Journal of the Formosan Medical Association (2019) 118, 1393e1400

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.jfma-online.com

Original Article

Gastric parietal cell and thyroid

autoantibodies in oral precancer patients
Yu-Hsueh Wu a,b, Yang-Che Wu c, Shih-Jung Cheng b,d,e,
Ying-Shiung Kuo a,d, Andy Sun b,d, Hsin-Ming Chen b,d,e,*

a
Department of Dentistry, Far Eastern Memorial Hospital, New Taipei City, Taiwan
b
Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei,
Taiwan
c
School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
d
Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan
University, Taipei, Taiwan
e
Graduate Institute of Oral Biology, School of Dentistry, National Taiwan University, Taipei, Taiwan

Received 30 April 2019; accepted 21 May 2019

KEYWORDS Background/Purpose: Gastric parietal cell antibody (GPCA), thyroglobulin antibody (TGA), and
Oral leukoplakia; thyroid microsomal antibody (TMA) may be present in oral mucosal disease patients. This study
Oral precancer; mainly assessed the frequencies of serum GPCA, TGA, and TMA positivities in 131 oral precan-
Gastric parietal cell cer patients.
antibody; Methods: Serum GPCA, TGA, and TMA levels were measured in 131 oral precancer patients
Thyroglobulin including 96 oral leukoplakia, 26 oral erythroleukoplakia, and 9 oral verrucous hyperplasia pa-
antibody; tients and in 131 age- and sex-matched healthy control subjects.
Thyroid microsomal Results: We found that 131 oral precancer patients had higher frequencies of serum GPCA
antibody (10.7% vs. 2.3%, P Z 0.012, statistically significant), TGA (4.6% vs. 2.3%, P Z 0.498), and
TMA (8.4% vs. 2.3%, P Z 0.054, marginal significance) positivities than 131 healthy control sub-
jects. We also found that 1 (0.8%), 6 (4.6%), and 16 (12.2%) oral precancer patients had the
presence of three (GPCA þ TGA þ TMA), two (GPCA þ TGA, GPCA þ TMA, or TGA þ TMA),
or one (GPCA only, TGA only, or TMA only) autoantibody in their sera, respectively. Of 10
TGA/TMA-positive oral precancer patients whose serum thyroid-stimulating hormone (TSH)
levels were measured, 80%, 10%, and 10% of these 10 TGA/TMA-positive oral precancer pa-
tients had normal, lower, and higher serum TSH levels, respectively. We also found a signifi-
cantly higher GPCA positive rate in 26 smokers consuming >20 cigarettes per day than in 61
smokers consuming 20 cigarettes per day (P Z 0.008).
Conclusion: Approximately 17.6% of 131 oral precancer patients have serum GPCA/TGA/TMA
positivity. Only approximately 20% of TGA/TMA-positive oral precancer patients have either
hypothyroidism or hyperthyroidism.

* Corresponding author. Department of Dentistry, National Taiwan University Hospital, No. 1, Chang-Te Street, Taipei, 10048, Taiwan. Fax:
þ02 2389 3853.
E-mail address: hmchen51@ntuh.gov.tw (H.-M. Chen).

https://doi.org/10.1016/j.jfma.2019.05.017
0929-6646/Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1394
Copyright ª 2019, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Introduction
In Taiwan, oral cancer is the fifth leading cause of cancer
death in the whole population and the fourth leading cause
of cancer death in males.1 Oral leukoplakia (OL), oral
erythroleukoplakia (OEL), and oral verrucous hyperplasia
(OVH) are the three common oral precancerous lesions that
may transform into an oral cancer.2e5 The malignant
transformation rate is reported to be 1e7% for homogenous
thick OL, 4e15% for granular or verruciform OL, and
18e47% (28% in average) for OEL.6 Cohort study found that
the risks of developing oral cancer after 20 years of follow-
up are 42.2% for OL and 95.0% for OEL.7 These findings
suggest a higher malignant transformation potential for OEL
lesions than for OL lesions. A retrospective clinical study
showed a malignant transformation rate of 3.1% and a mean
malignant transformation duration of 54.6 months for 324
OVH lesions arising from Taiwanese patients.8 A previous
study also demonstrated a 5-year malignant transformation
rate of 3% for 30 plaque-typed and of 17% for 30 mass-typed
OVH lesions.9 The high malignant transformation rates of
OL, OEL and OVH lesions highlight the importance of early
detection and treatment of these three types of oral pre-
cancerous lesions in Taiwan.
In our oral mucosal disease clinic, patients with atrophic
glossitis, burning mouth syndrome, oral lichen planus
(OLP), recurrent aphthous stomatitis (RAS), and oral sub-
mucous fibrosis (OSF) are frequently encountered and pa-
tients with Behcet’s disease are less commonly
seen.10e20,21-40,41e55 For patients with one of these six
specific diseases, complete blood count, serum iron,
vitamin B12, folic acid, homocysteine, gastric parietal cell
antibody (GPCA), thyroglobulin antibody (TGA), and thyroid
microsomal antibody (TMA, also known as anti-thyroid
peroxidase antibody or anti-TPO antibody) levels are
frequently measured to assess whether these patients have
anemia, hematinic deficiencies, hyperhomocysteinemia,
and serum GPCA, TGA and TMA positivities.10e20,21-40,41e55
Indeed, our previous studies found relatively higher fre-
quencies of blood hemoglobin (Hb), iron, vitamin B12, and
folic acid deficiencies, hyperhomocysteinemia, and serum
GPCA, TGA and TMA positivities in patients with afore-
mentioned six oral mucosal
diseases.10,11,16,18,19,30,31,36,37,42,43
The serum GPCA, TGA and TMA levels were evaluated
because patients with GPCA are more likely to have vitamin
B12 deficiency and pernicious anemia and to develop
autoimmune atrophic gastritis which may subsequently
progress to gastric carcinoma.56e59 Moreover, patients with
TGA and/or TMA may develop autoimmune thyroid disease
and finally result in thyroid dysfunction.52,60 For early
diagnosis and treatment of subsequent diseases, it is very
important to evaluate whether patients with oral
Y.-H. Wu et al.
precancerous lesions (so-called oral precancer patients in
this study) may have GPCA, TGA and TMA in their sera.
