In the Internet era, with the widespread application of digital technology, the way people travel has changed. Compared with traditional taxis, more and more people prefer to choose online car-hailing. The rapid development of the online car-hailing industry has solved the problem of taxi-hailing to a certain extent, but it has also brought some new problems. To change the dilemma of the online car-hailing industry, it is necessary to strengthen the regulation of the online car-hailing industry. In this study, we consider the regulatory system composed of a local government and an enterprise and use the differential game to study the regulation of online car-hailing. In the Nash non-cooperative game, Stackelberg master–slave game, and cooperative game, we, respectively, investigate the indicators, such as the optimal regulatory effort of the government, the optimal regulatory effort of the enterprise, the optimal benefit function of the government, the optimal benefit function of the enterprise, the optimal benefit function of the system, the optimal trajectory of the service quality level for the enterprise, and the optimal trajectory of the goodwill for the enterprise. Moreover, we analyze the corresponding conclusions through examples. We obtained some important results. (i) In the Stackelberg master–slave game, the optimal ratio of the local government subsidy to the enterprise's regulatory cost is only related to the benefit distribution coefficient and has nothing to do with other factors. Moreover, when the benefit distribution coefficient is >1/3, the local government is willing to share the regulatory cost of the enterprise. Otherwise, the local government refuses to share the regulatory cost of the enterprise. (ii) Compared with the Nash non-cooperative game, the optimal regulatory effort of the local government remains unchanged in the Stackelberg master–slave game, but the optimal benefit of the local government increases. Moreover, when the benefit distribution coefficient is >1/3, both the optimal regulatory effort and the optimal benefit of the enterprise increase. (iii) Compared with the Stackelberg master–slave game, in the cooperative game, the optimal regulatory effort of both government and enterprise increases, and the system's optimal benefit also increases. (iv) From the Nash non-cooperative game to the Stackelberg master–slave game and then to the cooperative game when the benefit distribution coefficient is >1/3, the service quality level and goodwill of the enterprise all increase. The rapid development of the Internet has had a huge impact on many aspects of society, such as economic development, environmental regulation and protection, energy consumption, people's health, and university students' academic achievement  and an enterprise (E). On this basis, we study the regulation of online car-hailing. The local government strengthens regulation of online car-hailing platforms through some means, such as strengthening administrative management and identifying barriers to entry. The enterprise regulates online car-hailing through some means, such as verifying the criminal background and driving records of online car-hailing drivers.Assumption 1: Referring to the assumption of effort cost for quality control in Hong and Huang  and CE(t) represent the regulatory cost of the local government and the enterprise at time t. KG and KE represent the cost coefficients of regulatory effort for the local government and the enterprise. KG > 0, KE > 0. EG(t) and EE(t) represent the regulatory effort of the local government and the enterprise at the time t.respectively, where Assumption 2: The service quality level of the enterprise is a dynamic process and is jointly determined by the regulatory effort of the local government and the enterprise. On the one hand, the local government strengthens regulation of online car-hailing platforms through some means, such as strengthening administrative management and identifying barriers to entry. Under strong regulation of the government, the platform can effectively restrain the behavior of online car-hailing. Thus, the service quality level of the enterprise can be improved. On the other hand, the enterprise regulates online car-hailing through some means, such as verifying the criminal background and driving records of online car-hailing drivers. Thus, the life and property safety of passengers can be protected, and the service quality level of the enterprise can be improved. Referring to the assumption of the service quality level for the enterprise in Wu et al.  represents the service quality level of the enterprise at time t, and the initial service quality level K(0) = K0 ≥ 0. μG and μE, respectively, represent the influence coefficients of the regulatory effort of the local government and the enterprise on the service quality level of the enterprise. μG > 0, μE > 0. δ represents the attenuation coefficient of the service quality level for the enterprise.where Assumption 3: The goodwill of the enterprise is simultaneously positively affected by the regulatory effort and the service quality level of the enterprise. Considering the natural attenuation of the goodwill for the enterprise, we adopt the deformation of the goodwill model in Nerlove and Arrow (nd Arrow  to repreG(t) represents the goodwill of the enterprise at the time t, and the initial goodwill G(0) = G0 ≥ 0. α and β represent the influence coefficients of the enterprise's regulatory effort and service quality level on the goodwill. α > 0, β > 0. ϕ represents the attenuation rate of the enterprise goodwill, which is usually caused by the launch of new products and consumers' forget, and ϕ > 0.where Assumption 4: The regulatory effort of the local government has an indirect impact on the benefit, while the regulatory effort, service quality level, and goodwill of the enterprise have a direct impact on the benefit. Therefore, it is assumed that the total benefit of the regulation for the government-enterprise online car-hailing iswhere φ represents the potential benefit when the enterprise does not invest effort in regulation, and φ > 0. γ represents the influence coefficient of the degree of regulatory effort of the enterprise on the benefit, and γ > 0. τ and θ, respectively, represent the influence coefficients of the service quality level and goodwill on the benefit. τ > 0, θ > 0.Assumption 5: To encourage the enterprise to take the initiative to implement regulatory strategies, the local government as the leader of the regulatory system should subsidize the regulatory cost of the enterprise. The ratio of the local government subsidy to the enterprise's regulatory cost is S(t), and 0 ≤ S(t) < 1, which implies that the government only bears part of the regulatory cost of the enterprise.Assumption 6: It is assumed that the total benefit of the regulation for the government-enterprise online car-hailing is shared by both parties. The local government gets ω and the enterprise gets 1 − ω, where ω is the benefit distribution coefficient. Moreover, ω is determined in advance by both parties and ω ∈ .Assumption 7: The local government and the enterprise have the same discount rate ρ > 0. They seek the optimal regulatory strategy to maximize their own benefit in an infinite time zone.Assumption 8: Since the relevant parameters in the model are time-independent, then the government and enterprise are playing the same game at any time in an infinite period. The optimal strategies of the government and the enterprise are determined by a static feedback control strategy. For the convenience of writing, the time t will be omitted in the following text.S(t) = 0. The Nash non-cooperative game is denoted by a superscript N, then the decision-making problems of the local government and the enterprise areIn the Nash non-cooperative game, the local government and the enterprise make decisions independently at the same time to maximize their own benefit. At this time, the local government will not provide any regulatory subsidy for the enterprise, that is, Proposition 1: In the Nash non-cooperative game, the optimal regulatory effort of the local government isand the optimal regulatory effort of the enterprise isProof: According to the optimal control theory, for any K, G ≥ 0, both EG and setting the partial derivative equal to zero, we getTaking the first-order partial derivative of the function on the right-hand side of (5) with respect to EE and setting the partial derivative equal to zero, we getTaking the first-order partial derivative of the function on the right-hand side of (6) with respect to Substituting (7) and (8) into (5), we obtainSubstituting (7) and (8) into (6), we obtainK and G are, respectively, as follows:According to the structures of (9) and (10), it is assumed that the linear analytical expressions of the optimal benefit functions m1, m2, m3 and r1, r2, r3 are parameters to be determined. Substituting (11) and (12) into (9), we obtain the following results through the method of undetermined coefficientswhere Substituting (11) and (12) into (10), we obtain the following results through the method of undetermined coefficientsQ.E.D.Substituting (13) into (7), we obtain the optimal regulatory effort of the local government as shown in (3). Substituting (16) and (17) into (8), we obtain the optimal regulatory effort of the enterprise as shown in (4).      Proposition 2: In the Nash non-cooperative game, the optimal benefit function of the local government isthe optimal benefit function of the enterprise isand the optimal benefit function of the system iswhere Proof: Substituting (13), (14), (16), and (17) into (15), we obtainSubstituting (13), (16), and (17) into (18), we obtainQ.E.D.Substituting (13), (14), and (22) into (11), we obtain the optimal benefit function of the local government as shown in (19). Substituting (16), (17), and (23) into (12), we obtain the optimal benefit function of the enterprise as shown in (20). Furthermore, we obtain the optimal benefit function of the system as shown in (21).      Proposition 3: In the Nash non-cooperative game, the optimal trajectory of the service quality level for the enterprise isand the optimal trajectory of the goodwill for the enterprise iswhereProof: Substituting (3) and (4) into (1), we getSubstituting (4) and (24) into (2), we getQ.E.D.By solving the differential equation (26), we can obtain the optimal trajectory of the service quality level for the enterprise as shown in (24). By solving the differential equation (27), we can obtain the optimal trajectory of the goodwill for the enterprise as shown in (25).      