(a) fractures and crush injuries (September 2013, December 2013 - 20 April 2014);

(b) shoulder and upper arm disorder (May 2014 - May 2015) and then in conjunction with other disorders;

(c) lower limb deficiencies (August 2015 - September 2015 and then in conjunction with other disorders);

(d) urinary tract disorders and bladder issues (January 2017 - 27 May 2017 and then in conjunction with other disorders);

(e) "cancer / tumour brain" (24 June 2020 and 6 April 2021), and

(f) neck disorder (28 September 2020 - 1 May 2021).

1. Other reasons also given are "musculo skeletal disorder - other", "spinal disorder - other", "urinary incontinence, and nervous system - other".

1. The hospital has provided records of the following attendances:

(a) 18/19 January 2014 - presents with shoulder dislocation to left shoulder - patient states hand was stuck in harden machinery and when pulling away felt shoulder pop. Attended the next day with pain and numbness in right arm where the intravenous drip had been;

(b) 4 February 2014 - acute onset mid thoracic back pain while at walking out of house - denies trauma;

(c) 28/29 September 2014 - claimant was in a hard collar following a motor vehicle accident - loss of consciousness and amnesic to events - face hit the steering wheel - neck and back pain, laceration to lip - had anxiety attack whilst in CT scanner;

(d) 2 December 2014 - injured mid thoracic lumbar spine pain after lifting heavy (50 - 60kg) slab of marble;

(e) 13 January 2015 - left shoulder dislocation - this was his sixth and the history was it occurred while driving;

(f) 16 July 2015 - fall while playing sport and injury to knee;

(g) 11 October 2015 - abdominal pain patient in distress - no PNH (past mental history). Had been moving boxes / heavy lifting all yesterday;

(h) 29 November 2018 - neck pain after motor vehicle accident today - rear ended while stationary at lights pain both sides radiating into head - reduced motion with pain;

(i) 12 February 2020 - central headache onset one to two months ago - feels increasing in last week - visual changes (spots loading in front of eyes) - central cyst seen The claimant was taken up to the ward and was distressed at being admitted - he left the ward to move his car and did not return - he was contacted and advised his girlfriend had locked herself out and he had to go home;

(j) 18 April 2021 - left shoulder dislocation on a background of left shoulder surgery;

(k) 1 October 2021 - left sided chest pain since yesterday evening. No shortness of breath. Past history of anxiety and depression noted;

(l) 21 October 2021 - chest pain left sided with shortness of breath;

(m) 7 March 2022 - atypical chest pain left sided no shortness of breath, and

(n) 17/18 November 2022 - chest pain with left arm numbness.

1. The hospital records do not indicate any previous jaw pain or dental injuries.

1. Records have been provided by the Medical and Dental Centre at Punchbowl (MDCP) as at 13 October 2020.[12] As most of these records relate to the claimant's shoulder and other physical injuries there is no need to document them at great length in these reasons.
2. At page 43 of these notes[13] is a list of previous prescriptions which include Seretide and Spiriva Amoxil from 20 October 2005 to 11 October 2006.
3. Pain killers (Brufen and Mobic) were prescribed commencing 27 May 2010 associated with recurrent discolorations of the left shoulder. Tramal was prescribed on multiple occasions from 2011 to 2017 and also appears to be related to the claimant's left shoulder dislocations and the pain associated with this.
4. Relevantly to the issues in this matter, on 11 December 2013 it was noted the claimant was to see a dentist.
5. On 20 January 2014 the claimant travelled overseas, an opportunity for his left shoulder surgery came up while he was away (he was a public patient) and he lost his place in the queue because of being overseas.
6. On 8 January 2015 the claimant developed mid back pain while lifting a 50kg slab of marble. He reported a car accident on 28 September 2014 and was still waiting for his shoulder surgery.
7. The claimant had an injury to his right knee playing soccer requiring several attendances on Dr Guirguis in July, August and September 2015.
8. In October 2015 he reported to Dr Selim having been to RPAH with abdominal pain as he had been "doing a lot of heavy work that day".
9. On 16 January 2017 the claimant attended with bladder issues which were causing him "significant distress".
10. On 15 January 2018 the claimant told Dr Selim of MDCP he was starting a parole period and required a full day of community service.
11. On 19 October 2018 the claimant reported to Dr Selim of MDCP he had worsening bladder symptoms with leakage and nocturia. The claimant travelled overseas and returned on

