Periodontitis

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Periodontitis

Example 1 of 1 · fictitious patient (Veteran R)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

BOP Code: 28 of 2022 (Periodontitis)
RH Code: 27 of 2022 (Periodontitis)

ADF History

Veteran R, date of birth 22 April 1976, Australian Army, Petroleum Operator, enlisted 08 July 1995, medically discharged 14 March 2017. Operational service: East Timor, 20 September 1999 to 15 February 2000 (warlike); Iraq, 18 April 2005 to 30 October 2005 (warlike); Afghanistan, 10 February 2009 to 25 September 2009 (warlike).

Occupational History

As a petroleum operator the veteran received, tested, stored and issued bulk fuels, including diesel, aviation turbine fuel and unleaded petrol, and cleaned fuel tanks and bladders. On deployment he decanted fuel by hand at forward refuelling points with little respiratory protection, giving repeated skin and inhalational exposure to benzene and fuel vapour in extreme heat.

The work involved heavy hoses and couplings under pressure, with a recognised risk of facial and dental injury, and forward refuelling points were exposed to casualties and the need to give first aid. Long field deployments limited access to dental hygiene and routine dental care, and the service culture of the period normalised smoking and heavy drinking.

History

Veteran R, a petroleum operator in the Australian Army, lost a lower incisor in a service injury in East Timor in 1999 and later developed HIV infection, ulcerative colitis, diabetes, chronic myeloid leukaemia and chronic renal failure in the course of his service. He developed periodontitis of the lower anterior teeth and implant in August 2013, which worsened in 2016 after further dental trauma and a nine-month gap in periodontal care.

Timeline

03 Dec 1999 — During warlike service in East Timor a pressurised fuel bladder coupling struck the veteran in the mouth. Tooth 31 was avulsed and the labial alveolar bone fractured. He was treated by a deployed dental officer and an implant was placed on 14 May 2001. He began smoking about 25 cigarettes a day on this deployment. "31 avulsed, alveolar fracture"
14 Mar 2006 — A gastroenterologist diagnosed ulcerative colitis on colonoscopy and biopsy, after severe infective gastroenteritis with bloody diarrhoea in Iraq in July 2005 that never fully settled. Sulfasalazine 3 g daily was commenced, with prednisolone courses for flares from then on. "ulcerative colitis, sulfasalazine commenced"
02 Oct 2009 — HIV infection was confirmed after a needle-stick injury from a casualty's cannula on 17 June 2009, while the veteran gave first aid at a forward refuelling point in Afghanistan. Antiretroviral therapy was started. In October 2009 he had a lower lip piercing placed during post-deployment leave, and his alcohol intake rose to about 40 standard drinks a week. "HIV positive, needle-stick Afghanistan"
11 Nov 2010 — Type 2 diabetes mellitus was diagnosed with an HbA1c of 8.4 per cent. Weight 106 kg, height 1.78 m, BMI 33.5, having been 31.2 in March 2010. A psychiatrist had diagnosed posttraumatic stress disorder related to Afghanistan earlier that year, and AUDIT recorded about 400 grams of alcohol a week. "T2DM, HbA1c 8.4, BMI 33.5"
05 Aug 2012 — A haematologist diagnosed chronic myeloid leukaemia, with a white cell count of 86 x 10^9/L and BCR-ABL1 on bone marrow testing, and started imatinib 400 mg daily. The absolute neutrophil count was 0.9 x 10^9/L. The veteran had stopped smoking on 01 January 2012. A dental examination on 14 September 2012 recorded gingivitis of the lower anterior teeth. "CML, imatinib, neutrophils 0.9"
02 Apr 2013 — Two weeks after starting haemodialysis on 18 March 2013 for HIV-associated and diabetic nephropathy, the veteran collapsed at work in a hypoglycaemic episode and struck his face. Radiographs showed subluxation of teeth 41 and 42 and a labial alveolar plate fracture. An oral and maxillofacial surgeon performed open reduction and splinting the next day. Periodontal charting on 18 February 2013 had shown gingivitis with pockets no deeper than 3 mm. "41, 42 subluxed, alveolar fracture"
19 Aug 2013 — The veteran presented to the garrison dental service with one week of bleeding gums, loosening of the lower front teeth, bad taste and recession beneath his lip stud. Pocket depths were 5 to 7 mm from 33 to 43 with suppuration around the implant. The renal dietitian recorded severe malnutrition, with an albumin of 24 g/L. Vitamin D was 28 nmol/L and ascorbic acid 1.8 mg/L. "pockets 5-7 mm, bleeding, mobility"
07 Oct 2013 — A periodontist confirmed periodontitis of the lower anterior sextant, stage III grade C, with peri-implantitis at the tooth 31 implant. Radiographs showed horizontal and vertical alveolar bone loss of 30 to 40 per cent. Non-surgical debridement and three-monthly maintenance were commenced, with chlorhexidine. "periodontitis stage III, peri-implantitis"
22 Jun 2016 — After nine months without periodontal maintenance, a fracture of tooth 42 in a post-dialysis collapse on 15 March 2016 and its extraction with flap debridement on 20 April 2016, re-charting showed pockets of 8 to 9 mm, grade 2 mobility of tooth 32 and peri-implant bone loss of 50 per cent. Tooth 41 was hopeless and was extracted. Bone densitometry on 09 June 2016 showed osteoporosis. "pockets 8-9 mm, 41 hopeless"