S(t). Second, the enterprise decides its own regulatory effort according to the regulatory effort of the local government. From a long-term dynamic perspective, the local government and the enterprise form the Stackelberg non-cooperative game, which is denoted by superscript D. At this time, the decision-making problems of the local government and enterprise areIn the Stackelberg master–slave game, the local government is the leader of the government-enterprise regulation of online car-hailing, and the enterprise is the follower of the government-enterprise regulation of online car-hailing. To stimulate the enterprise to invest more in regulation, the local government is willing to share some of the regulatory costs of the enterprise. The decision-making process is as follows: First, the local government decides its own regulatory effort and the ratio Proposition 4: In the Stackelberg master–slave game, the optimal regulatory effort of the local government isthe optimal ratio of the local government subsidy to the enterprise's regulatory cost isand the optimal regulatory effort of the enterprise isProposition 5: In the Stackelberg master–slave game, the optimal benefit function of the local government isthe optimal benefit function of the enterprise isand the optimal benefit function of the system iswhere EE. Second, we take the first-order partial derivative of the optimal benefit function EG and S, respectively. The proof of Proposition 4 (Proposition 5) is similar to that of Proposition 1 (Proposition 2), so it is omitted here.Proposition 4 and Proposition 5 can be proved through the method of backward induction. First, we take the first-order partial derivative of the optimal benefit function Proposition 6: In the Stackelberg master–slave game, the optimal trajectory of the service quality level for the enterprise isand the optimal trajectory of the goodwill for the enterprise iswhereThe proof of Proposition 6 is similar to that of Proposition 3, so it is omitted here.C. At this time, the decision problem of the system isIn the cooperative game, the local government and the enterprise make joint decisions to maximize the system benefit. The cooperative game is denoted by superscript Proposition 7: In the cooperative game, the optimal regulatory effort of the local government isand the optimal regulatory effort of the enterprise isProposition 8: In the cooperative game, the optimal benefit function of the system iswhere Proposition 9: In the cooperative game, the optimal trajectory of the service quality level for the enterprise isand the optimal trajectory of the goodwill for the enterprise iswhereThe proof of Proposition 7 (Proposition 8 and Proposition 9) is similar to that of Proposition 1 (Proposition 2 and Proposition 3), so it is omitted here.In the “Nash Non-cooperative Game” section, we obtain the optimal regulatory effort of the local government, the optimal regulatory effort of the enterprise, the optimal trajectory of the service quality level for the enterprise, the optimal trajectory of the goodwill for the enterprise, the optimal benefit function of the government, the optimal benefit function of the enterprise, and the optimal benefit function of the system under different game scenarios. In this section, we compare these results and draw some important conclusions.Corollary 1: (1) The optimal regulatory effort of the local government satisfies Since the regulatory effort of the local government has nothing to do with whether it provides the regulatory cost subsidy to the enterprise, we know that the optimal regulatory effort of the local government remains unchanged in the Stackelberg master–slave game compared with the Nash non-cooperative game. In the cooperative game, the regulatory activities of the local government and the enterprise as a whole are complementary. So the optimal regulatory effort of both local government and enterprise increases in the cooperative game compared with the Stackelberg master–slave game.When the benefit distribution coefficient is Corollary 2: (1) When KN*(t) < KD*(t) < KC*(t); (2) When GN*(t) < GD*(t) < GC*(t).According to Corollary 2, we know that when the benefit distribution coefficient is Corollary 3: (1) The optimal benefit function of the local government satisfies Compared with the Nash non-cooperative game, in the Stackelberg master–slave game, the optimal benefit of the local government increases. Furthermore, when the benefit distribution coefficient is Corollary 4: When Compared with the Nash non-cooperative game, in the Stackelberg master–slave game, when the benefit distribution coefficient is In this section, MatlabR2018a is used to carry out a numerical simulation on Corollary 2 and Corollary 4. In different game scenarios, the service quality level of the enterprise, the goodwill of the enterprise, and the system benefit all depends on the setting of model parameters. The benchmark parameters are set as follows:G = 0.8, μE = 0.8, δ = 0.2, α = 1, β = 0.5, ϕ = 0.3, φ = 2, γ = 1, τ = 0.5, θ = 0.5, KG = 1, KE = 1, ρ = 0.3, K0 = 0, G0 = 0.μLet Let Let Considering the simple regulatory system composed of the local government and the enterprise, we establish differential game models to study the regulation of online car-hailing in the era of the sharing economy. We calculate some indicators, such as the optimal regulatory effort of the local government, the optimal regulatory effort of the enterprise, the optimal benefit function of the local government, the optimal benefit function of the enterprise, the optimal benefit function of the system, the optimal trajectory of the service quality level for the enterprise, and the optimal trajectory of the goodwill for the enterprise. Moreover, we compare these indicators under different game scenarios. Combining numerical simulations, we can draw the following important conclusions:In the Stackelberg master–slave game, the optimal ratio of the local government subsidy to the enterprise's regulatory cost is only related to the benefit distribution coefficient ω and has nothing to do with other factors. Furthermore, when Compared with the Nash non-cooperative game, in the Stackelberg master–slave game, the optimal regulatory effort of the local government remains unchanged, while the optimal benefit of the local government increases. Furthermore, when Compared with the Stackelberg master–slave game, both the local government and enterprise aim to maximize the system benefit in the cooperative game. So when the benefit distribution coefficient In this study, it is assumed that the regulatory system is composed of a local government and an enterprise. However, in reality, there is often a complicated relationship between the government and enterprises. Therefore, we further consider the regulatory system composed of one government and multiple enterprises with competitive or cooperative relationships and study the regulation of online car-hailing in the future.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.MY was responsible for conceptualization and methodology of the manuscript. YL was responsible for software and investigation of the manuscript. LS and DW were responsible for writing of the manuscript. XL was responsible for supervision, project administration, and validation of the manuscript. All authors contributed to the manuscript and approved the submitted.This study was funded by the National Natural Science Foundation of China (11801352 and 71701122).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The proportion of HPV16 and 18-associated cervical cancer (CC) appears rather constant worldwide (≥70%), but the relative importance of the other HR-HPV differs slightly by geographical region. Here, we studied the HPV genotype distribution of HPV positive Latin American (LA) women by histological grade, in a sub-cohort from the ESTAMPA study; we also explored the association of age-specific HPV genotypes in severe lesions. Cervical samples from 1,252 participants  were genotyped by two PCRs-Reverse Blotting Hybridization strategies: i) Broad-Spectrum General Primers 5+/6+ and ii) PGMY9/11 PCRs. HPV16 was the most frequently found genotype in all histological grades, and increased with the severity of lesions from 14.5% in ≤ CIN1, 19.8% in CIN2, 51.5% in CIN3 to 65.1% in CC (p < 0.001). For the remaining HR-HPVs their frequency in CC did not increase when compared to less severe categories. The nonavalent vaccine HR-types ranked at the top in CC, the dominant ones being HPV16 and HPV45. HR-HPV single infection occurs, respectively, in 57.1% and 57.0% of ≤CIN1 and CIN2, increasing to 72.2% and 91.6% in CIN3 and CC (p<0.001). No association between age and HPV type was observed in CC, although the risk of HPV16 infection in CIN3 cases increased with age. Results confirm the relevance of HPV16 in the whole clinical spectrum, with a strong rise of its proportion in CIN3 and cancer. This information will be relevant in evaluating the impact of HPV vaccination, as a baseline against which to compare genotype changes in HPV type-specific distribution as vaccinated women participate in screening in LA region. Likewise, these data may help select the best HPV testing system for HPV-based efficient, affordable, and sustainable screening programmes. Human papillomaviruses (HPVs) are a large and diverse group of viruses comprising more than 230 fully characterized types, even though new HPV types are still being reported , 2. AmonThe International Agency for Research on Cancer (IARC) classifies twelve HPV genotypes as carcinogenic (HR-HPV) , while HPV68 is probably carcinogenic (probable HR-HPV) (Group 2A) and HPVs 26, 53, 66, 67, 69, 70, 73 and 82 are possibly carcinogenic (possible HR-HPV) (Group 2B); the so-called LR-HPV types  strongly evidence that they do not cause cancer (Group 4) Reviewers' comments:Reviewer's Responses to Questions  Comments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?  The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********  2. Has the statistical analysis been performed appropriately and rigorously?   Reviewer #1: YesReviewer #2: Yes**********  3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.  The Reviewer #1: YesReviewer #2: Yes**********  4. Is the manuscript presented in an intelligible fashion and written in standard English?  PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********  5. Review Comments to the Author  Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The study reported HPV genotyping results from 1252 LA women with positive HPV test and cervical biopsy findings. These data may help to evaluate screening strategies and the impact of HPV vaccination.Some comments:1. The participants include 854 cases of ≤CIN1. I agree it is easy to analyze the data to reduce the group numbers. However, it is interesting to know the HPV genotyping results in cases with negative biopsy and CIN1, separately. I suggest authors divide the 854 cases into two groups for analysis.2. Table 2 includes 5 groups, HPV16/18, other HR-HPV, Possibly HR-HPV, LR-HPV, negative. Many cases showed multiple HPV infections. The last row shows the numbers: 854, 121, 194, 83, all with 100%. I assume HPV16/18 group includes the cases with some other HPV infection (multiple); other HR-HPV group with no HPV 16/18; LR-HPV with no any other HR-HPV et al. Suggest the authors to explain details.3. Based the study design all the precipitants were HPV positive. I do not understand why these 138 women  had negative HPV testing in table 2.4. Overall, more than 20% cases had multiple HPV infections. I assume that Table 3 showed the prevalence of any hrHPV Genotype (single or multiple). It is great if the authors list also the prevalence of single hrHPV genotype, which can demonstrate individual HPV effect on cervical lesions.Reviewer #2: In the study ”Distribution of human papillomavirus genotypes by severity of cervical lesions in HPV screened positive women from the ESTAMPA study in Latin America.”, the authors are presenting the results of HPV genotyping of an impressive number of women.The used genotyping HPV assays are not commercially, clinically validated, but participating at HPV DNA typing proficiency panel, and IARC collaboration also, are a proof of high-quality assessment of samples.The results are necessary to sustain in this area also, the replacement of Pap smear with HPV genotyping for cervical cancer screening, which together with vaccination could lead to CC elimination.**********  6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.  Reviewer #1: NoYes: Ramona Gabriela UrsuReviewer #2: https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.