18 January 2019 with unchanged symptoms. The claimant saw a specialist and attendances on Dr Selim occurred on 5 July, 16 August and 1 November 2019. Stemzine and Prochlorperazxine (used to treat nausea and vomiting as well as anxiety and migraines) was prescribed on 5 July and 16 August 2019. 12. The claimant was "highly anxious" on 20 February 2020 when he attended MDCP for a Centrelink certificate and suffering from a headache. The claimant had seen another GP practice and had a CT of his brain which identified a cyst. 13. The claimant attended Dr Selim on 11 September 2020 complaining of right sided neck and back pain and normal shoulder motion. He was said to be "moving neck and walking normally". There is this note "Insisting on imaging; discussed lack of indication. Referral provided as instated". 14. The following day the claimant returned to Dr Selim, and he had a headache (occipital skull), pain in his lower back and neck. And thereafter most of the complaints of pain were left shoulder, low back and neck. He was said to be "very anxious". Voltaren was prescribed. 15. The claimant attended on Dr Guirguis of MDCP on 15 September 2020 complaining of neck pain, low back pain radiating to both legs, left shoulder pain, no loss of consciousness just dizziness. He was stressed with left shoulder pain having previous dislocations. An ultrasound was provided and on 18 September 2020 referrals were given to Dr Murrell and Dr McKechnie. 16. There are no complaints of jaw or bruxism in the MDCP records before the accident and one reference in 2013 to a dental consultation. On 20 May 2021, the claimant reported an increase in anxiety and "has started grinding teeth while he is awake and aware of this bilateral TMJ pains". On 7 June 2021 is another record of "TMJ pains ++++ due to clenching". There are no other references to jaw or dental issues from then until the end of the records on 13 February 2025.

1. There is a report from Dr Verma, psychiatrist addressed to Dr Selim dated 10 May 2021. She has a history of the claimant training to be a truck driver before the accident. She has a history of the 2015 left shoulder surgery and that he recovered from this.
2. She notes the claimant was seeing Mr Rababi which was helping. There was said to be a family history of anxiety in both of his brothers.
3. The claimant denied any previous mental health problems.
4. Dr Verma wrote a further report dated 31 May 2021.[14] Dr Verma has a report of "anxiety symptoms - teeth chattering, difficulty breathing, fear and palpitations". It was said there was a "very strong family history of anxiety and panic". The impression was of an adjustment disorder with depressed and anxious mood and there is a reference to Mr Saab's "WC" claim having been rejected.
5. On 9 July 2021, Mr Rababi, psychologist wrote a to whom it may concern letter[15] about the claimant. He has a history from the claimant of "no other known medical issues or serious injuries" and that after the accident he developed pain in his left lower back down hist left leg, pain in his left shoulder and both sides of his neck. He also reports:

"He advised most recently he has also started experiencing dental pain, which he has been advised is due to grinding of his teeth, something he had never done prior to the accident."

1. The report also documents "significant pain in his jaw" when he wakes.
2. Mr Rababi diagnosed a major depressive disorder, generalised anxiety disorder and post-traumatic stress disorder all resulting from the car accident.
3. Despite his treatment, Mr Rababi says Mr Saab has not made any progress. Noting that symptoms have been exacerbated "by the cultural expectations of a man to be working and establishing g a family". The claimant says he was preparing to be married at the time of his accident. Mr Rababi refers to the claimant's work history (but does not have a history of document what work the claimant had been doing).
4. The claimant said that before the accident he "worked, regularly engaged socially" and never had any prolonged feelings of sadness or nervousness.
5. Because there were no other factors, reported to him, Mr Rababi expressed the view all the claimant's symptoms were due to the accident. He suggested "long term psychological support" would be required.
6. Dr Verma's letter to Dr Selim dated 21 July 2021[16] confirms the consultations with Mr Rababi were making him feel better but his back pain was worsening, he had poor sleep, nightmares and ongoing anxiety. There is no reference to teeth grinding or jaw pain.
7. Dr Verma wrote to Dr Selim on 13 September 2021 and the claimant was "very pain focussed" and said that the accident had ruined his life. She considered there was adjustment disorder with depressed and anxious moods and some symptoms of post-traumatic stress disorder.
8. On 20 October 2021 Mr Rababi reported that the claimant had completed 17 sessions. Testing revealed significant depression and anxiety and significant distress. Again, he cited the DSM-V criteria. He suggests the claimant has shown some improvement but then says he has struggled to make any progress.
9. On 25 October 2021, Dr Verma wrote to Dr Ismail who was described as the claimant's new GP as his previous doctor was on leave. The claimant was anxious and had been to hospital with panic attacks.
10. On 6 December 2021 Dr Verma reported to Dr Ismail that the claimant was "pain and disability focussed" and that the insurer had not approved for any of his pain treatment and had stopped his psychological therapy. As Dr Naresh was only doing telehealth appointments, he suggested the claimant see another psychiatrist who could build a better relationship face to face.
11. On 3 February 2022, Mr Rababi reported again saying that the claimant has struggled to perform sexually and cannot be intimate with his current partner.
12. On 2 March 2022, Mr Rababi reported again with many similar complaints adding that he "has been grinding his teeth to the extent that his gums are now bleeding".

