Diagnostic Assessment — Teeth - Tooth Wear
Example 1 of 1 · fictitious patient (Veteran S)
Diagnostic Assessment
Teeth - Tooth Wear
BOP Code: 30 of 2026 (Tooth Wear)
RH Code: 29 of 2026 (Tooth Wear)
ADF History
Veteran S, date of birth 22 May 1983, Australian Army, Vehicle Mechanic (Royal Australian Electrical and Mechanical Engineers), enlisted 14 July 2003, medically discharged 30 November 2016. Operational service: Iraq, Middle East Area of Operations, 10 October 2005 to 30 May 2006 (warlike); Afghanistan, 05 February 2008 to 20 October 2008 (warlike); Afghanistan, 02 January 2010 to 15 September 2010, including decompression at a staging base in the Middle East Area of Operations from 05 September 2010 (warlike); Solomon Islands, 01 October 2012 to 25 January 2013 (non-warlike).
Occupational History
As a vehicle mechanic the veteran repaired, recovered and maintained wheeled and armoured vehicles in garrison workshops and in the field. The trade involves heavy manual handling, prolonged work in confined and awkward postures, grinding, cutting and sanding of metal and paint, and exposure to fuels, solvents, exhaust and lubricants. Maintenance of lead-acid vehicle batteries involves charging and topping up cells in battery bays, where sulphuric acid mist is released.
On operations in the Middle East and Afghanistan, workshop and recovery tasks were carried out in open-sided shelters and in the open desert, with heavy exposure to fine airborne dust, extreme heat and long shifts. Hydration in the heat was routinely supplemented with freely issued carbonated soft drinks and sports drinks. Deployed members were also exposed to indirect fire and the psychological stress of operations.
History
Veteran S, a vehicle mechanic in the Australian Army, developed generalised tooth wear with combined erosion, attrition and abrasion on 05 October 2010, three weeks after returning from her third warlike deployment, following years of heavy desert dust exposure, battery-acid mist, erosive drinks, posttraumatic stress disorder with bruxism, bulimia nervosa, reflux and drug-induced dry mouth. The condition was confirmed by a dental officer using the Basic Erosive Wear Examination on 02 November 2010 and worsened in early 2013 after hyperemesis gravidarum, while the prescribed restorations were repeatedly deferred.
Timeline
- 14 Jun 2008 — During warlike service in Afghanistan the veteran's workshop compound was struck by indirect rocket fire. A soldier working beside her was seriously wounded and she assisted with first aid under fire. She reported acute distress, nightmares and jaw clenching in the following weeks. The medical officer recorded heavy daily consumption of issued cola and sports drinks in the heat and noted that she had been taking chewable vitamin C tablets daily since March 2008. "rocket attack, clenching jaw at night"
- 20 Feb 2009 — A consultant psychiatrist diagnosed posttraumatic stress disorder arising from the June 2008 rocket attack, and alcohol use disorder of moderate severity, with an AUDIT score of 22. Amitriptyline 50 mg at night was commenced for insomnia and post-traumatic headaches and was continued without interruption through 2010. She was referred for psychological treatment. "PTSD, AUD, amitriptyline 50 mg nocte"
- 12 Mar 2009 — At a garrison dental examination the dental officer recorded nocturnal bruxism with attrition facets on the canines, a dry oral mucosa and an unstimulated salivary flow of 0.08 mL per minute, attributed to amitriptyline. An occlusal splint was issued. In the same month gastroscopy showed Los Angeles grade B reflux oesophagitis and a gastroenterologist diagnosed gastro-oesophageal reflux disease and commenced pantoprazole. "bruxism, xerostomia, salivary flow reduced"
- 15 Jun 2009 — The psychiatrist diagnosed bulimia nervosa, with binge eating followed by self-induced vomiting three to four times a week, which had begun after her return from Afghanistan. The vomiting continued, largely concealed, through her third deployment in 2010 and was disclosed in October 2010. "bulimia nervosa, purging 3-4/week"
- 10 Dec 2009 — Pre-deployment dental examination graded her Dental Fitness Class 1. The Basic Erosive Wear Examination cumulative score was 4, with early surface loss confined to the enamel and no exposed dentine. No restorative treatment was required before deployment. "wear confined to enamel, BEWE 4"
- 12 Oct 2010 — Three weeks after returning from Afghanistan she presented to the garrison dental clinic with severe sensitivity to cold drinks and toothbrushing and pain on chewing that had begun on 05 October 2010. She disclosed ongoing vomiting, daily swimming in the past month and continuing intake of about two litres a day of cola and sports drinks. The palatal surfaces of the upper incisors appeared glassy and thinned. Her occlusal splint had been lost on deployment. "severe cold sensitivity, chewing pain"