 While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  7 Jul 2022REBUTTAL LETTERDear Editor and Reviewer 1, First, the authors would like to thank the Editor and Reviewer1 for the time spent evaluating our manuscript, and the valuable comments made that helped improve it. Responses to Reviewer 1:1- The participants include 854 cases of ≤CIN1. I agree it is easy to analyze the data to reduce the group numbers. However, it is interesting to know the HPV genotyping results in cases with negative biopsy and CIN1, separately. I suggest authors divide the 854 The meta-analysis reported by Guan et al showed no clear difference in the HR-type distribution between HPV-positive normal cytology and CIN1, also that the CIN1 diagnoses had limited usefulness for risk-stratification of HPV-positive women; so CIN1 would predominantly be a “proxy” for HPV infection rather than a true cancer precursor . On the other hand, the genotypes that we identified in samples of women with “negative colposcopy/biopsy” and “CIN1” were similar. For such reasons, we initially put together these two categories in the same group (≤CIN1), and we would prefer to keep it that way.Nevertheless, we found the reviewer's suggestion interesting, so we decided to include a supplementary table in the support information (Table S1) where Table 2 appears with the ≤CIN1 group broken down into 2 groups: “negative colposcopy/ biopsy” and “CIN1”. Therefore, in RESULTS, a new sentence was added:Lines 210-212: “No substantial differences were observed in the prevalence of HPV genotype risk-based groups when distinguishing between colposcopy/biopsy negative and CIN1 diagnoses (Table S1)”2 - Table 2 includes 5 groups, HPV16/18, other HR-HPV, Possibly HR-HPV, LR-HPV, negative. Many cases showed multiple HPV infections. The last row shows the numbers: 854, 121, 194, 83, all with 100%. I assume HPV16/18 group includes the cases with some other HPV infection (multiple); other HR-HPV group with no HPV 16/18; LR-HPV with no any other HR-HPV et al. Suggest the authors to explain details.The reviewer interpreted correctly. To further clarify the description already included in MATERIAL AND METHODS , we added a phrase (highlighted in yellow in the revised manuscript) as follows:Lines 175- 181: “The five groups were mutually exclusive; participants were included in a single risk-based group following a hierarchical rule described as follows: (i) HPV16/18 included the participants positive for HPV16 and/or HPV18 (both in single and multiple infections) (ii) other HR-HPV included those positive for any genotype in the group without HPV16/18, (iii) possibly HR-HPV included those positive for any genotype in the group without HPV16/18 or other HR-HPV infections (iv) LR-HPV included those participants positive for any genotype in the group without any of the previous infections.” 3- Based on the study design all the precipitants were HPV positive. I do not understand why these 138 women  had negative HPV testing in table 2.As the Reviewer says, this study included women who had been HPV positive by a screening test (HC2 or Cobas HPV) performed on the first PreservCyt Vial 1 (first cytobrush obtained). In a second cytobrush, obtained subsequent to the previous one , genotyping was performed by PCR-RBH, which allows the identification of 37 HPV genotypes . In 138 samples, no HPV genotype was detected. This has been previously described by other authors .The DISCUSSION presents the possible reasons that justify this result, as follows:Lines 388-396: “We found 11% of samples (mostly in women diagnosed with ≤CIN1) that were HPV-positive at screening (predominantly by HC2 test), but not in HPV genotyping. It should be considered that the PCR-RBH genotyping was performed in vial 2, which could have had fewer cells than vial 1 in which the HPV screening test was performed. However, it cannot be ruled out that these discrepant results could be false positives or represent cross-reactions with non-carcinogenic HPV types. Others also reported this drawback of the HC2 test . Moreover, two studies have found that increasing the cut-off level from the FDA-approved of 1.0 to 2 or 3 relative light units (RLU/Co ratio) greatly decreases the HPV prevalence among women with normal cytology or mild cytological abnormalities and reduces screening’s false positive results .4- Overall, more than 20% cases had multiple HPV infections. I assume that Table 3 showed the prevalence of any HR-HPV Genotype (single or multiple). It is great if the authors list also the prevalence of single HR-HPV genotype, which can demonstrate individual HPV effect on cervical lesions. We have accepted the Reviewer´s suggestion. We added a new phrase in MATERIAL AND METHODS  and RESULTS as follows:  Line 185-187: “In addition, the frequency and prevalence of HR-HPV genotypes within each histologic group for single infections were also computed, thus restricting the analysis to those women whose sample was positive for only one HPV genotype ”Lines 238-239: “Similar results were found when considering the participants with a single infection”.We also added a supplementary table (Table S3) in the support information section, which shows individual HPV effect on the analyzed groups.Responses to Editor:1. Please ensure that your manuscript meets PLOS ONE's style requirements. The style requirements were met.2. Please review your reference list to ensure that it is complete and correctReferences were revised.3. Please update your submission to use the PLOS LaTeX templateAccording to instructions sent to us by Glenn Jackson (Production Editor), our revised manuscript was created using Word and submitted in PDF format (Revised Manuscript with Track Changes).4. Thank you for stating the following in the Acknowledgments Section of your manuscript: "The authors are obliged to all gynaecologists, pathologists, nurses, and technician who have contributed to the collection of samples analysed in this study. This research has been partially supported by IARC (CRA-PRI), Instituto Nacional del Cáncer (Argentina) and Agencia Nacional de Promoción de la Investigación, el Desarrollo Tecnológico y la Innovación (Argentina) (Grant No. 0364-2016 to MAP)." It was removed from Acknowledgments Section  We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscriptCurrently, your Funding Statement reads as follows: "Yes - Rol: María Alejandra Picconi (MAP) PI- Colaborative research agreement (IARC CRA-PRI) to MAP -Instituto Nacional del Cancer (Argentina) 2016 to MAP- Agencia Nacional de Promocion de la Investigacion , el Desarrollo Tecnologico y la Innovacion (Grant No. 0364-2016 to MAP)The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."Current Funding Statement is OK5. One of the noted authors is a group or consortium ESTAMPA Study Group. In addition to naming the author group, please list the individual authors and affiliations within this group in the acknowledgments section of your manuscript. Please also indicate clearly a lead author for this group along with a contact email address.ESTAMPA Study Group members were listed in the ACKNOWLEDGMENTS section as follows: LINES 419-440: “The team is thankful to all women who participated in this study.ESTAMPA Study Group: Valeria Mariel Padín, Servicio Virus Oncogénicos, Laboratorio Nacional y Regional de Referencia de HPV, Instituto Nacional de Enfermedades Infecciosas- ANLIS "Dr. Malbrán", Buenos Aires, Argentina; Juan Mural, Alicia Inés Figueredo, María Alejandra Borelli, Paula Gabriela Falabella, Natalia Gabriela Kaznowiecki, Servicio Ginecología, Hospital Nacional “Prof. Posadas”, El Palomar, Argentina; Sandra García, Adrián Moreno, Julieta Guyot, Melisa Alejandra Lencioni, Nerina Cattarin, Mariano Quinteiro, Servicio Anatomía Patológica, Hospital Nacional “Prof. Posadas”, El Palomar, Argentina; Ana Peraza González, Hospital México, Caja Costarricense de Seguro Social, San José, Costa Rica; Marisol Brizuela Hernandez, Centro Nacional de Citologías, Caja Costarricense de Seguro Social, San José, Costa Rica; Emmanuel González Solano, Hospital Dr. Enrique Baltodano, Caja Costarricense de Seguro Social, San José, Costa Rica; Carlos Sosa Quesada, Hospital Monseñor Víctor Manuel Sanabria, Caja Costarricense de Seguro Social, San José, Costa Rica; Rolando Pinastel Monet and Ricci Fernández Hidalgo, Área de Salud Barranca, Caja Costarricense de Seguro Social, San José, Costa Rica; Johanna González Arias, Área de Salud San Rafael de Puntarenas, Caja Costarricense de Seguro Social, San José, Costa Rica; Yessi Cabrera, Instituto de Investigaciones en Microbiología, Universidad Nacional Autónoma de Honduras, Tagucigalpa, Honduras; María Isabel Rodriguez, Malvina Paez, Amalia Castro, Claudia Centurión, Romina Báez, Jaime Vester, Instituto de Investigaciones en Ciencia de la Salud, Universidad Nacional de Asunción, Paraguay; Ana Soilán, Hospital Nacional de Itauguá y Hospital Materno Infantil de San Lorenzo, Ministerio de Salud Pública y Bienestar Social, Asunción, Paraguay; Marina Ortega, Hospital Nacional de Itauguá, e Instituto Nacional del Cáncer, Ministerio de Salud Pública y Bienestar Social, Asunción, Paraguay; Carmen Cristaldo, Hospital Nacional de Itauguá, Ministerio de Salud Pública y Bienestar Social, Asunción, Paraguay. oncovir@anlis.gob.ar”Lead author for this group; Valeria Mariel Padín. Email: Authors´comments to the Editor:1) Based on Reviewer 1's suggestions, we have added 2 supplementary tables. So, taking into account their order of appearance in the text, we should to renumber the supplementary tables.2) Some authors are members of the International Agency for Research on Cancer / World Health Organization; for this reason, they have to include a disclaimer statement. Due to we did not know where put it, we decided to add it in ACKNOWLEDGMENTS section, as follows:  LINES 441-444: “Where authors are identified as personnel of the International Agency for Research on Cancer / World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer / World Health Organization.”AttachmentResponse to Reviewers.pdfSubmitted filename: Click here for additional data file. 15 Jul 2022Distribution of human papillomavirus genotypes by severity of cervical lesions in HPV screened positive women from the ESTAMPA study in Latin America.PONE-D-22-10439R1Dear Dr. Correa,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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The IJPH series “Young Researcher Editorial” is a training project of the Swiss School of Public Health.Cervical cancer was designated a global health priority by the World Health Organization in 2018. Though preventable, cervical cancer is expected to affect 700,000 women and claim 400,000 lives annually by 2030. The human papillomavirus (HPV) is responsible for over 90% of cervical cancers, and 14 high-risk HPV (hrHPV) genotypes have been identified. Of these, HPV16 and HPV18 are involved in 70% of cervical cancers . However, in low- and middle-income countries (LMICs), adopting HPV extended genotyping can be challenging. Besides affordability, the capacity to conduct nucleic acid–based tests and quickly deliver results is an issue . A countEmerging technologies that expand HPV genotyping beyond HPV16/18 open the doors for developing clinical guidelines that improve cervical cancer outcomes. Expanded genotyping should allow us to stratify patients by genotype-specific risk of precancers or cancers and limit invasive procedures to those who need them. It will also reveal epidemiological trends in the evolution of HPV, providing data required to inform HPV vaccination policies. Though it may be difficult to implement these new technologies in LMICs, some of these barriers may be surmounted if governments can establish strategic partnerships among public, private, and non-governmental sectors.