In this study, the serum levels of autoantibodies
including GPCA, TGA, and TMA were measured in 131 oral
precancer patients and in 131 healthy control subjects. The
purposes of this study were to assess whether a certain
percentage of oral precancer patients might have serum
GPCA, TGA, and TMA positivities, to evaluate whether oral
precancer patients might have a significantly higher fre-
quency of serum GPCA, TGA, or TMA positivity than healthy
control subjects, to find whether TGA-positive and/or TMA-
positive (TGA/TMA-positive) patients might have thyroid
dysfunction such as hypothyroidism and hyperthyroidism,
and to examine whether the oral habits (including alcohol
drinking, betel quid chewing, and cigarette smoking) might
influence the presence of autoantibodies in sera of 131 oral
precancer patients.
Materials and methods
Subjects
The study group consisted of 131 oral precancer patients
(122 men and 9 women; age range, 25e78 years; mean,
48.6  11.6 years) including 96 (89 men and 7 women; age
range, 27e73 years; mean, 48.4  10.7 years) OL, 26 (24
men and 2 women; age range, 25e78 years; mean,
49.3  15.0 years) OEL, and 9 (9 men; age range, 33e69
years; mean, 47.9  11.0 years) OVH patients. The normal
control group consisted of 131 age- (3 years of each pa-
tient’s age) and sex-matched healthy control subjects (122
men and 9 women; age range, 25e76 years; mean,
48.8  11.6 years). All the patients were seen consecu-
tively, diagnosed, and treated in the Department of
Dentistry, Far Eastern Memorial Hospital, New Taipei City,
Taiwan from 2017 to 2019. They were selected according to
the following criteria: 1) a clinical presentation of oral
mucosal white patches or plaques (OL) that could not be
identified clinically or pathologically as any other oral dis-
ease,2,3 2) combined oral mucosal red and white lesions
(OEL) that could not be diagnosed clinically or pathologi-
cally as any other oral disease,4,5 and 3) single or multiple
elevated oral mucosal verrucous lesions without marginal
induration (OVH) that could not be recognized clinically or
pathologically as any other oral disease.4,5 All of these
clinically-diagnosed OL, OEL, and OVH lesions were
confirmed by histopathological examination of the biopsy
specimens taken from the characteristic part of the OL,
OEL, and OVH lesions at the patient’s first visits, respec-
tively. Histologically, OL lesions were diagnosed as epithe-
lial hyperplasia with either hyperkeratosis or parakeratosis,
when no dysplastic cell was found in the hyperplastic
Autoantibodies in oral precancer patients 1395

epithelium. Furthermore, OL lesions were diagnosed as produced fluorescence at a serum dilution of 10-fold or
mild, moderate or severe dysplasia, when enough more. Moreover, sera were scored as positive for TGA or
dysplastic cells were present in the basal one third, in the TMA when the serum TGA level was greater than 115 IU/mL
basal two thirds, or in more than the basal two thirds but or when the serum TMA level was greater than 34 IU/mL,
not the complete layer of the oral epithelium, respec- respectively.
tively.2,3 Histologically, OEL lesions usually showed mild,
moderate, or severe epithelial dysplasia.4,5 The histological Statistical analysis
criteria for a diagnosis of OVH were: 1) epithelial hyper-
plasia with parakeratosis or hyperkeratosis and verrucous
Comparisons of different serum autoantibody (GPCA, TGA,
surface, and 2) no invasion of the hyperplastic epithelium
or TMA) frequencies between 131 oral precancer patients,
into the lamina propria as compared to adjacent normal
96 OL patients, 26 OEL patients, or 9 OVH patients and 131
oral mucosal epithelium. Mild, moderate or severe
healthy control subjects were performed by chi-square
dysplasia detected in OVH lesions was also recorded.4,5
test. The GPCA, TGA or TMA positive rates between two
However, patients with autoimmune diseases (such as sys-
groups of oral precancer patients with or without alcohol
temic lupus erythematosus, rheumatoid arthritis, Sjogren’s
drinking, betel quid chewing, or cigarette smoking habits as
syndrome, pemphigus vulgaris, and cicatricial pemphigoid),
well as between two groups of chewers or smokers
inflammatory diseases, malignancy, or recent surgery were
consuming different amount or duration of betel quids or
excluded. In addition, all patients with serum creatinine
cigarettes respectively were compared by chi-square or
concentrations indicative of renal dysfunction (men,
Fisher exact test, where appropriate. Comparison of fre-
>131 mM; women, >115 mM) and who reported a history of
quency of patients with different serum TSH levels between
stroke, heavy alcohol use, or diseases of the liver, kidney,
10 TGA/TMA-positive oral precancer patients and 100
or coronary arteries were also excluded. Healthy control
healthy control subjects was also done by chi-square test.
subjects had dental caries, pulpal disease, malocclusion, or
The result was considered to be significant if the P-value
missing of teeth but did not have any oral mucosal or sys-
was less than 0.05.
temic diseases. In addition, none of our oral precancer
patients had taken any prescription medication for their
oral precancerous lesions at least 3 months before entering Results
the study.
Details of patients’ oral habits, including daily/weekly Comparisons of frequencies of serum GPCA, TGA, and TMA
consumption of betel quid, cigarette, and alcohol as well as positivities between 131 oral precancer patients, 96 OL
the duration of these habits, were recorded. Oral pre- patients, 26 OEL patients, or 9 OVH patients and 131
cancer patients were defined as betel quid chewers when healthy control subjects are shown in Table 1. We found
they chew 2 or more betel quids daily for at least one year, that 10.7%, 4.6%, and 8.4% of 131 oral precancer patients
as cigarette smokers when they smoked every day for at and 2.3%, 2.3%, and 2.3% of 131 healthy control subjects
least one year and consumed more than 50 packs of ciga- had the serum GPCA, TGA, and TMA positivities,
rettes per year, and as alcohol drinkers when they drank
more than three days and consumed more than 20 g of pure
alcohol per week for at least one year. The betel quid Table 1 The patient number and frequencies of presence
chewing and cigarette smoking habits were available for all of serum autoantibodies such as gastric parietal cell anti-
131 oral precancer patients, but the alcohol drinking habit body (GPCA), thyroglobulin antibody (TGA), and thyroid
was available for only 77 oral precancer patients. According microsomal antibody (TMA) in 131 oral precancer patients
to above-mentioned definitions, 52 (39.7%) patients were including 96 oral leukoplakia (OL), 26 oral eryth-
betel quid chewers, 87 (66.4%) were smokers, and 42 roleukoplakia (OEL), and 9 oral verrucous hyperplasia (OVH)
(54.5%) were drinkers. The oral habit data for the 131 patients and in 131 age- and sex-matched healthy control
healthy control subjects were not available. subjects.
