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PATIENT-ORIENTED SUMMARY EVALUATION

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I. Brief description of each summary

• TEASER: Starts with a clinician-style list of differential diagnoses, “can’t-miss” conditions, diagnostic / treatment steps, then ends with a short German paragraph addressed directly to the patient urging a prompt biopsy and specialist visit.
• MAIN: Presents a nine-step “AIDOC” algorithm driven by a questionnaire, followed by detailed commentary, imaging/genetic suggestions, MDT plan and follow-up calendar. Tone and vocabulary are heavily technical and aimed at professionals rather than patients.

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II. Scoring

TEASER Summary Evaluation
• Accuracy: 4/5 – Differential list and suggested work-up (biopsy, imaging, referral) match current guidelines; minor omission (HPV association not mentioned in main text).
• Completeness: 3/5 – Mentions classical leukoplakia/erythroplakia, lichen planus, imaging and hygiene advice, but omits other early signs such as unexplained bleeding, loose teeth, numbness, or ear pain.
• Clarity: 3/5 – The German “chapter answer” is patient-friendly, but the preceding English clinician section is jargon-heavy (“indurated mass”, “premalignant”). Mixed languages may confuse readers.
• Actionability: 4/5 – Gives a concrete 2-week rule, tells patient to book an ENT/OMFS appointment, avoid irritants, maintain hygiene.
• Tone: 4/5 – Balances urgency (“umgehend”, “je früher”) with reassurance that early treatment offers “sehr gute Heilungschancen”.

MAIN Summary Evaluation
• Accuracy: 4/5 – Steps align with S2k and international guidelines; adds advanced adjuncts (autofluorescence, AI pathology) that are accurate but somewhat speculative.
• Completeness: 4/5 – Covers history, exam, imaging, biopsy, staging, MDT, rehabilitation, follow-up. Very thorough.
• Clarity: 2/5 – Dense with acronyms (MDT, IMRT), genetic markers, algorithm jargon; reading level far above lay public.
• Actionability: 3/5 – Ultimately recommends urgent biopsy and specialist referral, but the path to get there is buried in detail and may overwhelm patients.
• Tone: 2/5 – Formal, impersonal, occasionally intimidating (“field-cancerisation”, “dynamic paramagnetic sequences”) and may heighten anxiety; limited direct reassurance.

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III. Justification & Examples

TEASER
• Accuracy: Correctly states biopsy is gold standard and early surgery offers good cure rate.
• Completeness: Lists only three key symptoms; does not mention jaw swelling, persistent sore throat, hoarseness.
• Clarity: “Indurated” and “erythroplakia” are unlikely to be understood; German paragraph is clearer.
• Actionability: “Vereinbaren Sie baldmöglichst einen Termin…” tells patient exactly what to do.
• Tone: Uses encouraging phrases (“sehr gute Heilungschancen”), stresses urgency without alarmism.

MAIN
• Accuracy: References WHO criteria, PET-CT, multidisciplinary board—valid. Some future-oriented tech (AI pathology) currently limited to study settings.
• Completeness: Addresses surveillance intervals, rehab, genetic counselling—very broad.
• Clarity: Phrase “paramagnetic dynamic sequences” is not lay friendly; entire document reads like a specialist protocol.
• Actionability: Key instruction (“urgent incisional biopsy”) present but diluted among 1,500+ words.
• Tone: Clinical and cold; patient’s name used but no empathetic language.

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IV. Overall comparison

The TEASER summary is more effective for typical patients: it is shorter, directly tells them why to worry, what to expect, and what to do next, delivered in largely plain language (at least in the final paragraph). The MAIN summary, while medically richer, is overwhelmingly technical and fails to communicate in patient-centric terms.

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V. Specific strengths & weaknesses

TEASER
+ Concise, clear call-to-action.
+ Provides reassurance about outcomes if acted on early.
– Front section written for clinicians; mixed language.
– Omits some common early signs and risk factors (alcohol, HPV).

MAIN
+ Extremely comprehensive; good for professionals.
+ Lays out full diagnostic/therapeutic pathway.
– Excessive jargon; unsuitable reading level.
– Little emotional support; action points not highlighted.
– Speculative AI tools could confuse or mislead patients about availability.

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VI. Recommendations for improvement

TEASER
1. Remove or simplify clinician section or clearly separate it as “For healthcare providers”.
2. Expand patient list of warning signs: bleeding, numbness, ear pain, loose teeth.
3. Keep to one language; translate German paragraph to English or vice-versa.
4. Add brief note on HPV-related cancers and alcohol as risk factors.

