"The standard test adopted in determining if medical treatment is reasonably necessary as a result of a work injury is that stated by Burke CCJ in Rose v Health Commission (NSW) [1986] NSWCC2; [1986] NSWCC 2; (1986) 2 NSWCCR 32 (Rose) where his Honour said, at 48A-C:

1. Any necessity for relevant treatment results from the injury where its purpose and potential effect is to alleviate the consequences of injury.
2. It is reasonably necessary that such treatment be afforded a worker if this Court concludes, exercising prudence, sound judgment and good sense, that it is so. That involves the Court in deciding, on the facts as it finds them, that the particular treatment is essential to, should be afforded to, and should not be forborne by, the worker.
3. In so deciding, the Court will have regard to medical opinion as to the relevance and appropriateness of the particular treatment, any available alternative treatment, the cost factor, the actual or potential effectiveness of the treatment and tis place in the usual medical armoury of treatments for the particular condition."
4. Roche DP also noted that the Commission has generally referred to and applied the decision of Burke CCJ in Bartolo v Western Sydney Area Health Service:[7]

"The question is should the patient have this treatment or not. If it is better that he have it, then it is necessary and should not be forborne. If in reason it should be said that the patient should not do without this treatment, then it satisfies the test of being reasonably necessary."

"In the context of s 60 the relevant matters, according to the criteria of reasonableness, include, but are not necessarily limited to, the matters noted by Burke CCJ at point (5) in Rose (see [76] above), namely:

(a) the appropriateness of the particular treatment;

(b) the availability of alternative treatment, and its potential effectiveness;

(c) the cost of the treatment;

(d) the actual or potential effectiveness of the treatment, and

(e) the acceptance by medical experts of the treatment as being appropriate and likely to be effective.

With respect to point (d), it should be noted that while the effectiveness of the treatment is relevant to whether the treatment was reasonably necessary, it is certainly not determinative. The evidence may show that the same outcome could be achieved by a different treatment, but at a much lower cost. Similarly, bearing in mind that all treatment, especially surgery, carries a risk of a less than ideal result, a poor outcome does not necessarily mean that the treatment was not reasonably necessary. As always, each case will depend on its facts."

1. The applicant's treating dentist, Dr Juhi Drishnaswamy provided a quote for the proposed treatment dated 27 August 2024, which estimates the total costs of the proposed treatment to be $7,803. The respondent has not raised any issue regarding the quantum of that estimate.
2. At the hearing, counsel accepted, and it is not in dispute, that the proposed treatment, being upper and lower dentures, is reasonably necessary treatment because of the applicant's dental condition.
3. In any event, I note that such a conclusion is generally consistent with the treating and independent medical evidence that is before me.

Does the need for the proposed treatment arise as a result of a work injury?

1. The critical question that I am required to determine in this case relates to the issue of causation, particularly whether the proposed treatment is reasonably necessary as a result of the injury.
2. A commonsense evaluation of the causal chain is required. In Kooragang Cement Pty Ltd v Bates,[8] Kirby P (as his Honour then was) stated:

"The result of the cases is that each case where causation is in issue in a workers compensation claim, must be determined on its own facts. Whether death or incapacity results from a relevant work injury is a question of fact. The importation of notions of proximate cause by the use of the phrase 'results from', is now not accepted. By the same token, the mere proof that certain events occurred which predisposed a worker to subsequent injury or death, will not, of itself, be sufficient to establish that such incapacity or death 'results from' a work injury. What is required is a commonsense evaluation of the causal chain. As the early cases demonstrate, the mere passage of time between a work incident and subsequent incapacity or death, is not determinative of the entitlement to compensation."[9]

1. In Murphy v Allity Management Services Pty Ltd[10] Roche DP stated:

"... a condition can have multiple causes (Migge v Wormald Bros Industries Ltd (1973) 47 ALJR 236; Pyrmont Publishing Co Pty Ltd v Peters (1972) 46 WCR 27; Cluff v Dorahy Bros (Wholesale) Pty Ltd Pty Ltd (1979) 53 WCR 167; ACQ Pty Ltd [2009] HCA 28 at [25] and [27]; [2009] HCA 28; 237 CLR 656). The work injury does not have to be the only, or even a substantial, cause of the need for the relevant treatment before the cost of that treatment is recoverable under s 60 of the 1987 Act.