Symptoms

At onset the veteran had bleeding from the lower front gums on brushing, a persistent bad taste, gum recession beneath the lip stud, tenderness on biting and loosening of the lower incisors, with suppuration around the implant. Over the following months the recession and mobility progressed, and the symptoms worsened markedly in 2016 with the loss of teeth 41 and 42.

He now has a removable partial denture replacing the lower incisors, ongoing gum bleeding and halitosis, difficulty biting and chewing firm food, and embarrassment about his appearance and speech.

Imaging

03 Dec 1999 — Dental radiographs (periapical and occlusal): "Empty socket of tooth 31 with fracture of the labial alveolar plate."
02 Apr 2013 — Orthopantomogram and periapical radiographs: "Widened periodontal ligament spaces of teeth 41 and 42 consistent with subluxation; fracture of the labial alveolar plate from 41 to 42. Alveolar crest heights otherwise within normal limits."
07 Oct 2013 — Periapical radiographs, lower anterior sextant: "Horizontal alveolar bone loss of 30 to 40 per cent from 33 to 43, vertical defects at 41 and 42, and saucer-shaped peri-implant bone loss of 30 per cent at the tooth 31 implant."
22 Jun 2016 — Periapical radiographs and orthopantomogram: "Progression of alveolar bone loss to 50 to 60 per cent at 32 and 41, socket of extracted 42, and peri-implant bone loss of 50 per cent at 31."
09 Jun 2016 — Dual-energy X-ray absorptiometry: "Lumbar spine T-score -2.9, femoral neck T-score -2.6, consistent with osteoporosis."

Onset Date

The most likely date of onset of this condition is 12 Aug 2013.

At that date the veteran was serving full time as a petroleum operator at a base in Australia, on restricted duties. He was on haemodialysis, imatinib, antiretroviral therapy and sulfasalazine, had been treated four months earlier for a lower anterior alveolar fracture, and was severely malnourished. Over the following week he noticed bleeding and loosening of his lower front teeth.

This date is appropriate because periodontal charting on 18 February 2013 showed gingivitis only, with no pocket deeper than 3 mm and intact alveolar crests on the radiographs of 02 April 2013, and he first presented with periodontal symptoms on 19 August 2013, one week after this date. It falls within uninterrupted full-time service.

For the gingivitis, foreign body and piercing factors, the 6 months before onset run from 12 Feb 2013 to 12 Aug 2013; gingivitis was recorded from September 2012, the implant had been in place since 2001 and the piercing since October 2009. The trauma of 02 Apr 2013 and the surgery of 03 Apr 2013 fall inside the same 6-month window. For obesity, the 3 years before onset run from 12 Aug 2010 to 12 Aug 2013, and his BMI was 30 or more throughout. For alcohol, the 2 years before onset run from 12 Aug 2011 to 12 Aug 2013, during which he drank about 400 grams a week. His smoking stopped on 01 Jan 2012, 1 year and 7 months before onset. Neutropenia, leukaemia, HIV infection, diabetes, chronic renal failure, ulcerative colitis, severe malnutrition and vitamin C and D deficiency were each established before 12 Aug 2013 and present on that date.

For the worsening factors, the documented worsening is 22 Jun 2016. The 6 months before it run from 22 Dec 2015 to 22 Jun 2016, covering the trauma of 15 Mar 2016, the surgery of 20 Apr 2016 and continuing gingivitis, implant and piercing. The 3 years before it run from 22 Jun 2013 to 22 Jun 2016, during which he remained obese, and the 2 years before it run from 22 Jun 2014 to 22 Jun 2016, during which he drank 300 to 400 grams of alcohol a week. Osteoporosis was confirmed on 09 Jun 2016, and periodontal maintenance was unavailable from September 2015.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Periodontitis (ICD-10-AM K05.3), chronic periodontitis of the lower anterior sextant with peri-implantitis at the tooth 31 implant, under the Statements of Principles concerning periodontitis, Balance of Probabilities No. 28 of 2022 and Reasonable Hypothesis No. 27 of 2022.

Periodontitis is chronic inflammation of the tissues that support the teeth. Bacterial plaque at the gum margin first causes gingivitis; where host defences are impaired, the inflammation extends to the periodontal ligament and alveolar bone, producing periodontal pockets, attachment loss, recession, mobility and eventually tooth loss. Peri-implantitis is the same process around a dental implant. Smoking, diabetes, neutropenia, immunosuppression, malnutrition and local factors such as trauma, piercings and implants accelerate it.