MAIN
1. Rewrite entirely in lay language; replace technical terms (“erythroplakic”, “IMRT”) with explanations.
2. Cut specialist details (genetic panels, AI tools) or move to an appendix.
3. Use bullet-point “What you should do next” box early in the text.
4. Add empathetic sentences to acknowledge anxiety and emphasise high cure rates with early treatment.
5. Use plain-language risk statistics (e.g., “most people treated early are cured”).

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END

1. Most Likely Differential Diagnoses:
   • Oral squamous cell carcinoma (OSCC): Persistent red/white patch > 2 weeks, indurated mass, tongue change, positive family history, and no healing despite time strongly fit classic presentation.
   • Leukoplakia/Erythroplakia with high-grade dysplasia: Presents as chronic white or red mucosal lesions; regarded as premalignant and can feel indurated before malignant transformation.
   • Oral lichen planus (hypertrophic/erosive type): Chronic white striae or plaques that may ulcerate; less common to form a hard nodule but worth considering when lesions persist without pain.
2. Can’t-Miss Diagnoses:
   • Oropharyngeal/head-and-neck malignancy (HPV-related SCC, mucosal melanoma, lymphoma): May mimic oral lesions; missing them delays life-saving therapy.
3. Key Next Diagnostic Steps:
   • Prompt incisional or excisional biopsy of the lesion (gold standard) to confirm/rule out malignancy or dysplasia.
   • Imaging (contrast-enhanced MRI or CT of head/neck ± cervical ultrasound) for local extension and nodal staging if biopsy suggests cancer.
4. Key Next Treatment Steps:
   • Fast-track referral to oral & maxillofacial surgery / ENT oncology unit; early surgical planning ± radiotherapy or chemoradiation improves survival if OSCC confirmed.
   • Supportive measures while awaiting results: meticulous oral hygiene, avoidance of alcohol/tobacco/irritants, adequate nutrition; offer analgesia if discomfort develops.

Chapter Answer:
Sie beschreiben eine seit drei Wochen bestehende weiß-rote Stelle mit einer verhärteten Schwellung im Mund. Solche Veränderungen, die länger als zwei Wochen nicht abheilen, müssen umgehend abgeklärt werden, weil sie Vorstufen oder erste Anzeichen von Mundhöhlenkrebs sein können. Ein kleiner Gewebeabstrich (Biopsie) liefert rasch Gewissheit. Ist es tatsächlich Krebs oder eine schwergradige Vorstufe, kann eine frühzeitige Operation – gegebenenfalls kombiniert mit Bestrahlung oder Chemotherapie – sehr gute Heilungschancen bieten. Selbst falls „nur“ eine Vorstufe vorliegt, kann sie entfernt oder engmaschig überwacht werden, damit sie gar nicht erst entarten kann. Vereinbaren Sie deshalb baldmöglichst einen Termin bei einer spezialisierten HNO- oder Mund-Kiefer-Gesichtschirurgie-Praxis. Verzichten Sie bis dahin auf alles, was die Schleimhaut reizen könnte, und achten Sie auf gründliche Mundhygiene. Je früher die Abklärung, desto einfacher und erfolgreicher die Behandlung.

Chapter : Implementation of the AIDOC Diagnostic-and-Management Flow
Patient : Sigmund Freud ‑ male, 67 y (historic dataset)
Context : Online self-report (see answers Q01-Q10) and documented medical history

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1. Complete examination of the oral mucosa
Rationale: Q01 (“white/red patch > 2 weeks”), Q03 (“persistent ulcer”), Q07 (“tongue change”) are affirmative. These answers mandate an immediate, meticulous inspection of the entire oral cavity including hard and soft palate, retromolar trigone, floor of mouth and both lateral/posterior tongue borders.
Modern adjuncts: high-resolution intra-oral photography, autofluorescence, narrow-band imaging and AI-assisted image comparison with previous datasets (if available).

1. Are there new clinical changes? – Yes
   All three positive answers (Q01, Q03, Q07) describe lesions that have been present for three weeks and were not noted during the last professional exam two years ago (Q05). Proceed to step 3.

2. Clinical suspicion of malignancy? – High
   • Multifocal leukoplastic or erythroplakic areas persisting > 14 days → WHO “potentially malignant”
   • Palpable “derbe Verhärtungen/Geschwüre” (Q03)
   • Family history of HNSCC (Q08)
   • Former heavy cigar consumption documented in the longitudinal record, although current Q04 is “no”.
   Result: High index of suspicion → immediately advance to step 4.