Ms Murphy only has to establish, applying the commonsense test of causation (Kooragang Cement Pty Ltd v Bates (1994) 35 NSWLR 452; 10 NSWCCR 796), that the treatment is reasonably necessary 'as a result of' the injury (see Taxis Combined Services (Victoria) Pty Ltd v Schokman [2014] NSWWCCPD 18 at [40]- [55]). That is, she has to establish that the injury materially contributed to the need for the surgery (see the discussion on the test of causation in Sutherland Shire Council v Baltica General Insurance Co Ltd (1996) 12 NSWCCR 716)."

1. The applicant gave evidence that his treating dentist, Dr Juhi Krishnaswamy has recommended that he obtain upper and lower dentures to treat his current dental condition, which was caused by bruxism which is a consequential condition of the accepted injury.
2. It is not in dispute that the applicant suffers from the condition of bruxism and that he had some degree of periodontal disease prior to the accepted injury.
3. The applicant gave evidence that his dental history prior to the accepted injury included the surgical removal of two of his teeth when he was 13 years old as he required braces, and the subsequent removal of three additional back teeth over 12 or 15-month period.
4. The applicant's evidence is that he developed the condition of bruxism subsequent to the accepted injury as a result of the psychological injuries, which included anxiety, depression and post-traumatic stress disorder and stress associated with the accepted injuries and the claim for compensation, and various medication that he was prescribed to treat his psychological condition.
5. The applicant stated that following the accepted injury, in around early 2024, he commenced experiencing pain in his jaw and frequent headaches, and he clenched his teeth and jaw as a reaction to anger and frustration, although he did not think to mention that to his treating general practitioner (GP). The applicant stated that, in or around July 2024, Dr Nabil Malik, psychiatrist, noted on examination that the applicant was constantly clenching his teeth and jaw and recommended that it should be investigated. The applicant stated that he was subsequently referred by his GP to a dentist and he has received treatment from his GP, psychiatrist, psychologist and dentist. The applicant stated that he currently takes medications Serotonin 50mg and Clonidine 150mg.
6. The applicant stated that the onset of bruxism has caused issues with his oral health generally. He stated that because of the bruxism, he is worried that he will lose his front teeth and a lot of time and money that he previously spent on his teeth seems to be useless.

Dr Juhi Krishnaswamy, the applicant's treating dentist

1. Dr Krishnaswamy's quotation detailed the dental treatment plan proposed to be undertaken over six visits.
2. In a report dated 16 September 2024, Dr Krishnaswamy stated that the applicant initially presented to him seeking treatment for a chip in his upper left front tooth and bruxism on the suggestion of a psychiatrist who was treating him for post-traumatic stress disorder following a workplace assault in 2023. Dr Krishnaswamy stated that the applicant has symptoms relating to bruxism, he has been waking up with bilateral headaches in the temporal region for about 18 months and he believes that he clenches more so during the day than the night. On examination, Dr Krishnaswamy noted a 21MIBP enamel dentine fracture, which could be repaired but had a poor long-term prognosis as there is a lack of surface area to bond to.

Dr Krishnaswamy noted that heavy wear is present on the anterior teeth and wear facets present on some posterior teeth, all canines exhibited heavy wear, many posterior teeth are missing and there exist three occluding units, two on the left side and one on the right side. Dr Krishnaswamy stated that:

"I discussed with [the applicant] the concept of the shortened dental arch in dentistry ie. 4 occluding units necessary for sound function.

No posterior guidance (canine guidance or group function) exists on the RHS and LHS due to tooth wear. Anterior guidance is via the premolars.

I recommend replacement of posterior teeth to prevent further wear on anterior teeth.

The POG showed potential calcifications in the carotid region, I wrote a letter to [the applicant's GP and asked him to follow up on this.