Human papilloma virus (HPV) infection could be considered a social disease, both for its high incidence, especially in younger subjects, and for the risk of neoplastic evolution linked to viral infection. Therefore, the National Health System, in collaboration with the state, must help women to understand the oncological risk of HPV and suitable methods of prevention. We conducted an Italian monocentric survey on HPV risk information as part of cervical cancer screening. An anonymous questionnaire was administered to 200 women with high-risk positive HPV and low-grade cervical lesions during second-level cervical cancer screening at the Gynecology and Obstetrics Unit of the “San Paolo” Hospital. From this survey, the need to improve communication for patients has emerged, as currently it is not exhaustive. In response to this need, organizational changes have been implemented to centralize the moment of counseling in the second levels of screening and to improve the training of health workers in level I as well as family doctors. In addition, psychological support was also proposed to patients who requested it, as was the dissemination of material such as that produced by GISCI  and updated in May 2018, which provides 100 answers to questions on HPV in order to achieve effective and comprehensive communication. This investigation requires further development, and the expansion of this investigation to the multicenter level is already underway. Therefore, this survey will represent a cornerstone for further discussion on the topic considering the necessity of appropriate communication in the oncological context. Human papillomavirus (HPV) infection is widely described as the most common virus in the uterine cervix cells, and high oncogenic risk genotypes 16 and 18 are the main players involved in tumor progression with a percentage of over 70% in the literature , which vAn anonymous questionnaire  was admiThe main patients’ clinical characteristics are reported in p-value < 2 × 10−16), with answering “no” to questions 1, 2, 3 and 16 being strongly associated with the group of patients that found themselves to be not appropriately informed about HPV  and colposcopy  and the presence of a clinician able to provide extensive information  increased the chance that a patient was appropriately informed .Thus, a multivariate logistic model was fitted considering the above-mentioned variables. The independent variables were the knowledge of colposcopy and the amount of information provided by the clinician .HPV screening is available to the entire population as a first-level test within territorial health structures ,30.The HPV test has a higher detection rate compared to cytology, which is now performed as a second step in patients identified as being high-risk  ,32,33,34In addition, there could be further integration of communication through the posting of iconographic material, to be posted in the dedicated screening centers both to better explain the evolution of the HPV-related dysplastic pathology  and to sIn addition, to date there are national and official information systems, provided by the GISCI  and updated in May 2018, which illustrate the collection of 100 answers to questions on HPV, whose content could be disseminated both on paper and electronically ,49. In aThe care of communication with the patient in medicine is fundamental. Therefore, the use of tools to facilitate understanding of the oncogenic risk related to HPV infection can change the evolution of the disease. Consequently, its use must be sensitized, and doctors and paramedical staff must be adequately trained. Consequently, this study represents a first step to bring back “the voice of patients”, which expresses the need for greater care in communication, and new projects may arise. In particular, this document could be a valid support tool in schools and educational centres for sensitizing women, mothers and daughters to this problem by informing them of the opportunities available to them or encouraging them to learn more. Indeed, vaccine prevention in women who have not yet had sexual intercourse may hold the key to eradicating HPV-related cervical cancer. With the same objective, it could be an integral part of brochures or information material to be distributed during awareness campaigns or days dedicated to HPV screening. Finally, the possibility should also be considered that this questionnaire could be a useful tool as psychological support within medical clinics or could even become a dissemination tool through the creation of dedicated and controlled online pages or institutional communications.


Human Papilloma Virus (HPV) infection and the occurrence of neoplastic transformations within oral, pharyngeal, and anal cancers. Other segments of the intestinal tract can also be involved. Knowledge about the association between HPV infection and gastrointestinal carcinogenesis is crucial for both cancer prevention and patient care. Unfortunately, definite conclusions cannot be drawn yet, due to the high number of contradictions in the published papers.Mounting evidence suggests a relationship between Human Papilloma Virus (HPV) is one of the most common sexually transmitted infections worldwide. HPV infection has a strong relationship with the onset of cervix uteri, vagina, penis, anus, and oropharynx, but also tonsils and tongue cancers. Some epidemiological data indicate that except for gynecologic cancers, HPV infection can be one of the risk factors associated with a greater risk of induction and progression of gastrointestinal cancers. Data, however, remain contradictory and definite conclusions cannot be drawn, so far. The following review aims to organize recent evidence and summarize the current state of knowledge regarding the association between HPV infection and gastrointestinal tumors primarily focusing on esophageal, liver, gastric, colorectal, and anal cancers. Human Papilloma Virus (HPV) belongs to the group of DNA viruses and Papovaviridae family, constituting a group of 174 characterized and documented types with the newest species being constantly discovered [Helicobacter pylori (H. pylori) [Epstein–Barr Virus (EBV), for instance, might be crucial in the development of this malignancy [scovered . Accordiscovered . On the scovered . It is escovered . Except scovered ,9. Appro pylori) ,11,12. Llignancy   is representative of the Papillomaviridiae family having a double-stranded circular DNA genome with a virion size of approximately 55 nm in diameter [diameter . To datediameter . The inddiameter . Alpha-pdiameter . Mucosaldiameter . HPV is diameter . Usuallydiameter . In 2018diameter . Of thesdiameter . Across diameter . HPV-16 diameter . Overalldiameter . Most andiameter . HPV infdiameter . Viral tdiameter ,28. The diameter . Among mdiameter . Concerndiameter . Interesdiameter .Concerning gastrointestinal tract (GIT) cancers, they accounted for 26% of new cancer cases worldwide and 35% of all cancer-related deaths in 2018, with the highest prevalence of colon cancer (1.8 million new cases) . Based oE) and late polyadenylation sites (pAL) [The HPV genome consists of three major functional regions including early, late, and long control regions, which are separated by early (pAes (pAL) . The eares (pAL) ,34. The es (pAL) . HPV gaies (pAL) . It is bes (pAL) . After tes (pAL) . Low-copIn the 1980s, the first reports of the possibility of HPV-induced cell transformation appeared and the greatest importance was assigned to the E7 gene encoding a protein of the same name ,42,43,44In addition to well-known E7 protein-transforming properties, it was quickly noticed that similar characteristics were exerted by the E6 protein encoded by different types of human papillomaviruses. E6 can bind to the p53 protein, which, in turn, correlates with in vitro-transforming activity and in vivo clinical behavior . The degApoptosis, as a process of programmed cell death, is one of the most important cellular processes that regulates the quantity of cells. Several tumors can inhibit apoptosis, thereby preventing cell death and allowing the cells to multiply uncontrollably. The E6 and E7 oncoproteins produced by HPV interfere with apoptotic processes. The E6 protein leads to the degradation of the pro-apoptotic Bak protein ,88. It aAnother mechanism responsible for the neoplastic transformation of many human tissues is related to the downregulation of miRNA, non-coding small RNAs that are posttranscriptional mRNA regulators . In one Concerning human papillomavirus detection, the determination of anti-HPV antibodies is of limited diagnostic value as they may persist for many years and their presence does not distinguish between past and present infection ,115. In p < 0.001) and EAC  [p = 0.048). Regarding the TP53 aberrations, in the HPV-positive EAC group, they were absent, whilst 50% of the HPV-negative patients with EAC tended to exhibit the TP53 mutations. The results indicate different biological mechanisms of tumor formation regarding HPV-positive and HPV-negative EAC [Esophageal cancer is currently the 10th most commonly diagnosed cancer worldwide, with an estimated number of 604,100 cases, being, at the same time, the 6th most common cause of cancer-related deaths with an estimated number of 544,076 deaths . Esophag< 0.001) . Based otive EAC . In the tive EAC . The reltive EAC . Esophagtive EAC . Randomitive EAC . Bognar tive EAC . TherefoPrimary liver cancer constitutes the 6th most prevalent cancer, as well as the 3rd leading cause of cancer death worldwide in 2020, with approximately 906,000 new cases and 830,000 deaths reported. Primary liver cancer includes hepatocellular carcinoma (HCC)  and intrahepatic cholangiocarcinoma (10–15%); other liver cancers constitute those of rare types ,140. ChrSmoking is another predisposing factor for HCC . The HPVH. pylori [H. pylori has been classified as a class I carcinogen by the World Health Organization. It directly inflames gastric mucosa and causes epigenetic effects on individual cells [H. pylori infection, EBV constitutes the second most relevant viral factors associated with the onset of GC. EBV-associated gastric carcinoma (EBVaGC) constitutes about 10% of all gastric carcinomas. The recruitment of the EBV-infected B-lymphocytes in the vicinity of gastric epithelia is primarily induced because the inflammation of the stomach will and might eventually increase the frequency of EBV infection of the epithelia [2 = 95.0%, p < 0.001). HPV detection in the cells of GC precursor lesions (gastric dysplasia or adenoma) constitutes the only possibility to confirm any relationships [Gastric cancer (GC) is responsible for over one million new cases along with an estimated number of 769,000 deaths in 2020 . GC is a. pylori ,153. The. pylori . Conside. pylori ,156. It al cells . Except pithelia ,159; in pithelia . It was pithelia . Snieturpithelia . On the pithelia . A meta-ionships . Based oWith respect to colorectal cancer (CRC), risk factors such as age over 50–60, genetic syndromes, adenomatous polyps of the colon, inflammatory bowel disease, and hereditary familial history of CRC were determined. It may also occur due to lifestyle and environmental factors including quality of nutrition, obesity, smoking, alcohol abuse, and many more ,165. HowCurrently used HPV vaccines tuned out to be effective in preventing intraepithelial neoplasia of the cervix, vulva, vagina, and anus, which are related to HPV type 16 and 18 . It was Anal cancer is a rare malignancy that accounts for approximately 3% of all gastrointestinal cancers. According to current data, it is estimated that in 2020, 50,865 new cases and 19,293 deaths occurred worldwide . DespiteThere is a close relationship between the development of anal cancer and HPV infection. Statistics show that 91% of all anal cancers are associated with this pathogen and 79% are caused only by the HPV-16 and HPV-18 subtype . SubtypeThe virus penetrates the transformation zone located in the rectal columnar mucosa, distal to the dentate line, and escalates proximally from the squamocolumnar junction . The iniThere are several risk factors for anal cancer such as older age, smoking, or immunosuppression. However, the greatest risk is seen in individuals who have multiple sexual partners and practice promiscuous sexual behaviors .Globally, 5% of all human cancers are attributable to HPV, including cervical, other anogenital, as well as head and neck cancers. Together, they pose a serious problem of 630,000 new cancer cases per year worldwide . HPVs arAs it comes to pathogenesis, HPV infects the basal epithelial cells, which may occur in microlesions of the skin or mucosa. The entry of the virus and its genome into the nucleus of the infected cell is possible due to the attachment of L1 and L2 capsid proteins to epithelial cell receptors . E6 and Fortunately, HPV prophylactic vaccines, which are based on recombinantly expressed virus-like particles (VLPs), were found to be effective at preventing infection and neoplastic disease . AccordiHPV vaccines development