## 1 Introduction  
Human Papillomavirus infections are now implicated in the etiology of six cancers, including a subset of head and neck squamous cell carcinomas, specifically oropharyngeal cancers (OPCs) [1]. Although a safe and effective vaccine prevents over 90% of oncogenic HPV infections [2], only 62.6% of the adolescents aged 13-17 were up to date with the HPV vaccine nationally [3], which is well below the Healthy People 2030 target of 80% [4]. It is projected that a decreased incidence of HPV-related head and neck cancers may not be evident until 2045, when the disease pattern may change and be more common among older and unvaccinated individuals [5].  
Given that HPV drives the majority of OPC cases, promoting HPV vaccination is a critical public health priority and is not solely the responsibility of physicians. Dentists, who routinely engage with adolescents through frequent and consistent patient interactions, are uniquely positioned to contribute significantly to vaccination advocacy and delivery. Dental visits provide excellent opportunities to gather patient vaccination data, deliver targeted educational interventions, and refer for or administer vaccinations, thereby promoting both oral and overall health. Advocacy of HPV vaccination as a cancer prevention strategy is endorsed by the American Academy of Pediatric Dentistry (AAPD) [6] and the American Dental Association (ADA) [7].  
Previous studies have explored dental professionals' knowledge, attitudes, and barriers regarding HPV vaccination. A survey of 208 parents on the knowledge and awareness of the HPV vaccine showed that most parents were comfortable with their child receiving counseling about HPV (68%) and HPV vaccinations (73%) from a dentist [8]. The literature reports on several studies assessing dental provider knowledge, barriers to promoting HPV vaccination, and the willingness to administer HPV vaccines if allowed by law [9; 10; 11; 12; 13]. A mixed-methods study [9] indicated that the majority of dental hygiists (78%) were not comfortable talking about the HPV vaccine with parents of their teenage patients. An extensive survey of 623 oral health professionals, including dental and dental hygiene students, showed that the majority would be willing to administer the HPV vaccine if permitted by law [11]. An online survey of licensed dentists in Indiana showed that 58% of dentists would offer vaccination if permitted by law; the percentage was higher among dentists working in federally qualified centers and academic institutions [12]. A common finding in these studies conducted in different states is the need to develop tailored continuing education for dental providers. In the United States, efforts are expanding toward authorizing dentists to administer vaccines. For example, dentists in Indiana, Kentucky, Louisiana, Mississippi, New Jersey, and Oregon can administer any vaccine, and in Massachusetts, dentists and dental hygiists can vaccinate patients [14]. Despite these insights, parental acceptance of HPV vaccination, specifically in dental school settings in the U.S., remains understudied.  
To help improve HPV immunization coverage in Texas, the Texas Medical Association implemented evidence-based programs to help increase HPV vaccination rates [15]. More recently, the University of Texas MD Anderson Cancer Center funded 12 projects to support new initiatives, including HPV vaccination in dental offices, to increase awareness and improve vaccine uptake [16]. The present study addresses this research gap by assessing pediatric dental patients' HPV vaccination status within a dental academic institution, evaluating parents' willingness to initiate or complete HPV vaccination in a dental setting, and categorizing reasons for parental refusal. The goal is to identify critical intervention points and barriers to optimizing HPV vaccination uptake through enhanced interdisciplinary collaborations and tailored educational strategies, thereby contributing to a reduction in HPV-related cancer incidences.