemia (serum level above 2.6 (serum level above 2.6 mg/dl) may occur in:mg/dl) may occur in: HypoparathyroidismHypoparathyroidismRenal insufficiencyRenal insufficiency

Excessive amounts of Excessive amounts of phosphorus bind with phosphorus bind with calcium, resulting in calcium, resulting in tetany and convulsionstetany and convulsions

From Thibodeau GA, Patton KT: Anatomy & Physiology, ed 6. From Thibodeau GA, Patton KT: Anatomy & Physiology, ed 6. St. Louis: Mosby, 2007.St. Louis: Mosby, 2007.


Hypostates: PhosphorusHypostates: Phosphorus

Long-term ingestion of aluminum hydroxide Long-term ingestion of aluminum hydroxide antacidsantacids

Stress conditions in calcium-to-phosphorus balanceStress conditions in calcium-to-phosphorus balanceMalabsorption conditions (sprue and celiac disease)Malabsorption conditions (sprue and celiac disease)During tooth development, phosphorus deficiency During tooth development, phosphorus deficiency

results in: results in: Incomplete calcification of teethIncomplete calcification of teethFailure of dentin formationFailure of dentin formationIncreased susceptibility to cariesIncreased susceptibility to caries


Physiological Roles:Physiological Roles:MagnesiumMagnesium

Bones contain almost two thirds of body’s Bones contain almost two thirds of body’s magnesium magnesium Role in bone and mineral physiologyRole in bone and mineral physiologyCofactor for more than 300 enzymesCofactor for more than 300 enzymesNecessary for DNA and RNA synthesisNecessary for DNA and RNA synthesisRegulates transmission of nerve impulses and Regulates transmission of nerve impulses and

muscle contractionmuscle contractionAssociated with vitamin D conversion in the liverAssociated with vitamin D conversion in the liverFacilitates blood clottingFacilitates blood clottingFacilitates PTH secretionFacilitates PTH secretion


Requirements and Sources:Requirements and Sources:MagnesiumMagnesium

RDA (19-30 yr)RDA (19-30 yr)Men: 400 mg/dayMen: 400 mg/dayWomen: 310 mg/dayWomen: 310 mg/day

ULUL350 mg/day from nonfood sources350 mg/day from nonfood sources

SourcesSourcesDark green, leafy vegetablesDark green, leafy vegetablesWhole grains and nutsWhole grains and nutsChocolateChocolate


Hypostates: MagnesiumHypostates: Magnesium

Deficiency rare in healthy peopleDeficiency rare in healthy peopleCan occur w/prolonged vomiting, Can occur w/prolonged vomiting,

malabsorption, kidney disease, intestinal malabsorption, kidney disease, intestinal surgery, excessive use of OTC and surgery, excessive use of OTC and medications (corticosteroids, diuretics)medications (corticosteroids, diuretics)

Present in nearly all chronic alcoholicsPresent in nearly all chronic alcoholicsSymptoms of deficiency:Symptoms of deficiency:

Fragility of alveolar bone and gingival hypertrophyFragility of alveolar bone and gingival hypertrophyCardiac dysrhythmiasCardiac dysrhythmiasNeuromuscular hyperexcitabilityNeuromuscular hyperexcitability


Hyperstates: MagnesiumHyperstates: Magnesium

No evidence of overconsumption of magnesium No evidence of overconsumption of magnesium from food sourcesfrom food sources

Kidney regulates magnesium and toxicity may Kidney regulates magnesium and toxicity may cause kidney failurecause kidney failure

Symptoms: Symptoms: DiarrheaDiarrheaNauseaNauseaCrampingCramping


Nutrition Directions: MagnesiumNutrition Directions: Magnesium

Evidence suggests that magnesium may play Evidence suggests that magnesium may play an important role in regulating blood pressurean important role in regulating blood pressureThe DASH study (Dietary Approaches to Stop The DASH study (Dietary Approaches to Stop

Hypertension) suggests HBP can be lowered by Hypertension) suggests HBP can be lowered by diet high in magnesium, potassium, and calcium, diet high in magnesium, potassium, and calcium, and low in sodium and fatand low in sodium and fat

The diet includes whole grains, fruits, vegetables The diet includes whole grains, fruits, vegetables and low-fat dairyand low-fat dairy

http://dashdiet.orghttp://dashdiet.org


Overview: FluorideOverview: Fluoride

In a strict nutritional sense, fluoride is not a In a strict nutritional sense, fluoride is not a nutrient essential for health because it has no nutrient essential for health because it has no known metabolic functionknown metabolic function