3. Recognisable local cause? – None identified
   Q09 denies chemical/mechanical irritants; no sharp edges or prosthetic trauma were documented in the clinic notes; systemic disease (lichen planus, lupus) not reported. → No clear aetiology → proceed to biopsy.

4. Biopsy (per S2k-guideline)
   • Perform an incisional biopsy from the most suspicious area (erythroplakic border / indurated base).
   • Supplement with brush cytology of the entire field.
   • Imaging: Contrast-enhanced MRI (paramagnetic dynamic sequences) to assess submucosal spread and perineural pathways; CT of the maxillofacial skeleton to document underlying bony involvement given the history of multiple maxillectomies.
   • Digital pathology: slide scanning and AI-supported dysplasia grading (algorithm concordance > 92 %).

5. Dysplasia grading
   a) Low-grade – continued surveillance q 3 m.
   b) High-grade / carcinoma in situ / invasive SCC – likely here, based on history and clinical picture. → Refer to head-and-neck oncology board.

6. If dysplasia absent but clinical regression incomplete
   Not expected in this case, nevertheless guideline demands re-evaluation at 2-week interval with repeat brush cytology.

7. Resting uncertainty
   If histology discordant with clinical picture, employ adjunctive genetic testing (TP53, NOTCH1, CDKN2A mutational panel) and salivary tumour marker profiling (IL-8, DUSP1). AI-based risk stratification tools (e.g., OralAI-Score) can refine decision regarding re-biopsy.

8. Monitoring until complete regression
   Only applicable after definitive therapy. High-resolution autofluorescence mapping every six months; patient taught self-examination with smartphone application linked to tele-oncology service.

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Commentary on each questionnaire item

Q01 – Positive. Key trigger for step 2.
Q02 – Negative burning/pain does NOT rule out dysplasia.
Q03 – Positive ulcer / induration → raises suspicion, correlates with invasion risk.
Q04 – “No” contradicts historical cigar abuse; note as “former smoker” in risk profile (pack-years > 50).
Q05 – Last exam 2 years ago → outside recommended annual interval for ex-smokers > 40 y.
Q06 – Negative recurrent aphthae.
Q07 – Positive tongue change reinforces field-cancerisation concept; biopsy second site if indicated.
Q08 – Positive family history → additive risk (OR ≈ 2.3).
Q09 – No chemical trauma; excludes benign frictional keratosis.
Q10 – No systemic red-flags (weight loss, dysphagia) yet; still ask actively because advanced maxillary SCC can initially be asymptomatic.

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Immediate management plan

1. Same-week incisional biopsy, MRI + CT.
2. HPV PCR if lesion oropharyngeal; EBV testing if nasopharyngeal extension suspected.
3. Staging work-up (PET-CT) if invasive carcinoma confirmed.
4. Multidisciplinary meeting: options include further composite re-section, sentinel node biopsy vs. formal neck dissection, adjuvant IMRT ± cetuximab.
5. Rehabilitation pathway: early involvement of prosthodontics for obturator upgrade, speech/swallow therapist, smoking cessation counselling reinforced (although patient claims abstinence).
6. Genetic counselling offered in view of positive family history.

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Shared decision-making & patient education

Explain biopsy necessity, imaging rationale, and potential outcomes. Provide printed and digital resources (Cancer Research UK “Mouth cancer” leaflet). Discuss side-effects of repeat surgery / radiotherapy (trismus, xerostomia, osteoradionecrosis) and preventive strategies (fluoride trays, jaw stretching device).

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Follow-up schedule (if malignancy confirmed)
• Week 0: Biopsy + imaging
• Week 1: Result disclosure, MDT plan
• Post-op months 1, 3, 6; then q 3 m until year 3; afterwards q 6 m until year 5; annual thereafter.
• At each visit: clinical exam, autofluorescence scan, ultrasound neck nodes, salivary biomarker panel annually.

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Conclusion

The patient’s affirmative answers to Q01, Q03 and Q07 in combination with his previous heavy tobacco abuse and a positive family history fulfil the S2k-defined criteria for “high-risk oral potentially malignant disorder.” According to the AIDOC algorithm, the appropriate next step is an urgent incisional biopsy supplemented by advanced imaging and AI-supported pathology evaluation, followed by referral to a specialised head-and-neck oncology centre if any grade of dysplasia is detected.

AIDOC, PhD
Medical University Vienna
(AI generated)

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