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Antonsson A, de Souza MMA, Panizza BJ, Whiteman DC. Sexual debut and association with oral human papillomavirus infection, persistence and oropharyngeal cancer-An analysis of two Australian cohorts. Int J Cancer 2022; 151:764-769. [PMID: 35225359 DOI: 10.1002/ijc.33986] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/07/2022]
Abstract
Oropharyngeal cancer is increasingly caused by human papillomavirus (HPV), and this increase is believed to be caused by changing sexual behaviour. It has been hypothesised that an immune response to HPV through sexual intercourse is much stronger than an immune response elicited from oral sex. Therefore, people who have their debut of oral sex before or at the same time as sexual intercourse would have a weaker immune response to HPV and hence be more likely to develop a persistent oral HPV infection and oropharyngeal cancer. Drake et al (Cancer. 2021;127[7]:1029-1038) found some evidence that supported this hypothesis. We have reanalysed two of our Australian cohorts with similar data in order to provide a perspective of Drake and colleagues' publication, as sexual behaviour varies depending on culture and geographical location. We found that engaging in oral sex (OR 4.46, 95% CI [1.88-10.62]) and being younger than 20 years at oral sex debut (OR 9.46, 95% CI [3.53-25.31]) were both very strong risk factors for oropharyngeal cancer. Participants in the general population cohort who had their sexual intercourse debut before the age of 18 were more likely to be oral HPV positive (OR 2.69, 95% CI [1.50-4.83]). Oral sex debut before sexual intercourse debut was quite uncommon in our two Australian cohorts. However, timing of or sexual debuts may further add to risks of oropharyngeal cancer, and future studies should be designed to investigate timing and order of sexual debuts to help clarify the roles of these potential causal factors.
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Affiliation(s)
- Annika Antonsson
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Marjorie M A de Souza
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Benedict J Panizza
- Faculty of Medicine, University of Queensland, Brisbane, Australia.,Department of Otolaryngology-Head and Neck Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - David C Whiteman
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Australia
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2
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Matos S, Boakye EA, Crosby D, Sharma A. Prevalence and Factors Associated With Oral Cavity and Pharyngeal Cancer Screening in a Rural Population. OTO Open 2021; 5:2473974X211065018. [PMID: 34926974 PMCID: PMC8671683 DOI: 10.1177/2473974x211065018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/13/2021] [Indexed: 11/23/2022] Open
Abstract
Objective (1) To quantify the prevalence of provider recommendation and receipt of oral cavity and pharyngeal cancer (OCPC) screening and (2) to examine the factors associated with OCPC screening recommendation and receipt among adults. Study Design Cross-sectional. Setting Rural counties in central Illinois. Methods This study among adults (N = 145) was conducted between January 1 and June 30, 2017. The outcomes of interest were provider recommendation and receipt of OCPC screening. Multivariable logistic regression models were used to examine the association between (1) sociodemographic, health care access and utilization, and OCPC risk factors and (2) provider recommendation and receipt of OCPC screening. Results The prevalence of provider recommendation and receipt of OCPC screening was 12.4% and 28.3%, respectively. Approximately 15% of current smokers, 13% of participants who consume alcohol, and 10% of participants with ≥5 lifetime sexual partners had received an OCPC screening recommendation. OCPC screening rates were 19% for current smokers, 30% for those who consume alcohol, and 32% for those with ≥5 lifetime sexual partners. In the adjusted analyses, respondents with ≥5 partners (adjusted odds ratio, 3.10 [95% CI, 1.25-7.66]) had a higher odds of receiving OCPC screening than those with <5. There were no significant associations between other OCPC risk factors and provider recommendation and receipt of OCPC screening. Conclusion OCPC screening recommendation and receipt were low; only number of lifetime sexual partners was associated with OCPC screening receipt. Our findings suggest that rural populations may be vulnerable to late-stage diagnosis of OCPC, and interventions to help improve screening rates are warranted.
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Affiliation(s)
- Sophia Matos
- School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
- Simmons Cancer Institute, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Dana Crosby
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Arun Sharma
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
- Arun Sharma, MD, MS, School of Medicine, Southern Illinois University, 720 Bond St, Springfield, IL 62702, USA.