I discussed with [the applicant] the opportunity to discuss the potential of planning for a partial upper and lower denture with a prosthetist. The upper partial denture can be constructed to replace 25 26 27 16 17. Teeth on the lower arch which do not have good long term prognosis include 47 45 36. These teeth are indicated for extraction. The lower partial denture can then be constructed to replace 47 46 45 36 37. This is accounted for in the treatment plan.

In relation to [the applicant's] bruxism we discussed the option of an occlusal splint. He may or may not be able to use this as he sleeps with a cpap machine. We also discussed the option of botox and muscle relaxants which can be prescribed by his GP. His bruxism not only be a manifestation of PTSD as it may also be a side effect of lexapro. I advised him to I discuss this with his GP. Other conservative options of stress management include yoga, meditation and exercise -

In relation to Leslie's airways, I offered him option of referral to an ENT. Bruxism can be related to sleep apnoea.

I also recommend a scale and clean and fluoride treatment and this has been added to the treatment plan."

1. In a report dated 11 February 2025, Dr Krishnaswamy:

(a) noted that in preparing the report, he considered material which included an OPG taken on 28 July 2022 (for Dr Daehoon Kang) and an OPG taken on

27 April 2024;

(b) noted a medical history which included the applicant taking Lexapro medication and also a dental history form completed on 25 July 2022, which responded "no" to the question "are you aware of grinding or clenching your teeth?"

(c) recorded a reported history taken on 27 August 2024, that over about the previous 18 months, the applicant had been waking up with headaches bilaterally in the temporal region and across his forehead and that he had been taking Lexapro medication on and off for about seven years, and he sought a dental opinion as to whether clenching and grinding could have caused damage to his 21 tooth;

(d) stated that on examination, Dr Krishnaswamy found an MIBIP fracture in tooth 21, in enamel and dentine, and evidence of significant bruxism;

(e) stated that over time, bruxism can lead to micro-cracks in the tooth which in turn may propagate, leading to fracture of the tooth structure;

(f) stated that the applicant's medical history discloses that her bruxism is likely to be multi-faceted, including general life stresses, side-effects of Lexapro, airway problems and post-traumatic stress disorder;

(g) stated that the bruxism will continue to destroy the applicant's remaining teeth;

(h) stated that the proposed treatment will provide artificial replaceable teeth to enable the applicant to have a functioning oral cavity and, in conjunction with the general dentistry work identified in the treatment plan, will be effective to provide the applicant with a long-term functioning mouth;

(i) stated that he is unaware of any viable forms of alternate treatment, and

(j) stated that replacement of posterior teeth will provide the applicant with a functioning mouth and an occlusal splint to mitigate damage on remaining teeth during nocturnal bruxism will prolong longevity of the applicant's remaining dentition.

1. In a report dated 6 April 2025, Dr Krishnaswamy stated that:

(a) bruxism is a medical term for teeth grinding and clenching and that the main contributing causes of bruxism include general life stresses, post-traumatic stress disorder, airway problems and side effects of various drugs including Lexapro;

(b) in his opinion the fracture of tooth 21 is likely to have been a consequence of bruxism over time;

(c) over time without treatment, bruxism, can cause significant wear to teeth and can lead to cracked teeth whereby the formation of microcracks within the tooth structure may propagate and lead to tooth fracture, and

(d) wear of the tooth through bruxism will lead to loss of effective mouth function which can impact on general health, it may cause widening of the periodontal ligament which can lead to pain on biting, it may lead to straining of the muscles on mastication which may lead to headaches, which the applicant did note.

Dr Leila Mirbagher Ajorpaz, treating general practitioner

1. In a referral letter dated 11 June 2024, Dr Ajoropaz recorded that the applicant was undergoing psychological treatment for post-traumatic stress disorder following the accepted injury. Dr Ajoropaz recorded various medications that were prescribed to the applicant.
2. In a report dated 17 February 2025, Dr Ajorpaz reported that the applicant has a history of bruxism, which has been causing irritation. Dr Ajorpaz stated that it is uncertain whether the applicant's employment was a substantial contributing factor. Dr Ajorpaz could not give an opinion regarding the reasonable necessity of the proposed treatment and referred to the opinion of the treating dentist.