1. Dr Yu wrote a letter to Dr Ismael of the Al Zahraa Medical Centre in Arncliffe on

30 November 2021.[17] The claimant reported lower back pain, left leg pain, neck pain, left shoulder and left ankle pain. He rated extremely high severe for anxiety, depression and stress. The regain pain program was recommended. There was no mention in this letter of jaw pain or teeth griding. 2. Dr Noore, psychiatrist and pain physician in a letter to Dr Ismael dated 10 February 2022[18] had a full history of the claimant's pre-accident problems and after testing expressed the view the claimant had "low pain self-efficacy", and high levels of pain, catastrophising with associated with high levels of depression, anxiety and stress. He diagnosed panic disorder, depression and multisite pain. 3. In a further letter dated 24 March 2022, Dr Noore also refers to stress associated with the claims process and engagement with the insurer. The claimant had been offered participation in a pain management program, but he declined on the basis he was not ready due to his severe pain. 4. The claimant saw Dr Yu again on 14 April 2022. The claimant declined the pain management program as prolonged sitting provoked his pain. He had a panic attack and was admitted to RPAH. 5. On 10 June 2022, Dr Yu wrote another letter to NRMA justifying the various medications and again recommending the claimant participate in the pain program. 6. In a third letter dated 7 October 2022 Dr Noore refers to the claimant grinding his teeth, having frequent panic attacks, he was anxious worried and distressed. Five weeks earlier, the claimant had left shoulder surgery with Professor Murrell. 7. Further attendances in November 2022 referred to teeth grinding, panic attacks leading to presentations at RPAH. The claimant was reluctant to have further surgery (neck and back) because he had two unsuccessful surgeries to his left shoulder. He was going to think about the pain management program further. 8. On 27 January 2023 the claimant said he was still not ready for the pain management program. 9. On 1 March 2023 Dr Noore recommended the claimant have a mouth guard for his teeth grinding. 10. On 12 April 2023, Dr Noore clarified aspects of the claimant's history. The claimant told

Dr Noore his post-traumatic stress disorder symptoms related to the car accident and that he had been treated by Dr Verma. The claimant also said he did not have a brain cyst but that he had a "cavernous malformation" which did not need treatment and caused no symptoms. He corrected the claimant's arrival date into Australia as 1998 not 1988. 11. In a letter dated 7 June 2023, the claimant complained of bruxism associated with post-motor accident pain and psychological distress. The claimant was having distressing dreams and bilateral mandibular pain. He "described difficulties getting approval for his dental problem treatment from his insurers". 12. There were further attendances on Dr Noore on 3 July, 21 August, 3 October (at which stage the claimant was willing to participate in the pain management program) and

12 December 2023 with many of the same observations. 13. On 23 November 2023, Dr Yu refers to "significant sleep disturbance associated with his pain condition". The claimant had commenced the pain program. 14. Dr Noore saw the claimant on 9 February 2024 and the claimant was anxious and worried with continued pain, panic attacks, disturbed sleep and bruxism with bleeding. A further appointment occurred on 9 April 2024 and again on 21 May 2024. Two further reports of

4 July and 30 July 2024 also deal with the teeth grinding and a new symptom of loss of vision. On 8 October 2024 the claimant had developed a new symptom of waking with panic attacks and difficulty breathing. The claimant saw Dr Noore again. The claimant reported he was going to have the lumbar spine surgery, and he complained that his dental treatment was unsatisfactory, and he was considering seeing an orthodontist. The claimant was seen again on 28 January 2025 with no improvement.

1. At page 499 of the claimant's bundle is a document headed "dental condition and hygiene assessment" on 25 October 2021. This document is not on letterhead or signed. The Panel notes the typeface and the words used and it would appear this report may have been written by Dr Farag.
2. Whoever its author, the report says, "during the last dental visit" (there is no indication of when this was) that "a thorough examination of the teeth was done "evaluating their condition and identifying any visible signs of decay, damage..." and,

(a) there were no significant dental problems;

(b) the claimant's oral hygiene was good with the claimant brushing twice a day and flossing once a day;

(c) no major dental treatments or interventions were recommended, and

(d) six monthly checkups only were required.

1. The report then says "dental check-up and treatment recommendations (post-accident)" and notes:

(a) the claimant reported teeth sensitivity after the accident;

(b) severe bruxism "likely resulting from stress";

(c) this has led to teeth damage and was affecting the TMJ, and

(d) further treatment was recommended.

1. On 4 April 2023, NRMA wrote to the claimant[19] after conducting an internal review of an earlier decision now agreeing to pay for the consultation with a dentist for a mouth guard to assist his bruxism as requested by Dr Noore. The insurer says at paragraph 29:

"I note that the above medical findings support that following the subject accident you developed psychological symptoms satisfying a diagnosis of adjustment disorder with mixed anxiety and depressed mood. I note that is it also well documented that you have reported teeth grinding to multiple treatment providers and there is medical opinion to support that your teeth grinding may be an anxiety related symptom."

1. Dr Farag wrote a report dated 22 February 2024[20] "to whom it may concern" referring to:

(a) successful dental treatment in 2023 (no details given of this treatment);

(b) 13 December 2023 and 2 February 2024 gum bleeding, TMJ issues and cracked teeth;

(c) tooth wear and chipping indicative of bruxism observed during the examination, and

(d) TMJ dysfunction symptoms such as jaw pain and limited range of motion.

