Baldarrago_et

Odovtos-International Journal of Dental Sciences (Odovtos-Int. J. Dent. Sc.), Online First, 2026. ISSN: 2215-3411

https://revistas.ucr.ac.cr/index.php/rOdontos

CASE REPORT:

Verrucous Palatal Lesion Mimicking Candidiasis Revealing Well-Differentiated Oral Squamous Cell Carcinoma: A Case Report

Lesión verrucosa del paladar que simuló candidiasis y reveló un carcinoma escamoso oral bien diferenciado: Reporte de caso

Willmer José Baldárrago Salas1 https://orcid.org/0009-0007-5276-1476

Kenyo Sebastian Samayani Baldárrago1 https://orcid.org/0009-0002-1751-7789

Gilberto Centeno San Román1 https://orcid.org/0000-0001-6275-7672

Mauricio Postigo Mac Dowall1 https://orcid.org/0000-0002-1310-404X

Wilfredo Gustavo Escalante Otárola1 https://orcid.org/0000-0003-4879-3938

1School of Dentistry, Universidad Catolica de Santa Maria - UCSM, Arequipa, Peru.

Correspondence to: Wilfredo Gustavo Escalante Otárola - wilfredo.escalante@ucsm.edu.pe

Received: 5-III-2026 Accepted: 9-V-2026

ABSTRACT: Oral squamous cell carcinoma (ICD-10 C05.0) is the most common malignant neoplasm of the oral cavity, associated with high mortality and a poor prognosis. Early diagnosis is essential to improve survival, particularly in older adults. We report the case of a 90-year-old female patient who sought care due to a “palatal mass.” Clinical examination revealed an ulcerated and verrucous lesion on the left maxillary alveolar ridge, initially treated as candidiasis without clinical improvement, which delayed the definitive diagnosis. The progressive enlargement of the lesion led to discontinuation of complete denture use. An incisional biopsy was performed, and histopathological analysis confirmed a well-differentiated squamous cell carcinoma, with pseudoepitheliomatous hyperplasia considered as a differential diagnosis. Computed tomography demonstrated irregular margins and bone involvement, findings consistent with locally invasive tumor behavior. Postoperative healing was uneventful, and the patient was referred for oncologic management through her health insurance system. This case highlights the importance of clinical, radiographic, and histopathological correlation in the diagnosis of suspicious oral lesions, as well as the need for early biopsy of persistent or progressive lesions, particularly in older denture-wearing patients.

KEYWORDS: Squamous cell carcinoma; Oral cavity; Biopsy; Computed tomography; Aged.

RESUMEN: El carcinoma de células escamosas oral (CIE 10 C05.0) es la neoplasia maligna más frecuente de la cavidad oral, con elevada mortalidad y pronóstico reservado. Su diagnóstico temprano es fundamental para mejorar la supervivencia, especialmente en adultos mayores. Se presenta el caso de una paciente femenina de 90 años que acudió a consulta por un “bulto en el paladar”. La evaluación clínica reveló una lesión ulcerada y verrucosa en el maxilar superior izquierdo, inicialmente tratada como candidiasis sin mejoría, lo que retrasó el diagnóstico definitivo y motivó la suspensión del uso de prótesis total. Se realizó una biopsia incisional, cuyo estudio histopatológico confirmó un carcinoma de células escamosas bien diferenciado, considerando como diagnóstico diferencial una hiperplasia pseudoepiteliomatosa reactiva. La tomografía mostró rebordes irregulares y compromiso óseo, hallazgos compatibles con la invasividad local del tumor. La evolución postoperatoria fue favorable y la paciente fue derivada a tratamiento oncológico mediante su seguro de salud. Este caso enfatiza la importancia de la correlación clínica, radiográfica e histopatológica en el diagnóstico de lesiones orales sospechosas, así como la necesidad de realizar biopsias tempranas en lesiones persistentes o progresivas, particularmente en adultos mayores portadores de prótesis dentales.