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3
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Giuliani E, Rollo F, Donà MG, Garbuglia AR. Human Papillomavirus Oral Infection: Review of Methodological Aspects and Epidemiology. Pathogens 2021; 10:pathogens10111411. [PMID: 34832567 PMCID: PMC8625118 DOI: 10.3390/pathogens10111411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/15/2021] [Accepted: 10/27/2021] [Indexed: 11/16/2022] Open
Abstract
Oral infection by Human Papillomavirus (HPV) has recently gained great attention because of its involvement in the development of a subset of head and neck squamous cell carcinoma. The role of specific Alpha-HPVs in this regard has been well established, whereas the contribution of other genera is under investigation. Despite their traditional classification as “cutaneous” types, Beta and Gamma HPVs are frequently detected in oral samples. Due to the lack of a standardized protocol, a large variety of methodologies have been used for oral sample collection, DNA extraction, HPV detection and genotyping. Laboratory procedures influence the evaluation of oral HPV prevalence, which largely varies also according to the population characteristics, e.g., age, gender, sexual behavior, Human Immunodeficiency Virus (HIV) status. Nevertheless, oral infection by Beta and Gamma HPVs seems to be even more common than Alpha-HPVs. The latter is 5–7% in the general population, and increases up to 30% approximately in HIV-infected men who have sex with men. Despite major advances in the evaluation of oral HPV prevalence, its natural history is still little understood, especially for Beta and Gamma HPVs. The latest technologies, such as Next Generation Sequencing (NGS), can be exploited to gain new insights into oral HPV, and to improve the identification of novel HPV types.
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Affiliation(s)
- Eugenia Giuliani
- Scientific Direction, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy;
| | - Francesca Rollo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy;
| | - Maria Gabriella Donà
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy
- Correspondence: ; Tel.: +39-0652665393
| | - Anna Rosa Garbuglia
- Laboratory of Virology, National Institute for Infectious Diseases, INMI Lazzaro Spallanzani IRCCS, Via Portuense 292, 00149 Rome, Italy;
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4
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Zakrzewski M, Gannon OM, Panizza BJ, Saunders NA, Antonsson A. Human papillomavirus infection and tumor microenvironment are associated with the microbiota in patients with oropharyngeal cancers-pilot study. Head Neck 2021; 43:3324-3330. [PMID: 34278648 DOI: 10.1002/hed.26821] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/07/2021] [Accepted: 07/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous microbiome studies of oropharyngeal cancer have shown that there are differences in the oral microbiota between human papillomavirus (HPV)-positive and HPV-negative patients. METHODS We collected saliva, normal tissue, and tumor biopsies from 13 patients with oropharyngeal cancer (eight HPV-positive, five HPV-negative). We obtained basic clinical data from each patient. Extracted DNA was 16S rRNA gene sequenced. Analysis was based on HPV status and sample site using univariate, multivariate, and mixed effect regression methods. RESULTS Multivariate analysis methods separated samples based on HPV status (Adonis, p < 0.001). Comparison of patients showed that there were significant changes in microbial richness across all sites based on HPV status (linear mixed effects regression, p = 0.0002). CONCLUSIONS We found significant differences in overall microbial community and bacterial richness between oropharyngeal patients based on HPV status. Our results suggest that there are significant differences in the microbiome in patients with oropharyngeal cancer based on HPV status.
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Affiliation(s)
- Martha Zakrzewski
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Orla Margaret Gannon
- The University of Queensland Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia
| | - Benedict James Panizza
- Department of Otolaryngology - Head and Neck Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Andrew Saunders
- The University of Queensland Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia
| | - Annika Antonsson
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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5
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Rajasekaran K, Carey RM, Lin X, Seckar TD, Wei Z, Chorath K, Newman JG, O'Malley BW, Weinstein GS, Feldman MD, Robertson E. The microbiome of HPV-positive tonsil squamous cell carcinoma and neck metastasis. Oral Oncol 2021; 117:105305. [PMID: 33905914 DOI: 10.1016/j.oraloncology.2021.105305] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/01/2021] [Accepted: 04/12/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Oropharyngeal squamous cell carcinoma (OPSCC) has now surpassed cervical cancer as the most common site of HPV-related cancer in the United States. HPV-positive OPSCCs behave differently from HPV-negative tumors and often present with early lymph node involvement. The bacterial microbiome of HPV-associated OPSCC may contribute to carcinogenesis, and certain bacteria may influence the spread of cancer from the primary site to regional lymphatics. OBJECTIVE To determine the bacterial microbiome in patients with HPV-associated, early tonsil SCC and compare them to benign tonsil specimens. METHOD The microbiome of primary tumor specimens and lymph nodes was compared to benign tonsillectomy specimens with pan-pathogen microarray (PathoChip). RESULTS A total of 114 patients were enrolled in the study. Patients with OPSCC had a microbiome that shifted towards more gram-negative. Numerous signatures of bacterial family and species were associated with the primary tumors and lymph nodes of cancer patients, including the urogenital pathogens Proteus mirabilis and Chlamydia trachomatis, Neisseria gonorrhoeae, Shigella dysenteriae, and Orientia tsutsugamushi. CONCLUSION Our results suggest that detection of urogenital pathogens is associated with lymph node metastasis for patients with HPV-positive OPSCCs. Additional studies are necessary to determine the effects of the OPSCC microbiome on disease progression and clinical outcomes.
