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TEASER Summary Evaluation

1. Brief purpose & content
   • Opens with a differential-diagnosis table written in professional language, then finishes with a short, plain-English “Chapter Answer” for patients.
   • Core message: any sore/patch/lump that lasts > 2 weeks needs a professional exam and probably a biopsy; meanwhile practise good oral hygiene and avoid tobacco/alcohol.

2. Scores

• Accuracy: 4/5 – Describes common benign disorders and correctly states that a biopsy is gold standard for lesions > 2 weeks. No evident factual errors, but implies biopsy is “painless,” which can be misleading.
• Completeness: 3/5 – Covers classic red/white patches, ulcers, lumps and burning, but leaves out some warning signs (unexplained mouth bleeding, loose teeth, numbness, ear pain, difficulty swallowing).
• Clarity: 3/5 – The final paragraph is clear and readable (≈8th-grade level). However, the long medical list that precedes it uses terminology (e.g., “erythroplakia,” “incisional biopsy”) that typical patients may not understand.
• Actionability: 4/5 – Gives a concrete rule (“> 2 weeks → see dentist/ENT, possible biopsy”) plus self-care tips (soft foods, numbing gel, risk-factor cessation).
• Tone: 4/5 – Reassuring (“sometimes harmless”) yet appropriately urgent (“rarely… early oral cancer”). Balanced and encouraging.

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MAIN Summary Evaluation

1. Brief purpose & content
   • Presents an AIDOC algorithm applied to the historical case of Sigmund Freud after maxillectomy for oral SCC.
   • Focuses on specialist steps: imaging, AI radiomics, next-generation sequencing, MDT planning.

2. Scores

• Accuracy: 4/5 – Specialist content is technically sound and guideline-conform; no major inaccuracies detected.
• Completeness: 3/5 – Thorough for management of recurrent cancer but only incidentally mentions early signs; several common symptoms in average patients are omitted.
• Clarity: 1/5 – Dense with jargon (“parapharyngeal,” “p16 IHC,” “radiomics”) and references to a 1930s patient. Nearly unreadable for laypersons.
• Actionability: 2/5 – Advises biopsy and imaging but in a specialist framework. A typical patient would not know what to do next or who to contact.
• Tone: 2/5 – Technical, detached, sometimes alarming (“options likely limited to palliative…”). Minimal reassurance or empathy.

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Side-by-Side Comparison

Overall, the TEASER version is more effective for patients. Although front-loaded with professional language, it eventually delivers a concise, understandable take-home message with clear next steps and a balanced tone. The MAIN version functions as an internal clinical protocol; it fails on clarity, tone and layperson actionability despite good technical accuracy.

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Strengths & Weaknesses

TEASER
+ Accurate description of two-week rule and biopsy.
+ Provides self-help (oral hygiene, avoid irritants).
+ Balanced urgency vs. reassurance.
– Medical jargon in first two-thirds may confuse.
– Misses several early signs (bleeding, numbness, loose teeth).
– “Painless” biopsy may raise unrealistic expectations.

MAIN
+ Technically meticulous, guideline-based.
+ Demonstrates comprehensive work-up and follow-up.
– Written for clinicians; readability extremely low.
– Centers on a unique high-risk case, not the average worried patient.
– Provides little emotional support or simple next steps.
– Excessive historical detail (Sigmund Freud) distracts from message.

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Recommendations for Improvement

TEASER
1. Remove or greatly simplify the differential-diagnosis table; keep only patient-relevant info.
2. Add missing warning signs: bleeding, numbness, ear pain, swallowing difficulty, unexplained loose teeth.
3. Rephrase “painless” biopsy to “quick outpatient procedure with local anaesthetic; most people feel only mild discomfort.”
4. Use bullet points or a short checklist to make early signs stand out.

MAIN
1. Rewrite entirely in plain language, stripping out specialist jargon and historic case specifics.
2. Focus on common early symptoms and simple guidance: “If you notice X, do Y.”
3. Adopt a more reassuring tone: explain that most mouth sores are benign but warrant checking.
4. Provide concrete, achievable next steps (e.g., “Book an appointment with your dentist or GP within two weeks”).
5. Reduce or move advanced imaging/genomics details to a provider-only appendix.