1. In a report dated 13 March 2025, Ms Lefman reported on psychological treatment of the applicant following the accepted injury. Ms Lefman diagnosed post-traumatic stress disorder, caused by the workplace assault. Ms Lefman expressed the opinion that the assault, along with the subsequent development of post-traumatic stress disorder, is a significant contributing factor to the aggravation and exacerbation of deterioration of the applicant's dental condition.

1. In a report dated 25 April 2025, Dr Bochsler reported on his review of the applicant and stated an impression of exacerbation of post-traumatic stress disorder, triggered by further aggressive interaction at work.

1. Clinical notes of Atune Health Centre record the applicant's various attendances during 2024 and 2025.

1. Imaging included an OPG image and a CT scan taken on 16 January 2023.

1. Other treating medical evidence included a Discharge Summary issued by the Singleton District Hospital dated 7 January 2023.

Dr Georgios Sotiropoulos, dental surgeon, independent medical expert qualified by the respondent

1. In a report dated 27 November 2024, Dr Sotiropoulos:

(a) recorded that the applicant reported experiencing bilateral tightness in the temporal muscles, headaches and recently chipped front tooth (21);

(b) recorded a diagnosis of mild bruxism due to pre-existing factors including loss of posterior support and development malocclusion, sleep apnoea, but possibly associated with and exacerbated by, recent primary psychological injury, noting that a side-effect of long-term administration of Lexapro is an association with bruxism, and

(c) expressed the opinion that the applicant's employment with the respondent is unlikely to be "the main substantial contributing factor" to the applicant's dental condition.

1. In a report dated 20 December 2024, Dr Sotiropoulos:

(a) expressed the opinion that the applicant's current dental condition has a likely aetiology including (but not limited to) poor oral hygiene, diet, neglect, lifestyle factors and that it is not "substantially consequential" to the accepted injury;

(b) stated that the OPG demonstrates the presence of Chronic Generalised Advanced Periodontal Disease (Stage 3-4 periodontitis) which is the likely cause of historic tooth loss (loss of posterior support) and present occlusal instability and changes;

(c) opined that any bruxism is likely due to occlusal changes consequential to loss of posterior support, "with possibly a minor, if any, exacerbation due to" the accepted injury;

(d) expressed the opinion that the applicant's pre-existing condition was "not substantially consequential to, nor aggravated by" the accepted injury;

(e) expressed the opinion that the proposed treatment is necessary to the applicant's condition but not due to the accepted injury, and

(f) stated that occlusal splint therapy is contraindicated and not necessary due to the accepted injury.

Dr Marios Argyou, dental surgeon, independent medical expert qualified by the applicant

1. In a report dated 17 February 2025, Dr Argyrou:

(a) noted that he reviewed various documents including "COC 4/02/25";

(b) recorded a medical history that the applicant had a complex medical history following the accepted injury, which has led to significant physical, psychological and dental complications, and that the applicant has reported ongoing chronic pain, psychological distress and functional impairments which have progressively worsened since his injury, and had been placed on an extensive medication regimen;

(c) stated that the combination of chronic stress, bruxism (teeth grinding), medication-induced dry mouth and acid reflux has significantly impacted the applicant's dental health, leading to structural tooth loss and functional limitations;

(d) expressed the opinion that, on the balance of probabilities, the applicant's employment has been a substantial contributing factor to the applicant's current dental pathology diagnosed, noting that the applicant's work-related psychological injury, including post-traumatic stress disorder, anxiety and depression, has directly contributed to his severe bruxism, xerostomia, and progressive dental deterioration, leading to enamel erosion, occlusal wear, stress fractures, increased tooth mobility, and temporomandibular joint dysfunction, all of which are clinically evident upon examination, and that the long-term use of medications prescribed for the applicant's psychological condition, including antidepressants and anxiolytics, has caused significant salivary gland suppression, resulting in persistent xerostomia;