The condition followed the loss of tooth 31 in East Timor, the systemic diseases that arose from his operational service, and lower anterior dental trauma in April 2013. It began on 12 August 2013, was confirmed by a periodontist on 07 October 2013 and worsened in 2016.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

12 August 2013.

When did the veteran first present to a health / medical provider for this condition?

19 August 2013.

When was the condition confirmed / formally diagnosed?

07 October 2013.

When did the veteran first present to you (or your practice) for this condition?

18 June 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by a periodontist on 07 October 2013 on full periodontal charting and radiographs, which showed periodontal pocketing of 5 to 7 mm with bleeding on probing, clinical attachment loss and 30 to 40 per cent alveolar bone loss from tooth 33 to tooth 43, and progressive bone loss around the tooth 31 implant. This meets the Statement of Principles definition of periodontitis, which includes chronic periodontitis and peri-implantitis, and none of the exclusions applies.

The clinical picture was consistent: bleeding gums, recession, mobility and suppuration on a background of documented gingivitis. Re-charting on 22 June 2016 confirmed progression to pockets of 8 to 9 mm and the loss of teeth 41 and 42.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 12 August 2013, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in East Timor in 1999 to 2000, where tooth 31 was lost and he began smoking, in Iraq in 2005, where the illness leading to ulcerative colitis began, and in Afghanistan in 2009, where he acquired HIV infection and the posttraumatic stress disorder that drove his drinking.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Periodontitis, No. 28 of 2022

Causative factors

Factor 9(1): having gingivitis involving the affected region of the periodontium for a continuous period of at least the 6 months before the clinical onset of periodontitis; — MET

- Generalised marginal gingivitis of the lower anterior sextant, the affected region, was first recorded at a dental examination on 14 September 2012, with bleeding on probing at every site from tooth 33 to tooth 43 and pocket depths no greater than 3 mm. It was recorded again on 18 February 2013 and persisted without interruption to the onset on 12 August 2013, a continuous period of 11 months that covers the whole of the 6 months before onset, from 12 February 2013 to 12 August 2013. Neutropenia, diabetes and his inability to clean around the implant and piercing kept the gingival inflammation active.

Factor 9(2): having a foreign body in contact with the affected region of the periodontium, on more days than not for a continuous period of at least 6 months before the clinical onset of periodontitis, and where the foreign body has been removed before the clinical onset of periodontitis, then that onset occurred within 4 weeks of removal; — MET

- An osseointegrated implant and crown replaced tooth 31 on 14 May 2001, after the tooth was avulsed in a service injury in East Timor in December 1999. The implant has been in contact with the lower anterior periodontium every day since 2001 and was never removed, so it was in contact on more days than not throughout the continuous 6 months before onset, from 12 February 2013 to 12 August 2013. Peri-implant bone loss around it was part of the presentation at onset.

Factor 9(3): having an oral piercing adjacent to the affected region of the periodontium for a continuous period of at least the 6 months before the clinical onset of periodontitis; — MET

- The veteran has worn a lower lip (labret) piercing, a titanium stud whose inner disc sits against the labial gingiva of teeth 31 and 41, continuously since October 2009. It was recorded at every dental examination from 2010 and was in place throughout the 6 months before onset, from 12 February 2013 to 12 August 2013. Gingival recession and bone loss were greatest directly beneath the disc.

Factor 9(4): having trauma to the affected region of the periodontium within the 6 months before the clinical onset of periodontitis; — MET

- On 02 April 2013, while on duty at his base, the veteran collapsed in a hypoglycaemic episode from his service-related diabetes and struck his face on a concrete loading bay. He sustained subluxation of teeth 41 and 42 and a fracture of the labial alveolar plate in the lower anterior region, confirmed on radiographs that day. This is trauma to the affected region as defined, 4 months and 10 days before the onset on 12 August 2013, inside the window of 12 February 2013 to 12 August 2013.

Factor 9(5): having surgery to the affected region of the periodontium within the 6 months before the clinical onset of periodontitis; — MET

- On 03 April 2013 an oral and maxillofacial surgeon performed open reduction of the alveolar fracture through a mucoperiosteal flap, repositioned teeth 41 and 42 and placed a wire and composite splint, removed on 15 May 2013. This surgery to the lower anterior periodontium took place 4 months and 9 days before onset, within the 6 months from 12 February 2013 to 12 August 2013.

Factor 9(6): having neutropenia or agranulocytosis at the time of the clinical onset of periodontitis; — MET

- The veteran had neutropenia at the onset. His absolute neutrophil count was 0.9 x 10^9/L on 05 August 2012 and 0.8 x 10^9/L on 30 July 2013, attributed by the haematologist to imatinib for chronic myeloid leukaemia, to HIV infection and to sulfasalazine for ulcerative colitis. A count of 0.7 x 10^9/L on 19 August 2013, one week after onset, confirmed it was present on 12 August 2013. Neutrophils are the main defence of the periodontium against plaque bacteria.