The blood samples were drawn from 131 oral precancer
Group Autoantibody-positive
patients and 131 healthy control subjects for the mea-
patient number (%)
surement of serum GPCA, TGA, and TMA concentrations.
This study was reviewed and approved by the Institutional GPCA TGA TMA
Review Board at the Far Eastern Memorial Hospital (FEMH Oral precancer patients (n Z 131) 14 (10.7) 6 (4.6) 11 (8.4)
No.: 107116-E). a
P-value 0.012 0.498 0.054
OL patients (n Z 96) 8 (8.3) 5 (5.2) 8 (8.3)
a
Determination of serum gastric parietal cell P-value 0.075 0.416 0.075
antibody, thyroglobulin antibody, thyroid OEL patients (n Z 26) 4 (15.4) 1 (3.8) 2 (7.7)
a
P-value 0.015 0.825 0.411
microsomal antibody, or thyroid stimulating
OVH patients (n Z 9) 2 (22.2) 0 (0) 1 (11.1)
hormone level a
P-value 0.029 0.465 0.615
Healthy control subjects (n Z 131) 3 (2.3) 3 (2.3) 3 (2.3)
GPCA, TGA, TMA, and thyroid stimulating hormone (TSH) a
Comparisons of different serum autoantibody frequencies
levels were measured by the routine tests performed in the
between patients and healthy control subjects by chi-square
Department of Laboratory Medicine, Far Eastern Memorial
test.
Hospital. Sera were scored as positive for GPCA when they
1396
respectively. Oral precancer patients had a significantly
higher frequency of GPCA positivity (P Z 0.012) and a
higher frequency of TMA positivity (P Z 0.054, marginal
significance) than healthy control subjects (Table 1).
Although oral precancer patients also had a higher fre-
quency of TGA positivity (4.6%) than healthy control sub-
jects (2.3%), the difference was not significant. Moreover,
96 OL patients had higher frequencies of GPCA and TMA
positivities (P Z 0.075, marginal significance) than 131
healthy control subjects (Table 1). In addition, both 26 OEL
and 9 OVH patients had a significantly higher frequency of
GPCA positivity (P Z 0.015 and P Z 0.029, respectively)
than 131 healthy control subjects (Table 1).
We also found that parts of oral precancer patients
might have the presence of one, two or three organ-specific
autoantibodies such as GPCA, TGA, and TMA in their sera.
The patient number and frequencies of presence of one,
two or three organ-specific autoantibodies such as GPCA,
TGA, and TMA in 131 oral precancer patients are shown in
Table 2. Of the 131 oral precancer patients, 1 (0.8%), 6
(4.6%), and 16 (12.2%) had the presence of three
(GPCA þ TGA þ TMA), two (GPCA þ TGA, GPCA þ TMA, or
TGA þ TMA), or one (GPCA only, TGA only, or TMA only)
organ-specific autoantibody in their sera, respectively
(Table 2).
In this study, the serum TSH levels were measured in 10
out of 12 TGA/TMA-positive oral precancer patients and in
100 healthy control subjects (Table 3). Ten TGA/TMA-
positive oral precancer patients had a significantly lower
frequency (80%) of patients with serum TSH levels within
the normal range (0.4e4.0 mIU/mL) than that (100%) of 100
healthy control subjects. However, 10.0% and 10.0% of 10
TGA/TMA-positive oral precancer patients had a lower
serum TSH level (<0.4 mIU/mL) and a higher serum TSH
level (>4.0 mIU/mL), respectively (Table 3).
We further investigated whether the oral habits might
influence the presence of autoantibodies in sera of 131 oral
precancer patients. The relations between alcohol drink-
ing, betel quid chewing, or cigarette smoking habit and the
autoantibody positive rates in two different groups of oral
precancer patients are shown in Table 4. We found a
significantly higher GPCA positive rate in 26 smokers
Table 2 The patient number and frequencies of presence
of one, two or three organ-specific autoantibodies such as
gastric parietal cell antibody (GPCA), thyroglobulin anti-
body (TGA), and thyroid microsomal antibody (TMA) in 131
oral precancer patients.
Autoantibodies Patient number (%)
Oral precancer patients (n Z 131)
GPCA þ TGA þ TMA 1 (0.8)
GPCA þ TGA 0 (0)
GPCA þ TMA 2 (1.5)
TGA þ TMA 4 (3.1)
GPCA only 11 (8.4)
TGA only 1 (0.8)
TMA only 4 (3.1)
none 108 (82.4)
Y.-H. Wu et al.
Table 3 The number and percentage of individuals with
different serum levels of thyroid-stimulating hormone (TSH)
in 10 thyroglobulin antibody (TGA)-positive and/or thyroid
microsomal antibody (TMA)-positive (TGA/TMA-positive)
oral precancer patients and in 100 healthy control subjects.
a
TSH TGA/TMA-positive oral Healthy control P-
levels precancer patients subjects value
(n Z 10) (n Z 100)
<0.4 1 (10%) 0 (0%) 0.153
mIU/
mL
0.4e4.0 8 (80%) 100 (100%) 0.001
mIU/
mL
>4.0 1 (10%) 0 (0%) 0.153
mIU/
mL
a
Comparisons of frequencies of patients with lower, normal,
and higher TSH levels between 10 TGA/TMA-positive oral pre-
cancer patients and 100 healthy control subjects by chi-square
test.
consuming >20 cigarettes per day than in 61 smokers
consuming 20 cigarettes per day (P Z 0.008). In addition,
we also discovered a significantly higher TGA positive rate
in 44 non-smokers than in 87 smokers (P Z 0.028, Table 4).
