Anda di halaman 1dari 24

Accepted Manuscript

Title: Human papillomavirus infection in oral potentially

malignant disorders and cancer

Authors: Xun Chen, Yu Zhao

PII: S0003-9969(17)30266-2
Reference: AOB 3974

To appear in: Archives of Oral Biology

Received date: 27-4-2017

Revised date: 21-8-2017
Accepted date: 21-8-2017

Please cite this article as: Chen Xun, Zhao Yu.Human papillomavirus infection
in oral potentially malignant disorders and cancer.Archives of Oral Biology

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
Human papillomavirus infection in oral potentially malignant disorders and


Running title: HPV and oral cancer

Xun Chen* and Yu Zhao*

Department of Prosthodontics, Guanghua School of Stomatology, Hospital of

Stomatology, Sun Yat-sen University; Guangdong Provincial Key Laboratory of

Stomatology, Guangzhou 510055, People's Republic of China.

*Corresponding authors.

Email: (X. Chen), (Y. Zhao)


 High prevalence of HPV was found in oral potentially malignant disorders and


 Association of HPV with oral potentially malignant lesions remains to be


 Further studies are proposed to investigate the significance of HPV in oral



Human papillomavirus (HPV) infects keratinocytes in the mucosa or skin, and

persistent infection with HPV may lead to premalignant lesions and invasive cancer,

especially cervical cancer. It has also been hypothesized that HPV infection is an

etiological factor of oral squamous cell carcinoma and oral precancerous disorders

such as lichen planus, leukoplakia, and erythroplakia. A high percentage of HPV in

oral lesions supports the possible viral contribution, but an association of HPV

infection with these lesions remains to be established. The current paper will update

the latest progress of HPV infection in several oral potentially malignant disorders

and oral squamous cell carcinoma and discuss the impact of HPV infection on the

progression of oral potentially malignant disorders.

Keywords: Human papillomavirus (HPV), oral potentially malignant disorders, oral

squamous cell carcinoma (OSCC), oral lichen planus, oral leukoplakia.

Human papillomavirus (HPV) is a kind of small circular DNA virus infecting

epithelial cells of the skin or mucosa. HPV infections are usually asymptomatic, but

infections in some people will cause benign papillomas and premalignant lesions that

will drive to cancers (Stanley et al., 2012). Over 170 types of HPV have been reported

(Ghittoni et al., 2015). Out of them, HPV 6 and 11 infections are believed to

develop genital warts. Sustained infection with high-risk HPV may develop

precancerous disorders and invasive cancer (zur Hausen, 2002). In fact, the majority

of cervical cancers are caused with high-risk HPV infection. Around 70% cervical

cancers are specially caused by HPV16 and 18 (Ghittoni et al., 2015).

The HPV genome consists of the early genes (E) and the late genes (L). The early

genes encode proteins E1 to E7 and the late genes encode viral capsid proteins L1 and

L2 (Rautava & Syrjanen, 2012). E6 and E7 are important viral oncoproteins

associated with cell malignant transformation. E6 directly binds to E6-associated

protein, an ubiquitin ligase, targeting p53 for degradation. E6 protein also binds to

several other cellular targets, leading to genomic instability (Rautava & Syrjanen,

2012). E7 binds to the retinoblastoma protein (pRb) and prevents the association of

pRb with transcription factor E2F (Sritippho et al., 2015). Consequent E2F activation

induces cell cycle progression and promotes transcription of the p16INK4A (p16)

gene. p16 is a cell-cycle inhibitor, binding to cyclin-dependent kinase 4

(CDK4)/CDK6 and preventing the phosphorylation and subsequent inactivation of

pRb (Kalof & Cooper, 2006). The expression of p16 was frequently down-regulated

during carcinogenesis (Leversha et al., 2003, Makitie et al., 2003). However, the HPV

E7 could bind to and inactivate pRb, which facilitates the production of p16 via a

negative feedback mechanism (Klaes et al., 2002). Thus, p16 is a surrogate marker of

high-risk HPV infection (Halloush et al., 2008).

Accumulating evidence demonstrates a pathogenic role of HPV in oral carcinoma and

a number of oral potentially malignant disorders including lichen planus, leukoplakia,

and erythroplakia (Dalla Torre et al., 2015, Gorsky & Epstein, 2011, Mattila et al.,

2012, Szarka et al., 2009). HPV infection has been proposed to be an etiological

factor of these diseases. The viruses may inactivate tumor suppressors and induce

abnormal cellular signaling pathway leading to disease development (Rampias et al.,

2010, Brand et al., 2016, Schiffman et al., 2016). A high percentage of HPV in oral

lesions supports the possible viral contribution as shown by immunohistochemistry

(OFlatharta et al., 2003, Campisi et al., 2004) and polymerase chain reaction (Pol et

al., 2015, Yildirim et al., 2011) or Southern blot hybridization (Table 1) (Khanna et al.,

2009, Ostwald et al., 2003). However, whether HPV infection is a coincident event or

an etiological factor of these diseases is still controversial (Marini et al., 2007). In this

article, based on the published literatures and data in the PubMed, we will summarize

the association of HPV infection with several oral potentially malignant disorders and

oral squamous cell carcinoma and discuss the effects of HPV infection on the

progression of oral potentially malignant disorders.