Factor 9(7): having leukaemia at the time of the clinical onset of periodontitis; — MET

- Chronic myeloid leukaemia was diagnosed by a haematologist on 05 August 2012, with a white cell count of 86 x 10^9/L and the BCR-ABL1 fusion gene on bone marrow testing. It was attributed to benzene exposure during 17 years as a petroleum operator handling fuels, including on three deployments. He was on imatinib 400 mg daily and the leukaemia was present at the onset on 12 August 2013.

Factor 9(8): having infection with human immunodeficiency virus at the time of the clinical onset of periodontitis; — MET

- HIV infection was confirmed on 02 October 2009 after a needle-stick injury from a casualty's cannula on 17 June 2009 while the veteran assisted with first aid at a forward refuelling point in Afghanistan. He has taken antiretroviral therapy continuously since, with a CD4 count of 310 cells/microlitre on 30 July 2013. The infection was present at the onset on 12 August 2013.

Factor 9(9): having diabetes mellitus at the time of the clinical onset of periodontitis; — MET

- Type 2 diabetes mellitus was diagnosed on 11 November 2010 with an HbA1c of 8.4 per cent, on a background of obesity and repeated prednisolone courses for ulcerative colitis. HbA1c was 9.1 per cent on 30 July 2013, and the diabetes was present and poorly controlled at the onset on 12 August 2013.

Factor 9(10): being obese for a continuous period of at least the 3 years before the clinical onset of periodontitis; — MET

- The veteran's BMI was 31.2 on 04 March 2010 and was recorded at or above 30 at every examination after that, peaking at 34.1 in 2012 and measuring 30.6 on 19 August 2013. He was therefore obese continuously for the 3 years before onset, from 12 August 2010 to 12 August 2013. The weight gain followed heavy drinking after his return from Afghanistan and prednisolone treatment.

Factor 9(11): having chronic renal failure at the time of the clinical onset of periodontitis; — MET

- The veteran's eGFR was below 15 mL/min/1.73 m2 from December 2012 and he commenced haemodialysis three times a week on 18 March 2013 for HIV-associated nephropathy combined with diabetic nephropathy. He remained on chronic dialysis at onset on 12 August 2013, meeting the definition of chronic renal failure.

Factor 9(12): having inflammatory bowel disease or rheumatoid arthritis at the time of the clinical onset of periodontitis; — MET

- Ulcerative colitis was diagnosed by a gastroenterologist on 14 March 2006 on colonoscopy and biopsy, following severe infective gastroenteritis in Iraq in July 2005. It was active at the onset, with a flare in June 2013 requiring prednisolone 40 mg daily, and he was taking sulfasalazine 3 g daily. Inflammatory bowel disease was therefore present on 12 August 2013.

Factor 9(13)(a): having smoked tobacco products: in an amount of at least 5 pack-years before the clinical onset of periodontitis; and — MET

- The veteran began smoking during his deployment to East Timor in October 1999 and smoked 25 cigarettes a day until he stopped on 01 January 2012, a period of 12 years and 3 months. That is about 15.3 pack-years, well above the 5 pack-years required, all of it before the onset on 12 August 2013.

Factor 9(13)(b): having smoked tobacco products: if smoking has ceased before the clinical onset of periodontitis, then that onset occurred within 10 years of cessation; — MET

- The veteran ceased smoking on 01 January 2012, and the onset of periodontitis on 12 August 2013 occurred 1 year and 7 months later, within 10 years of cessation.

Factor 9(14): having severe malnutrition at the time of the clinical onset of periodontitis; — MET

- At onset the veteran had severe protein-energy malnutrition despite his raised BMI. On 19 August 2013 the renal dietitian recorded an unintended weight loss of 11 kg over the preceding four months, a serum albumin of 24 g/L, a Subjective Global Assessment grade C (severely malnourished) and muscle wasting, caused by an ulcerative colitis flare, dialysis-related protein losses and poor intake. A dietetic review on 30 July 2013 had already recorded grade C. The malnutrition was present on 12 August 2013.

Factor 9(15): having severe vitamin C deficiency or vitamin D deficiency at the time of the clinical onset of periodontitis; — MET

- Bloods on 30 July 2013 showed a serum 25-hydroxyvitamin D of 28 nmol/L, below the 50 nmol/L that defines vitamin D deficiency, and a serum ascorbic acid level of 1.8 mg/L, below the 2.5 mg/L that defines severe vitamin C deficiency, with perifollicular haemorrhages on the legs. Both deficiencies were present at onset on 12 August 2013 and were treated from 21 August 2013.

Factor 9(16): consuming an average of at least 200 grams of alcohol per week for a continuous period of at least the 2 years before the clinical onset of periodontitis; — MET

- After returning from Afghanistan in 2009 the veteran drank about 40 standard drinks a week, recorded on AUDIT screening as 400 grams of alcohol a week in March 2010, November 2011 and July 2013. This continued throughout the 2 years before onset, from 12 August 2011 to 12 August 2013, at twice the 200 grams a week required.