(a) a new night guard to alleviate pressure;

(b) physical therapy for TMJ;

(c) restorative work fillings, crown to address the tooth damage, and

(d) continuous education on stress management techniques to reduce bruxism and further dental and TMJ issues.

1. The cost of the dental component of this treatment was estimated at $10,700.

1. There is a medicolegal report from Dr Ashwell, orthopaedic surgeon addressed to NRMA and dated 12 February 2021.[21]
2. The claimant reported neck, back and shoulder complaints and states "he is not woken at night with pain from any of these areas." He said he was taking Nurofen Plus, Tramal and a "new medication for his nerves" but he was not sure what it was. He did not complain of jaw or dental pain.
3. Dr Ashwell queried with the claimant why he had been out of work since 2013, and in particular, after his apparently successful left shoulder surgery in 2015. The claimant said, "it was because of some social issues, as well as anxiety and depression and an abdominal issue with an enlarged prostate." Dr Ashwell noted the medical records suggest that the left shoulder issue may have been the reason from 2013 to 2017.
4. His conclusion was the claimant had musculo-skeletal injuries to the neck and lower back and bursitis of the left shoulder. And commented "there is no explanation for the ongoing severity of his symptoms".

Medical Assessor Cameron - physical threshold injury

1. Medical Assessor Cameron was asked to assess the claimant's neck, back and both shoulders in his assessment of a dispute about whether the claimant's injuries were minor (now threshold) injuries. He examined the claimant on 14 June 2022 and issued his decision on 27 June 2022.
2. The claimant gave a history of the accident and that his cousin drove him to the police to make a report. There is no reference to an ambulance.
3. The claimant complained of back pain, left shoulder pain, neck pain, psychological issues and intermittent chest pain, difficulty breathing and teeth grinding.
4. Medical Assessor Cameron diagnosed soft tissue injuries to the lower back, neck and left shoulder and while he found the right shoulder was not injured in the accident, he gave no reasons or explanation for that decision. The left shoulder injury was said to involve a rupture of tendon or cartilage which took the injury outside the definition of "minor" injury in the legislation.

Medical Assessor Mason - psychiatric threshold injury

1. Medical Assessor Mason assessed the claimant's psychological injuries as minor (now threshold) on 6 July 2022. The claimant denied any previous motor accidents. He was taken to records suggesting a 2014 motor accident and said he only went to hospital because his cousin told him to, and he was not injured. The claimant denied problems with the law and was taken to a note in his GP's records of being on parole and he confirmed he was required to do 9 months and not 12 months of a community corrections order. The claimant denied any previous psychiatric injury or any family history. He was taken to Dr Verma's record of a strong family history of anxiety and panic attacks which he said was wrong. He was then taken to his claim form and denied he had been anxious and depressed.
2. The claimant gave a history of the accident, that he exchanged details with the driver, the police attended but did not create a report and he was required to make a report at the station.
3. The claimant described his psychological symptoms and Medical Assessor Mason said he had difficulty getting a proper history. The claimant mentioned he was grinding his teeth and having nightmares.
4. Medical Assessor Mason stated that the claimant was not involved in a life-threatening motor accident and therefore does not satisfy the criterion A of an acute or post-traumatic stress disorder. He diagnosed an adjustment disorder with mixed anxiety and depression which he found to be a minor (now termed a threshold) injury.

1. Medical Assessor Canaris assessed the claimant on 10 July 2024 in relation to his WPI. He has a consistent history of the accident, that Mr Saab's cousin came to get him and police advised him to "press charges".
2. Mr Saab denied:

(a) any previous psychological issues;

(b) any previous accidents;

(c) any problems with the law, and

(d) that his family had no history of psychiatric illness.

"He was initially "irritated so much because of my situation - my pain - I was going through severe anxiety - depression... sitting at home - just feeling completely lost... like I don't know what to do... my life feels completely empty in every way... I sometimes get breathing problems with chest pain... grinding of my teeth... I have a mouth guard - some crowns... every night I'm on my own and I think about my health - my pain... I wake up with nightmares and the minute I wake up, my heart is shaking... sometimes I wake up with sweating..."

1. Medical Assessor Canaris did not diagnose a post-traumatic stress disorder on the basis of the minor nature of the accident. However, he did diagnose a persistent depressive disorder with anxious distress. He noted the claimant was very pain focused, and a diagnosis of somatic symptom disorder was also warranted.
2. He notes both conditions were caused by the accident and that neither were present before the accident. He assessed WPI at 5%. No application for Review has been lodged by either party in relation to that determination.