Discussion
This study found that the serum GPCA, TGA, and TMA
positive rates were 10.7%, 4.6%, and 8.4% in 131 oral pre-
cancer patients and 2.3%, 2.3%, and 2.3% in 131 age- and
sex-matched healthy control subjects. These findings indi-
cate that oral precancer patients had a significantly higher
frequency of GPCA and a relatively higher frequency of TMA
(marginal significance) than healthy control subjects. Our
previous study showed that the serum positive rate is 14.7%
for GPCA and 5.5% for TMA in 109 OSF patients.42 We also
demonstrated that the frequencies of serum GPCA, TGA
and TMA positivities are 13.0%, 19.4%, and 19.7% for 355
RAS patients,31 16.7%, 23.3%, and 21.7% for 60 major-typed
RAS patients,31 12.2%, 18.6%, and 19.3% for 295 minor-
typed RAS patients,31 26.3%, 21.3%, and 24.4% for 320 OLP
patients,19 26.7%, 21.2%, and 24.7% for 292 erosive OLP
patients,19 and 39.6%, 46.4%, and 45.1% for 455 erosive OLP
patients with desquamative gingivitis.23 These findings
indicate that for RAS patients, major-typed RAS patients
have relatively higher frequencies of serum GPCA, TGA and
TMA positivities than minor-typed RAS or RAS patients.31
Moreover, for OLP patients, erosive OLP patients with
desquamative gingivitis have relatively higher frequencies
of serum GPCA, TGA and TMA positivities than OLP and
erosive OLP patients.19,23 In addition, for RAS, major-typed
RAS, minor-typed RAS patients, and erosive OLP patients
with desquamative gingivitis, the serum TGA or TMA posi-
tive rate is higher than serum GPCA positive rate.23,31
However, for OLP, erosive OLP, OSF, and oral precancer
patients, the serum GPCA positive rate is higher than serum
TGA or TMA positive rate.19,42 Erosive OLP patients with
Autoantibodies in oral precancer patients 1397

factor (decrease the autoantibody production). Thus, the

Table 4 Comparisons of gastric parietal cell antibody
final serum autoantibody level in a patient was determined
(GPCA), thyroglobulin antibody (TGA) or thyroid microsomal
by the combination effect of gender, environmental, and
antibody (TMA) positive rates between two groups of oral
genetic factors. In our previous study, we found that all OSF
precancer patients with or without alcohol drinking, betel
patients have betel quid chewing habit and 80 (73.4%) of
quid chewing, or cigarette smoking habits as well as be-
109 OSF patients swallow the juice of betel quid into the
tween two groups of chewers or smokers consuming
stomach during the chewing process.42 Because betel quid
different amount or duration of betel quids or cigarettes,
has been shown to contain cytotoxic and genotoxic com-
respectively.
pounds which cause cell death and DNA strand breaks in
Group Autoantibody-positive patient cultured human buccal epithelial cells and fibroblasts.61,62
number (autoantibody In addition, a previous animal study also showed that oral
positive rate) administration of extract of betel nut with lime and to-
GPCA TGA TMA bacco for 5 months can induce gastric ulcers as well as
dysplasia and metaplasia of gastric glands in mice.63
Alcohol drinking (n [ 77)
Therefore, it was possible that betel quid toxic constitu-
Drinker (n Z 42) 4 (9.5%) 0 (0%) 3 (7.1%)
ents might destroy gastric parietal cells. The released
Non-drinker (n Z 35) 2 (5.7%) 1 (2.9%) 4 (11.4%)
a gastric parietal cell autoantigens were picked up by den-
P-value 0.683 0.455 0.695
dritic cells and B cells, processed by these antigen-
Betel-quit chewing (n [ 131)
presenting cells, and further presented to the Th2 cells in
Chewer (n Z 52) 3 (5.8%) 0 (0%) 2 (3.8%)
the lymphatic nodules situated in the lamina propria of the
Non-chewer (n Z 79) 11 (13.9%) 6 (7.6%) 9 (11.4%)
a stomach. By the help of Th2 cells, the antigen-specific and
P-value 0.234 0.108 0.229
activated B cells or plasma cells thus produce high level of
Daily consumption (n Z 52)
GPCA in the local gastric tissues and blood circulation of
>20 quids (n Z 24) 1 (4.2%) 0 (0%) 0 (0%)
OSF patients.42 This explanation indicates that betel quid
20 quids (n Z 28) 2 (7.1%) 0 (0%) 2 (7.1%)
chewing may be a risk factor for the generation of serum
a
P-value >0.999 e 0.493
GPCA in OSF patients.42 However, we also found that for
Duration (n Z 52)
OSF patients the GPCA positive rate is significantly lower in
>10 years (n Z 25) 2 (8.0%) 0 (0%) 1 (4.0%)
50 chewers (6.0%) consuming > 20 quids per day than in 59
10 years (n Z 27) 1 (3.7%) 0 (0%) 1 (3.7%)
chewers (22.0%) consuming  20 quid per day (P Z 0.018),
a
P-value 0.603 e >0.999
in 27 smokers (7.4%) consuming > 20 cigarettes per day
Cigarette smoking (n [ 131)
than in 82 smokers (17.1%) consuming  20 cigarettes per
Smoker (n Z 87) 8 (9.2%) 1 (1.1%) 6 (6.9%)
day (P Z 0.218), and in 51 drinkers (9.8%)
Non-smoker (n Z 44) 6 (13.6%) 5 (11.4%) 5 (11.4%)
a consuming > 270 g of alcohol per week than in 58 drinkers
P-value 0.633 0.028 0.591
(19.0%) consuming  270 g of alcohol per week
Daily consumption (n Z 87)
(P Z 0.177).42 These findings suggest that betel quid,
>20 cigarettes (n Z 26) 6 (23.1%) 0 (0%) 2 (7.7%)
smoking, and alcohol may have some mild protective effect
20 cigarettes (n Z 61) 2 (3.3%) 1 (1.6%) 4 (6.6%)
on the GPCA production in OSF patients. For 131 oral pre-
a
P-value 0.008 >0.999 >0.999
cancer patients in the present study, we found a signifi-
Duration (n Z 87)
cantly higher GPCA positive rate in 26 smokers (23.1%)
>10 years (n Z 80) 7 (8.8%) 1 (1.3%) 5 (6.3%)
consuming > 20 cigarettes per day than in 61 smokers
10 years (n Z 7) 1 (14.3%) 0 (0%) 1 (14.3%)
(3.3%) consuming  20 cigarettes per day (P Z 0.008),
a
P-value 0.504 >0.999 0.405
suggesting that smoking is a risk factor for the GPCA pro-