started at the beginning of the early 1990s. Currently, there are three available HPV vaccines including bivalent Cervarix, quadrivalent Gardasil, and nonavalent Gardasil9. Cervarix protects against two high-risk types, HPV 16 and 18, while Gardasil is also directed against two low-risk types, HPV 6 and 11. Gardasil9 targets the four HPV types  that are in the quadrivalent HPV vaccine and five additional oncogenic types including type 31, 33, 45, 52, and 58 . AdditioPersistent HPV infection targets immune signaling as well as tumor suppression pathways, eventually leading to the induction of oncogenic promotion in the form of tumors primarily located within the cervix, vulva, head and neck, and anus. Although HPV infection is mostly recognized as being associated with gynecologic tumors, the increasing amount of research also suggests its association with GI cancers; amongst these, most of the data concern anal cancer, indicating a clear relationship between HPV infection and the possible induction and progression of anal cancerous lesions. HPV infection is most likely to facilitate the worsening of the course of other concomitant infections  that, together with other coexisting infections by highly oncogenic bacteria and viruses, might include precancerous alterations, ultimately leading to cancer. The aspect of concomitant viral and bacterial diseases that are potentially oncogenic is crucial regarding the discussion about the potential oncogenic effects of HPV infection and its association with GI cancers. Based on the current state of knowledge, the relationship between HPV infection and the onset of esophageal, liver, colorectal, and gastric cancer cannot be clearly established, due to many contradictory research data. What should further be evaluated as well is the association between HPV vaccination and the risk of GI cancers as, except for gynecological cancers, it was suggested that the HPV vaccine might also minimize the risk of CRC. Nevertheless, much research suggests strong evidence for a potential association between HPV infection and either the induction or progression of GI cancers, which should be further evaluated via more research with improved methodological tools and on the greatest number of patients as possible.


Human wellbeing has been linked with lifestyle factors such as physical activity, diet balance, sleep quality, depression, and anxiety. However, few studies illustrate the relationship between such lifestyle factors and HPV infection. In this study, we investigated the association between lifestyle factors, age, disease status and HPV infection.Participants were recruited through a digital eHealth platform in Shenzhen, Mainland China. Both lifestyle factors and cervicovaginal mucus (CVM) samples to test for HPV outcomes were collected from each participant as a cross-sectional study. In addition, the eHealth platform recorded age and current or history diseases, which were adjusted to apply for both univariable and multivariable logistic regression. Furthermore, lifestyle factors were categorized as different levels to conduct stratification analysis.We recruited 149 HPV positive and 346 HPV negative participants through HPV detection. Physical activity and diet balance were significantly associated with HPV infection in lifestyle factors  after adjusting for age and current or history diseases. However, stratified analysis showed three factors were insignificant for HPV infection – namely, sleep quality, depression, and anxiety. Most HPV infections involved a sole HPV serotype (83%), and diet balance was the most significant difference between sole and multiple HPV infections.Among lifestyle factors, physical inactivity or diet imbalance can significantly increase HPV infection risk. In particular, diet balance might be related to the number of HPV serotypes. Our results suggest that exercising and regulating diet may reduce the risk of HPV infection. Lifestyle factors is important for both population and individual level to achieve the optimal health, appropriate bodyweight and reducing the gynecological cancer burden in global , 2. TheyThough epidemiological research has shown that a diet balance is associated with decreasing cancer mortality , 8, relaHowever, relatively few studies have focused on connecting these lifestyle factors with HPV infection or HPV persistent infections, which is the common cause for most cervical cancers . HPV infTo clearly elucidates the hypothesis between lifestyle factors and HPV infection, we collected the standard questionnaires of lifestyle factors and adjust for the potential confounders of age and other current or history diseases like STDs. The possible mechanisms might monocyte engagement or cell immunity for physical activity –20. In dThis study was approved by the ethics committee of the Institutional Review Board at Beijing Sports University. From May 2021 to August 2021, study population were registered through the digital eHealth platform from Shenzhen in Mainland China, as a cross-sectional study. The inclusion criteria were nonpregnant and nonlactating women for eligible participants. They were also unvaccinated for HPV but had sexual experience at least once in their lifetime. The enrolled participants have not been tested for HPV in the past 12 months and willing to accept the free SeqHPV  testing services. Our team explained the study objectives and obtained signed informed consent from participants to collect questionnaires.Once participants enrolled this research, they received a mailed package consisting of a nylon conical brush and graphic user instructions of SeqHPV. Participants were required to collect cervicovaginal mucus (CVM) samples by rotating brush and smear samples onto a Flinders Technology Associates (FTA) card. Participants were provided with a package and free express delivery to send their FTA cards to the laboratory. Personalized online guidance was offered if participants had any queries about sampling or delivery.After the samples were returned to the laboratory, each FTA card was suspended in 5ml PreservCyt media in order for each self-sample to be sequenced for HPV (seqHPV) testing. The main bioinformatic workflows and pipelines have been described in the literature under the same kit as well as methodology . These tvia weekly live streaming while regularly providing advice for participants.A digital eHealth platform tool was developed on May 2020 to record age, lifestyle factors through the standard questionnaires and strategies, and disease status. Physical activity was monitored through the International Physical Activity Questionnaire (IPAQ) and could be beneficial for cancer control. Diet balance, sleep quality, depression and anxiety were recorded by the Diet Balance Index (DBI), Pittsburgh Sleep Quality Index (PSQI), Patient Depression Questionnaire-9 (PDQ-9), and Generalized Anxiety Disorder 7 (GAD-7) respectively. In addition, the digital eHealth platform provided information on HPV prevention courses Physical activity was scored in three groups for low level, moderate level, and high-level. Based on IPAQ in The preliminary demographics were reported for two groups – one HPV-positive and the other HPV-negative. For the two groups, we summarized the continuous variables of age and lifestyle factors scores with both mean and standard deviation. Disease statuses were summarized as categorical variables with numbers and percentages. Differences were compared using the Wilcoxon rank sum test for continuous variables  and the To compare and assess the effect of HPV serotype, we differentiated the three risk groups for HPV infection as hrHPV (high-risk HPV), irHPV (intermediate-risk HPV) and lrHPV (low-risk HPV). We also enumerated the number of serotypes 1 ~ 4 from participants. For one serotype (sole) and 2 ~ 4 serotypes (multiple), physical activity and diet balance scores were tested by the Wilcoxon sum rank. All analysis was conducted utilizing R software (4.0.4) for the Macintosh Operating System (Mac OS).via our digital eHealth tool with 149 HPV positive and 346 HPV negative women , depression (1.92 vs 2.27) and anxiety (2.75 vs 2.92). However, their statistical power reduced to 0.593 and 0.330 with P-value = 0.01.Among lifestyle behavior scores, there were statistically significant results for physical activity, diet balance, sleep quality, and depression. According to the cross-sectional study, HPV positive had the higher scores than HPV negative group on physical activities (14.36 vs 12.83) and diet balance (25.44 vs 17.29), which the higher scores indicate the unhealthier lifestyle factors. They have a statistical power of 0.998 and over 0.999 respectively with To evaluate the association of risk factors for HPV infection, both univariate and multivariate logistic regression were performed for one demography factor, seven disease status factors, and five lifestyle factors Table 2.P-values < 0.01 from univariate logistic regression, and P-values < 0.001 from multivariate logistic regression. Though patients with high level had the less likelihood of being infected when compared with the moderate level group, it was not statistically significant for P-value = 0.22 from univariate logistic regression, and P-value = 0.132 from multivariate logistic regression  among the lifestyle factors.To adjust for the potential confounders, our pilot study has already summarized 32 clinical factors with finding the possible confounders age as well as history of reproductive tract infection . Hence, Our statistical analysis shed light on the most significant lifestyle factors. To decrease HPV infection risk through physical activity, stratification analysis reported the many benefits of high level physical activity. Potential reasons may include a decrease in monocyte engagement in the preinvasive tumor microenvironment (TME) causing a depletion in tumor-associated macrophages (TAMs) , 32; or in vivo  was much easier to infect HPV than almost no problem diet balance. This may be explained by the reduced intake levels of vitamin A or lycopene for low level of under intake of diet balance in vivo , 34. Thein vivo . Therefoin vivo . Beyond P-values: 0.160 ~ 0.652) and multivariable logistic regression  based on data collected from our eHealth platform.After adjusting for confounders, three lifestyle factors  were shown to be insignificant in relation to HPV infection based on univariable and multivariable logistic regression. Moreover, HPV infection does not appear to be associated with 7 current or history diseases, whether current or history, as validated by univariable  was comparable with HPV negative participants (41.56 ± 8.51). This age range is also the one in which women experience a high risk for HPV infection. Another strength was how the digital eHealth platform enabled participants to fill in their information electronically st China , UK 39)via theirst China  and AustThere are three limitations to our study. First, other lifestyle factors might affect common HPV clearance risk, such as sexual behavior, smoking, or alcohol consumption. However, our study focused on determining whether the lifestyle factors belong to HPV infection factors. Other studies have shown that HPV infection factors are different from clearance factors. To response the clearance factors, we have already designed the prospective follow-up study systematically. Second, our study locations consisted of more well-off areas such as Shenzhen, where there is greater opportunity for abundant physical activity and dietary resources. A more comprehensive study would expand to other locations such as second-line cities or even the countryside in order to reduce geographical bias. To address this issue, our next formal study will focus on areas that encompass a broader scale, from less economically developed to more economically developed.This study suggests that both physical activity and diet balance are significantly beneficial lifestyle factors to reduce HPV infection risk. However, our current evidences showed there were no significant association for another three lifestyle factors as sleep quality, depression, and anxiety. Though we recommend that regular exercise and regulating one’s diet balance might reduce the risk of HPV infection, it still requires the further evidence to intervene HPV persistent infection or further disease progression through the related randomized controlled trials.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Beijing Sports University (2021173H). The patients/participants provided their written informed consent to participate in this study.YL and ZY designed the project and carried out this study. AW found this project. ZY and ML analyzed the data and prepared the manuscript. YJ helped to draft the manuscript and provided the substantial suggestions to improve the manuscript. In addition, WW revised the manuscript together. YL collected the dataset and AW helped to obtain approval from the relevant ethics committees. All authors contributed to the article and approved the submitted version.