HPV and oral squamous cell carcinoma (OSCC)

An association of HPV infection with development of OSCC has been reported in

many researches several decades ago (Wang et al., 1998, Woods et al., 1993, Ostwald

et al., 1994). HPV DNA is detected in 24% (15/62) patients with OSCC, and 16%

(10/62) OSCC patients are positive for HPV 16 and 18 (Jalouli et al., 2010). The

higher prevalence of HPV infection in OSCC has been obtained in another two

studies. HPV DNA is detected in 43% of OSCC patients and HPV 16 and 18 DNAs

are present in 35% OSCC when HPV DNAs are investigated in 118 OSCC (Ostwald

et al., 2003). Mathew et al found that more than 70% of OSCC patients are infected

with HPV 16 (33/45) or HPV 18 (32/45) and 58% (26/45) patients have both HPV16

and HPV 18 infections (Mathew et al., 2011). Thus, HPV infection, particularly

high-risk HPV, is a potential risk factor of OSCC (Miller & Johnstone, 2001, Chen et

al., 2016). A systematic analysis of published data in PubMed and EMBASE before

2010 indicates a significant association between OSCC and HPV infection and even

HPV16 only (Syrjanen et al., 2011). In addition, 71% cases of OSCC (49/69) are

found to be positive for p16 (Prakash et al., 2013), a critical marker of high-risk HPV

infection (Halloush et al., 2008). But there is a study arguing that detection of p16

instead of HPV for OSCC is not a proper method. The data of p16 immunostaining do

not agree with results of HPV DNA detection (Gotz et al., 2016).

In a study with 21 verrucous carcinomas, high-risk HPV is detectable in 3 specimens

(14%) and each of them contains both HPV 16 and 18, but HPV is not significantly

associated with verrucous carcinoma (Saghravanian et al., 2011). This discrepancy is

likely due to sample size limitation. It also remains unclear whether this is relative to

tumor type because of the least invasive and metastatic potential of verrucous

carcinoma. Moreover, HPV DNA, either HPV type 16 or 18, is detectable from 20%

(9/45) normal oral mucosa in a previous study, although the prevalence in OSCC

increases to 65% (29/45) (Khanna et al., 2009).

HPV and oral lichen planus (OLP)

Oral lichen planus (OLP) is a chronic inflammatory lesion of oral mucosa. It is

believed that OLP has malignant potential and is caused by the dysfunction of cellular

immunity. However, HPV is detectable more often in OLP tissues than in normal oral

mucosa (Gorsky & Epstein, 2011). Several researches report a relatively high

frequency of HPV DNA or HPV-encoded proteins in OLP tissues. Over 15% OLP

lesions are HPV DNA positive in two studies (Mattila et al., 2012, Ostwald et al.,

2003). HPV DNA detection in OLP is a statistically significant correlation with DNA

content and ploidy markers, and HPV infection is associated with cell proliferation

index (Mattila et al., 2012). Moreover, 9-26% OLP lesions are positive for either HPV

16 or HPV 16 and 18, while none of the 20 normal control tissues shows HPV

positive, suggesting that high-risk HPV infection is significantly related to OLP

(Ostwald et al., 2003, OFlatharta et al., 2003). Since OLP can be classified as several

subgroups, a comprehensive study investigated HPV DNA in 71 OLP cases including

44 atrophic/erosive forms and 27 non-atrophic/erosive forms. Compared with 5.6%

detection rate in controls, nearly 20% OLP patients are infected with HPV, implying

that HPV infection is a risk factor of OLP. The detection rates of HPV DNA in

non-atrophic/erosive OLP and atrophic/erosive OLP groups are comparable and the

most frequent HPV type is HPV 18, followed by HPV 16, 31, and 6 (Campisi et al.,

2004). A systematic analysis of published data also supports an association of HPV

with OLP (Syrjanen et al., 2011). Taking into account a high prevalence of HPV in

OLP patients and the oncogenic role of HPV, patients with OLP are encouraged to

screen for the HPV infection (Pol et al., 2015).

The assay of HPV-encoded proteins also supports the relationship between HPV

infection and OLP. When HPV 16 marker is immunohistochemically measured in 30

Indian samples histologically confirmed as OLP and 30 normal oral mucosa

specimens, a significant correlation is observed between HPV16 infection and OLP

(Pol et al., 2015), suggesting an involvement of HPV16 in the development of OLP. In

a previous study, HPV proteins were detected in 65 OLP cases by

immunohistochemistry and 21% cases were HPV positive, with a statistically

significant difference compared to control subjects but no significant association with

histopathology (Yildirim et al., 2011). Erosive OLP is also characterized with

expanded CD8+ T cells specific for HPV 16, further supporting the involvement of

HPV in the pathological process of OLP (Viguier et al., 2015).

p16 can be treated as a marker of high-risk HPV infection and its expression is

usually upregulated in cervical cancer and corresponding premalignant lesions (Yu et

al., 2010). Interestingly, expression of p16 was not found to be correlated with HPV

infection in OLP (Montebugnoli et al., 2014). In 35 OLP specimens, p16 is expressed

in 26 cases, but HPV DNA is only found in 4 samples. The overexpression of p16 is

observed in all HPV-positive lesions, whereas 22 p16-overexpressed cases are HPV

negative. As we discussed above, there is no enough evidence that supports the role of

p16 protein expression as a surrogate marker of OSCC.

Although HPV is found to be significantly associated with OLP, the strength of the

association is believed to vary across geographic populations, clinical types of OLP,

and HPV genotypes (Ma et al., 2016, Arirachakaran et al., 2013). Nine out of 29 (31%)

OLP samples and one out of 14 (7%) controls investigated in Iranian population are

HPV 18 positive detected with polymerase chain reaction. HPV18 infection is not

significantly correlated with OLP, and instead is probably a coincidence (Razavi et al.,

2009). However, the result is not consistent with a previous study in European

population, in which the most frequently detected HPV genotype in OLP is HPV 18

(Campisi et al., 2004). When polymerase chain reaction is used to amplify the HPV

genes covering 32 genotypes of HPV in 37 pared OLP specimens from Thai patients

and control normal oral samples, HPV16 DNA is only detected in one atrophic OLP

specimens, but none in the controls, indicating a low detection rate in Thai patients

(Arirachakaran et al., 2013). In another study with similar method, none of 16 OLP

samples from Thai patients is positive for HPV (Khovidhunkit et al., 2008). In

addition, biopsies seem more accurate than saliva analysis for evaluating HPV

prevalence in OLP patients (Sahebjamiee et al., 2015).