Worsening factors

Factor 9(17): having gingivitis involving the affected region of the periodontium for a continuous period of at least the 6 months before the clinical worsening of periodontitis; — MET

- Gingivitis of the lower anterior sextant continued after onset and was recorded at periodontal maintenance visits from 2014 to 2016, including on 10 December 2015 and 22 June 2016. It was present continuously throughout the 6 months before the documented worsening, from 22 December 2015 to 22 June 2016.

Factor 9(18): having a foreign body in contact with the affected region of the periodontium, on more days than not for a continuous period of at least 6 months before the clinical worsening of periodontitis, and where the foreign body has been removed before the clinical worsening of periodontitis, then that worsening occurred within 4 weeks of removal; — MET

- The implant at tooth 31 remained in place every day after onset and throughout the 6 months before the worsening, from 22 December 2015 to 22 June 2016. Radiographs on 22 June 2016 showed peri-implant bone loss had progressed from 30 per cent to 50 per cent of the implant length.

Factor 9(19): having an oral piercing adjacent to the affected region of the periodontium for a continuous period of at least the 6 months before the clinical worsening of periodontitis; — MET

- The labret piercing was retained continuously after onset, against dental advice, and was in place throughout the 6 months before the worsening, from 22 December 2015 to 22 June 2016.

Factor 9(20): having trauma to the affected region of the periodontium within the 6 months before the clinical worsening of periodontitis; — MET

- On 15 March 2016 the veteran collapsed from post-dialysis hypotension and struck his face on a door frame, fracturing the crown and root of tooth 42 in the affected region, confirmed on a periapical radiograph that day. This was 3 months and 7 days before the worsening on 22 June 2016, within the 6 months from 22 December 2015 to 22 June 2016.

Factor 9(21): having surgery to the affected region of the periodontium within the 6 months before the clinical worsening of periodontitis; — MET

- On 20 April 2016 a periodontist extracted the fractured tooth 42 and performed open flap debridement of the lower anterior sextant. This surgery to the affected region took place 2 months before the worsening on 22 June 2016, within the window of 22 December 2015 to 22 June 2016.

Factor 9(22): having neutropenia or agranulocytosis at the time of the clinical worsening of periodontitis; — MET

- Neutropenia persisted, with an absolute neutrophil count of 0.8 x 10^9/L on 14 June 2016, at the time of the worsening.

Factor 9(23): having leukaemia at the time of the clinical worsening of periodontitis; — MET

- Chronic myeloid leukaemia was present at the worsening; imatinib was changed to dasatinib in February 2016 after loss of major molecular response.

Factor 9(24): having infection with human immunodeficiency virus at the time of the clinical worsening of periodontitis; — MET

- HIV infection, acquired on service in 2009, was present at the worsening, with a CD4 count of 280 cells/microlitre in June 2016.

Factor 9(25): having diabetes mellitus at the time of the clinical worsening of periodontitis; — MET

- Type 2 diabetes was present and poorly controlled at the worsening, with an HbA1c of 9.6 per cent on 14 June 2016, and insulin had been added in 2015.

Factor 9(26): being obese for a continuous period of at least the 3 years before the clinical worsening of periodontitis; — MET

- The veteran's BMI remained between 30.4 and 32.0 at every measurement from 2013 to 2016, so he was obese continuously for the 3 years before the worsening, from 22 June 2013 to 22 June 2016.

Factor 9(27): having chronic renal failure at the time of the clinical worsening of periodontitis; — MET

- The veteran remained on haemodialysis three times a week for chronic renal failure at the worsening in June 2016.

Factor 9(28): having inflammatory bowel disease or rheumatoid arthritis at the time of the clinical worsening of periodontitis; — MET

- Ulcerative colitis was active at the worsening, with a flare in May 2016 treated with prednisolone and continued sulfasalazine.

Factor 9(29)(a): having smoked tobacco products: in an amount of at least 5 pack-years before the clinical worsening of periodontitis; and — MET

- The veteran's smoking history of about 15.3 pack-years, all accrued between October 1999 and January 2012, preceded the worsening on 22 June 2016.

Factor 9(29)(b): having smoked tobacco products: if smoking has ceased before the clinical worsening of periodontitis, then that worsening occurred within 10 years of cessation; — MET

- The veteran ceased smoking on 01 January 2012 and the worsening on 22 June 2016 occurred 4 years and 6 months later, within 10 years of cessation.

Factor 9(30): having severe malnutrition at the time of the clinical worsening of periodontitis; — MET

- Severe malnutrition was present at the worsening: on 14 June 2016 serum albumin was 23 g/L and the renal dietitian again graded him Subjective Global Assessment C after a colitis flare.

Factor 9(31): having severe vitamin C deficiency or vitamin D deficiency at the time of the clinical worsening of periodontitis; — MET

- Bloods on 14 June 2016 showed a serum 25-hydroxyvitamin D of 31 nmol/L, which is vitamin D deficiency, despite supplementation interrupted by malabsorption during colitis flares.