- 02 Nov 2010 — A dental officer confirmed generalised tooth wear using the Basic Erosive Wear Examination, with a cumulative score of 11 and exposed dentine on the palatal surfaces of the upper incisors, cupping of the molar cusps, attrition facets extending into dentine on the canines and premolars, and cervical abrasion of the lower premolars. Composite restorations of the affected surfaces, a replacement occlusal splint and dietary and reflux counselling were prescribed. "tooth wear confirmed, BEWE 11"
- 10 Jan 2013 — On non-warlike service in the Solomon Islands she was found to be eight weeks pregnant and developed hyperemesis gravidarum, vomiting up to ten times a day with 6 kg of weight loss, ketonuria and dehydration requiring intravenous fluids at the deployed medical facility. No dental care was available in theatre. She was aeromedically evacuated on 25 January 2013 and the hyperemesis continued until late March 2013. "hyperemesis gravidarum, IV fluids"
- 12 Apr 2013 — Dental review showed marked worsening of the tooth wear, with a Basic Erosive Wear Examination cumulative score of 17, dentine exposed on 14 teeth, near pulpal exposure of the upper right central incisor and loss of occlusal vertical dimension. None of the restorations prescribed in November 2010 had been completed. She was referred to a prosthodontist for full-mouth rehabilitation. "BEWE 17, near pulp exposure"
Symptoms
At onset the veteran had severe sensitivity of her teeth to cold drinks, sweet foods and toothbrushing, pain on biting, and a thinned, glassy appearance of the upper front teeth. After onset the sensitivity became constant, she avoided chewing on the back teeth, and her partner reported nightly grinding.
She now reports persistent tooth sensitivity, difficulty chewing firm foods, chipping of the front teeth and self-consciousness about her smile. She has undergone extensive restorative work, including crowns and a root canal treatment, and wears an occlusal splint every night.
Imaging
- 02 Nov 2010 — Orthopantomogram and bitewing radiographs: "Generalised loss of incisal and occlusal tooth structure with reduced enamel thickness on the upper incisors and molars. No caries. No periapical pathology. Normal alveolar bone levels."
- 12 Apr 2013 — Periapical and bitewing radiographs: "Progression of tooth surface loss compared with November 2010, with marked thinning of the palatal dentine of the upper incisors and the pulp chamber of the upper right central incisor lying within 0.5 mm of the worn surface. Reduced crown height of the molars. No caries."
Onset Date
The most likely date of onset of this condition is 05 Oct 2010.
At that date the veteran was serving full time as a vehicle mechanic in a garrison workshop in Australia, three weeks after returning from warlike service in Afghanistan on 15 September 2010. She was taking amitriptyline 50 mg at night and pantoprazole, had active bulimia nervosa and alcohol use disorder, was grinding her teeth nightly without a splint, and had been swimming daily in pools later found to have a low pH.
This date is appropriate because her pre-deployment dental examination of 10 December 2009 recorded wear confined to the enamel, which is excluded from the definition, and she first presented with severe sensitivity and exposed dentine on 12 October 2010, one week after the symptoms began. It falls within uninterrupted full-time service.
For the dust factor, oral exposure accumulated over her three warlike deployments from 10 October 2005 to 15 September 2010, about 10,400 hours, and ceased on 15 September 2010, 20 days before onset and well within 6 months. For the acid fume factors, exposure in battery bays from July 2006 to 05 September 2010 totalled about 4,000 hours, including about 1,500 hours on deployment, and ceased one month before onset. For the erosive drinks factors, the 5 years before onset run from 05 Oct 2005 to 05 Oct 2010 and the 2 years from 05 Oct 2008 to 05 Oct 2010; she drank about two litres a day continuously from January 2005. The 2 years before onset for reflux run from 05 Oct 2008 to 05 Oct 2010, and reflux was diagnosed in March 2009. The 1 year before onset for vomiting runs from 05 Oct 2009 to 05 Oct 2010, in which she vomited about 150 times. The xerostomia and chewable vitamin C periods began in February 2009 and March 2008 respectively and so filled the 6 months (05 Apr 2010 to 05 Oct 2010) and 1 year (05 Oct 2009 to 05 Oct 2010) windows. The 30 days before onset for the swimming factors run from 05 Sep 2010 to 05 Oct 2010. Bruxism, alcohol use disorder and bulimia nervosa were each present on 05 Oct 2010.