Oral leukoplakia

Oral leukoplakia is the white patches in the mucous membrane of the mouth. The

plaques cannot be rubbed off and characterized as any other disease. The association

of HPV with oral leukoplakia has been found three decade ago (Syrjanen et al., 1986).

A study by in situ hybridization supports that the HPV infection is associated with

oral leukoplakia as well as the progression of oral precancerous disorders (Cianfriglia

et al., 2006). In a study with 68 oral leukoplakia cases, HPV DNA can be detected in

18% oral leukoplakia by polymerase chain reaction and DNA sequencing, whereas it

is detectable in 6% controls (Campisi et al., 2004). HPV 18 is the most common HPV

genotype. The significant difference of the prevalence suggests a higher risk

of HPV infection in oral leukoplakia. However, the prevalence of HPV is not

associated with specific clinic characteristics since the HPV detection rates between

homogeneous and nonhomogeneous leukoplakia are not statistically different

(Campisi et al., 2004). In another study, HPV 6/11, 16 and 18 DNAs are investigated

in 72 oral leukoplakias. 22% oral leukoplakia cases are HPV positive and HPV 16 and

18 DNAs are present in 17% cases (Ostwald et al., 2003).

Several studies report that HPV is observed in over 40% oral leukoplakia lesions.

45% of oral leukoplakia samples are HPV-infected as compared to 23% in controls

(Sikka & Sikka, 2014). 58% of oral leukoplakia patients show the presence of HPV

18 in the buccal mucosa lesion (Mathew et al., 2011). The prevalence of either HPV

16 or 18 is found in 40% oral leukoplakia and 20% controls by Southern blot

hybridization in Indian (Khanna et al., 2009). A systematic analysis of published data

also suggests that HPV infection is a high risk factor of oral leukoplakia (Syrjanen et

al., 2011). In addition, over 50% oral leukoplakia cases are positive for

overexpression of p16 (Prakash et al., 2013). Similar to the findings in OSCC and

OLP, no HPV DNA is detected in 17 oral leukoplakia specimens from Thai patients

by polymerase chain reaction (Khovidhunkit et al., 2008). In three studies in Iranian

population HPV is not observed in 20, 50, and 121 oral leukoplakia tissues,

respectively (Saghravanian et al., 2011, Bhargava et al., 2016, Bhosale et al., 2016).

Although several studies document the association of HPV infection with oral

leukoplakia, whether the HPV infection is a causal factor of oral leukoplakia or HPV

infection can promote the malignant progression of oral leukoplakia remain unclear

(Feller & Lemmer, 2012). The role of HPV infection in oral leukoplakia pathogenesis

appears to be overemphasized (Bhargava et al., 2016, Bhosale et al., 2016).

Oral submucous fibrosis (OSMF) and erythroplakia

Oral submucous fibrosis (OSMF) is characterized by progressive submucosal fibrosis

of the oral cavity. It is a chronic insidious disease and remotely linked to oral cancers.

HPV 16 and 18 DNAs are detected in 67% (8/12) OSMF (Jalouli et al., 2010). In

another study, 31% OSMF patients are found to be positive for high-risk HPV

(Mehrotra et al., 2010). Over one quarter of OSMF cases are positive for HPV 16

either by polymerase chain reaction or by the HC-II assay (Chaudhary et al.,

2010). However, there are only a few of studies reporting the association of oral

erythroplakia with HPV infection. HPV DNA is observed in 25% erythroplakia cases

in gutka chewers of Karachi (Baig et al., 2012).

The significance of HPV infection in the malignant progression of oral

potentially malignant disorders

Several studies attempt to investigate the significance of HPV infection in

transformation of precancerous oral mucosal disorders. In a study with 118 OSCC,

72 oral leukoplakia, and 65 OLP, HPV DNA detection rates are 43%, 22%, and 15%,

respectively (Ostwald et al., 2003). When the prevalence of high-risk and low-risk

HPV is analyzed separately, the differences are increased. HPV 16/18 DNAs are

detected in 35% OSCC, 17% oral leukoplakia, and 9% OLP. In contrast, HPV 6/11

detection rates in OSCC, oral leukoplakia, and OLP are 4%, 11%, and 8%,

respectively, with the lowest detection rate in oral carcinomas. It is obvious that the

infection rates of high-risk HPV are gradually increased along with malignant

progression of lesions from OLP to oral leukoplakia and OSCC, supporting a role of

HPV infection in the progression of oral potentially malignant disorders (Ostwald et

al., 2003).

Similar results have been achieved in another study. HPV is detected in 119 OLP, 44

oral leukoplakias, and 65 OSCC patients and the positive rates are 33%, 41%, and

48%, respectively, significantly higher than in healthy controls (Szarka et al., 2009).