Factor 9(32): consuming an average of at least 200 grams of alcohol per week for a continuous period of at least the 2 years before the clinical worsening of periodontitis; — MET

- AUDIT screening in July 2014, August 2015 and June 2016 recorded about 30 to 40 standard drinks a week, 300 to 400 grams of alcohol, throughout the 2 years before the worsening, from 22 June 2014 to 22 June 2016.

Factor 9(33): having osteoporosis at the time of the clinical worsening of periodontitis; — MET

- Bone densitometry on 09 June 2016 showed a lumbar spine T-score of -2.9 and a femoral neck T-score of -2.6, diagnosed as osteoporosis from prednisolone, chronic renal failure, vitamin D deficiency and HIV infection. It was present at the worsening on 22 June 2016.

Factor 9(34): inability to obtain appropriate clinical management for periodontitis. — MET

- Periodontal maintenance at three-monthly intervals was prescribed after diagnosis, but from September 2015 to June 2016 no treatment was provided because the garrison dental service required haematology clearance before any procedure for his neutropenia, and appointments were repeatedly cancelled while clearance was sought. The disease went untreated for nine months and worsened. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Periodontitis, No. 27 of 2022

Causative factors

Factor 9(1): having gingivitis involving the affected region of the periodontium for a continuous period of at least the 6 months before the clinical onset of periodontitis; — MET

- Gingivitis of the lower anterior sextant was recorded continuously from 14 September 2012 to the onset on 12 August 2013, covering the 6 months from 12 February 2013 to 12 August 2013. The gingival inflammation was sustained by neutropenia from HIV infection acquired on warlike service in Afghanistan in 2009 and by the implant placed after his injury on warlike service in East Timor.

- The implant at tooth 31 replaced a tooth avulsed when a fuel bladder coupling struck the veteran in the mouth on warlike service in East Timor on 03 December 1999. It has been in contact with the periodontium every day since 14 May 2001, including throughout the 6 months before onset, from 12 February 2013 to 12 August 2013.

Factor 9(3): having an oral piercing adjacent to the affected region of the periodontium for a continuous period of at least the 6 months before the clinical onset of periodontitis; — MET

- The labret piercing was placed during post-deployment leave in October 2009, on return from warlike service in Afghanistan, and was worn continuously against the labial gingiva of teeth 31 and 41 throughout the 6 months before onset, from 12 February 2013 to 12 August 2013.

Factor 9(4): having trauma to the affected region of the periodontium within the 6 months before the clinical onset of periodontitis; — MET

- The facial trauma of 02 April 2013, with subluxation of teeth 41 and 42 and a labial alveolar fracture, occurred in a hypoglycaemic collapse from diabetes that followed prednisolone treatment for ulcerative colitis arising after gastroenteritis on warlike service in Iraq in 2005. It was 4 months and 10 days before onset.

Factor 9(5): having surgery to the affected region of the periodontium within the 6 months before the clinical onset of periodontitis; — MET

- Open reduction of the alveolar fracture with a mucoperiosteal flap and splinting on 03 April 2013, made necessary by the trauma that flowed from his Iraq-related ulcerative colitis, was performed 4 months and 9 days before onset, within the 6 months from 12 February 2013 to 12 August 2013.

Factor 9(6): having neutropenia or agranulocytosis at the time of the clinical onset of periodontitis; — MET

- Neutropenia, with an absolute neutrophil count of 0.8 x 10^9/L on 30 July 2013, was present at onset. It was caused in part by HIV infection acquired on warlike service in Afghanistan in 2009 and by sulfasalazine for ulcerative colitis that followed warlike service in Iraq.

Factor 9(7): having leukaemia at the time of the clinical onset of periodontitis; — MET

- Chronic myeloid leukaemia, diagnosed on 05 August 2012, followed benzene exposure as a petroleum operator, including open fuel decanting and tank cleaning in extreme heat on warlike service in East Timor, Iraq and Afghanistan. It was present at onset on 12 August 2013.

Factor 9(8): having infection with human immunodeficiency virus at the time of the clinical onset of periodontitis; — MET

- HIV infection followed a needle-stick injury on warlike service in Afghanistan on 17 June 2009 and was confirmed on 02 October 2009. It was present at onset on 12 August 2013.

Factor 9(9): having diabetes mellitus at the time of the clinical onset of periodontitis; — MET

- Type 2 diabetes, diagnosed on 11 November 2010, followed obesity from heavy drinking after warlike service in Afghanistan and prednisolone for ulcerative colitis that followed warlike service in Iraq. It was present at onset on 12 August 2013.

Factor 9(10): being obese for a continuous period of at least the 3 years before the clinical onset of periodontitis; — MET

- The veteran was obese, with a BMI of 30 or more, continuously from 04 March 2010, covering the 3 years before onset from 12 August 2010 to 12 August 2013. The weight gain followed alcohol misuse linked to posttraumatic stress disorder from warlike service in Afghanistan.

