Common causes of human mitochondrial diseases are mutations affecting DNA polymerase (Pol) ␥, the sole polymerase responsible for DNA synthesis in mitochondria. Although the polymerase and exonuclease active sites are located on the catalytic subunit Pol ␥A, in holoenzyme both activities are regulated by the accessory subunit Pol ␥B. Several patients with severe neurological and muscular disorders were reported to carry the Pol ␥A substitutions R232G or R232H, which lie outside of either active site. We report that Arg 232 substitutions have no effect on independent Pol ␥A activities but show major defects in the Pol ␥A-Pol ␥B holoenzyme, including decreased polymerase and increased exonuclease activities, the latter with decreased selectivity for mismatches. We show that Pol ␥B facilitates distinguishing mismatched from base-paired primer termini and that Pol ␥A Arg 232 is essential for mediating this regulatory function of the accessory subunit. This study provides a molecular basis for the disease symptoms exhibited by patients carrying those substitutions.Ever since the discovery of the first mitochondrion-associated disease, mitochondrial dysfunctions have been implicated in a wide range of clinical disorders (reviewed by Wallace (1)). Major causes of the dysfunction are mutations on mitochondrial DNA (mtDNA) 2 and/or the DNA polymerase (Pol ␥). Pol ␥ mutations clinically manifest different onset times and multisystem disorders (2, 3). Although there is a clear phenotypegenotype association, the molecular or structural basis for many mutations is unknown.Mitochondrial DNA codes for a subset of components for ATP synthesis via the oxidative phosphorylation electron transfer chain and is maintained by Pol ␥. Reduced Pol ␥ activity leads to depletion of mtDNA and impairment of cellular metabolism. Human Pol ␥ is a heterotrimeric holoenzyme of two subunits: a catalytic subunit, Pol ␥A, which contains polymerase and exonuclease activities, and a dimeric accessory subunit, Pol ␥B. Although it has no known independent function, Pol ␥B alters Pol ␥A activity by increasing its processivity (4, 5). Pol ␥B is known to suppress the exonuclease activity of the holoenzyme (6, 7). The genes for both Pol ␥A (POLG) and Pol ␥B (POLG2), and other components of the mitochondrial replisome) are encoded in the nucleus, and the protein products are transported into mitochondria. Humans heterozygous for POLG may therefore have multiple forms of Pol ␥ holoenzyme in each mitochondrion.Neurological disorders associated with mutations affecting Pol ␥A often present different clinical symptoms (for an overview, see Ref. 8). Pol ␥A is the most commonly affected gene in both dominant and recessive progressive external ophthalmoplegia (a disorder characterized by slow paralysis of external eye muscle and exercise intolerance), as well as Alpers syndrome. A patient who died at 6 months of age was found to carry an arginine to glycine substitution at position 232 (R232G) on one chromosomal copy of Pol ␥A and the double substitution T251I/P5...