Oral papilloma lesions may appear as a result of HPV infection, or not, and only special molecular methods could differentiate them. Low-risk and high-risk HPV types could induce oral HPV papillomatosis with different natural evolution, clearance and persistence mechanisms. The pathogenic mechanisms are based on the crosstalk between the oral epithelial and immune cells and this very efficient virus. HPV acts as a direct inducer in the process of transforming a benign lesion into a malignant one, the cancerization process being also debated in this paper. According to the degree of malignity, three types of papillomatous lesions can be described in the oral cavity: benign lesions, potential malign disorders and malignant lesions. The precise molecular diagnostic is important to identify the presence of various virus types and also the virus products responsible for its oncogenicity. An accurate diagnostic of oral papilloma can be established through a good knowledge of etiological and epidemiological factors, clinical examination and laboratory tests. This review intends to update the pathogenic mechanisms driving the macroscopic and histological features of oral papillomatosis having HPV infection as the main etiological factor, focusing on its interreference in the local immunity. In the absence of an accurate molecular diagnostic and knowledge of local immunological conditions, the therapeutic strategy could be difficult to decide. Oral papillomatosis is a heteromorphic group of benign lesions of the oral mucosa whose cause has not been fully elucidated yet. The importance of human papillomavirus (HPV) as an etiological factor of papillomatous lesions is considerably increased with the development of molecular biology techniques used for diagnostics, but papillomatosis has also a non-viral etiology, various factors producing the chronic irritation of the oral mucosa for a long time or having a detrimental effect on tissues being involved: excessive smoking, chronic alcoholism ,2,3,4 orThe same etiological factors inducing papillomas are incriminated in the development of malignant tumors of the oral cavity, part of the head and neck squamous cell carcinoma (HNSCC) ,13, clasThe incidence of HPV viruses varies by the geographic area, being higher in underdeveloped countries (East African countries), with the lowest incidence in West Asia ,21; the HPVs are part of the Papillomaviridae family, non-enveloped viruses with a DNA double-stranded circular genome ,25,26,27Based on their association with cervical cancer, HPV types are classified as high-risk  or low-risk  ,32. The Low-risk types of HPV also infect the oral cavity, but the pathogeny and the evolution of the subsequent lesions are different. Frequently, low-risk strains produce warts in the oral mucosa, while high-risk strains can lead to intraepithelial squamous lesions evolving into oral carcinoma ,34. Low-Aims. To update the pathogenic mechanisms driving the macroscopic and histological features of oral papillomatosis having HPV infection as the main etiological factor. High-risk HPVs are those leading to oral cancer, so we paid particular attention to defining them regarding their natural infection  and ability to interfere with the local immune pathways. We focused also on HPV autophagy and oncogenicity. The clinical aspects of benign and intermediate papillomatous lesions and the laboratory tools useful to the physician for an etiologic accurate diagnostic were also addressed.For this review, we conducted an electronic literature search in the PubMed, Science Direct, Google Scholar, Scopus and Web of Science databases related to human oral papillomatosis and HPV oral papillomatosis, using as keywords: oral papilloma, HPV infection, HPV innate local immunity, HPV oncogenicity, Toll-like receptors, HPV vaccination, and HPV oral clinical manifestations in all the relevant combinations. Case reports, case series, and literature review-type articles from the earliest data available to February 2022 were included in our research.Morphologically, these non-enveloped viruses have a hemispherical shape and dimensions between 50 and 60 nm ,29,30. EThe six early genes  are depicted in blue and the late L1 and L2 in yellow. The free space between L1 and E6 represents the long control region (LCR).The main role of these proteins during the HPV cycle is to create a permissive cellular milieu for viral replication: the induction of DNA replication machinery, immune evasion and the downregulation of apoptosis. The viral oncogenes achieve these conditions by distorting the p53 and pRb cellular regulatory pathways . E1 and HPV infection of the oral mucosa is determined by sexual or non-sexual transmission. The oro-sexual practices are incriminated in the sexual transmission, correlated with sexual behavior . IntOral papillomatous lesions can be transmitted from the skin to the oral mucosa. An eloquent example of this situation is verruca vulgaris, frequently found in children ,41.Both low-risk and high-risk HPVs have an affinity for the squamous epithelium of the oral and cervical mucosa and infect epithelial cells (Kcs). HPV’s capacity to immortalize in vitro in oral Kcs allows the extrapolation of the biological infection from the genital mucosa to the oral one .lamina propria. An orthokeratinized epithelium, similar to the skin, is present in the gum—the gingival mucosa—and at the level of the hard palate [The mucosa lining the oral cavity is formed of an epithelium sustained by a basal membrane (BM) which joins the epithelium with the underlined chorion or d palate ,43,44. Id palate ,45,46.HPVs are exclusively intraepithelial pathogens, and an epithelial wound creating a discontinuity through the Kcs is necessary in order to allow the access of virions to the basal membrane and the profound cell layer ,47. SincA study on a mouse model highlighted, surprisingly, that HPVs do not initially bind the Kcs in vivo, but first the heparan sulfate proteoglycans (HSPGs) of BM exposed after the upper epithelial trauma via the L1 major capsid protein. HSPG is considered the first receptor. It also emphasizes the natural dependence of some viruses, including HPVs, on HSPGs used as hijacked receptors in order to bind to host cells. This typical interaction occurs through electrostatic interactions between the cell membrane and the virus. After binding to HSPGs, the mature virus particle undergoes a series of conformational changes to enter the host cell ,49. Follstratum spinosum and stratum granulosum, under the E4 gene control [Different viral genes are expressed during the cell-hosting virus superficialization , and the control ,50. Here control , and fin control ,29.stratum corneous from the basal membrane [The accomplishment of a virus cycle takes time even in optimal conditions, and depending on the oral topographic area, the delay from the infection to the virion release is about 20 days, the time for keratinocyte daughters to reach the membrane .The pathogenesis of low- and high-risk HPVs is notably different, even in the presence of the same gene products: low-risk HPVs produce a rapid progeny and a large lesion of the mucosa and induce the local immune response and inflammation; E6 and E7 proteins display low activity of transforming the host genome and lack the capacity to produce genomic instability . DependiClearance is a feature of the majority of HPVs. Usually, 63% to 70% of viral infections cleared rapidly within 12 months in response to an efficient immune system . For mosThe resolution of infection requires the cross-priming of dendritic cells (DCs) followed by T-cell infiltration into the site of infection and the shut-off of viral gene expression . An inteVirus clearance could be illusory as lesion regression is not associated with massive apoptosis or cell death. The lesion is cleared by the replacement of actively infected cells with ‘apparently normal’ cells as the basal cells continue to divide. These ’apparently normal’ cells may still contain viral genomes but without concomitant viral gene expression, and, in animal models, it has been suggested that the virus life cycle may become ‘reactivated’ depending on individual conditions .It is a general agreement that the Kcs of the oral mucosa are the reservoir of HPV, and the most common behavior of the oncogenic HPVs, especially HPV-16 and 18, but also of the low-risk HPV-6 and 11, is the virus persistence . In ordeHPV-6 and 11 are responsible for RRP that rarely can convert to cancer . It has Among the risk factors for virus persistence, there are the immunosuppression of HIV-infected patients and renal transplant recipients and smoking , albeit Research data is not congruent that co-infection with various HPV types is a potential predictor of subsequent persistence of the HPVs . ChronolThe state of viral genome integration in the host cells, with no viral DNA replication but production of the oncoviral proteins and nuclear mutagenesis, is called “pseudolatency”, three oncogenic genes being expressed in this stage, E5, E6 and E7. E5 gene product stimulates EGF-mediated cell proliferation and affects apoptosis ,63. The Some events  may determine the virus from the proliferative zone of the epithelium to leave the stable replication to their entry into the vegetative mechanism , and, asThe production of the HPV-16 early E5 gene ensures the persistence of infection in immortalized HPV-infected Kcs (Kcs) by downregulating the expression of MHC-I molecules through retention in the Golgi apparatus membranes and the inhibition of their transport to the cell surface , reducinIt should be noted that, in contrast to cervix carcinoma and epidermis, in the oral mucosa, virus multiplication is achieved without the damage of oral Kcs, and consequently premalignancies associated with OSCC are unknown . HoweverIt is not evident that a particular area of the epithelium is more susceptible to becoming a transitional host or a long-term reservoir for HPVs. A surprising finding is that among the HNSCN etiology, HPV’s prevalence in the oropharyngeal location is significantly higher in palatines tonsils 61, 8%) and the base of the tongue/lingual tonsil  , 8% and .criptae, the Kcs dynamically multiply with the faster turnover of the oral cavity, 4–6 days, loose packing and the numerous intercellular spaces created filling with crevicular fluid [A second interesting site, with a particular histological organization and a huge involvement in the gingival