Factor 9(11): having chronic renal failure at the time of the clinical onset of periodontitis; — MET

- Chronic renal failure from HIV-associated nephropathy, with haemodialysis from 18 March 2013, followed the HIV infection acquired on warlike service in Afghanistan in 2009. It was present at onset on 12 August 2013.

Factor 9(12): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of periodontitis; — MET

- Ulcerative colitis, on the specified list of autoimmune diseases as an inflammatory bowel disease, was diagnosed on 14 March 2006 after severe infective gastroenteritis on warlike service in Iraq in July 2005, and was active at onset on 12 August 2013.

Factor 9(13)(a): having smoked tobacco products: in an amount of at least 2.5 pack-years before the clinical onset of periodontitis; and — MET

- The veteran took up smoking during warlike service in East Timor in October 1999, where cigarettes were cheap and smoking breaks were part of the routine on fuel points, and smoked about 15.3 pack-years before stopping on 01 January 2012, well above the 2.5 pack-years required.

Factor 9(13)(b): having smoked tobacco products: if smoking has ceased before the clinical onset of periodontitis, then that onset occurred within 10 years of cessation; — MET

- Smoking ceased on 01 January 2012 and onset occurred on 12 August 2013, within 10 years of cessation.

Factor 9(14): having severe malnutrition at the time of the clinical onset of periodontitis; — MET

- Severe protein-energy malnutrition, with a serum albumin of 24 g/L and Subjective Global Assessment grade C on 30 July 2013, was caused by ulcerative colitis that followed warlike service in Iraq and by dialysis for renal failure that followed HIV acquired in Afghanistan. It was present at onset.

Factor 9(15): having severe vitamin C deficiency or vitamin D deficiency at the time of the clinical onset of periodontitis; — MET

- Serum 25-hydroxyvitamin D of 28 nmol/L and serum ascorbic acid of 1.8 mg/L on 30 July 2013 confirmed vitamin D deficiency and severe vitamin C deficiency at onset, from malabsorption in Iraq-related ulcerative colitis and dialysis dietary restrictions.

Factor 9(16): consuming an average of at least 200 grams of alcohol per week for a continuous period of at least the 2 years before the clinical onset of periodontitis; — MET

- Drinking of about 400 grams of alcohol a week began after warlike service in Afghanistan in 2009, as a way of coping with posttraumatic stress disorder diagnosed in 2010, and continued throughout the 2 years before onset, from 12 August 2011 to 12 August 2013.

Worsening factors

Factor 9(17): having gingivitis involving the affected region of the periodontium for a continuous period of at least the 6 months before the clinical worsening of periodontitis; — MET

- Gingivitis of the lower anterior sextant persisted throughout the 6 months before the worsening, from 22 December 2015 to 22 June 2016, sustained by neutropenia linked to the HIV infection acquired on warlike service in Afghanistan.

- The implant replacing the tooth lost on warlike service in East Timor remained in contact with the periodontium every day throughout the 6 months before the worsening, from 22 December 2015 to 22 June 2016.

- The labret piercing placed on return from warlike service in Afghanistan remained in place throughout the 6 months before the worsening, from 22 December 2015 to 22 June 2016.

Factor 9(20): having trauma to the affected region of the periodontium within the 6 months before the clinical worsening of periodontitis; — MET

- The fracture of tooth 42 on 15 March 2016 occurred when the veteran collapsed from post-dialysis hypotension, his renal failure having followed HIV infection acquired on warlike service in Afghanistan. It was 3 months and 7 days before the worsening.

Factor 9(21): having surgery to the affected region of the periodontium within the 6 months before the clinical worsening of periodontitis; — MET

- Extraction of tooth 42 and open flap debridement on 20 April 2016, required because of that trauma, took place 2 months before the worsening on 22 June 2016.

Factor 9(22): having neutropenia or agranulocytosis at the time of the clinical worsening of periodontitis; — MET

- Neutropenia linked to HIV infection from warlike service in Afghanistan was present at the worsening, with a neutrophil count of 0.8 x 10^9/L on 14 June 2016.

Factor 9(23): having leukaemia at the time of the clinical worsening of periodontitis; — MET

- Chronic myeloid leukaemia related to benzene exposure on warlike service was present at the worsening in June 2016.

Factor 9(24): having infection with human immunodeficiency virus at the time of the clinical worsening of periodontitis; — MET

- HIV infection acquired on warlike service in Afghanistan was present at the worsening in June 2016.

Factor 9(25): having diabetes mellitus at the time of the clinical worsening of periodontitis; — MET

- Type 2 diabetes was present at the worsening, with an HbA1c of 9.6 per cent on 14 June 2016.

Factor 9(26): being obese for a continuous period of at least the 3 years before the clinical worsening of periodontitis; — MET

- The veteran was obese continuously from 22 June 2013 to 22 June 2016, the 3 years before the worsening, the obesity having followed alcohol misuse after warlike service in Afghanistan.