PALABRAS CLAVE: Carcinoma de células escamosas; Cavidad oral; Biopsia; Tomografía computarizada; Adulto mayor.

INTRODUCTION

Oral carcinoma is a malignant neoplasm that affects structures of the oral cavity and oropharynx, and may arise primarily from the oral mucosa, represent metastasis from distant sites, or result from extension of adjacent anatomical areas (1,2). More than 90% of oral cancers correspond to oral squamous cell carcinoma (OSCC), which develops from the lining epithelium of the oral cavity and oropharynx (1).

Several risk factors have been associated with the development of this neoplasm, including tobacco and alcohol consumption, socioeconomic status, immunodeficiency conditions, genetic predisposition, and infection with high-risk human papillomavirus (HPV) (2). A possible association with periodontal disease has also been suggested, due to the involvement of bacteria that promote a pro-inflammatory microenvironment (3). Globally, oral cancer ranks eighth among cancer-related causes of death, and it is often underestimated, particularly in developing countries (1).

Biopsy remains the gold standard for establishing the definitive diagnosis of OSCC. However, in recent years, complementary imaging methods such as tissue autofluorescence and cone-beam computed tomography (CBCT) have been incorporated to improve diagnostic accuracy (4). The treatment of oral carcinoma is based on surgery, radiotherapy, and systemic therapies, and more recently, immunotherapy has shown promising results in advanced cases (5,6).

OSCC represents a heterogeneous entity, capable of presenting in different locations within the oral cavity, including the lips, tongue, floor of the mouth, gingiva, and buccal mucosa (7). Despite advances in diagnostic and therapeutic techniques over recent decades, the 5-year overall survival rate remains around 50% (7), highlighting the need for early and accurate diagnosis to improve patient prognosis (3). However, diagnostic delay may occur when malignant lesions clinically resemble common inflammatory or infectious conditions.

In this context, the present report describes the clinical case of an elderly patient with a palatal lesion diagnosed as well-differentiated squamous cell carcinoma following incisional biopsy. Therefore, the aim of this report is to describe the clinical, radiographic, and histopathological features of this lesion, highlighting the importance of timely clinical evaluation and histological confirmation in suspicious oral lesions.

PATIENT INFORMATION

The patient was a 90-year-old female, widowed and a homemaker, originally from Arequipa, Peru. She sought dental consultation with the chief complaint of a “lump on the palate.”

The history of the present illness revealed that three months earlier, a swelling had been detected in the left maxillary region accompanied by whitish lesions. During the initial consultation, antifungal treatment for candidiasis was prescribed; however, no clinical improvement was observed. Subsequently, the lesion continued to increase in size, eventually preventing the use of her maxillary complete denture. The onset was insidious, with a progressive course and an estimated duration of three months.

Regarding her medical history, the patient had controlled arterial hypertension and a surgical history of cholecystectomy in 2017 and ocular surgery in 2023. In her family history, she reported that both parents had died of natural causes and that three of her four siblings had also died. She denied any history of tobacco use, alcohol consumption, or illicit drug use.

Written informed consent was obtained from the patient for the publication of this case report, including the associated clinical photographs.

CLINICAL FINDINGS

Intraoral examination revealed a tumor-like lesion measuring 8 × 6 × 5 cm located on the left maxillary alveolar ridge (Figure 1). The dimensions were clinically estimated using a periodontal probe as a reference during intraoral examination, due to the irregular morphology of the lesion.

Figure 1. Clinical lesion. Intraoral image showing enlargement of the left maxillary region, with a verrucous and ulcerated surface, associated with the maxillary complete denture.

The lesion exhibited a pearly white coloration, with displacement of both the buccal and palatal cortical plates. It presented irregular and infiltrative borders, a sessile base, rough surface texture, and was fixed and painful on palpation. Palpation of the cervical region revealed the presence of two lymph nodes in the upper left cervical region, which were fixed, infiltrated, and painless.