However, because of benefits to dental and However, because of benefits to dental and bone health, fluoride is considered a desirable bone health, fluoride is considered a desirable element for humanselement for humans

Fluoride ions can replace hydroxyl ions in the Fluoride ions can replace hydroxyl ions in the hydroxyapatite crystal lattice, making it more hydroxyapatite crystal lattice, making it more resistant to cariesresistant to caries


Physiological Roles: FluoridePhysiological Roles: FluorideForms fluorapatite, which is more caries resistantForms fluorapatite, which is more caries resistantSystemic fluoride results in changes to tooth Systemic fluoride results in changes to tooth

morphology; increases tooth’s resistance to morphology; increases tooth’s resistance to adherence of plaque biofilmadherence of plaque biofilm

Fluoride in saliva also interferes with demineralization Fluoride in saliva also interferes with demineralization Higher concentrations of fluorideHigher concentrations of fluoride

inhibit inhibit Streptococcus mutansStreptococcus mutans, , Streptococcus sobrinusStreptococcus sobrinus,, and and Lactobacillus Lactobacillus speciesspecies

Stimulates osteoblast proliferation and increases new Stimulates osteoblast proliferation and increases new mineral deposition in cancellous bonemineral deposition in cancellous bone

From Bird DL, Robinson DS: Torres and From Bird DL, Robinson DS: Torres and Ehrlich Modern Dental Assisting, ed 9. St. Ehrlich Modern Dental Assisting, ed 9. St.

Louis: Saunders, 2009.Louis: Saunders, 2009.


Requirements: FluorideRequirements: Fluoride

Absorption occurs in the stomachAbsorption occurs in the stomachAIAI

6–12 mo: 0.5 mg/day6–12 mo: 0.5 mg/day1–3 yr: 0.7 mg/day1–3 yr: 0.7 mg/day2–8 yr: 1.1 mg/day2–8 yr: 1.1 mg/day9–13 yr: 2.0 mg/day9–13 yr: 2.0 mg/day14–18 yr: 2.9–3.2 mg/day14–18 yr: 2.9–3.2 mg/day19+ yr: 3.1–3.8 mg/day19+ yr: 3.1–3.8 mg/day


Requirements: FluorideRequirements: Fluoride

ULUL6–12 mo: 0.9 mg/day6–12 mo: 0.9 mg/day1–3 yr: 1.3 mg/day1–3 yr: 1.3 mg/day4–8 yr: 2.2 mg/day4–8 yr: 2.2 mg/day9+ yr: 10 mg/day9+ yr: 10 mg/day

SourcesSourcesFluoridated waterFluoridated waterBrewed teaBrewed teaOcean fish w/bones (salmon, herring, sardines)Ocean fish w/bones (salmon, herring, sardines)


Hyperstates: FluorideHyperstates: FluorideDental Dental fluorosisfluorosis (hypomineralization (hypomineralization

of enamel) directly related to fluoride of enamel) directly related to fluoride exposure during tooth development exposure during tooth development Varies from white flecks, to white or Varies from white flecks, to white or

brown staining, to brownish discoloration brown staining, to brownish discoloration and varying degrees of enamel pittingand varying degrees of enamel pitting

Ingestion of large amounts of fluoride Ingestion of large amounts of fluoride in adults can result in adverse effects in adults can result in adverse effects on skeletal tissue and kidney function on skeletal tissue and kidney function

Courtesy Alton McWhorter, DDS, MS; Courtesy Alton McWhorter, DDS, MS; Associate Professor Pediatric Dentistry; Associate Professor Pediatric Dentistry;

The Texas A&M University System; The Texas A&M University System; Baylor College of Dentistry; Dallas.Baylor College of Dentistry; Dallas.


Nutritional DirectionsNutritional DirectionsEncourage use of fluoridated water for those >6 Encourage use of fluoridated water for those >6

months of age and topical fluorides for adults months of age and topical fluorides for adults and childrenand children

Encourage low-fat dairy, whole grains, and Encourage low-fat dairy, whole grains, and vegetables as calcium and magnesium sourcesvegetables as calcium and magnesium sources

Evaluate use of supplements and refer to a Evaluate use of supplements and refer to a medical provider and/or registered dietitian as medical provider and/or registered dietitian as neededneeded

Stress need to minimize use of antacids and Stress need to minimize use of antacids and seek medical care for chronic heartburnseek medical care for chronic heartburn

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