(a) the overall pattern of wear of the claimant's teeth;

(b) the claimant has mild right sided masseteric myalgia (pain) which is clinically related to teeth grinding and jaw clenching, and

(c) the light vertical stress lines in the enamel of many of the claimant's teeth.

1. It is also the clinical judgment of the Medical Assessors that:

(a) the light vertical stress lines apparent on transillumination of the lower anterior teeth are not fractures of the teeth but are a sign of long-term damage to multiple teeth and there are no fractures to any other of Ms Kaur's teeth, and

(b) there are very small chips on the mesio-incisal corner of tooth 31 and the mesio-incisal corner of tooth 41.

1. The Panel is required to consider the injuries caused by the accident before determining whether they are threshold or non-threshold injuries.
2. The test of causation of injury is two-fold:

(a) could the accident have caused of materially contributed to the injury (a medical judgment), and

(b) did the accident cause or materially contribute to the injury (a factual non-medical judgment).

Could the accident have caused or contributed to the alleged oral injuries?

(a) whether the accident could have caused or materially contributed to the claimant's bruxism, and

(b) whether the bruxing could have caused or materially contributed to a chipped tooth.

1. It is the clinical judgment of the Medical Assessors that the cause of bruxing is often multi-factorial and stress is only a possible cause but is not the only cause of bruxing. Bruxing can also be related to other factors including personality type, gastro-oesophageal reflux disorder (GORD) and sleep apnoea.
2. It is the clinical judgment of the Medical Assessors that:

(a) if a person develops a stress-related psychiatric disorder as a result of a motor accident that this could cause or materially contribute to the development of bruxism;

(b) while they are not aware of any literature that supports that a new sources of stress would increase bruxing in an already chronic long term bruxer, they accept that daytime and nighttime bruxing are different and that daytime bruxing in addition to nighttime bruxing can lead to additional bruxing damage, and

(c) a person with a chronic long terms bruxing habit can stop bruxing however as this cannot be guaranteed, a splint is needed to minimise long term damage to the teeth.

1. It is the clinical judgment of the Medical Assessors that bruxing leads to changes in the teeth including smooth wear and tear on the posterior teeth but that bruxing can cause changes to the edges of the anterior teeth which could feel like "chips" of the teeth.

Did the accident cause or contribute to the alleged oral injuries?

1. The question remains whether Ms Kaur's accident on 11 May 2023 did cause or materially contribute to her bruxing (or an increase in her bruxing) and whether that bruxing (or increase in bruxing) caused or materially contributed to a chip of a tooth.
2. The Panel has already found that none of the claimant's teeth (including teeth 31, 41 and 43) have been fractured but that tooth 31 and tooth 41 currently have very small chips.
3. It is the clinical judgment of the Medical Assessors that chips on the front teeth (such as those seen on teeth 31 and 41) can be caused by bruxing but are usually caused by habits such as nail biting and the type of food that are eaten. Ms Kaur said at the re-examination that she has always (before and after the accident) enjoyed biting into chicken and chop bones and eating nuts. The Medical Assessors are of the view that long term biting into chop and chicken bones and eating hard foods such as nuts are a more medically plausible explanation for the ragged incisal edges of her maxillary anterior teeth and the chipping of the mesio-incisal corners of tooth 31 and tooth 41 than bruxing. The light vertical stress lines appearing on transillumination of the four lateral and central upper teeth (which also have ragged incisal edges) are, in the clinical judgment of the Medical Assessors also likely related to the bone nibbling and nut eating.
4. The Panel is not therefore satisfied that the claimant's allegedly chipped teeth were chipped because of her bruxism or as a result of a material contribution from her bruxism.
5. The clinical examination by Medical Assessor Vertoudakis satisfies the Panel that the claimant has chronic long-term bruxing with wear and tear on multiple teeth. The amount of wear is not consistent with short-term bruxing noting it was one year after the accident that the claimant went to India and obtained her splint. This is supported by Dr Pulapaka's clinical examination in April 2022 after which she stated that the claimant's bruxing was at that time so heavy that she suggested an immediate night splint. This is also supported by the claimant's own history given to Medical Assessor Vertoudakis. This supports a finding that bruxing commenced long before the motor accident. The Panel notes that before the accident there are multiple references to stress in the GP notes that have been provided.
6. Ms Kaur identified numerous past and current sources of stress in her life including her own serious illnesses and medical conditions unrelated to the accident. There are significant financial issues relating to her husband and injuries he sustained in another accident or incident. The Panel notes the findings of Medical Assessor Jones. While he found the claimant had some psychological symptoms, he found they were not of sufficient severity to constitute a psychiatric disorder. He also made the comment that Ms Kaur "came across as someone who had constitutional traits of anxiety."
7. If the claimant's very small chips of teeth 31 or 41 or any other of her lower teeth were caused by bruxing, in the light of the medical evidence and the claimant's history given at the re-examination, the Panel is not satisfied that any stress caused by the motor accident is a material contribution to her chronic bruxing habit.
8. The claimant's history of the recent development of daytime bruxing was given in the context of unrelated stressors and again, the Panel is not satisfied that the motor accident was a material contribution to any increase, worsening or aggravation of her bruxing habit.

1. The Panel is not satisfied that the claimant's alleged fractured or chipped tooth was caused by bruxism or that the claimant's chronic long-term bruxism was caused or materially contributed to by the physical or psychological injuries caused by the accident.
2. The Panel is not therefore satisfied that the claimant has sustained any dental injuries, threshold or non-threshold, caused by the accident.
3. As the Panel has come to the same conclusion as Medical Assessor Nichols, the Panel confirms his certificate.

48 disto occluso buccal (DOB) composite resin restoration

47 disto occluso buccal (DOB) composite resin restoration

46 disto occluso buccal (DOB) composite resin restoration

[1] Citation to be provided when decision published.

[2] [2022] NSWPICMP 6 at [62].

[3] [2022] NSWSC 372 (31 March 2022) see for example at paragraph 73.

[4] Other practitioners have not used the FDI system. Where this is the case, the Panel will refer to FDI tooth number in square brackets.

[5] The numbers in square brackets are a reference to the section number in the Medical Assessor's reasons.

[6] The numbers in square brackets are a reference to the paragraph number in the submissions.

[7] No third party specialist reports have been provided in the clinical notes and the Panel does not have a copy of Dr Wallace's report.

[10] This is how the canine teeth on one side of the mouth guide side-to-side movements of the jaw, keeping the back teeth from touching and preventing excessive wear of the molars.