The rates of HPV infection from OLP to oral leukoplakia and OSCC present a

gradually increasing tendency. When OLP is classified as atrophic/erosive and non-

atrophic/erosive forms, HPV infection rates in atrophic/erosive group (43%) are

significantly higher than in non-atrophic/erosive (22%) group. The frequency of HPV

infection in atrophic/erosive OLP patients is similar to the finding in oral leukoplakia

patients (Szarka et al., 2009). When 10 HPV types are analyzed, total detection rates

in normal controls, oral leukoplakia, and OSCC are 23%, 46%, and 39%, respectively,

and only HPV 16 prevalence in oral leukoplakia and OSCC is statistically higher than

controls (Llamas-Martinez et al., 2008). A current study further supports an

association high-risk HPV infection with the oral potentially malignant disorders

(Dalla Torre et al., 2015).

When 82 OLP individuals were followed up in a study, five patients developed cancer.

Only 2 of them were found to be infected with low-risk HPV6/11, suggesting that

low-risk HPV might be related to the progression of oral premalignant disorders

(Mattila et al., 2012). HPV prevalence is found in over 20% of 167 oral leukoplakia

cases in a previous study (Yang et al., 2009). However, the data analysis of 12 cancer

patients who developed from oral leukoplakia suggests that HPV infection does not

predict the malignant progression of oral leukoplakia patients (Yang et al., 2009).

Thus, a comprehensive study is necessary to evaluate the significance of HPV

infection in the malignant progression of oral potentially malignant disorders.

Direct experimental evidence of HPV-inducing oral carcinogenesis is very limited

both in vitro and in vivo (Markopoulos, 2012). In the earlier studies, S100

calcium-binding protein A8 was identified as a biomarker in HPV18-infected OSCC,

suggesting an important role in oral carcinogenesis following HPV18 infection (Lo et

al., 2007). Thioredoxin and epidermal-fatty acid binding protein were identified to be

upregulated in HPV related OSCC tissues (Melle et al., 2009). HPV was also

associated with upregulation of BUBR1 in OSCC (Lira et al., 2010). BUBR1 is an

important protein in the mitotic spindle assembly checkpoint and has been associated

with some virus-encoded proteins and cancer. The HPV E7 protein seems to be able

to enhance hypoxia inducible factor-1 alpha (HIF-1α) activity. A positive association

of HIF-1α activity with HPV16 E7 was observed in HPV16-infected OSCC. HIF-1α

expression was upregulated in the early stage of HPV16-infected OSCC, suggesting a

very early involvement in the development of HPV-induced OSCC (Rodolico et al.,


The effects of HPV may be involved in the regulation of cytokines and miRNAs.

HPV infection may promote cancer development via modulating the production of

host cytokines. The forced expression of HPV16 E6 in oral cancer cells significantly

upregulated Oncostatin M, an IL-6 family cytokine (Chuerduangphui et al., 2016).

High-risk HPV infection enhanced tumor growth and cancer stemness of OSCC cells

via miR-181 regulation (Lee et al., 2015). HPV16 E7-mediated miR-20a upregulation

inhibited the proliferation, invasion, and migration of OSCC cells (Hu et al., 2016).

Since HPV activates E2F1-mediated transcription via the E7-pRb-E2F pathway, the

E2F1 polymorphism influenced the susceptibility to HPV-associated OSCC (Yuan et

al., 2017). The incidence of HPV integration in OSCC is lower and thus its role seems

to be limited (McBride & Warburton, 2017, Olthof et al., 2014).


In the recent years, oral HPV infection become increased (Pierangeli et al., 2016).

Systematic analysis has suggested that HPV infection is probably a potential

etiological factor of oral potentially malignant disorders and OSCC (Syrjanen et al.,

2011). However, we note that the HPV prevalence frequency varies according to

different studies. Several reasons may lead to the frequency variation. Sample size is

probably a major problem. Other factors include sampling and detection methods,

geographic populations, disease types, and HPV genotypes. For example, biopsy

specimens appear more accurate for HPV detection than brushing in OSCC and OLP

(Termine et al., 2012, Sahebjamiee et al., 2015). The nested polymerase chain reaction

is better than single polymerase chain reaction (Jalouli et al., 2015). Only two (5%)

young patients and one (2.5%) older control were positive for HPV DNA in 40 young

Japanese patients with OSCC and 40 controls aged more than 40 years. Thus, HPV is

less likely to cause OSCC in young Japanese patients (Rushatamukayanunt et al.,

2014). p16 can also be used as a surrogate marker for high-risk HPV in OSCC

(Sritippho et al., 2016). As we know, amplification and hybridization-based HPV

DNA detection or immunochemistry-based p16 assay is widely used in the screening

and auxiliary diagnosis of cervical cancer and precancer lesions. These methods could

be optimized and applied to detect HPV in OSCC and oral potentially malignant


The significance of HPV infection in the malignant progression of oral potentially

malignant disorders is a major concern. Due to the tumorigenic potential of HPV,

more attention should be paid to the HPV infection in oral tissues. First, it is essential

to determine the status of HPV infection between local and corresponding adjacent

sites of lesions. HPV DNA is detectable in both oral lesion and adjacent sites of the

patients, but a higher detection rate is found in the lesions close to HPV-infected

normal sites (Giovannelli et al., 2006). Thus, a further study with a large scale

samples is certainly required to conclude that HPV infection is a causal or coincident

phenomenon. Second, whether the risk of malignant progression is related to viral

loads remains unclear. Common high-risk and low-risk HPV DNAs are investigated

in OLP, oral leukoplakia, and controls and a higher HPV16/18 DNA loads are found

in patients compared with in controls (Pierangeli et al., 2016). The clinical

significance of high-risk HPV loads in the malignant progression of oral potentially

malignant disorders needs to be clarified (Pierangeli et al., 2016). Finally or the most

importantly, what is the underlying mechanism of HPV-mediated transformation of

oral mucosal epithelia? It is well-known that HPV infection is an essential factor of

the cervical cancers (Yu et al., 2010). Protumorigenic effects of HPV in cervical

epithelial carcinogenesis are associated with the overexpression of virus-encoded E6

and E7 and inactivation of pRb and p53 (Schiffman et al., 2016). However, current

understanding of the mechanism which HPV promotes oral mucosal epithelial

transformation is very limited. A further study will be critical to reveal the regulatory

mechanism of HPV in oral epithelial lesions and OSCC.