a
Comparisons of autoantibody positive rates of parameters duction in oral precancer patients. However, we also
between two groups of patients by chi-square or Fisher exact discovered a lower TGA or TMA positive rate in 42 drinkers
test, where appropriate. than in 35 non-drinkers as well as a lower GPCA, TGA, or
TMA positive rate in 52 chewers than in 79 non-chewers and
in 87 smokers than in 44 non-smokers, suggesting that betel
desquamative gingivitis have the highest serum GPCA, TGA, quid and smoking have a mild protective effect on the GPCA
and TMA positive rates, oral precancer patients have the production, and alcohol, betel quid, and smoking possess a
lowest serum GPCA and TGA positive rates, and OSF pa- mild protective effect on the TGA and TMA production in
tients have the lowest serum TMA positive rate.23,42 In oral precancer patients. Because in our previous OSF study
general, patients with different oral mucosal diseases may and in this oral precancer study the sample size is relatively
have different frequencies of serum GPCA, TGA, and TMA small, it may need a large-scale study to clarify whether
positivities. Moreover, the frequencies of serum GPCA, alcohol, betel quid, and smoking are risk factor or protec-
TGA, and TMA positivity seem to have a close association tive factor for the GPCA, TGA, and TMA production in OSF or
with the severity of oral mucosal diseases.19,23,31 oral precancer patients. Actually, enough evidences
The production of organ-specific autoantibodies in sera discover that smoking is associated with a lower prevalence
of patients is associated with gender, environmental factors of serum thyroid autoantibodies, and moderate alcohol
(such as smoking, alcohol, betel quid, and others), and consumption has a protective effect on autoimmune thyroid
genetic factors (HLA-DR and HLA-DQ genes and others). diseases and on the generation of serum TGA and TMA.64e67
Each environmental or genetic factor may be either risk There is a close association of human leukocyte antigen
factor (increase the autoantibody production) or protective (HLA) class II antigen with some human autoimmune
1398
diseases. Higher frequencies of DR3 antigens and of hap-
lotypic pairs A10/DR3 and B8/DR3 have been reported in
OSF patients than in normal control subjects.68 Further-
more, HLA-typing performed by use of the polymerase
chain reaction also shows significantly greater frequencies
of DRB1-11and DRB3-0202/3 in OSF patients than in the
English controls.69 Canniff et al. also discovered a third of
OSF patients with HLA-DR3 antigen.68 Thus, the intimate
association of HLA-DR3 and DRB1-11 (genetic factors) with
OSF patients may partially explain why a small percentage
of OSF patients may have GPCA and TMA in their sera.68,69
Genetic screens identify HLA-DR3, CD40, cytotoxic T
lymphocyte-associated antigen 4 (CTLA-4), protein tyrosine
phosphatase nonreceptor type 22 (PTPN22), and CD 25
genes as susceptibility genes for autoimmune thyroid dis-
eases including Graves’ disease and Hashimoto’s thyroid-
itis. Therefore, those patients with these specific
susceptibility genes may tend to have high levels of TGA or
TMA in their sera. However, the association of some specific
HLA class II antigens and other susceptible or protective
genes for autoimmune thyroid diseases with our oral pre-
cancer patients has not yet been examined. Therefore,
further studies are needed to elucidate the exact mecha-
nisms that may induce part of oral precancer patients to
generate GPCA, TGA and TMA in their sera.
The two major criteria for the diagnosis of chronic
autoimmune thyroiditis are high TSH concentration and the
presence of TGA/TMA in patients’ sera.60 This study
measured the serum TSH levels in 10 oral precancer pa-
tients and found that 8 (80%), 1 (10%), and 1 (10%) oral
precancer patients had normal (suggestive of euthyroid),
lower (suggestive of hyperthyroidism), and higher serum
TSH levels (suggestive of hypothyroidism), respectively. Our
previous studies also quantified the serum TSH levels in
TGA/TMA-positive patients with different kinds of oral
mucosal disease. We found that 85.8%, 4.2%, and 10.0% of
190 TGA/TMA-positive patients (including 83 atrophic
glossitis and 107 burning mouth syndrome patients),52
76.9%, 12.3%, and 10.8% of 65 TGA/TMA-positive RAS pa-
tients,31 84.3%, 6.7%, 9.0% of 210 TGA/TMA-positive des-
quamative gingivitis patients,23 87.5%, 6.3%, and 6.3% of 16
TGA/TMA-positive Behcet’s disease patients,37 and 78.6%,
8.0%, and 13.4% of 373 TGA/TMA-positive atrophic glossitis
patients have normal, lower, and higher serum TSH levels,11
respectively. Moreover, previous community survey studies
discovered that 50%e75% of subjects with TGA/TMA posi-
tivity are euthyroid, 25%e50% have subclinical hypothy-
roidism, and only 5%e10% have overt hypothyroidism.60 The
results of aforementioned studies are comparable and
indicate that the majority of the TGA/TMA-positive oral
mucosal disease patients actually have euthyroid. Only
4.2e12.3% and 6.3e13.4% of TGA/TMA-positive oral
mucosal disease patients have hyperthyroidism and hypo-
thyroidism, respectively.11,23,31,37,52,60
In conclusion, we found that 131 oral precancer patients
had higher frequencies of serum GPCA (10.7% vs. 2.3%,
P Z 0.012), TGA (4.6% vs. 2.3%, P Z 0.498), and TMA (8.4%
vs. 2.3%, P Z 0.054) positivities than 131 healthy control
subjects. Moreover, 16 (12.2%), 6 (4.6%), and 1 (0.8%) oral
precancer patients had the presence of one, two, and three
organ-specific autoantibodies including GPCA, TGA, and
TMA in their sera, respectively. Of 10 TGA/TMA-positive
Y.-H. Wu et al.