1. Medical Assessor Menogue examined the claimant on 20 August 2024 and issued his reasons on 3 September 2024. He was asked to assess the cervical spine, lumbar spine, left shoulder and scarring.
2. Medical Assessor Menogue noted that the claimant sustained injuries in 2013 and applied for Centrelink benefits and has remained on those benefits to date with conditions including "crush fractures and upper limb injuries", bladder problems and his current injuries. The claimant gave a history of left shoulder problems since 2009 and recurrent dislocations with surgery in 2015. Medical Assessor Menogue has a history of a 2014 accident, a right knee injury in 2015 and left shoulder pain in 2017. Mr Saab said however that he was not receiving medical management for any musculoskeletal disorder at the time of the accident.
3. The claimant confirmed the history of the accident and said no ambulance attended, his cousin arrived to take him home (and another drove the car home) and the claimant reported the matter to the police.
4. The claimant complained of constant left sided neck pain, left shoulder pain and lumbar pain spreading to the left buttock and left lower limb.
5. Medical Assessor Menogue diagnosed injuries to the neck, left shoulder and lumbar spine caused by the accident. Mr Saab's neck injury was assessed as a soft tissue injury with no radicular symptoms or signs of radiculopathy and so too the lumbar spine injury. Medical Assessor Menogue diagnosed a soft tissue injury to the left shoulder requiring arthroscopic repair and leading to the development of adhesive capsulitis.
6. Whole person impairment was assessed at 5% for the left shoulder and 0% for the other injuries and 0% for the scarring.

RE-EXAMINATION FINDINGS - MEDICAL ASSESSOR VERTOUDAKIS

1. The following paragraphs [135] - [157] are the results of the re-examination conducted by Medical Assessor Vertoukakis as provided to the Panel.
2. I examined Mr Saab in my Macquarie Street rooms on 28 April 2025 as arranged. He was pleasant and co-operative throughout the hour-long examination and spoke clearly with no indication of any problems with his speech.

1. Mr Saab told me he was involved in a motor accident on 10 September 2020. He says he was hit from behind by another vehicle. He said he was not taken by ambulance to RPAH but was picked up from the scene of the accident by his cousin.
2. He said he had previous accidents and that the one before his 2020 accident was a minor accident in 2014.
3. He told me he started seeing Dr Farag approximately five years before the accident and cannot remember the name of the previous dentist. He said he only attended that dentist for cleaning, and he cannot remember how often he went. He has not had another dentist since Dr Farag stopped practicing. He is having no dental treatment at present.
4. Dr Ismail is his current medical GP. He changed from Dr Selim (GP, MDCP) as she fell pregnant and since this was an insurance case she asked that he see another GP.
5. He is seeing medical specialists for other injuries such as his shoulder and back. He is seeing Dr Richmond, pain specialist and is also under psychiatric care from Dr Noore. He is seeing a physiotherapist for his medical problems.
6. Mr Saab told me he feels tired and sleepy during the day and was referred for a sleep apnoea test. He has completed a sleep study, and the result was that he had severe sleep apnoea and that he stops breathing several times during the night.
7. I asked him about his jaw and dental injuries. He cannot remember striking his head during the accident and says he was in shock. I drew his attention to there being no mention of dental or TMJ problems in his claim form dated 21 September 2020 or in his early GP records and he said these issues started after that (but he could not be more specific). He said that his current dental problems are related to post-accident psychological stress and pain from multiple body parts which has led to him clenching his jaw and grinding his teeth. He has pain on both sides of his jaw. He said the insurer paid for his mouth guard in an effort to prevent further grinding and further damage.

1. The tooth numbering system of the Fédération Dentaire Internationale (FDI) is used throughout this report[22] and the chart is set out below.

1. A two-digit system is used to identify individual teeth. The first number refers to the quadrant and second number refers to the actual tooth. The quadrants are numbered this way:

(a) upper right (quadrant 1);

(b) upper left (quadrant 2);

(c) lower left (quadrant 3), and

(d) lower right (quadrant 4).

1. Each individual tooth is numbered from the midline to the back of the mouth. For example, tooth 26 (pronounced two six) refers to the upper left (quadrant 2), sixth tooth from the midline. Tooth 43 (pronounced four three) refers to the lower right quadrant (quadrant 4), third tooth from the midline.
2. Mr Saab's mouth was examined. He had a reasonable oral hygiene standard. He had a solid occlusion with generalised occlusal and incisal wear especially heavy on the palatal (roof of mouth side) cusps of teeth 27 and 28.
3. There were bruxo-facets[23] on the lower anterior incisors and a heavy disto-incisal wear facet of tooth 33. Worn buccal cusps[24] were evident on teeth 44, 45 and 46.
4. The findings in respect of each tooth are listed below,

(a) Upper right quadrant:

(i) 18 clear;

(ii) 17 occlusal composite;

(iii) 16 clear;

(iv) 15 missing;

(v) 14 clear;

(vi) 13 ceramic crown;

(vii) 12 clear, and

(viii) 11 ceramic crown.

(b) Upper left quadrant:

(i) 21 ceramic crown;

(ii) 22 clear;

(iii) 23 clear - slight incisal wear;

(iv) 24 clear;

(v) 25 clear;

(vi) 26 clear;

(vii) 27 clear - has heavy bruxo facets occlusal palatal, and

(viii) 28 clear - has heavy bruxo facets occlusal palatal.