For the worsening factors, the documented worsening occurred on 12 Apr 2013. The 4 months before the worsening run from 12 Dec 2012 to 12 Apr 2013, during which she had hyperemesis gravidarum from January to March 2013, beginning on non-warlike service in the Solomon Islands. The restorations prescribed on 02 Nov 2010 had not been provided at any time between that date and the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Tooth Wear (ICD-10-AM K03.2, with K03.0 and K03.1), comprising dental erosion, dental attrition and dental abrasion, under the Statements of Principles concerning tooth wear, Balance of Probabilities No. 30 of 2026 and Reasonable Hypothesis No. 29 of 2026.
Tooth wear is the progressive loss of the hard tissues of the teeth from causes other than decay or discrete trauma. Dental erosion is the chemical dissolution of enamel and dentine by acids from the diet, from the stomach or from the environment. Dental attrition is wear from tooth-to-tooth contact, most often from grinding or clenching. Dental abrasion is wear from foreign material rubbed over the teeth, such as abrasive dust. Once the enamel is breached and dentine is exposed, the teeth become sensitive and painful, wear accelerates, and function and appearance deteriorate, often requiring extensive restoration.
The condition followed heavy dust and acid fume exposure on deployment and in garrison workshops, erosive drinks, bruxism from posttraumatic stress disorder, bulimia nervosa, reflux and drug-induced dry mouth. It began on 05 October 2010, was confirmed on 02 November 2010 and worsened in 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
05 October 2010.
When did the veteran first present to a health / medical provider for this condition?
12 October 2010.
When was the condition confirmed / formally diagnosed?
02 November 2010.
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 dental officer on 02 November 2010 using the Basic Erosive Wear Examination, a recognised tooth wear evaluation system, with a cumulative score of 11. Dentine was exposed on multiple tooth surfaces, causing severe sensitivity and significant impairment of chewing. The pattern showed erosion of the palatal surfaces of the upper incisors and molar cupping, attrition facets into dentine on the canines and premolars, and cervical abrasion. The wear was not confined to enamel and was not caused by caries or discrete trauma. This meets the Statement of Principles definition of tooth wear.
Radiographs showed generalised loss of tooth structure without caries or periapical disease. Repeat examination on 12 April 2013 confirmed progression, with a Basic Erosive Wear Examination score of 17, dentine exposure on 14 teeth and near pulpal exposure, and a prosthodontist confirmed the diagnosis and commenced full-mouth rehabilitation.
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 05 October 2010, 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, including her garrison workshop duties and the swimming, drinks, reflux and medication exposures in Australia. The Reasonable Hypothesis instrument applies to her warlike service in Iraq in 2005 to 2006 and Afghanistan in 2008 and 2010, where the dust and acid fume exposures, the rocket attack and the resulting posttraumatic stress disorder arose, and to her non-warlike service in the Solomon Islands in 2012 to 2013, where the hyperemesis gravidarum began and the condition worsened.
Each factor in these instruments applies to clinical onset or clinical worsening and 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 Tooth Wear, No. 30 of 2026
Causative factors
Factor 9(1): for dental attrition only, having bruxism at the time of clinical onset or clinical worsening; — MET
- Nocturnal bruxism was recorded by the dental officer on 12 March 2009, with attrition facets on the canines, and an occlusal splint was issued. The bruxism arose with the posttraumatic stress disorder that followed the rocket attack of June 2008. The splint was lost on deployment in 2010 and her partner reported nightly grinding when she returned. Bruxism was present at onset on 05 October 2010, and attrition facets extending into dentine were documented on 02 November 2010.
Factor 9(2): for dental erosion only, consuming an average of at least 1.5 litres per day of any combination of drinks from the specified list of erosive drinks: (a) for a continuous period of at least 5 years before clinical onset or clinical worsening; and (b) where that exposure has ceased, clinical onset or clinical worsening has occurred within 1 year of cessation; — MET
- From her posting to a tropical northern Australian base in January 2005 the veteran drank about two litres a day of carbonated cola and non-calcium-enriched sports drinks to replace fluid lost during heavy workshop work in the heat, a pattern recorded by the medical officer in June 2008 and again on 12 October 2010. The intake continued without a break, including during deployments where these drinks were freely issued, throughout the 5 years before onset, from 05 October 2005 to 05 October 2010. The exposure had not ceased at onset.