The lesion showed a direct relationship with the supporting area of the maxillary complete denture, which the patient had discontinued using due to the progressive increase in tumor volume.

Based on the clinical characteristics, squamous cell carcinoma and adenocarcinoma were considered as differential diagnoses. Therefore, an incisional biopsy was performed for histopathological examination.

TIMELINE

Date	Event	Details
10 June 2025	Initial evaluation	A whitish lesion was observed in the left maxillary region. Computed tomography and an incisional biopsy were indicated. The procedure was explained to the patient and her family member.
13 June 2025	Incisional biopsy	An incisional biopsy of the lesion was performed, and the specimen was sent to the pathology laboratory for histopathological analysis.
20 June 2025	Histopathological report	The histopathological report confirmed well-differentiated squamous cell carcinoma. Sutures were removed, and the diagnosis was explained to the patient and her daughter. The family decided to continue treatment through their health insurance system.

SURGICAL INTERVENTION

An incisional biopsy was performed in the left maxillary region, corresponding to the area of the lesion. After local asepsis, infiltration anesthesia with mepivacaine without a vasoconstrictor was administered, considering the patient’s history of arterial hypertension. The incision was made in the most representative area of the lesion, allowing the retrieval of a light-gray tissue fragment measuring 0.9 × 0.6 × 0.2 cm, with a papillary epithelial surface measuring 0.6 × 0.5 cm. The clinical lesion measured approximately 8 × 6 × 5 cm. The specimen was submitted in its entirety to the pathology laboratory for histopathological analysis (Figure 2.a-d).

The surgical site was closed with 3-0 braided black silk sutures (TC20 needle), achieving adequate approximation of the wound margins. In the immediate postoperative period, the patient was advised to maintain relative rest for three days and a soft diet, in addition to a pharmacological regimen consisting of clindamycin 300 mg (one capsule every 8 hours for four days) and ketorolac 10 mg (one tablet every 6 hours for three days). The immediate postoperative course was favorable, without complications.

DIAGNOSTIC ASSESSMENT

During the initial clinical evaluation, based on the characteristics of the lesion, squamous cell carcinoma and adenocarcinoma were considered as presumptive diagnoses. Computed tomography (CT) revealed a soft tissue tumor with ill-defined margins, located on the left side of the midface, causing partial destruction of the left maxilla with loss of the cortical bone plates. The tumor involved the floor and lateral wall of the left nasal cavity, as well as the palatine bone involving both its horizontal and vertical plates. Additionally, it affected the ethmoid bone in the region corresponding to the left inferior turbinate and produced loss of the cortical floor of the left maxillary sinus with partial opacification of the sinus. These findings were consistent with the locally invasive behavior of a malignant neoplasm (Figure 3.a-c).

To establish a definitive diagnosis, an incisional biopsy was performed. Histopathological examination revealed an atypical squamous epithelial proliferation compatible with well-differentiated squamous cell carcinoma, characterized by invasive epithelial nests extending into the underlying connective tissue, keratin pearl formation, dyskeratosis, and cellular atypia with preserved squamous differentiation (Figure 4.a-c). The radiographic findings correlated with the histopathological diagnosis, supporting the malignant nature and local aggressiveness of the lesion.

Figure 2. Incisional biopsy procedure of the lesion. (a) Initiation of the incision in the representative area of the verrucous lesion. (b) Progression of the biopsy with tissue separation to obtain the specimen. (c) Intraoral view after surgical closure with 3-0 braided black silk sutures. (d) Tissue fragment measuring approximately 0.9 × 0.6 × 0.2 cm, submitted to the pathology laboratory and preserved in 10% formalin.