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Numeric Summary

TEASER
• Accuracy: 4/5
• Completeness: 3/5
• Clarity: 3/5
• Actionability: 4/5
• Tone: 4/5

MAIN
• Accuracy: 4/5
• Completeness: 3/5
• Clarity: 1/5
• Actionability: 2/5
• Tone: 2/5

1. Most Likely Differential Diagnoses:
   • Oral Lichen Planus (OLP): Typical cause of chronic white-patch or reticular lesions that persist >2 weeks, often sore or burning; common in middle age and easily overlooked.
   • Recurrent Aphthous Stomatitis (RAS): Produces painful ulcers that heal and recur; consistent with “wounds/blisters that don’t heal quickly” in the questionnaire.
   • Oral Candidiasis: White or erythematous plaques, altered taste and burning; risk rises with antibiotics, steroids, poor oral hygiene, smoking or xerostomia—all queried in the survey.
2. Can’t-Miss Diagnoses:
   • Oral Squamous Cell Carcinoma: Any non-healing ulcer, induration, leukoplakia or erythroplakia persisting >2 weeks mandates exclusion because delay worsens prognosis.
   • Hematologic Malignancy (e.g., Leukemia): Can manifest with persistent oral ulcers, petechiae or gingival hypertrophy and carries high morbidity if missed.
3. Key Next Diagnostic Steps:
   • Complete Head-and-Neck and Intra-oral Examination by dentist/ENT: To document site, size, surface and induration of lesions and palpate lymph nodes; foundation for all further testing.
   • Incisional Biopsy of any lesion persisting >2 weeks or showing induration/erythroplakia: Gold standard to rule out dysplasia or carcinoma.
   • Swab/PAS stain or empiric KOH of lesions: To confirm or exclude candidiasis.
   • Basic Laboratory Panel incl. CBC, ferritin, B12, folate, HbA1c: Screens for anemia, immunosuppression or hematologic disease contributing to mucosal changes.
4. Key Next Treatment Steps:
   • Symptomatic Care: Topical anesthetic (lidocaine 2 %), bland diet, good oral hygiene to reduce discomfort while evaluation proceeds.
   • Risk-factor Modification: Immediate counseling on smoking and alcohol cessation and avoidance of mucosal irritants (very hot/spicy foods, harsh mouthwash).
   • Empiric Antifungal (e.g., Nystatin suspension) if candidiasis suspected and no contraindication; adjust once cultures return.
   • Arrange Rapid Specialist Referral (max 2 weeks) for biopsy results discussion and, if carcinoma confirmed, multidisciplinary oncologic management (imaging, staging, surgical ± adjuvant therapy).

Chapter Answer:
Your mouth’s lining should heal quickly—usually within a week. Any sore, white or red patch, lump or burning that lasts longer than two weeks deserves a professional look. Sometimes these spots are harmless, such as minor ulcers or a yeast infection, and they clear with simple treatment. Rarely, they warn of more serious problems like an early oral cancer. Because it is impossible to tell by sight alone, the safest plan is a careful exam and, when a spot lingers, taking a tiny tissue sample (biopsy). This painless office procedure can rule out dangerous changes long before they become life-threatening. While you wait, keep your mouth clean, avoid tobacco and alcohol, choose soft, non-spicy foods and use a numbing gel if eating hurts. Early checking and, if needed, early treatment offer the best chance for complete cure and a healthy, comfortable mouth.

Chapter: Implementation of the AIDOC Diagnostic and Management Algorithm
Patient: Sigmund Freud, † 23-09-1939 (historic case – post-maxillectomy oral SCC)
Date of virtual review: ‑–
Consultant: Maxillofacial Surgery / Head & Neck Oncology Service, Medical University Vienna

1. Mapping of Online Questionnaire Responses to the AIDOC Algorithm

   (Because the patient entered non-semantic character strings, each reply is classified as “UNINTERPRETABLE – clarification required.” Nevertheless, Freud’s documented clinical history already places him in an ultra-high-risk category for secondary primary or recurrent oral squamous-cell carcinoma [OSCC].)

   Q01 – Q10: “etqert … 35t4” → UNINTERPRETABLE.
   Clinical consequence: Treat as “information not available.” History of OSCC over-rides any negative screening answers.