Factor 9(3): for dental erosion only, having alcohol use disorder at the time of clinical onset or clinical worsening; — MET
- A consultant psychiatrist diagnosed alcohol use disorder of moderate severity on 20 February 2009, with an AUDIT score of 22, as a way of coping with the posttraumatic stress disorder from her service. The disorder was unresolved at onset on 05 October 2010, when she was drinking wine and pre-mixed spirits most nights after her return from Afghanistan.
Factor 9(4): for dental erosion only, having an eating disorder at the time of clinical onset or clinical worsening; — MET
- The psychiatrist diagnosed bulimia nervosa on 15 June 2009, with binge eating and self-induced vomiting three to four times a week, developing in the context of her service-related posttraumatic stress disorder. The eating disorder was active at onset on 05 October 2010 and was disclosed at the dental presentation on 12 October 2010.
Factor 9(5): for dental erosion only, having gastro-oesophageal reflux disease within the 2 years before clinical onset or clinical worsening; — MET
- Gastroscopy in March 2009 showed Los Angeles grade B reflux oesophagitis and a gastroenterologist diagnosed gastro-oesophageal reflux disease, treated with pantoprazole. The reflux persisted with breakthrough symptoms throughout the 2 years before onset, from 05 October 2008 to 05 October 2010, aggravated by alcohol, carbonated drinks and repeated vomiting.
Factor 9(6): For dental erosion only, having hyperemesis gravidarum within the 4 months before clinical onset or clinical worsening; — MET
- The veteran developed hyperemesis gravidarum on 10 January 2013, vomiting up to ten times a day with 6 kg of weight loss and dehydration requiring intravenous fluids, and it continued in Australia until late March 2013. This was within the 4 months before the documented worsening on 12 April 2013, which run from 12 December 2012 to 12 April 2013. Gastric acid repeatedly bathed the already eroded palatal surfaces of the upper teeth.
Factor 9(7): for dental erosion only, vomiting or regurgitating gastric contents on at least 100 occasions within the 1 year before clinical onset or clinical worsening; — MET
- From the bulimia nervosa diagnosed on 15 June 2009, the veteran induced vomiting three to four times a week, about 150 occasions within the 1 year before onset, from 05 October 2009 to 05 October 2010, in addition to regurgitation from her reflux disease. The palatal distribution of the erosion on 02 November 2010 is the typical pattern of erosion from gastric acid.
Factor 9(8): For dental erosion only, having xerostomia for at least the 1 year before clinical onset or clinical worsening; — MET
- Xerostomia was documented on 12 March 2009, with a dry oral mucosa and an unstimulated salivary flow of 0.08 mL per minute, caused by amitriptyline 50 mg at night, a tricyclic antidepressant prescribed from 20 February 2009 for her service-related posttraumatic stress disorder. The amitriptyline and the dry mouth continued throughout the 1 year before onset, from 05 October 2009 to 05 October 2010, removing the buffering and protective effect of saliva.
Factor 9(9): for dental erosion only, swimming in a swimming pool with a pH below 5.5 for a cumulative period of at least 50 hours within the 30 days before clinical onset or clinical worsening; — MET
- After her return to Australia the veteran swam twice daily in the garrison pool from 16 September to 04 October 2010, for lumbar rehabilitation prescribed by the unit physiotherapist and fitness test preparation, about 2.75 hours a day and 52 hours in total. Facility logs recorded a pH between 5.0 and 5.4 during this period because of a faulty automated acid-dosing pump, which was replaced on 06 October 2010. All of this swimming fell within the 30 days before onset, from 05 September 2010 to 05 October 2010.
Factor 9(10): for dental erosion only, having oral exposure to fumes of a substance from the specified list of acidic substances at a concentration of greater than 0.5 milligrams per cubic metre: (a) for a cumulative period of at least 2,000 hours before clinical onset or clinical worsening; and (b) where that exposure has ceased, clinical onset or clinical worsening has occurred within 6 months of cessation; — MET
- From July 2006 the veteran was the battery bay non-commissioned officer at a garrison workshop, charging and topping up lead-acid vehicle batteries for about four hours a day in a poorly ventilated bay. A workplace health and safety survey in 2007 measured sulphuric acid mist at 0.8 to 1.4 milligrams per cubic metre, and no respiratory protection was issued. With further battery work on her 2008 and 2010 deployments, her cumulative exposure was about 4,000 hours. The exposure ceased on 05 September 2010, one month before onset and within 6 months.