Conflict of interest The authors declare that they have no conflict of interest.


Arirachakaran P, Chansaengroj J, Lurchachaiwong W, Kanjanabud P, Thongprasom K and

Poovorawan Y (2013). Oral lichen planus in thai patients has a low prevalence of human
papillomavirus. ISRN Dent 2013: 362750.

Baig S, Lucky MH, Qamar A, Ahmad F, Khan S, Ahmed W, Chughtai T, Hassan W, Hussain BA
and Khan A (2012). Human papilloma virus and oral lesions in gutka eating subjects in Karachi.
J Coll Physicians Surg Pak 22: 135-8.

Bhargava A, Shakeel M, Srivastava AN, Raza TS, Rizvi S and Varshney P (2016). Role of human
papilloma virus in oral leukoplakia. Indian J Cancer 53: 206-9.

Bhosale PG, Pandey M, Desai RS, Patil A, Kane S, Prabhash K and Mahimkar MB (2016). Low
prevalence of transcriptionally active human papilloma virus in Indian patients with HNSCC
and leukoplakia. Oral Surg Oral Med Oral Pathol Oral Radiol 122: 609-618 e7.

Brand TM, Hartmann S, Bhola NE, Peyser ND, Li H, Zeng Y, Isaacson Wechsler E, Ranall MV,
Bandyopadhyay S, Duvvuri U, LaVallee TM, Jordan RC, Johnson DE and Grandis JR (2017).
Human papillomavirus regulates HER3 expression in head and neck cancer: implications for
targeted HER3 therapy in HPV(+) patients. Clin Cancer Res 23:3072-83.

Campisi G, Giovannelli L, Arico P, Lama A, Di Liberto C, Ammatuna P and D'Angelo M (2004).

HPV DNA in clinically different variants of oral leukoplakia and lichen planus. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 98: 705-11.

Chaudhary AK, Pandya S, Mehrotra R, Bharti AC and Singh M (2010). Comparative study
between the Hybrid Capture II test and PCR based assay for the detection of human
papillomavirus DNA in oral submucous fibrosis and oral squamous cell carcinoma. Virol J 7:

Chen F, Yan L, Liu F, Huang J, Wu J, Qiu Y, Zheng X, Cai L, Lin L and He B (2016). Oral human
papillomavirus infection, sexual behaviors and risk of oral squamous cell carcinoma in
southeast of China: A case-control study. J Clin Virol 85: 7-12.

Chuerduangphui J, Pientong C, Chaiyarit P, Patarapadungkit N, Chotiyano A, Kongyingyoes B,

Promthet S, Swangphon P, Wongjampa W and Ekalaksananan T (2016). Effect of human
papillomavirus 16 oncoproteins on oncostatin M upregulation in oral squamous cell carcinoma.
Med Oncol 33: 83.

Cianfriglia F, Di Gregorio DA, Cianfriglia C, Marandino F, Perrone Donnorso R and Vocaturo A

(2006). Incidence of human papillomavirus infection in oral leukoplakia. Indications for a viral
aetiology. J Exp Clin Cancer Res 25: 21-8.

Dalla Torre D, Burtscher D, Edlinger M, Solder E, Widschwendter A, Rasse M and Puelacher W

(2015). Comparison of the prevalence of human papilloma virus infection in histopathologically
confirmed premalignant oral lesions and healthy oral mucosa by brush smear detection. Oral
Surg Oral Med Oral Pathol Oral Radiol 119: 333-9.

Feller L and Lemmer J (2012). Oral Leukoplakia as It Relates to HPV Infection: A Review. Int J
Dent 2012: 540561.

Ghittoni R, Accardi R, Chiocca S and Tommasino M (2015). Role of human papillomaviruses in

carcinogenesis. Ecancermedicalscience 9: 526.

Giovannelli L, Campisi G, Colella G, Capra G, Di Liberto C, Caleca MP, Matranga D, D'Angelo

M, Lo Muzio L and Ammatuna P (2006). Brushing of oral mucosa for diagnosis of HPV
infection in patients with potentially malignant and malignant oral lesions. Mol Diagn Ther 10:

Gorsky M and Epstein JB (2011). Oral lichen planus: malignant transformation and human
papilloma virus: a review of potential clinical implications. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 111: 461-4.

Gotz C, Drecoll E, Straub M, Bissinger O, Wolff KD and Kolk A (2016). Impact of HPV infection
on oral squamous cell carcinoma. Oncotarget 7: 76704-12.

Halloush RA, Akpolat I, Jim Zhai Q, Schwartz MR and Mody DR (2008). Comparison of ProEx
C with p16INK4a and Ki-67 immunohistochemical staining of cell blocks prepared from
residual liquid-based cervicovaginal material: a pilot study. Cancer 114: 474-80.

Hu J, Ge W and Xu J (2016). HPV 16 E7 inhibits OSCC cell proliferation, invasion, and

metastasis by upregulating the expression of miR-20a. Tumour Biol 37: 9433-40.

Jalouli J, Ibrahim SO, Mehrotra R, Jalouli MM, Sapkota D, Larsson PA and Hirsch JM (2010).
Prevalence of viral (HPV, EBV, HSV) infections in oral submucous fibrosis and oral cancer
from India. Acta Otolaryngol 130: 1306-11.