homeostasis, able to host a latent HPV, is the epithelium forming the wall of the gingival pocket. As in the tonsillar ar fluid . The accar fluid ,73. Epidar fluid .The fate of the HPV virus infection of the mucosa is determined by its ability to hide itself and survive and the inability of the local cells to catch and neutralize the viral antigens. The balance between these conditions defines the virus clearance, persistence or cancerization. Some biological mechanisms used by HPV in order to escape the immunity cascade are summarized in ,50,74.The effective evasion of all levels of innate immune recognition seems to be the hallmark of HPV infections. HPV globally down-regulates the innate immune signaling pathways in the infected Kcs; pro-inflammatory cytokines, particularly the type I interferons, are not released, and the signals for Langerhans cell activation and migration and consecutively for the recruitment of stromal DCs are diminished or abolished .We intend a brief description of HPV influence on the main actors of the innate immune response in order to understand the heterogeneity of clinical aspects in HPV infection.Keratinocytes (Kcs) targeted by HPVs are considered as nonprofessional antigen-presenting cells (APCs), defined as “immune sentinels”, because of the various cytokines produced in response to innate immune sensor signaling [ignaling . The locignaling ,77,78,79ignaling .adherens and tight junctions favoring other viral infections, i.e., HIV infection [TLRs are particularly important in establishing the evolution of lesions because they have the role to guide the individual’s acquired immunity in order to neutralize viral HPV infection. The activation of TLRs on Kcs leads to the production of type I (α and β) interferons (IFNs) and enhances the cytotoxic response of Th1 lymphocytes . A reducnfection .The natural life cycle of the HPV virus is entirely intraepithelial, and the infection does not produce local inflammation, cellular apoptosis or cytolysis, viremia after virus release with a successful getaway of innate immune recognition and consecutively the activation of adaptative immune reaction. Viral regression is associated with the successful priming of an adaptative immune response after antigen takeover by the APCs .In HVP infection, Kcs response as APCs are abolished, and they are not able to activate the other APCs or synthesize regulatory and signaling molecules, such as IFNs, TNF-α and intercellular adhesion molecules as a response to the activation of TLRs ,50. IL-1In the effective innate immune response, consecutively to NLRs stimulation, Kcs secrete a lot of cytokines IL-6, 10, 18, TNF-α and IL-1, the vault stone of the downstream immune activation of DCs and T helper lymphocytes. In HPV episomic infection, the reduced number of viral genomes and lack of cellular necrosis decrease NLR proinflammatory signals . The cenProfessional antigen-presenting cells. Dcs and macrophages act as professional APCs as they activate the T lymphocytes, the effector cells of the acquired immune system.The 1–8 arrows: Biological communication ways affected by the presence of the HPV in Kcs. (1). The innate immune response is principally affected by the choking of TLRs expression, with the diminished synthesis of interferons and ILs acting on effector cells. The absence of TNFα inhibits the synthesis of MCP1 by Kc, and the chemotaxis of MΦ is impaired (3). MΦ may be also directly infected by the Kc without the activation of immune phagocytosis (4). (2) and (7). The action of NK and NKT cells is diminished by the lack of necrosis and inflammation and the loss of Cd1 receptors. The functions of dendritic cells are affected by Kc in many ways, including (5) the failure to synthetize CCL20, so their chemotaxis in the epithelium and connective tissue is impaired, and (8) the suppression of Ecad and the shortening of the dendritic cells’ presence in the infected tissues. Infected cells escape the recognition by Ly specialized cells due to the cessation of HLA synthesis and expression and the impairment of immune cell cooperation. The viral genes involved are highlighted.Macrophages hosted in the lamina propria of the mucosa play a pivotal role in innate immunity. Tissue-resident-macrophages are activated by TLRs binding to viral components and as a response, they release several types of inflammatory cytokines, chemokines, and IFNs. One of the chemokines active on macrophages is monocyte chemotactic protein-1 (MCP-1), released by Kcs in the presence of TNF-α, but such secretion is downregulated by the HPV16 E6 protein. Activated macrophages kill HPV-infected cells via TNF-α secretion or antibody-dependent cytotoxicity [toxicity .The main effect of HPV E6 and E7 proteins on macrophage action against HPV infection is the inhibition of macrophage chemotaxis to the site of viral infiltration ,95.Another interesting pathogenic way of HPV infection is that the viral particles end up infecting macrophages. In a very elegant experiment, Cao et al. demonstrate that macrophages take up microparticles containing HPV leading to their infection. Such microparticles with a 0.1–1 µm diameter are released by the first infected Kcs and enter the macrophages through a non-phagocytic pathway, triggering the transfer of HPV into the macrophage cytoplasm by avoiding the phagolysosome synthesis and the virus lysis . This inHowever, even if they are mobile and major scavengers responsible for the phagocytosis of apoptotic cells and maintenance of local homeostasis, macrophages do not specifically migrate to the draining lymph nodes (LNs) and are less efficient in antigens presentation to T cells than the DCs .Dendritic cells are generally divided into two classes: conventional DCs (cDCs) and plasmacytoid DCs (pDCs) [s (pDCs) . In the s (pDCs) , while Cs (pDCs) . pDCs ars (pDCs) .lamina propria, DCs migrate to the local lymph node. Antigen presentation in lymph nodes is necessary for the initiation of the acquired immune response by activating T helper (Th) CD4+ T cells differentiated into various subtypes: Th1, Th2, Th17, and T regulatory cells (Treg) [Through the s (Treg) ,80,101.In their immature state, DCs are the only mobile professional APCs that efficiently cross-present cell-associated antigens which refer to their ability to transfer exogenously derived antigens directly to the MHC class I and transport processed antigens to the neighboring lymph node in order to present them to CD8+ T cells .LCs’ migration depends on the environmental chemokines and their specific receptors. The pair C-C motif chemokine ligand 20 (CCL20)-chemokine receptor 6 (CCR6) is responsible for the chemotaxis of DCs and plays an important role in the mucosal surfaces under homeostatic and inflammatory conditions . CCL20 iSeveral data suggest that the E-cadherin-mediated contact between KCs and LCs is important for the immune response during chronic HPV infection. The adhesive molecule E-cadherin, secreted by the KCs, mediates their adherence and allows LCs to remain longer in contact with the antigen . In highCCR7 expressed by phenotypically mature DCs plays a role in mediating DC trafficking in response to the lymph node-homing CCL19 and CCL21 ,110,111.It is emphasized that mainly E5 and E7 of HPV16 and HPV18 are able to interfere with MHC class I  and also with MHC class II (HLA DR) and escape the recognition of T cells . EffectoAdditionally, the low-risk HPVs’ dysfunctional activation of acquired immunity by APCs was demonstrated to suppress HPV clearance and perpetuate the infection .NK cells and NKT cells. NK cells, a population of Lys, are key effectors of the innate immune system, known to act as a bridge between the innate and adaptative immune response. When NK cells encounter their own healthy cells expressing normal MHC molecules, they are in a resting state; when modified cells with abnormal expression of MHC molecules are detected and surrounded by enough activating ligands, NKs immediately identify and eliminate virus-infected transformed cells activating mechanisms such as cytotoxic particles, cell apoptosis and antibody-dependent, cell-mediated cytotoxicity (ADCC) [y (ADCC) . NK celly (ADCC)  or (ii) y (ADCC) . NK celly (ADCC)  and uprey (ADCC) , as founNKT cells are a subset of T lymphocytes that express the surface receptor characteristics of the T and NK cell lineages. They are subclassified in invariant and semi-invariant NKTs. NKT cells, similarly to conventional T lymphocytes, express a T-cell Receptor (TCR) , but unlThe imbalance in the immune response is relevant to both high- and low-risk HPVs as demonstrated by the progression of a respiratory tract infection with a low-risk HPV to RRP .These main signaling immune pathways suppressed after the infection of Kcs by high-risk HPVs are summarized in Autophagy is a self-consumption cellular mechanism, important for maintaining the internal homeostasis and the functionality of the cells, which may be activated in physiological or pathological conditions, initially described in cellular starvation and the recycling of macromolecules. Following infection, autophagy can help to eliminate invading intracellular microbes and damaged proteins and sustain the organelles’ function as a cellular defense mechanism .Atg genes); it consists of the lysosomal digestion of the proper organelles, such as mitochondria (mitophagy), endoplasmic reticulum (ER-phagy) or pathogen-like viruses or bacteria (xenophagy) in a succession of activities: the phagophore initiation, elongation and fusion of the autophagosome with the lysosome which results in an autolysosome. Autophagy primarily acts as a protective mechanism that may prevent cell death and contributes to the regulation and function of innate and adaptive immune responses. During infection, it plays an important role in the innate response to degrading intracellular bacteria and viruses: in adaptive immune responses, autophagy is involved in antigen presentation and lymphocyte development [Autophagy is under the control of more than 30 autophagy-related genes  tumor suppression. P16 protein is a product of p16INK4a, a tumor suppressor gene encoded by the CDKN2A locus, located on 9p21 ,137. P16The HPV oncoproteins E6 and E7 target the same pathogenic pathway with different mechanisms, showing a strong corroborating action in promoting cellular transformation in the field of the cancerization and neutralization of the immune response ,139. ThuThe high-risk HPV E6 protein