Figure 3. Computed tomography of the left maxilla. (a) Coronal section: soft tissue tumor with ill-defined margins associated with loss of cortical bone in the left maxilla and involvement of the floor and lateral wall of the left nasal cavity (arrow). (b) Axial section: extension of the lesion with partial absence of the palatine bone and involvement of the ethmoid bone in the region of the left inferior turbinate, as well as partial occupation of the maxillary sinus (arrow). (c) Three-dimensional reconstruction: evidence of bone loss in the left midfacial region, consistent with the invasive behavior of a malignant neoplasm (arrow).

Figure 4. Histopathological section of well-differentiated squamous cell carcinoma (H&E). (a) Low-power view showing epithelial proliferation with a verrucous growth pattern and stromal invasion (10×). (b) Tumor nests with formation of keratin pearls (arrow) and dyskeratosis (20×). (c) Infiltration of epithelial nests into the stromal tissue, with peritumoral inflammatory infiltrate (arrow) (20×).

FOLLOW-UP AND OUTCOMES

The incisional biopsy was performed without immediate complications. Seven days after the procedure, sutures were removed, and adequate healing of the surgical site was observed, with no signs of infection or local complications.

During the same visit, the histopathological findings were explained to the patient. Subsequently, she was referred to the oncology service through her health insurance system for further management.

Regarding functional outcomes, the patient did not present any limitations or subsequent complications related to the biopsy site. Long-term follow-up was not available because the patient continued oncologic management through her health insurance system.

DISCUSSION

The present case describes a 90-year-old female patient with an ulcerated and verrucous lesion in the maxilla, initially treated as candidiasis, which progressively evolved until it prevented the use of her maxillary complete denture. An incisional biopsy confirmed well-differentiated squamous cell carcinoma, while the histopathological examination included reactive pseudoepitheliomatous hyperplasia as a differential diagnosis. Computed tomography revealed a lesion with irregular margins and bone involvement, findings consistent with the invasive nature of this neoplasm. This case highlights the importance of clinical, radiographic, and histopathological correlation for the timely diagnosis of suspicious oral lesions in elderly patients.

The diagnosis of oral carcinoma in 90-year-old female patients is relatively uncommon, as the incidence is generally higher in elderly males (8). Oral cancer, particularly oral squamous cell carcinoma (OSCC), is prevalent among older adults due to age-related changes in the oral mucosa and the cumulative exposure to classical risk factors such as tobacco and alcohol consumption (9). However, the literature also reports cases in elderly women without these classical risk factors (10-12), indicating that oral carcinogenesis may occur even in the absence of tobacco or alcohol exposure. In such patients, other mechanisms have been proposed, including chronic mucosal irritation caused by dentures, age-related epithelial changes, persistent inflammation, and local microbiological factors, which may contribute to malignant transformation (14,17-19,21). This observation is consistent with the clinical course of the present patient, who did not report traditional risk habits but had a long history of complete denture use.

The relationship between denture use and oral cancer has long been debated. While a classical study involving 400 patients did not find a direct association between dentures and tumor location, concluding that denture-related irritation was not a significant carcinogenic factor (13), more recent investigations have linked removable prostheses with a higher incidence of potentially malignant disorders in the maxilla (14). In this regard, our case illustrates how a lesion associated with denture use may mimic inflammatory or infectious conditions, thereby delaying the definitive diagnosis.

Denture stomatitis is a common form of oral candidiasis among denture wearers and is associated with the accumulation of Candida species on the prosthetic surface and the underlying mucosa (15,16). Some reports suggest that chronic Candida albicans infection may contribute to malignant transformation through the production of carcinogenic metabolites and inflammatory mediators (17,18). Although the patient in this case was initially treated for candidiasis without improvement, precise information regarding the clinical response to antifungal therapy was not available. This limitation restricts further interpretation but reinforces the need to suspect malignant lesions when there is no response to conventional antifungal treatment.

Chronic irritation caused by poorly fitting dentures has also been proposed as a risk factor in non-smokers and non-drinkers, as it may lead to persistent ulcers and fibrotic tissue prone to dysplastic changes (19). In agreement with this hypothesis, previous reports have described cases of squamous cell carcinoma initially diagnosed as traumatic ulcers related to dentures (20), which resembles the clinical history of our patient, whose initial diagnosis suggested an inflammatory condition.