(c) Lower left quadrant:

(i) 38 occlusal composite seal;

(ii) 37 occlusal composite seal;

(iii) 36 ceramic crown;

(iv) 35 ceramic crown;

(v) 34 clear - buccal cusp slight wear;

(vi) 33 clear - heavy distal incisal wear;

(vii) 32 clear, and

(viii) 31 clear - although there was a slight surface stress fracture on labial

(d) Lower right quadrant:

(i) 41 clear;

(ii) 42 clear;

(iii) 43 clear;

(iv) 44 clear - heavy bruxo facet on buccal cusp;

(v) 45 clear - slightly worn buccal cusp;

(vi) 46 clear - slightly worn buccal cusp;

(vii) 47 clear, and

(viii) 48 occlusal composite.

1. Mr Saab had been asked to bring to the re-examination the splint ordered by Dr Farag and paid for by the insurer. He brought with him a soft suck down splint stating he wore it every night.
2. With the splint in place I noted:

(a) posterior occlusion is only achieved as he bites heavily onto the splint. This is not satisfactory to stabilise the TMJs which need good posterior support on a hard acrylic flat surface;

(b) there is no anterior disocclusion and disoccluding only occurs on the molars, and

(c) there was left side canine guidance and right-side group function.

1. When I queried the splint with Mr Saab, he said he thought this may have been the first splint made for him and not the "final" one and that he had brought the wrong splint. Mr Saab then stated that a new splint was made as this one (the old splint) could not fit over his new crowns. There was no evidence of any occlusal wear on the soft suck down splint or any indication that it had been worn suggesting it is not an old splint. The splint he bought with him did however fit perfectly over his existing crowns.
2. The suck down splint brought to the examination was a splint made for Mr Saab because it fits well, but it does not look worn and therefore cannot be the old splint that allegedly was worn but did not fit. I cannot explain this inconsistency and Mr Saab was unable to shed any light on this. In the light of the final decision on the degree of impairment it is not necessary to consider this issue further.

1. Mr Saab says he does not use heat packs for his jaw problems. He said his symptoms mainly consist of the two sides of his jaw feeling tired and painful.
2. There is a solid occlusion except on teeth 31 and 41. On clenching there is:

(a) right masseteric tenderness (mild) on palpation at angle of mandible;

(b) left side masseteric tenderness (strong) in the body of the left masseter on palpation;

(c) no pain on palpation on left or right temporalis;

(d) medium tenderness on palpation of left and right TMJ lateral poles on opening;

(e) there is no swinging side to side of jaw on opening or closing;

(f) there is a 43mm inter-incisal anterior opening gape which is normal, and

(g) there is no clicking or crepitus on left or right TMJs on opening or closing

1. I asked the claimant the following questions in accordance with the temporomandibular dysfunction or disorder pain screener:

(a) in the last 30 days how long did any pain in your jaw or temple area on either side? His answer was that jaw pain is always present;

(b) in the last 30 days have you had pain or stiffness in your jaw on awakening? He answered yes;

(c) in the last 30 days did the following activities change any pain (that is make it better or make it worse) in your jaw or temple area on either side:

(i) chewing hard or tough food? He said no;

(ii) opening your mouth or moving your jaw forward or to the side? He said no;

(iii) jaw habits such as holding teeth together, clenching, grinding or chewing gum? He said he had not, and

(iv) other jaw activities such as talking, kissing or yawning? He said no.

1. I asked Mr Saab about his diet. He states he has no restriction and eats all kinds of food from soft foods as well as food requiring chewing and he can eat normally without any additional pain other than his usual jaw pain. He has no pain in his teeth.
2. For completeness I note that the clinical examination did not disclose any evidence of any impairment to the nervous system manifesting in TMJ dysfunction and there is no impairment to the claimant's speech.

1. The Panel adopts the above re-examination findings.

1. Medical Assessor Vertoudakis and Medical Assessor Curtin are of the view that the clinical findings at the re-examination indicate that the claimant's teeth show evidence of bruxing.
2. In terms of the claimant's alleged jaw dysfunction, the Medical Assessors are of the view that the clinical examination established that the claimant has:

(a) bilateral localised masseteric myalgia (muscle pain) in particular on the left side;

(b) bilateral mild temporomandibular arthralgia (joint pain), and

(c) no other signs of ongoing TMJ dysfunction such as joint crepitus or restriction of jaw opening.

1. If the splint brought to the examination is the splint being worn every night, then it is the clinical judgment of the Medical Assessors that this splint may be contributing to his masseteric myalgia (muscle pain in the masseter muscles) due to the features noted at paragraph 149 above. If the splint he is using was left at home, a further examination with the proper splint could occur, however in the light of the ultimate impairment finding, it is unnecessary to consider deferring the current Review pending a consideration of this possible other splint.