Factor 9(11): for dental erosion only, taking a drug from the specified list of drugs, on average at least daily, for a continuous period of at least the 1 year before clinical onset or clinical worsening, and where: (a) a dissolved solution of the drug is swilled around the teeth; or (b) the drug is retained in the mouth adjacent to the affected site; — MET
- From March 2008 the veteran took chewable vitamin C 500 mg tablets daily, first supplied by the unit medic on deployment to supplement field rations, and continued them in garrison. She habitually held the tablet against the palatal surfaces of her upper front teeth until it dissolved, as recorded on 12 October 2010. She took them daily throughout the 1 year before onset, from 05 October 2009 to 05 October 2010, and the upper incisors were the most severely eroded teeth.
Worsening factors
Factor 9(12): inability to obtain appropriate clinical management for tooth wear before clinical worsening. — MET
- Composite restorations, a replacement occlusal splint and reflux and dietary management were prescribed on 02 November 2010. Over the following two years they were repeatedly deferred because of field exercises, pre-deployment readiness training and her deployment to the Solomon Islands, where no dental care was available, and later because of pregnancy. None had been provided by the documented worsening on 12 April 2013, when the Basic Erosive Wear Examination score had risen from 11 to 17. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Tooth Wear, No. 29 of 2026
Causative factors
Factor 9(1): for dental abrasion only, having oral exposure to dust in air at a concentration of greater than five milligrams per cubic metre: (a) for a cumulative period of at least 10,000 hours before clinical onset or clinical worsening; and (b) where that exposure has ceased, clinical onset or clinical worsening has occurred within 6 months of cessation; — MET
- On warlike service in Iraq from October 2005 to May 2006 and in Afghanistan in 2008 and 2010, a total of 746 days, the veteran worked about 14 hours a day in open-sided workshops and on vehicle recoveries in the open desert. Occupational hygiene monitoring at the deployed workshop recorded inhalable dust of 7 to 12 milligrams per cubic metre. She breathed through her mouth during heavy work and ate in dust-laden conditions, giving cumulative oral exposure of about 10,400 hours. The exposure ceased on 15 September 2010, 20 days before onset, and cervical abrasion was documented on 02 November 2010.
Factor 9(2): for dental attrition only, having bruxism at the time of clinical onset or clinical worsening; — MET
- Nocturnal bruxism developed with the posttraumatic stress disorder that followed the rocket attack on her workshop on warlike service in Afghanistan on 14 June 2008, was recorded by the dental officer on 12 March 2009 and was present at onset on 05 October 2010, when her splint had been lost on deployment.
Factor 9(3): for dental erosion only, consuming an average of at least 750 millilitres per day of any combination of drinks from the specified list of erosive drinks: (a) for a continuous period of at least 2 years before clinical onset or clinical worsening; and (b) where that exposure has ceased, clinical onset or clinical worsening has occurred within 1 year of cessation; — MET
- The veteran drank about two litres a day of cola and non-calcium-enriched sports drinks, issued freely for hydration during her warlike deployments in Afghanistan in 2008 and 2010, and continued at that level between deployments. The intake was continuous throughout the 2 years before onset, from 05 October 2008 to 05 October 2010, and had not ceased at onset.
Factor 9(4): for dental erosion only, having alcohol use disorder at the time of clinical onset or clinical worsening; — MET
- Alcohol use disorder was diagnosed on 20 February 2009 as part of her response to the rocket attack on warlike service in Afghanistan, and it was present at onset on 05 October 2010.
Factor 9(5): for dental erosion only, having an eating disorder at the time of clinical onset or clinical worsening; — MET
- Bulimia nervosa was diagnosed on 15 June 2009, after her return from warlike service in Afghanistan, in the setting of deployment-related posttraumatic stress disorder. It continued through her 2010 deployment and was active at onset on 05 October 2010.
Factor 9(6): for dental erosion only, having gastro-oesophageal reflux disease within the 2 years before clinical onset or clinical worsening; — MET
- Gastro-oesophageal reflux disease was confirmed on gastroscopy in March 2009 and persisted through her warlike deployment to Afghanistan in 2010, aggravated by the carbonated drinks and irregular meals of deployed life. It was present throughout the 2 years before onset, from 05 October 2008 to 05 October 2010.
Factor 9(7): for dental erosion only, having hyperemesis gravidarum within the 4 months before clinical onset or clinical worsening; — MET
- Hyperemesis gravidarum began on non-warlike service in the Solomon Islands on 10 January 2013, where she required intravenous fluids at the deployed medical facility before aeromedical evacuation, and continued to late March 2013. This was within the 4 months before the worsening on 12 April 2013.