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Affiliation(s)
- Karthik Rajasekaran
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - Ryan M Carey
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Xiang Lin
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Department of Computer Science, New Jersey Institute of Technology, Newark, NJ, United States
| | - Tyler D Seckar
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Zhi Wei
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Department of Computer Science, New Jersey Institute of Technology, Newark, NJ, United States
| | - Kevin Chorath
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Bert W O'Malley
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Gregory S Weinstein
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael D Feldman
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Erle Robertson
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
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6
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Antonsson A, de Souza M, Wood ZC, Carroll A, Van K, Paterson L, Pandeya N, Whiteman DC. Natural history of oral HPV infection: Longitudinal analyses in prospective cohorts from Australia. Int J Cancer 2020; 148:1964-1972. [PMID: 33320983 DOI: 10.1002/ijc.33442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/24/2020] [Accepted: 12/09/2020] [Indexed: 12/31/2022]
Abstract
Oral infection with human papillomavirus (HPV) is likely to underpin the rapidly rising incidence of oropharyngeal squamous cell carcinoma; however, there are few data describing the natural history of oral HPV infection. We recruited 704 participants aged 20 to 70 years from worksites, universities and primary care practices in Brisbane, Australia. Participants completed questionnaires at baseline, 12 and 24 months and donate four saliva samples at baseline, 6, 12 and 24 months for HPV polymerase chain reaction testing and typing. We estimated the prevalence of oral HPV infection at baseline, incidence of new infections among those HPV-negative at baseline, clearance rate and persistent infections. At baseline, 10.7% of participants had oral HPV infections from 26 different HPV types. Sexual behaviours were associated with oral HPV infection, including more partners for passionate kissing (29 or more; odds ratio [OR] 3.4, 95% confidence interval [CI] 1.5-8.0), and giving and receiving oral sex (16 or more; OR 5.4, 95% CI 1.6-17.7 and OR 5.6, 95% CI 1.6-18.7, respectively). Of 343 participants, HPV-free at baseline and with subsequent saliva samples, 87 (25%) acquired new infections over the 24 months. Sixty-eight of 87 people included in the clearance analysis (78%) cleared their oral HPV infections. Clearance was associated with being a nonsmoker (OR 12.7, 95% CI 1.3-122.8), and no previous diagnosis of a sexually transmitted infection (OR 6.2, 95% CI 2.0-19.9). New oral infections with HPV in this sample were not rare. Although most infections were cleared, clearance was not universal suggesting a reservoir of infection exists that might predispose to oropharyngeal carcinogenesis.
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Affiliation(s)
- Annika Antonsson
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Marjorie de Souza
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Zoe C Wood
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Angela Carroll
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Kim Van
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Lachlan Paterson
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Nirmala Pandeya
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - David C Whiteman
- Department of Population Health, QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, Queensland, Australia
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7
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Meng HX, Yang XX, Liu RQ, Bao JJ, Hou YJ, Sun J, Miao SS, Qu GF. The Relationship Between Human Papillomavirus, OFD1 and Primary Ciliogenesis in the Progression of Oropharyngeal Cancer: A Retrospective Cohort Study. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:633-644. [PMID: 33244255 PMCID: PMC7685095 DOI: 10.2147/pgpm.s271735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
Purpose Infection with human papillomavirus (HPV) has been indicated to be a important risk factor for oropharyngeal squamous cell carcinoma (OPSCC). Primary ciliogenesis defects contribute to tumorigenesis, and OFD1 at centriolar satellites is a crucial suppressor of primary ciliogenesis. To identify novel markers associated with HPV-induced carcinogenesis, the interactions between HPV infection and primary ciliogenesis in the tumorigenesis and progression of OPSCC were investigated in this study. Patients and Methods The 1530 OPSCC patients recruited in this research were treated from 2000 to 2017. Immunohistochemistry and RT-PCR were performed on tissue samples to compare the expression of p16, TSLP, TGFβ1, IFNγ, OFD1, and their relationship with clinical characteristics of patients. Results We speculate that the positive expression of p16 is related to early primary OPSCC, and the survival rate of p16 positive patients after radiotherapy and surgery is higher. Expression of TSLP on dendritic cells in HPV-positive OPSCC correlated with the expression of OFD1. HPV-positive OPSCC showed increased expression of OFD1 combined with reduced ciliogenesis. Hence, TSLP induced by HPV infection may reduce the invasive potential of OPSCC cells by promoting OFD1 expression, thereby inhibiting primary ciliogenesis. Conclusion Our study demonstrated that HPV may be related to the progression of OPSCC by regulating OFD1 expression and primary ciliogenesis, making this protein a potential therapeutic target.