promotes cell proliferation and activates telomerase, and HPV E7 induces the entry into the S phase of the cell cycle ,136.HNSCC associated with tobacco and alcohol abuse has a worse prognosis due to the perturbation of the cell cycle regulation, the loss of p16 expression by deletion, mutation or hypermethylation resulting in p53 overexpression and causing the limitless replicative potential of head and neck cancer ,147,148.In direct relation to the action of p16 and the abrogation of the p53 tumor suppressor, the HPV oncoprotein E6 contributes to cell immortalization by telomerase activation. Telomerase is a ribonucleoprotein complex containing an RNA component (TR) and a catalytic protein (TERT) able to maintain telomere elongation, one of the mechanisms of telomere preservation in dysfunctional telomeres. Telomere dysfunction leading to genomic instability is considered an early carcinogenetic condition ,150. ShoIntending to improve the molecular diagnostic of HCSCC and the specific therapy, a distinct phenotypical population of cells was described—cancer stem cells (CSCs). From the heterogeneous population of cells forming epithelial cancer, it is the first implicated in tumor cell survival and progression, being highly tumorigenic as compared to the other cancer cells and is considered to be largely responsible for the biological characteristics of cancer—rapid growth, invasion and metastasis . It was If a clinical examination of a patient’s oral cavity reveals the presence of a tumor, this could be a papilloma of non-viral etiology or HPV-induced . The hisAccording to the degree of malignity, three types of papillomatous lesions can be identified in the oral cavity: benign lesions, potentially malign disorders and malignant lesions. In this paper, we discuss the most important features regarding the first two.Benign epithelial lesions in the oral cavity include squamous cell papilloma, condyloma acuminatum, skin verruca vulgaris, multifocal epithelial hyperplasia and papillary hyperplasia [erplasia . All thesquamous cell papilloma, with an incidence of 1:250 people, frequently affecting men aged between 30 and 50. However, the condition can occur at any age, even in children [The most common benign lesion, reviewed in , is the children ,162. Theverruca vulgaris appears as a solitary lesion, being characterized by “keratinized turns” and a very well-developed granular layer [Verruca vulgaris is a sessile formation, while squamous papilloma has a pedunculated appearance. Microscopically, squamous papilloma has a poor representation of the granular cell layer compared to verruca vulgaris, and a finger-like aspect. Both have koilocytes in the prickle layer and no atypia accompanying the mitotic aspects in basal and parabasal Kcs, although authors claimed in some cases a reduced number or the absence of koilocytes [Generically, at the oral level, ar layer . It is iar layer . Verrucailocytes .Condyloma acuminatum, most usually found in the genital rather than in the oral mucosa, is determined by HPV-6, 11, 16 and 18 subtypes and is located on the soft palate, lingual frenum and labial mucosa [condyloma acuminatum varies: the shape can be sessile or pediculate, the color pink or white and the size proportional to the age of the lesion, but always significant compared to squamous papilloma. Koilocytes, a pathognomonic element for viral infection with HPV, are present, but acanthosis, important parakeratosis and bulbous rete pegs may also be highlighted by the microscopical examination [l mucosa . It occul mucosa ,166. Nevl mucosa . Clinicamination ,166,167.mination .Multifocal epithelial hyperplasia or Heck’s disease, reviewed in [iewed in , is induiewed in . In the iewed in . Recent iewed in ,168,170.Examining atypical and malignant papillary lesions for low- and high-risk HPV, it was demonstrated that simple squamous papilloma are rarely HPV-positive. Low-risk HPV-6 and 11 infection lead to papillary proliferations with clinically and/or histologically atypical features but with a benign clinical evolution, meanwhile potentially malignant lesions are not associated with low- or high-risk HPV .Potential malignant disorders. Oral potentially malignant disorders (OPMDs) is a term which refers to a potential precancer stage of oral squamous cell carcinoma. Papillomatous lesions considered with the potential of malignancy are oral leukoplakia, oral erythroplakia, proliferative verrucous leukoplakia and oral lichen planus [n planus ,131.Leukoplakia consists of the presence of white plaques in the oral mucosa. In a cohort study of 890 leukoplakic and keratotic lesions tested for HPV, 25.4% were HPV-positive [positive . ClinicaErythroplakia, defined as “a fiery red patch”, cannot be confused clinically or pathologically with any other definable lesion and occurs mainly in middle-aged and elderly subjects. Microscopically, erythroplakia commonly shows at least some degree of dysplasia and often even carcinoma in situ or invasive carcinoma, more than 54.5% being HPV-16 positive [positive .Oral proliferative verrucous leukoplakia (PVL) is very rare, has recently been defined as a form of oral leukoplakia [koplakia  or an inkoplakia . PVL is koplakia .Oral lichen planus (OLP) is a chronic oral inflammatory disease of multiple disputed etiology, frequently defined as an autoimmune disorder because of the profound imbalance of lymphocytes and APCs. OLP affects the oral mucosa, the tongue and, to a lesser extent, the gums and lips [and lips .By molecular methods, some studies have detected the presence of HPV in OLP in a range of 0.22% to 5% worldwide, 23% being positive for HPV-6 and 11, followed by HPV-16 . The typCandida sp., various other bacterial infections) and dental metals precipitating allergic contact reactions [Genetic studies noted various HLA-based susceptibilities of LP in different populations: HLA-B27, HLA-B51, HLA-Bw57 , HLA DR1  and HLA-DR9 . The trigger for the onset of the lesion is environmental factors such as systemic viral infection, hepatitis C and members of the human herpesvirus (HHV) family, specifically HHV-6 and HHV-7 . Additioeactions .Some researchers supported the idea that the chronic inflammation of OLP could promote the malignant transformation , the mosThe presence of HPV may be suspected only in productive lesions with objective changes in the oral mucosa. In these cases, the histopathological examination highlights the presence of koilocytes, a pathognomonic element of HPV infection ,181. TheAn inconsistent presence of koilocytes in oral lesions of condyloma means it is difficult to distinguish between oral papilloma and condyloma ,187. AtyThe precise etiologic diagnostic may be direct by identifying the virus or indirect by measuring the antibody concentrations in the biological secretions. Unfortunately, standard diagnostic protocols are not in use in oral medicine as they are in gynecological services. In cervix carcinoma, the premalignant stages are detected by staining with acetic acid while the standardized diagnostic techniques of the premalignancies of OSCC associated with HPV are missing .The presence of HPV in the lesion may be searched by a variety of methods, including immunohistochemical staining for HPV common antigen, in situ hybridization (ISH) with DNA probes, polymerase chain reaction (PCR), and in situ RT-PCR .INK4a IHC is highly sensitive but moderately specific to diagnose HPV-transformed OPSCC when used as a single test [Immunohistochemical methods are useful because they identify capsid proteins expressed in the late stage of the HPV life cycle. The only immunohistochemical marker with recognized diagnostic significance is p16 protein (INK4), a surrogate marker, whose overexpression in dysplastic/neoplastic oral or cervical histological samples is strongly associated with high-risk HPV infection, although it is not possible to rule out the simultaneous presence of other genotypes ,39,188. gle test .The molecular detection of HPV, performed in tissue samples or in exfoliated cells, is increasingly used in clinical gynecologic practice for various purposes: either to identify women with cervical cancer risk, or to follow up the subjects after local treatment, and presently to screen the subject prior to vaccination. The molecular techniques, PCR and ISH, performed in tissue biopsies or in secretion are different in sensitivity and specificity and may be classified into: (i) target amplification assays/PCR, a highly sensitive and specific method, able to detect 10–100 HPV viral genome in 100 ng of cellular DNA. The SPF10-LiPA system, to identify a 65 bp fragment of the HPV genome, has been introduced, enabling successive PCR amplification and genotype identification ,192;  are present in the plasma more than 10 years before the diagnosis of oropharyngeal cancers . The detHPV vaccination is nowadays recommended both for children and adolescents. The adults between 27 and 45 years who are not already vaccinated may decide also to get the HPV vaccine, but it is recommended to be tested for serum level of anti-HPV antibodies ,202.The ability of the major capsid antigen of HPV, L1, to self-assemble into highly immunogenic virus-like particles led to the development of three HPV vaccines  . In contThe main HPV vaccines used worldwide are Gardasil 9 and Cervarix ,206,207.Numerous studies that have been conducted over time have demonstrated the prophylactic nature of vaccines, but also their safety ,210,211.An etiological factor of major importance for oral papillomatosis is HPV infection, but other non-viral factors that exert detrimental effects on the oral mucosa are involved. The evolution of natural HPV infection depends on the virus type, oncogenic or non-oncogenic, but also on the particularities of the innate immune response whose main effectors are subjected to systematic suppression. The fight between the virus and the aggressed epithelium determines the evolution of the infection: clearance or persistence and oncogenicity. Understanding how local immunity works guides the physician in establishing a correct diagnosis and in applying personalized treatment to the patient. A complete diagnosis of oral papilloma can be established through a good knowledge of etiological and epidemiological factors, clinical examination and laboratory tests. It is noted that OSCCs have acquired an increased incidence, and there is a need for the development of more accessible methods for an earlier precise diagnosis.