(e) stated that the proposed treatment is reasonably necessary as it directly addresses the functional and structural consequences of the applicant's dental deterioration;

(f) stated that, given the applicant's multiple missing teeth, severe bruxism, periodontal instability, and temporomandibular joint dysfunction, prosthetic rehabilitation is required to restore occlusal stability, improve mastication, and prevent further dental and TMJ complications;

(g) stated that the proposed treatment is reasonably necessary for the applicant to restore oral function, improve mastication, and prevent further complications related to his missing teeth and deteriorating dentition;

(h) noted that the applicant has multiple missing teeth, including 17, 18, 26, 27, 28, 46, 47, 48, 37, and 38, which has resulted in reduced occlusal stability, inefficient chewing, and increased strain on his remaining dentition, and that the absence of those teeth has led to greater functional stress on the remaining teeth, worsening the applicant's bruxism and temporomandibular joint dysfunction, and

(i) stated that without prosthetic rehabilitation, the applicant is at increased risk of further tooth loss, occlusal imbalance, and worsening TMJ-related symptoms and that the proposed treatment is a necessary and reasonable treatment to restore function, alleviate symptoms, and prevent further oral health decline.

1. The treating medical evidence and the history recorded by the independent medical experts indicates that the applicant reported experiencing bilateral tightness in the temporal muscles, headaches and recently chipped front tooth (21) only subsequently to the accepted injury.
2. I note that Dr Sotiropoulos diagnosed mile bruxism due to several factors "with possibly a minor, if any, exacerbation due to the" accepted injury. Dr Sotiropoulos referred to and apparently applied various causal tests which involved a finding of "substantially consequential". That is not the test that I am required to apply to determine this claim. I just have to determine whether there was a material contribution.
3. I found Dr Argrou's report to be particularly compelling as it provided a particularly detailed and comprehensive analysis of the applicant's medical history and causal factors relevant to the development of the applicant's bruxism and current dental condition and the need for the proposed treatment. Further, it provided a detailed and considered explanation of the need, purpose and appropriateness of the proposed treatment to treat the applicant's current dental condition, specifically in relation to the present and future consequences of the applicant's bruxism condition, noting a clear connection between the applicant's employment and the dental pathology diagnosed.
4. Having regard to the evidence as a whole and applying a commonsense evaluation of the causal chain, I consider that it is logical and likely that the applicant developed the condition of bruxism as a consequence of the accepted injury, which materially contributed to the applicant's current dental condition.
5. I do not need to be satisfied that the accepted injury was the only, or even a substantial, cause of the need for the proposed treatment.
6. For these reasons, I am satisfied that the accepted injury materially contributed to the need for the proposed treatment and that the need for the proposed treatment arose as a result of the accepted injury.

1. For all the reasons above, I am satisfied, having regard to the considerations identified in Diab v NRMA Ltd[11] and Rose v Health Commission (NSW)[12] that the proposed treatment is, therefore, reasonably necessary as a result of the accepted injury.

1. In summary, the following findings and orders are made:

(a) The Commission determines:

(i) the proposed treatment, in particular upper and lower dentures, is reasonably necessary as a result of the accepted injury.

(b) The Commission orders:

(i) the respondent to pay the costs of and incidental to the proposed treatment.

[1] [2014] NSWWCCPD 72.

[2] [2015] NSWWCCPD 49 at [57].

[3] (1994) 35 NSWLR 452; 10 NSWCCR 796.

[4] [2014] NSWWCCPD 72.

[5] [2014] NSWWCCPD 72.

[6] [1986] NSWCC2; [1986] NSWCC 2; (1986) 2 NSWCCR 32.

[7] [1997] NSWCC 1; 14 NSWCCR 233.

[8] (1994) 35 NSWLR 452; 10 NSWCCR 796.

[9] (1994) 10 NSWCCR 796 at [810].

[10] [2015] NSWWCCPD 49 at [57].

[11] [2014] NSWWCCPD 72.

[12] [1986] NSWCC 2; (1986) 2 NSWCCR 32.