oral precancer patients whose serum TSH levels were
measured, 10% and 10% oral precancer patients had higher
(suggestive of hypothyroidism) and lower (suggestive of
hyperthyroidism) serum TSH levels, respectively. As stated
before, without proper early diagnosis and treatment,
GPCA-positive patients are more likely to have vitamin B12
deficiency and pernicious anemia and to develop autoim-
mune atrophic gastritis which may subsequently progress to
gastric carcinoma.56e59 Moreover, TGA/TMA-positive pa-
tients may develop autoimmune thyroid disease and finally
result in thyroid dysfunction.52,60 Those TGA/TMA-positive
oral precancer patients with either hyperthyroidism or hy-
pothyroidism should be referred to endocrinology depart-
ment for further treatment. Moreover, those GPCA-positive
oral precancer patients should be referred to department
of gastroenterology for endoscopic examination of stomach
to check for the presence of autoimmune atrophic gastritis
that can be further treated by medical doctors in that
department. In addition, it needs a long-term follow-up
study to assess whether GPCA-positive oral precancer pa-
tients with or without treatment may develop oral cancer
and/or gastric carcinoma.
Conflicts of interest
The authors have no conflicts of interest relevant to this
article.
Acknowledgements
This study was partially supported by the grant (FEMH-2019-
C-059) of Far Eastern Memorial Hospital, New Taipei City,
Taiwan.
References
1. Cancer registry annual report in Taiwan area. The Executive
Yuan, Taiwan: Department of Health and Welfare; 2017.
2018.
2. Lin HP, Chen HM, Cheng SJ, Yu CH, Chiang CP. Cryogun cryo-
therapy for oral leukoplakia. Head Neck 2012;34:1306e11.
3. Yu CH, Lin HP, Cheng SJ, Sun A, Chen HM. Cryotherapy for oral
precancers and cancers. J Formos Med Assoc 2014;113:272e7.
4. Lin HP, Chen HM, Yu CH, Yang H, Wang YP, Chiang CP. Topical
photodynamic therapy is very effective for oral verrucous hy-
perplasia and oral erythroleukoplakia. J Oral Pathol Med 2010;
39:624e30.
5. Chen HM, Yu CH, Lin HP, Cheng SJ, Chiang CP. 5-Aminolevulinic
acid-mediated photodynamic therapy for oral cancers and
precancers. J Dent Sci 2012;7:307e15.
6. Neville BW, Damm DD, Allen CM, Chi AC. Oral and maxillofacial
pathology. 4th ed. St. Louis: Elsevier; 2016. p. 355e63.
7. Yen AM, Chen SC, Chang SH, Chen TH. The effect of betel quid
and cigarette on multistate progression of oral pre-malignancy.
J Oral Pathol Med 2008;37:417e22.
8. Hsue SS, Wang WC, Chen CH, Lin CC, Chen YK, Lin LM. Malig-
nant transformation in 1458 patients with potentially malig-
nant oral mucosal disorders: a follow-up study based in a
Taiwanese hospital. J Oral Pathol Med 2007;36:25e9.
9. Wang YP, Chen HM, Kuo RC, Yu CH, Sun A, Liu BY, et al. Oral
verrucous hyperplasia: histological classification, prognosis and
clinical implications. J Oral Pathol Med 2009;38:651e6.
Autoantibodies in oral precancer patients
10. Chiang CP, Chang JYF, Wang YP, Wu YC, Wu YH, Sun A.
Significantly higher frequencies of anemia, hematinic de-
ficiencies, hyperhomocysteinemia, and serum gastric parietal
cell antibody positivity in atrophic glossitis patients. J Formos
Med Assoc 2018;117:1065e71.
11. Chiang CP, Chang JYF, Wang YP, Wu YH, Wu YC, Sun A. Gastric
parietal cell and thyroid autoantibodies in patients with atro-
phic glossitis. J Formos Med Assoc 2019;118:973e8.
12. Chiang CP, Chang JYF, Wang YP, Wu YH, Wu YC, Sun A. Anemia,
hematinic deficiencies, and hyperhomocysteinemia in gastric
parietal cell antibody-positive and -negative atrophic glossitis
patients. J Formos Med Assoc 2019;118:565e71.
13. Chiang CP, Chang JYF, Wang YP, Wu YH, Wu YC, Sun A. He-
matinic deficiencies and hyperhomocysteinemia in gastric pa-
rietal cell antibody-positive or gastric and thyroid
autoantibodies-negative atrophic glossitis patients. J Formos
Med Assoc 2019;118:1114e21.
14. Kuo YS, Wu YH, Chang JYF, Wang YP, Wu YC, Sun A. Blood
profile of atrophic glossitis patients with thyroglobulin anti-
body/thyroid microsomal antibody positivity but without
gastric parietal cell antibody positivity. J Formos Med Assoc
2019;118:1218e24.
15. Sun A, Wang YP, Lin HP, Chen HM, Cheng SJ, Chiang CP. Sig-
nificant reduction of homocysteine level with multiple B vita-
mins in atrophic glossitis patients. Oral Dis 2013;19:519e24.
16. Lin HP, Wang YP, Chen HM, Kuo YS, Lang MJ, Sun A. Significant
association of hematinic deficiencies and high blood homo-
cysteine levels with burning mouth syndrome. J Formos Med
Assoc 2013;112:319e25.
17. Sun A, Lin HP, Wang YP, Chen HM, Cheng SJ, Chiang CP. Sig-
nificant reduction of serum homocysteine level and oral
symptoms after different vitamin supplement treatments in
patients with burning mouth syndrome. J Oral Pathol Med
2013;42:474e9.
18. Chen HM, Wang YP, Chang JYF, Wu YC, Cheng SJ, Sun A. Sig-
nificant association of deficiencies of hemoglobin, iron, folic
acid, and vitamin B12 and high homocysteine level with oral
lichen planus. J Formos Med Assoc 2015;114:124e9.
19. Chang JYF, Chiang CP, Hsiao CK, Sun A. Significantly higher
frequencies of presence of serum autoantibodies in Chinese
patients with oral lichen planus. J Oral Pathol Med 2009;38:
48e54.