Jalouli M, Jalouli J, Ibrahim SO, Hirsch JM and Sand L (2015). Comparison between single PCR
and nested PCR in detection of human papilloma viruses in paraffin-embedded OSCC and fresh
oral mucosa. In Vivo 29: 65-70.

Kalof AN and Cooper K (2006). p16INK4a immunoexpression: surrogate marker of high-risk

HPV and high-grade cervical intraepithelial neoplasia. Adv Anat Pathol 13: 190-4.

Khanna R, Rao GR, Tiwary SK, Rai A, Khanna S and Khanna AK (2009). Detection of human
papilloma virus 16 and 18 DNA sequences by southern blot hybridization in oral leukoplakia
and squamous cell carcinoma. Indian J Surg 71: 69-72.

Khovidhunkit SO, Buajeeb W, Sanguansin S, Poomsawat S and Weerapradist W (2008). Detection

of human papillomavirus in oral squamous cell carcinoma, leukoplakia and lichen planus in
Thai patients. Asian Pac J Cancer Prev 9: 771-5.

Klaes R, Benner A, Friedrich T, Ridder R, Herrington S, Jenkins D, Kurman RJ, Schmidt D, Stoler
M and von Knebel Doeberitz M (2002). p16INK4a immunohistochemistry improves
interobserver agreement in the diagnosis of cervical intraepithelial neoplasia. Am J Surg Pathol
26: 1389-99.

Lee SH, Lee CR, Rigas NK, Kim RH, Kang MK, Park NH and Shin KH (2015). Human
papillomavirus 16 (HPV16) enhances tumor growth and cancer stemness of HPV-negative
oral/oropharyngeal squamous cell carcinoma cells via miR-181 regulation. Papillomavirus Res
1: 116-125.

Leversha MA, Fielding P, Watson S, Gosney JR and Field JK (2003). Expression of p53, pRB, and
p16 in lung tumours: a validation study on tissue microarrays. J Pathol 200: 610-9.

Lira RC, Miranda FA, Guimaraes MC, Simoes RT, Donadi EA, Soares CP and Soares EG (2010).
BUBR1 expression in benign oral lesions and squamous cell carcinomas: correlation with
human papillomavirus. Oncol Rep 23: 1027-36.

Llamas-Martinez S, Esparza-Gomez G, Campo-Trapero J, Cancela-Rodriguez P,

Bascones-Martinez A, Moreno-Lopez LA, Garcia-Nunez JA and Cerero-Lapiedra R (2008).
Genotypic determination by PCR-RFLP of human papillomavirus in normal oral mucosa, oral
leukoplakia and oral squamous cell carcinoma samples in Madrid (Spain). Anticancer Res 28:

Lo WY, Lai CC, Hua CH, Tsai MH, Huang SY, Tsai CH and Tsai FJ (2007). S100A8 is identified
as a biomarker of HPV18-infected oral squamous cell carcinomas by suppression subtraction
hybridization, clinical proteomics analysis, and immunohistochemistry staining. J Proteome Res
6: 2143-51.

Ma J, Zhang J, Zhang Y, Lv T and Liu J (2016). The Magnitude of the Association between
Human Papillomavirus and Oral Lichen Planus: A Meta-Analysis. PLoS One 11: e0161339.

Makitie AA, MacMillan C, Ho J, Shi W, Lee A, O'Sullivan B, Payne D, Pintilie M, Cummings B,

Waldron J, Warde P, Irish J, Brown D, Gilbert R, Gullane P, Liu FF and Kamel-Reid S (2003).
Loss of p16 expression has prognostic significance in human nasopharyngeal carcinoma.
Clinical Cancer Research 9: 2177-2184.

Marini A, Wagenmann M, Ting E and Hengge UR (2007). Squamous cell cancer and human
papillomavirus infection in oral lichen planus: case report and literature review. Dermatol Surg
33: 756-60.

Markopoulos AK (2012). Role of human papillomavirus in the pathogenesis of oral squamous cell
carcinoma. World J Exp Med 2: 65-9.

Mathew A, Mody RN, Patait MR, Razooki AA, Varghese NT and Saraf K (2011). Prevalence and

relationship of human papilloma virus type 16 and type 18 with oral squamous cell carcinoma
and oral leukoplakia in fresh scrappings: a PCR study. Indian J Med Sci 65: 212-21.

Mattila R, Rautava J and Syrjanen S (2012). Human papillomavirus in oral atrophic lichen planus
lesions. Oral Oncol 48: 980-4.

McBride AA and Warburton A (2017). The role of integration in oncogenic progression of

HPV-associated cancers. PLoS Pathog 13: e1006211.

Mehrotra R, Chaudhary AK, Pandya S, Debnath S and Singh M (2010). Correlation of addictive
factors, human papilloma virus infection and histopathology of oral submucous fibrosis. J Oral
Pathol Med 39: 460-4.

Melle C, Ernst G, Winkler R, Schimmel B, Klussmann JP, Wittekindt C, Guntinas-Lichius O and

von Eggeling F (2009). Proteomic analysis of human papillomavirus-related oral squamous cell
carcinoma: identification of thioredoxin and epidermal-fatty acid binding protein as upregulated
protein markers in microdissected tumor tissue. Proteomics 9: 2193-201.

Miller CS and Johnstone BM (2001). Human papillomavirus as a risk factor for oral squamous
cell carcinoma: a meta-analysis, 1982-1997. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 91: 622-35.