Factor 9(27): having chronic renal failure at the time of the clinical worsening of periodontitis; — MET

- Chronic renal failure on haemodialysis, flowing from HIV acquired on warlike service in Afghanistan, was present at the worsening in June 2016.

Factor 9(28): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of periodontitis; — MET

- Ulcerative colitis, which followed warlike service in Iraq, was active at the worsening, with a flare in May 2016.

Factor 9(29)(a): having smoked tobacco products: in an amount of at least 2.5 pack-years before the clinical worsening of periodontitis; and — MET

- The 15.3 pack-year smoking history that began on warlike service in East Timor preceded the worsening on 22 June 2016.

Factor 9(29)(b): having smoked tobacco products: if smoking has ceased before the clinical worsening of periodontitis, then that worsening occurred within 10 years of cessation; — MET

- Smoking ceased on 01 January 2012 and the worsening on 22 June 2016 occurred within 10 years of cessation.

Factor 9(30): having severe malnutrition at the time of the clinical worsening of periodontitis; — MET

- Severe malnutrition, with a serum albumin of 23 g/L and Subjective Global Assessment grade C on 14 June 2016, was present at the worsening.

Factor 9(31): having severe vitamin C deficiency or vitamin D deficiency at the time of the clinical worsening of periodontitis; — MET

- Vitamin D deficiency, with a serum 25-hydroxyvitamin D of 31 nmol/L on 14 June 2016, was present at the worsening.

Factor 9(32): consuming an average of at least 200 grams of alcohol per week for a continuous period of at least the 2 years before the clinical worsening of periodontitis; — MET

- Alcohol intake of 300 to 400 grams a week, which began after warlike service in Afghanistan, continued throughout the 2 years before the worsening, from 22 June 2014 to 22 June 2016.

Factor 9(33): having osteoporosis at the time of the clinical worsening of periodontitis; — MET

- Osteoporosis, with a lumbar spine T-score of -2.9 on 09 June 2016, was present at the worsening and arose from prednisolone for Iraq-related ulcerative colitis and from renal failure and HIV infection linked to Afghanistan.

Factor 9(34): inability to obtain appropriate clinical management for periodontitis. — MET

- From September 2015 to June 2016 periodontal maintenance was not provided because haematology clearance for neutropenia, itself linked to HIV acquired on warlike service in Afghanistan, could not be obtained in time, and the disease went untreated for nine months and worsened.

The % contribution of the causes is 100% and significant.

Sequelae

The periodontitis is a sequela of the veteran's accepted conditions: the loss of tooth 31 in East Timor and the implant that replaced it, HIV infection, ulcerative colitis, type 2 diabetes, chronic myeloid leukaemia and chronic renal failure, each of which impaired periodontal defences or directly damaged the lower anterior periodontium.

Unintended Consequence

Met. The neutropenia that contributed to the periodontitis is an unintended consequence of imatinib and sulfasalazine, and the osteoporosis present at the worsening is an unintended consequence of repeated prednisolone courses, all prescribed and paid for by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. From September 2015 to June 2016 the veteran's prescribed three-monthly periodontal maintenance was not provided because the garrison dental service required haematology clearance for his neutropenia before any procedure, and appointments were cancelled repeatedly while that clearance was sought. The disease went untreated for nine months, pocket depths increased from 5 to 7 mm to 8 to 9 mm and two teeth were lost. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), administrative barriers within the service health system that prevent prescribed treatment amount to an inability to obtain appropriate clinical management. The seven-week delay between his first presentation in August 2013 and specialist assessment in October 2013 also reflects barriers to care.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

03 Dec 1999, Dental treatment record and radiographs, Deployed dental officer, East Timor
14 May 2001, Implant placement record, Oral and maxillofacial surgeon
14 Mar 2006, Colonoscopy and gastroenterology consultation, Gastroenterologist
02 Oct 2009, Specialist letter, Infectious diseases physician
11 Nov 2010, Outpatient health record and pathology, Medical Officer, Garrison health centre
05 Aug 2012, Haematology consultation and bone marrow report, Haematologist
14 Sep 2012, Dental examination record, Dental officer, Garrison dental service
18 Feb 2013, Periodontal charting, Dental officer, Garrison dental service
18 Mar 2013, Renal medicine consultation, Renal physician
03 Apr 2013, Operation report, Oral and maxillofacial surgeon
19 Aug 2013, Dental record and dietetic assessment, Dental officer and renal dietitian
07 Oct 2013, Specialist periodontal assessment and radiographs, Periodontist
09 Jun 2016, Bone densitometry report, Radiologist
22 Jun 2016, Periodontal re-evaluation, Periodontist
Statement of Principles concerning Periodontitis (Balance of Probabilities) No. 28 of 2022, Repatriation Medical Authority
Statement of Principles concerning Periodontitis (Reasonable Hypothesis) No. 27 of 2022, Repatriation Medical Authority

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Periodontitis — DVA claim example