20. Chang JYF, Chen IC, Wang YP, Wu YH, Chen HM, Sun A. Anemia
and hematinic deficiencies in gastric parietal cell antibody-
positive and antibody-negative erosive oral lichen planus pa-
tients with thyroid antibody positivity. J Formos Med Assoc
2016;115:1004e11.
21. Chang JYF, Wang YP, Wu YH, Su YX, Tu YK, Sun A. Hematinic
deficiencies and anemia statuses in anti-gastric parietal cell
antibody-positive or all autoantibodies-negative erosive oral
lichen planus patients. J Formos Med Assoc 2018;117:227e34.
22. Chang JYF, Wang YP, Wu YC, Wu YH, Tseng CH, Sun A. Hema-
tinic deficiencies and anemia statuses in antigastric parietal
cell antibody-positive erosive oral lichen planus patients with
desquamative gingivitis. J Formos Med Assoc 2016;115:860e6.
23. Chang JYF, Chiang CP, Wang YP, Wu YC, Chen HM, Sun A.
Antigastric parietal cell and antithyroid autoantibodies in pa-
tients with desquamative gingivitis. J Oral Pathol Med 2017;
46:307e12.
24. Kuo RC, Lin HP, Sun A, Wang YP. Prompt healing of erosive oral
lichen planus lesion after combined corticosteroid treatment
with locally injected triamcinolone acetonide plus oral pred-
nisolone. J Formos Med Assoc 2012;112:216e20.
25. Sun A, Chang JYF, Chiang CP. Examination of circulating serum
autoantibodies and hematinics is important for treatment of
oral lichen planus. J Formos Med Assoc 2017;116:569e70.
26. Lin HP, Wang YP, Chia JS, Sun A. Modulation of serum anti-
thyroglobulin and anti-thyroid microsomal autoantibody
1399
levels by levamisole in patients with oral lichen planus. J
Formos Med Assoc 2011;110:169e74.
27. Lin HP, Wang YP, Chia JS, Sun A. Modulation of serum antinu-
clear antibody levels by levamisole treatment in patients with
oral lichen planus. J Formos Med Assoc 2011;110:316e21.
28. Wu KM, Wang YP, Lin HP, Chen HM, Chia JS, Sun A. Modulation
of serum smooth muscle antibody levels by levamisole treat-
ment in patients with oral lichen planus. J Formos Med Assoc
2013;112:352e7.
29. Chiang CP, Chang JYF, Wang YP, Wu YH, Lu SY, Sun A. Oral
lichen planus e differential diagnoses, serum autoantibodies,
hematinic deficiencies, and management. J Formos Med Assoc
2018;117:756e65.
30. Sun A, Chen HM, Cheng SJ, Wang YP, Chang JYF, Wu YC, et al.
Significant association of deficiency of hemoglobin, iron,
vitamin B12, and folic acid and high homocysteine level with
recurrent aphthous stomatitis. J Oral Pathol Med 2015;44:
300e5.
31. Wu YC, Wu YH, Wang YP, Chang JYF, Chen HM, Sun A. Anti-
gastric parietal cell and antithyroid autoantibodies in patients
with recurrent aphthous stomatitis. J Formos Med Assoc 2017;
116:4e9.
32. Wu YC, Wu YH, Wang YP, Chang JYF, Chen HM, Sun A. Hema-
tinic deficiencies and anemia statuses in recurrent aphthous
stomatitis patients with or without atrophic glossitis. J Formos
Med Assoc 2016;115:1061e8.
33. Wu YH, Chang JYF, Wang YP, Wu YC, Chen HM, Sun A. Anemia
and hematinic deficiencies in anti-gastric parietal cell
antibody-positive and enegative recurrent aphthous stomatitis
patients with anti-thyroid antibody positivity. J Formos Med
Assoc 2017;116:145e52.
34. Lin HP, Wu YH, Wang YP, Wu YC, Chang JYF, Sun A. Anemia and
hematinic deficiencies in anti-gastric parietal cell antibody-
positive or all autoantibodies-negative recurrent aphthous
stomatitis patients. J Formos Med Assoc 2017;116:99e106.
35. Chiang CP, Chang JYF, Sun A. Examination of serum hema-
tinics and autoantibodies is important for treatment of
recurrent aphthous stomatitis. J Formos Med Assoc 2018;117:
258e60.
36. Kuo YS, Chang JYF, Wang YP, Wu YC, Wu YH, Sun A. Signifi-
cantly higher frequencies of hemoglobin, iron, vitamin B12,
and folic acid deficiencies and of hyperhomocysteinemia in
patients with Behcet’s disease. J Formos Med Assoc 2018;117:
932e8.
37. Lin HP, Wu YH, Chang JYF, Wang YP, Chen HM, Sun A. Gastric
parietal cell and thyroid autoantibodies in patients with Beh-
cet’s disease. J Formos Med Assoc 2018;117:505e11.
38. Wu YH, Chang JYF, Wang YP, Wu YC, Chen HM, Sun A. Gastric
parietal cell and thyroid autoantibodies in Behcet’s disease
patients with or without atrophic glossitis. J Formos Med Assoc
2018;117:691e6.
39. Wu YH, Chang JYF, Wang YP, Wu YC, Chen HM, Sun A. Hemo-
globin, iron, vitamin B12, and folic acid deficiencies and
hyperhomocysteinemia in Behcet’s disease patients with
atrophic glossitis. J Formos Med Assoc 2018;117:559e65.
40. Chiang CP, Wu YH, Chang JYF, Wang YP, Wu YC, Sun A. He-
matinic deficiencies and hyperhomocysteinemia in gastric pa-
rietal cell antibody-positive or gastric and thyroid
autoantibodies-negative Behcet’s disease patients. J Formos
Med Assoc 2019;118:347e53.
41. Chiang CP, Wu YH, Chang JYF, Wang YP, Chen HM, Sun A. Serum
thyroid autoantibodies are not associated with anemia, he-
matinic deficiencies, and hyperhomocysteinemia in patients
with Behcet’s disease. J Dent Sci 2018;13:256e62.
42. Chiang CP, Hsieh RP, Chen THH, ChangYF, Liu BY, Wang JT,
et al. High incidence of autoantibodies in Taiwanese patients
with oral submucous fibrosis. J Oral Pathol Med 2002;31:
402e9.