Montebugnoli L, Gissi DB, Scapoli L, Palmieri A, Morandi L, Manelli I and Foschini MP (2014).
p16(INK4) expression is not associated with human papillomavirus in oral lichen planus. Oral
Surg Oral Med Oral Pathol Oral Radiol 118: 694-702.

OFlatharta C, Flint SR, Toner M, Butler D and Mabruk MJ (2003). Investigation into a possible
association between oral lichen planus, the human herpesviruses, and the human
papillomaviruses. Mol Diagn 7: 73-83.

Olthof NC, Speel EJ, Kolligs J, Haesevoets A, Henfling M, Ramaekers FC, Preuss SF, Drebber U,
Wieland U, Silling S, Lam WL, Vucic EA, Kremer B, Klussmann JP and Huebbers CU (2014).
Comprehensive analysis of HPV16 integration in OSCC reveals no significant impact of
physical status on viral oncogene and virally disrupted human gene expression. PLoS One 9:

Ostwald C, Muller P, Barten M, Rutsatz K, Sonnenburg M, Milde-Langosch K and Loning T

(1994). Human papillomavirus DNA in oral squamous cell carcinomas and normal mucosa. J
Oral Pathol Med 23: 220-5.

Ostwald C, Rutsatz K, Schweder J, Schmidt W, Gundlach K and Barten M (2003). Human

papillomavirus 6/11, 16 and 18 in oral carcinomas and benign oral lesions. Med Microbiol
Immunol 192: 145-8.

Pierangeli A, Cannella F, Scagnolari C, Gentile M, Sciandra I, Antonelli G, Ciolfi C, Russo C,

Palaia G, Romeo U and Polimeni A (2016). Frequent detection of high human papillomavirus
DNA loads in oral potentially malignant disorders. Clin Microbiol Infect 22: 95 e9-95 e15.

Pol CA, Ghige SK and Gosavi SR (2015). Role of human papilloma virus-16 in the pathogenesis
of oral lichen planus--an immunohistochemical study. Int Dent J 65: 11-4.

Prakash P, Khandare M, Kumar M, Khanna R, Singh GP, Nath G and Gulati AK (2013).
Immunohistochemical Detection of p16(INK4a) in Leukoplakia and Oral Squamous Cell
Carcinoma. J Clin Diagn Res 7: 2793-5.

Rampias T, Boutati E, Pectasides E, Sasaki C, Kountourakis P, Weinberger P and Psyrri A (2010).

Activation of Wnt signaling pathway by human papillomavirus E6 and E7 oncogenes in
HPV16-positive oropharyngeal squamous carcinoma cells. Mol Cancer Res 8: 433-43.

Rautava J and Syrjanen S (2012). Biology of human papillomavirus infections in head and neck
carcinogenesis. Head Neck Pathol 6 Suppl 1: S3-15.

Razavi SM, Ghalayani P, Salehi MR, Attarzadeh H and Shahmoradi M (2009). Human papilloma
virus as a possible factor in the pathogenesis of oral lichen planus. Dent Res J (Isfahan) 6: 82-6.

Rodolico V, Arancio W, Amato MC, Aragona F, Cappello F, Di Fede O, Pannone G and Campisi G
(2011). Hypoxia inducible factor-1 alpha expression is increased in infected positive HPV16
DNA oral squamous cell carcinoma and positively associated with HPV16 E7 oncoprotein.
Infect Agent Cancer 6: 18.

Rushatamukayanunt P, Morita K, Matsukawa S, Harada H, Shimamoto H, Tomioka H and Omura

K (2014). Lack of association between high-risk human papillomaviruses and oral squamous
cell carcinoma in young Japanese patients. Asian Pac J Cancer Prev 15: 4135-41.

Saghravanian N, Ghazvini K, Babakoohi S, Firooz A and Mohtasham N (2011). Low prevalence

of high risk genotypes of human papilloma virus in normal oral mucosa, oral leukoplakia and
verrucous carcinoma. Acta Odontol Scand 69: 406-9.

Sahebjamiee M, Sand L, Karimi S, Biettolahi JM, Jabalameli F and Jalouli J (2015). Prevalence of
human papillomavirus in oral lichen planus in an Iranian cohort. J Oral Maxillofac Pathol 19:

Schiffman M, Doorbar J, Wentzensen N, de Sanjose S, Fakhry C, Monk BJ, Stanley MA and

Franceschi S (2016). Carcinogenic human papillomavirus infection. Nat Rev Dis Primers 2:

Sikka S and Sikka P (2014). Association of Human Papilloma Virus 16 Infection and p53
Polymorphism among Tobacco using Oral Leukoplakia Patients: A Clinicopathologic and
Genotypic Study. Int J Prev Med 5: 430-8.

Sritippho T, Chotjumlong P and Iamaroon A (2015). Roles of Human Papillomaviruses and p16 in
Oral Cancer. Asian Pac J Cancer Prev 16: 6193-200.

Sritippho T, Pongsiriwet S, Lertprasertsuke N, Buddhachat K, Sastraruji T and Iamaroon A (2016).

p16 - a Possible Surrogate Marker for High-Risk Human Papillomaviruses in Oral Cancer?
Asian Pac J Cancer Prev 17: 4049-57.

Stanley MA, Winder DM, Sterling JC and Goon PK (2012). HPV infection, anal intra-epithelial
neoplasia (AIN) and anal cancer: current issues. BMC Cancer 12: 398.

Syrjanen S, Lodi G, von Bultzingslowen I, Aliko A, Arduino P, Campisi G, Challacombe S, Ficarra

G, Flaitz C, Zhou HM, Maeda H, Miller C and Jontell M (2011). Human papillomaviruses in
oral carcinoma and oral potentially malignant disorders: a systematic review. Oral Dis 17 Suppl
1: 58-72.