1. Mr Saab denies any frank or specific injury to his jaw or teeth in the accident. He says his jaw pain started after the accident as did his bruxing and which he says is a response to pain from his physical injuries and his psychological injury (stress).
2. The test of causation in cls 6.5 - 6.7 of the Guidelines is twofold:

(a) could the motor accident have caused or materially contributed to the injury resulting in the impairment (a medical judgment), and

(b) did the motor accident cause or materially contribute to the injury resulting in the impairment (a non-medical judgment).

1. It is the clinical judgment of the Medical Assessors that emotional factors and a person's physical response to stress, including muscle tension can lead to excessive jaw clenching and teeth grinding. Severe sleep apnoea is also a possible contributing factor to sleep time clenching and bruxing. The Panel is therefore satisfied that if the motor accident did cause physical injuries resulting in pain and psychological injuries resulting in stress that the claimant's jaw pain and bruxing could have been caused or materially contributed to by the accident.
2. The question remains whether the accident did cause the claimed consequential injury of bruxing and the claimant's jaw pain.
3. The claimant has an extensive pre-accident medical history including physical ailments and anxiety. He has also had previous stressful events in his life including a condition affecting his brain and a period of incarceration.
4. The claimant did not mention a jaw condition or teeth problems such as grinding in his claim form completed within two weeks of the date of the accident. This is not surprising as

Mr Saab confirmed with Medical Assessor Vertoudakis that his jaw and teeth problems only commenced after the accident. 5. There is a reference to jaw or teeth problems in the GP records in May and June 2021 but not after that. Dr Verma on 10 May 2021 does not list bruxism (but she mentions teeth chattering) and Mr Rababi, psychologist took a history of dental pain and teeth grinding on

7 July 2021. 6. The letter apparently from Dr Farag dated 25 October 2021 begins with, "during the last dental visit a general assessment of the patient's teeth and dental hygiene was conducted the overall condition of the patient's teeth was found to be reasonable with no major issues reported or documented at the time". Halfway down the page he lists multiple dental problems after the accident. It may be that Dr Farag has provided a before-the-accident picture of the claimant's dental health based on the last (pre-accident) attendance and clearly an assessment of Mr Saab's dental health on 25 October 2021 over a year after the accident. The letter purporting to be from Dr Farag records "severe" bruxing, tooth damage and jaw pain. Records from Dr Farag or any other pre-accident dentist have not been provided and the claimant has had not recent treatment from a dentist. 7. Dr Noore on 10 February 2022 and Dr Anderson on 15 March 2023 both mention bruxism. 8. The Panel notes the insurer accepted the dental problems as accident-related and paid for the claimant's dental splint. The insurer's decision is not determinative of the matters the Panel has to determine. 9. The claimant has referred two separate conditions to be assessed, a jaw condition and a condition related to his teeth. The Panel will consider each of those in turn.

Did the accident cause or contribute to the claimant's bruxism?

1. While the level of wear on teeth can indicate short term, medium term or long term bruxing it is impossible to more accurately determine the precise time bruxing starts. The Panel had requested pre-accident dental records and they would certainly help narrow down the time frame. The Panel has not been provided with any such records. While we appear to have all relevant clinical records there is little reference to dental issues in them.
2. The clinical judgment of the Medical Assessors is that the level of bruxing evident on Mr Saab's teeth is not recent but is long term as evidenced by the heavy bruxo facets on teeth 27 and 28 and 33 the very worn buccal cusp on teeth 44, 45 and 46 and the degree of lower anterior incisal edge wear and the need for 5 crowns. In terms of long term, it is the Medical Assessor's clinical view that Mr Saab's bruxing started well before the motor accident. Mr Saab's bruxism was therefore not, in the clinical judgment of the Medical Assessors caused by the accident.
3. The Medical Assessors are not aware of any studies that suggest chronic bruxing is aggravated or worsened by further or additional traumatic events or stressors. The Panel is of the view that any additional wear on the claimant's teeth caused by bruxing after the accident is therefore not caused by the accident.

Did the accident cause or contribute to the symptoms in the claimant's jaw?

1. The claimant denies any actual injury to his jaw and says pain in his jaw commenced after the accident and is a result of his teeth grinding habit. The clinical re-examination indicated both muscle pain and joint pain in the jaw area.
2. The Panel is not satisfied that Mr Saab's bruxing caused the symptoms he is experiencing in his jaw for the following reasons:

(a) the claimant's bruxing is chronic and in the Panel's view was present and has been causing teeth damage before the accident, and

(b) the first reports of jaw pain (as opposed to tooth or dental pain) were from May to July 2021 and there is then a gap with no reports of symptoms before complaints to Dr Noore and Dr Anderson more than two to three years after the accident.

1. The claimant complains of ongoing pain in his jaw, which may be related to the splint prescribed by Dr Farag but in the absence of his notes and the claimant's evidence about the splint, the Panel cannot be satisfied that this is the case.
2. The ongoing complaints of jaw pain may be a response to physical pain from the claimant's other injuries or psychological stressors but that is not a matter for the Panel to determine and is more appropriately dealt with by those examiners or Medical Assessors dealing with Mr Saab's other injuries.
3. For all of the reasons above, based on the evidence currently before the Panel, the Panel is not satisfied that the claimant's ongoing jaw pain and any associated impairment is related to or caused by the injuries sustained in the accident.