1400
43. Wang YP, Wu YC, Cheng SJ, Chen HM, Sun A, Chang JYF. High
frequencies of vitamin B12 and folic acid deficiencies and
gastric parietal cell antibody positivity in oral submucous
fibrosis patients. J Formos Med Assoc 2015;114:813e9.
44. Chiang CP, Chang JYF, Wu YH, Sun A, Wang YP, Chen HM. He-
matinic deficiencies and anemia in gastric parietal cell
antibody-positive and -negative oral submucous fibrosis pa-
tients. J Dent Sci 2018;13:68e74.
45. Sun A, Wang YP, Lin HP, Jia JS, Chiang CP. Do all the patients
with gastric parietal cell antibodies have pernicious anemia?
Oral Dis 2013;19:381e6.
46. Sun A, Chang JYF, Wang YP, Cheng SJ, Chen HM, Chiang CP. Do
all the patients with vitamin B12 deficiency have pernicious
anemia? J Oral Pathol Med 2016;45:23e7.
47. Chang JYF, Wang YP, Wu YC, Cheng SJ, Chen HM, Sun A. He-
matinic deficiencies and pernicious anemia in oral mucosal
disease patients with macrocytosis. J Formos Med Assoc 2015;
114:736e41.
48. Sun A, Chang JYF, Wang YP, Cheng SJ, Chen HM, Chiang CP.
Effective vitamin B12 treatment can reduce serum anti-gastric
parietal cell antibody titer in patients with oral mucosal dis-
ease. J Formos Med Assoc 2016;115:837e44.
49. Wu YC, Wang YP, Chang JYF, Cheng SJ, Chen HM, Sun A. Oral
manifestations and blood profile in patients with iron defi-
ciency anemia. J Formos Med Assoc 2014;113:83e7.
50. Wang YP, Chang JYF, Wu YC, Cheng SJ, Chen HM, Sun A. Oral
manifestations and blood profile in patients with thalassemia
trait. J Formos Med Assoc 2013;112:761e5.
51. Lin HP, Wu YH, Wang YP, Wu YC, Chang JYF, Sun A. Anemia and
hematinic deficiencies in gastric parietal cell antibody-positive
and enegative oral mucosal disease patients with micro-
cytosis. J Formos Med Assoc 2017;116:613e9.
52. Wang YP, Lin HP, Chen HM, Kuo YS, Lang MJ, Sun A. Hemo-
globin, iron, and vitamin B12 deficiencies and high blood ho-
mocysteine levels in patients with anti-thyroid autoantibodies.
J Formos Med Assoc 2014;113:155e60.
53. Chang JYF, Wang YP, Wu YC, Cheng SJ, Chen HM, Sun A. He-
matinic deficiencies and anemia statuses in oral mucosal dis-
ease patients with folic acid deficiency. J Formos Med Assoc
2015;114:806e12.
54. Chang JYF, Wang YP, Wu YC, Cheng SJ, Chen HM, Sun A. Blood
profile of oral mucosal disease patients with both vitamin B12
and iron deficiencies. J Formos Med Assoc 2015;114:532e8.
55. Sun A, Chang JYF, Chiang CP. Blood examination is necessary
for oral mucosal disease patients. J Formos Med Assoc 2016;
115:1e2.
Y.-H. Wu et al.
56. Lo CC, Hsu PI, Lo GH, Lai KH, Tseng HH, Lin CK, et al. Impli-
cations of anti-parietal cell antibodies and anti-Helicobacter
pylori antibodies in histological gastritis and patient
outcome. World J Gastroenterol 2005;11:4715e20.
57. Lee HW, Hahm KB, Lee JS, Ju YS, Lee KM, Lee KW. Association
of the human leukocyte antigen class II alleles with chronic
atrophic gastritis and gastric carcinoma in Koreans. J Dig Dis
2009;10:265e71.
58. Taylor KB, Roitt IM, Doniach D, Coushman KG, Shapland C.
Autoimmune phenomena in pernicious anemia: gastric anti-
bodies. BMJ 1962;2:1347e52.
59. Lahner E, Annibale B. Pernicious anemia: new insights from a
gastroenterological point of view. World J Gastroenterol 2009;
15:5121e8.
60. Dayan CM, Daniels GH. Chronic autoimmune thyroiditis. N Engl
J Med 1996;335:99e107.
61. Sundqvist H, Liu Y, Nair J, Battsch H, Grafstrom RC. Cytotoxic
and genotoxic effect of areca nut-related compounds in
cultured human buccal epithelial cells. Cancer Res 1989;49:
5294e8.
62. Jeng JH, Kuo ML, Hahn LJ, Kuo MYP. Genotoxic and non-
genotoxic effects of betel quid ingredients on oral mucosal
fibroblasts in vitro. J Dent Res 1994;73:1043e9.
63. Sen S, Talukder G, Sharma A. Potentiation of betel-induced
alterations of mouse glandular stomach mucosa by tobacco in
studies simulating betel addiction. Int J Crude Drug Res 1987;
25:209e15.
64. Dong YH, Fu DG. Autoimmune thyroid disease: mechanism,
genetics and current knowledge. Eur Rev Med Pharmacol Sci
2014;18:3611e8.
65. Belin RM, Astor BC, Powe NR, Ladenson PW. Smoke exposure is
associated with a lower prevalence of serum thyroid autoan-
tibodies and thyrotropin concentration elevation and a higher
prevalence of mild thyrotropin concentration suppression in
the third National Health and Nutrition Examination Survey
(NHANES III). J Clin Endocrinol Metab 2004;89:6077e86.
66. Romeo J, Wärnberg J, Nova E, Dı́az LE, Gómez-Martinez S,
Marcos A. Moderate alcohol consumption and the immune
system: a review. Br J Nutr 2007;98(Suppl. 1):S111e5.
67. Effraimidis G, Wiersinga WM. Mechanism in endocrinology:
autoimmune thyroid disease: old and new players. Eur J
Endocrinol 2014;170:R241e52.
68. Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: its
pathogenesis and management. Br Dent J 1986;160:429e34.
69. Saeed B, Haque MF, Meghji S, Harris M. HLA-typing in oral
submucous fibrosis. J Dent Res 1997;76:1024 [Abstract].