Syrjanen SM, Syrjanen KJ and Lamberg MA (1986). Detection of human papillomavirus DNA in
oral mucosal lesions using in situ DNA-hybridization applied on paraffin sections. Oral Surg
Oral Med Oral Pathol 62: 660-7.

Szarka K, Tar I, Feher E, Gall T, Kis A, Toth ED, Boda R, Marton I and Gergely L (2009).
Progressive increase of human papillomavirus carriage rates in potentially malignant and
malignant oral disorders with increasing malignant potential. Oral Microbiol Immunol 24:

Termine N, Giovannelli L, Rodolico V, Matranga D, Pannone G and Campisi G (2012). Biopsy vs.
brushing: comparison of two sampling methods for the detection of HPV-DNA in squamous cell
carcinoma of the oral cavity. Oral Oncol 48: 870-5.

Viguier M, Bachelez H, Poirier B, Kagan J, Battistella M, Aubin F, Touze A, Carmagnat M,

Frances C, Gougeon ML and Fazilleau N (2015). Peripheral and local human papillomavirus
16-specific CD8+ T-cell expansions characterize erosive oral lichen planus. J Invest Dermatol
135: 418-24.

Wang J, Li J, Huang H and Fu Y (1998). Detection of the E7 transform gene of human papilloma
virus type 16 in human oral squamous cell carcinoma. Chin J Dent Res 1: 35-7.

Woods KV, Shillitoe EJ, Spitz MR, Schantz SP and Adler-Storthz K (1993). Analysis of human
papillomavirus DNA in oral squamous cell carcinomas. J Oral Pathol Med 22: 101-8.

Yang SW, Lee YS, Chen TA, Wu CJ and Tsai CN (2009). Human papillomavirus in oral
leukoplakia is no prognostic indicator of malignant transformation. Cancer Epidemiol 33:

Yildirim B, Senguven B and Demir C (2011). Prevalence of herpes simplex, Epstein Barr and
human papilloma viruses in oral lichen planus. Med Oral Patol Oral Cir Bucal 16: e170-4.

Yu L, Wang L, Zhong J and Chen S (2010). Diagnostic value of p16INK4A, Ki-67, and human
papillomavirus L1 capsid protein immunochemical staining on cell blocks from residual
liquid-based gynecologic cytology specimens. Cancer Cytopathol 118: 47-55.

Yuan Y, Sturgis EM, Zhu L, Lu M, Li Y, Wei Q and Li G (2017). A functional variant at the
miRNA binding site in E2F1 gene is associated with risk and tumor HPV16 status of
oropharynx squamous cell carcinoma. Mol Carcinog 56: 1100-1106.

zur Hausen H (2002). Papillomaviruses and cancer: from basic studies to clinical application. Nat
Rev Cancer 2: 342-50.

Table 1 HPV infection in oral potentially malignant disorders and oral squamous cell
Method and OSCC* OLP OL OSMF Normal


PCR/Southern 43.2% (118) HPV; 15.4% (65) HPV; 22.2% (72) HPV;

(Ostwald et al., 34.7% (118) HPV 9.2% (65) HPV 16.7% (72) HPV

2003) 16/18 16/18 16/18

PCR 3.1% (32) HPV 0% (16) HPV 5.9% (17) HPV


et al., 2008)

PCR (Szarka et 47.7% (65) HPV 32.8% (119) HPV 40.9% (44) HPV

al., 2009)

PCR 39.4% (33) HPV; 45.7% (35) HPV; 23.3% (30) HPV;

(Llamas-Martine 33.3% (33) HPV 16 40% (35) HPV 16 0% (30) HPV 16

z et al., 2008)

PCR/sequencing 24% (62) HPV; 67% (12) HPV

(Jalouli et al., 16% (62) HPV 16/18

2010) 16/18

PCR/HC-II 32.4% (222) HPV 26% (208) HPV 16

(Chaudhary et 16 by PCR; 31.4% by PCR; 27.4%

al., 2010) (222) HPV 16 by (208) HPV 16 by


PCR (Mathew et 73.3% (45) HPV 58.3% (20) HPV

al., 2011) 16; 71.1% (45) 18; 50% (20)

HPV 18; 57.7% HPV 16/18

(45) HPV 16/18

Southern 64.5% (45) HPV 40%(30) HPV 20% (45) HPV

(Khanna et al., 16/18 16/18 16/18


Flow-through 14.04% HPV; 3.17% HPV; 2.12%

hybridization 10.67% HPV 18 HPV 18

and gene chip

(Chen et al.,


PCR/sequencing 19.7% (71) HPV 17.6% (68) HPV 5.6% (90) HPV

(Campisi et al.,


PCR (OFlatharta 26.3% (38) HPV 16 0% (20) HPV 16

et al., 2003)

PCR (Razavi et 31.0% (29) HPV 18 7.1% (14) HPV 18

al., 2009)

PCR 2.7% (37) HPV


et al., 2013)

IHC (Yildirim et 21% (65) HPV

al., 2011)

Microassay 15.9% (82) HPV

(Mattila et al.,


PCR/sequencing 45% (91) HPV 23% (100) HPV 16

(Sikka & Sikka, 16


HC-II (Mehrotra 31.4% (105)

et al., 2010) high-risk HPV

Detection rates (cases).


HC-II, Hybrid Capture II assay; HPV, human papillomavirus; IHC, immunohistochemistry;

Normal, normal mucosal control; OL, oral erythroplakia; OLP, oral lichen planus; OSMF, oral
submucous fibrosis; PCR: polymerase chain reaction; Southern: Southern blot.