1. If the Panel is wrong in respect of our finding on causation, then the Panel considers it appropriate to undertake an assessment of impairment.
2. Chapter 9 of the AMA 4 Guides provides for the assessment of impairments to the "ear, nose and related structures, and section 9.3 is devoted to the assessment the nose, throat and related structures. The oral region is described therein as "the mouth and lips, teeth, temporomandibular joint, tongue, hard and soft palate, region of the palatine tonsil and oropharynx."
3. There was no loss of structural integrity to Mr Saab's face.
4. The claimant complains of constant pain in the muscles and joints of the jaw. There was no clicking or crepitation on opening or closing of the mouth and the claimant's gape opening was measured at 43mm which is normal. The only abnormality of the jaw was pain.
5. Clause 6.38 of the Guidelines provides that in the case of neurological impairment some of the Tables in the AMA 4 Guides require pain to be assessed. However, the clause also says that "medical assessors must not make separate allowance for permanent impairment due to pain" and the Chapter 15 of the AMA 4 Guides (entitled "Pain") must not be used. The Guidelines acknowledge that "each chapter of the AMA 4 Guides includes an allowance for associated pain in the impairment percentages".
6. The claimant grinds his teeth and there is clear damage to his teeth. Clause 6.195 of the Guidelines provides that "Damage to the teeth can only be assessed when there is a permanent impact on mastication and deglutition ... and/or loss of structural integrity of the face..."
7. Section 9.3(b) of the AMA 4 Guides concerns mastication (chewing) and deglutition (swallowing) and says that when there is impairment "the imposition of dietary restrictions usually results". Table 6 provides three categories of restrictions and three ranges of impairments (the first modified by cl 6.197 of the Guidelines) as follows:

(a) diet is limited to semisolid or soft foods (0 - 19%);

(b) diet is limited to liquid foods (20 - 39%), and

(c) ingestion of food requires tube feeding or gastrostomy (40 - 60%).

1. Mr Saab said he had no dietary restrictions and that he eats all sorts of foods and chewing hard or tough food did not make his pain worse.
2. As the claimant has no restrictions to his diet, the claimant's WPI resulting from his jaw symptoms, bruxing and tooth damage is 0%.

1. The splint brought to the examination (which may not be the current splint) may be a contributing factor to Mr Saab's masseteric myalgia. If that is his current splint the Medical Assessors are of the view that Mr Saab needs to be referred to a prosthodontist for a correct diagnosis of his jaw pain, construction of a correct splint, discussion of heat application to his masseters, a short-term soft diet and other treatments the prosthodontic specialist sees fit.
2. Section 7.21(4) provides that a Medical Assessor (and a Review Panel) "may decline to make an assessment of the degree of permanent impairment ... until the assessor is satisfied that the impairment caused by the injury has become permanent."
3. It is the Medical Assessor's view that the claimant's current jaw injury or condition has not reached maximum medical improvement and his long-term bruxing habit may improve with appropriate sleep apnoea treatment. However, cl 6.19 requires that before an assessment is conducted, the impairment caused by a particular injury or condition "has been present for a period of time, and is static, well stabilised and unlikely to change substantially regardless of treatment". Clause 6.19 does not require the particular injury or condition resulting in the impairment to have stabilised or reached maximum medical improvement. Clause 6.20 illustrates this with reference to a traumatic amputation. In such a case the impairment can be assessed soon after the injury and while the injury is still being treated.
4. The Panel is of the view that the claimant's impairment to mastication and deglutition is permanent and can be assessed. He has no dietary restrictions now and any further treatment will not change that but is likely to improve Mr Saab's pain levels. If the impairment is not yet permanent, then s 7.21(4) provides a discretion to decline to assess. In the light of the current impairment of 0%, the degree of WPI is unlikely to change regardless of treatment, the Panel does not wish to decline to assess Mr Saab's impairment.

1. As the Panel has come to the same conclusion as Medical Assessor Nichols, it follows the Panel must affirm his certificate.

[1] The current maximum as of October 2024 is $654,000.

[4] Section 7.21. The current version of the Guidelines is Version 9.3.

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

[6] The claimant's submissions are dated 2 October 2024. The numbers in square brackets are a reference to the paragraph number in the submissions.

[12] Page 179 of the insurer's bundle - doctors at this practice include Dr Selim.

[13] Page 197 of the insurer's bundle".

[16] Page 324 of the claimant's bundle.

[17] Page 108 of the claimant's bundle.

[21] Page 470 of the claimant's bundle.

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

[23] Bruxo-facets are the flat, polished surfaces that develop on teeth due to bruxism or grinding.

[24] Cusps are a feature of molars and are the raised, pointed or rounded projections on the endge of the tooth. Buccal cusps are on the cheek side of the teeth, Lingual cusps are on the tongue side of the teeth.