2. Step-by-Step AIDOC Flow (S2k Guideline-conform) with Commentary

   STEP 1 – Complete Examination of the Oral Mucosa
   • Perform meticulous inspection and bimanual palpation with removal of the obturator.
   • Pay special attention to the right maxillectomy cavity, soft-palate remnant, pterygomandibular raphe and skin fistula track.
   • Use adjuncts: autofluorescence (VELscope) and narrow-band imaging to delineate subclinical fields of dysplasia.

   STEP 2 – New Clinical Changes?
   • Historic note: persistent ulceration and fistulation of right zygomatic skin; progressive trismus; “premalignant lesion” treated with radium in 1934.
   • CURRENT ASSUMPTION: yes, new/ongoing mucosal and cutaneous changes → proceed.

   STEP 3 – Clinical Suspicion of Malignancy or Malignant Lesion?
   • Given visible ulceration, fistula, pain and previous recurrences, suspicion is HIGH → proceed to diagnostic work-up.

   STEP 4 – Recognisable Cause?
   • Mechanical irritation from obturator (“the monster”) and chronic scarring contribute but cannot solely explain progressive, indurated ulcer.
   • No reversible cause identified → mandate biopsy.

   STEP 5 – Biopsy
   • Targeted punch or scalpel biopsies from:
   ① Ulcer margin on skin-oral fistula,
   ② Floor of maxillectomy cavity,
   ③ Any leukoplakic/red areas at soft-palate margin.
   • Send in separate pots, include deep margins to evaluate depth of invasion.
   • Consider brush cytology for multifocal white plaques.

   STEP 6 – Dysplasia / Carcinoma in situ / Invasive SCC
   • If high-grade dysplasia or invasive SCC confirmed → refer for definitive oncologic treatment (multidisciplinary tumor board, H&N oncology centre).
   • If low-grade dysplasia → close surveillance q8-12 weeks.

   STEP 7 – Complete Regression & Non-Suspicious Cytology
   • Unlikely in Freud’s case. Should regression occur, revert to 6-monthly review.

   STEP 8 – Residual Uncertainty
   • If histology equivocal: repeat biopsy after 2 weeks, add p16 IHC and HPV DNA PCR (although HPV-related SCC in palate is rare).

   STEP 9 – Monitoring Until Complete Regression
   • Lifelong follow-up is mandatory; second primaries occur in up to 20 % of OSCC survivors.

3. Advanced Diagnostic Technologies Recommended

   • High-resolution contrast-enhanced MRI of skull base, parapharyngeal and masticator spaces to define recurrent mass and perineural spread along V2/V3.
   • Dual-energy CT for bone infiltration (zygomatic, pterygoid plates).
   • 18F-FDG PET/CT for regional/distant metastases.
   • Radiomics / AI-assisted segmentation to quantify tumor heterogeneity and predict radiosensitivity.
   • Next-generation sequencing panel (TP53, NOTCH1, FAT1, CDKN2A) on biopsy specimen for prognostic stratification and potential enrolment in precision-oncology trials.
   • Salivary transcriptomic assay (e.g., IL-8, OAZ1, SAT) every 6 months as non-invasive surveillance adjunct.

4. Current Management Plan

   1. Immediate punch biopsy (see Step 5).
   2. Pan-MR + PET/CT within 2 weeks.
   3. MDT discussion: options likely limited to palliative re-resection + immunotherapy (PD-1 inhibitor) ± re-irradiation.
   4. Optimise obturator fit with digital intraoral scanning and 3-D printed titanium framework to minimise mechanical trauma.
   5. Intensify pain control (step-wise WHO ladder; consider intrathecal pump if oral intake inadequate).
   6. Smoking cessation counselling (late but beneficial for mucosal healing).
   7. Nutritional optimisation: PEG feeding if oronasal fistula prevents adequate intake.
   8. Psycho-oncologic support for quality-of-life issues.
5. Key Take-Home Points (bold indicates AIDOC checkpoints):

   • Complete mucosal exam is indispensable even in long-term survivors.
   • Any new ulcer or induration in a previously treated field warrants immediate biopsy.
   • Chronic obturator irritation is rarely the sole cause of a persistent lesion – maintain high index of suspicion.
   • Modern imaging (MRI, PET/CT) and AI-based radiomics refine decision-making and surgical planning.
   • Lifelong, guideline-driven surveillance reduces mortality from second primaries.

AIDOC, PhD
Medical University Vienna
(AI generated)

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