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Affiliation(s)
- Hong-Xue Meng
- Department of Pathology, Harbin Medical University Cancer Hospital, Harbin, People's Republic of China.,Department of Pathology, Harbin Medical University, Harbin, People's Republic of China
| | - Xin-Xin Yang
- Department of Pathology, Harbin Medical University Cancer Hospital, Harbin, People's Republic of China
| | - Rui-Qi Liu
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Hospital, Guangzhou, People's Republic of China
| | - Jun-Jie Bao
- Department of Orthopedics, Harbin Medical University Cancer Hospital, Harbin, People's Republic of China
| | - Yun-Jing Hou
- Department of Pathology, Harbin Medical University Cancer Hospital, Harbin, People's Republic of China
| | - Ji Sun
- Department of Otolaryngology, Head and Neck Surgery, Harbin Medical University Cancer Hospital, Harbin, People's Republic of China
| | - Su-Sheng Miao
- Department of Otolaryngology, Head and Neck Surgery, Harbin Medical University Cancer Hospital, Harbin, People's Republic of China
| | - Guo-Fan Qu
- Department of Orthopedics, Harbin Medical University Cancer Hospital, Harbin, People's Republic of China
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Komolmalai N, Pongsiriwet S, Lertprasertsuke N, Lekwanavijit S, Kintarak S, Phattarataratip E, Subarnbhesaj A, Dhanuthai K, Chaisuparat R, Iamaroon A. Human Papillomavirus 16 and 18 Infection in Oral Cancer in Thailand: A Multicenter Study. Asian Pac J Cancer Prev 2020; 21:3349-3355. [PMID: 33247695 PMCID: PMC8033133 DOI: 10.31557/apjcp.2020.21.11.3349] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives: To identify the prevalence of high-risk human papillomavirus (HPV) genotypes 16 and 18 among patients with oral squamous cell carcinoma (OSCC) in Thailand and investigate the associations of p16 expression and HPV16/18 with the demographic, clinicopathologic, and risk parameters. Materials and Methods: A total of 403 formalin-fixed paraffin-embedded OSCC specimens from four centers in four regions were obtained. p16 expression was evaluated by immunohistochemistry. The detection of HPV16/18 DNA was performed by polymerase chain reaction. Results: Of all, 172 specimens (42.7%) were presented with amplifiable extracted DNA. Among these, 62.8% were positive for p16, 8.1% were positive for HPV16/18, and 5.8% were positive for both methods. Of all HPV-positive specimens, HPV18 was detected in 57.1%; HPV16 in 14.3%; and HPV16 and 18 (co-infection) in 28.6%. The prevalence of HPV16/18 varied between centers, with the highest rate in the northern center (20.0%). There was no significant correlation between p16 expression and HPV16/18. There were no significant associations of p16 expression and/or HPV16/18 with all variables. Conclusions: The prevalence of HPV16/18 infection in OSCC geographically varied in Thailand, with the highest rate in the northern region. Poor correlation between p16 and HPV16/18 suggests p16 not be used as a surrogate marker for HPV-positive OSCC.
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Affiliation(s)
- Nicha Komolmalai
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Surawut Pongsiriwet
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Nirush Lertprasertsuke
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suree Lekwanavijit
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sompid Kintarak
- Department of Stomatology, Faculty of Dentistry, Prince of Songkla University, Songkhla, Thailand
| | - Ekarat Phattarataratip
- Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Ajiravudh Subarnbhesaj
- Department of Oral Diagnosis, Faculty of Dentistry, Khon Kaen University, Khon Kaen, Thailand
| | - Kittipong Dhanuthai
- Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Risa Chaisuparat
- Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Anak Iamaroon
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
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