Likewise, the literature has linked poor oral hygiene and inadequate prosthetic fit with mucosal lesions such as denture stomatitis and inflammatory fibrous hyperplasia, which are more commonly observed in users of complete dentures (21). These findings reinforce the importance of regular dental examinations in denture wearers, particularly in elderly patients with accumulated risk factors.

Regarding histopathological findings, oral squamous cell carcinoma exhibits a variety of patterns that are essential for diagnosis, prognosis, and treatment planning. These include the degree of differentiation (22), patterns of invasion (23) and the presence of specific cellular abnormalities (24). In the present case, the identification of a well-differentiated carcinoma and the mention of pseudoepitheliomatous hyperplasia as a differential diagnosis highlight the importance of adequate tissue sampling and careful interpretation by the pathologist.

Although the lesion exhibited a clinically verrucous appearance, the histopathological findings were consistent with conventional well-differentiated oral squamous cell carcinoma rather than verrucous carcinoma. Verrucous carcinoma is typically characterized by a broad pushing invasion front and minimal cytological atypia, whereas in the present case the biopsy demonstrated invasive epithelial nests and keratin pearl formation, findings consistent with conventional OSCC. Therefore, the verrucous morphology observed clinically should be interpreted as a verruciform presentation of conventional squamous cell carcinoma rather than a distinct verrucous carcinoma variant (22-24).

Computed tomography also represents a valuable tool for assessing the local extent of OSCC, particularly in the detection of bone invasion (25). The most frequent radiographic findings include areas of bone lysis and the presence of regional lymphadenopathy, which are common features of malignant oral tumors (26). In this case, the observation of irregular borders and bone involvement is consistent with findings reported in the literature and reinforces the role of imaging as an essential complement to clinical and histopathological evaluation.

This report presents limitations inherent to its single-case design, which restricts the generalization of its findings. Furthermore, detailed long-term follow-up after diagnostic confirmation could not be documented, as the patient was referred for oncologic management through her health insurance system. For this reason, clinicians should maintain a high index of suspicion when evaluating persistent lesions in denture-bearing areas, particularly in elderly patients. Nevertheless, this case emphasizes an important lesson for clinical practice: any persistent or progressively evolving oral lesion should be evaluated through early biopsy, as timely histopathological confirmation remains the cornerstone for improving prognosis and guiding appropriate therapeutic decisions.

PATIENT PERSPECTIVE

The patient’s daughter reported that the process was initially difficult due to the progressive growth of the lesion and the lack of response to the initial treatment. However, she expressed satisfaction with having obtained a definitive diagnosis through the biopsy, which allowed a better understanding of the patient’s condition and facilitated informed decision-making regarding subsequent treatment through their health insurance system. She also noted that the procedure was well tolerated and appreciated the clarity with which the results and management options were explained.

INFORMED CONSENT: Written informed consent was obtained from the patient and her family member for the publication of this case report and the accompanying clinical images.

AUTHOR CONTRIBUTION STATEMENT: Conceptualization and design: W.J.B.S., K.S.S.B., G.C.S.R. and W.G.E.O.; Literature review: W.J.B.S., K.S.S.B. and M.P.M.D.; Methodology and validation: G.C.S.R., M.P.M.D. and W.G.E.O.; Investigation and data collection: W.J.B.S., K.S.S.B., G.C.S.R. and M.P.M.D.; Resources: G.C.S.R. and M.P.M.D.; Data analysis and interpretation: W.J.B.S., K.S.S.B., G.C.S.R., M.P.M.D. and W.G.E.O.; Writing-review and editing: W.J.B.S., K.S.S.B., G.C.S.R., M.P.M.D. and W.G.E.O.; Supervision: G.C.S.R., M.P.M.D. and W.G.E.O.; Project administration: W.G.E.O.

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