Factor 9(8): for dental erosion only, vomiting or regurgitating gastric contents on at least 100 occasions within the 1 year before clinical onset or clinical worsening; — MET
- Self-induced vomiting from bulimia nervosa occurred three to four times a week, about 150 occasions within the 1 year before onset, from 05 October 2009 to 05 October 2010, including throughout her warlike deployment to Afghanistan from January to September 2010.
Factor 9(9): for dental erosion only, having xerostomia for at least the 6 months before clinical onset or clinical worsening; — MET
- Xerostomia from amitriptyline, prescribed for posttraumatic stress disorder arising from the rocket attack on warlike service in Afghanistan, was documented on 12 March 2009 and continued throughout the 6 months before onset, from 05 April 2010 to 05 October 2010, including in the desert heat of her 2010 deployment.
Factor 9(10): for dental erosion only, swimming in a swimming pool with a pH below 5.5 for a cumulative period of at least 25 hours within the 30 days before clinical onset or clinical worsening; — MET
- During post-operational decompression at a staging base in the Middle East Area of Operations from 05 to 15 September 2010, part of her warlike deployment, she swam about three hours a day, 30 hours in total. The preventive medicine team recorded a pool pH of 5.1 after an acid-dosing fault. This swimming fell within the 30 days before onset, from 05 September 2010 to 05 October 2010.
Factor 9(11): for dental erosion only, having oral exposure to fumes of a substance from the specified list of acidic substances at a concentration of greater than 0.5 milligrams per cubic metre: (a) for a cumulative period of at least 1,000 hours before clinical onset or clinical worsening; and (b) where that exposure has ceased, clinical onset or clinical worsening has occurred within 6 months of cessation; — MET
- On warlike service in Afghanistan in 2008 and 2010 the veteran charged vehicle batteries for about three hours a day in an enclosed container bay without extraction, with sulphuric acid mist above 0.5 milligrams per cubic metre, about 1,500 hours in total. The exposure ceased on 05 September 2010, one month before onset.
Factor 9(12): for dental erosion only, taking a drug from the specified list of drugs, on average at least daily, for a continuous period of at least the 6 months before clinical onset or clinical worsening, and where: (a) a dissolved solution of the drug is swilled around the teeth; or (b) the drug is retained in the mouth adjacent to the affected site; — MET
- Chewable vitamin C tablets were first supplied by the unit medic on warlike service in Afghanistan in March 2008 to supplement field rations. She took one daily, holding it against the palatal surfaces of the upper incisors until it dissolved, continuously through her 2010 deployment and throughout the 6 months before onset, from 05 April 2010 to 05 October 2010.
Worsening factors
Factor 9(13): inability to obtain appropriate clinical management for tooth wear before clinical worsening. — MET
- The restorations and splint prescribed on 02 November 2010 were not provided before the worsening on 12 April 2013. During her non-warlike service in the Solomon Islands from October 2012 to January 2013 no dental officer or dental facility was available, and her deteriorating teeth went untreated while she had hyperemesis gravidarum. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The tooth wear is a sequela of the veteran's accepted conditions: the bruxism of her posttraumatic stress disorder, the vomiting of bulimia nervosa, gastro-oesophageal reflux disease and the xerostomia caused by amitriptyline prescribed for her posttraumatic stress disorder. The tooth wear has in turn led to dentine hypersensitivity, pulpal inflammation requiring root canal treatment of the upper right central incisor, and loss of occlusal vertical dimension requiring full-mouth rehabilitation.
Unintended Consequence
Met. The xerostomia that contributed to the dental erosion is an unintended consequence of amitriptyline prescribed and paid for by the Commonwealth for her service-related posttraumatic stress disorder, and the chewable vitamin C tablets were supplied by the unit medic on deployment (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. Restorative treatment and a replacement occlusal splint were prescribed on 02 November 2010 but were deferred for more than two years because of exercises, readiness training and deployment, and no dental care was available on her non-warlike service in the Solomon Islands. During that time the Basic Erosive Wear Examination score rose from 11 to 17 and the upper right central incisor approached pulpal exposure. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), service demands and the absence of dental services on deployment that prevent prescribed treatment amount to an inability to obtain appropriate clinical management. The loss of her occlusal splint on deployment in 2010, with no replacement available in theatre, is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 14 Jun 2008, Deployed health record, Medical Officer, Afghanistan
- 20 Feb 2009, Psychiatric assessment, Consultant psychiatrist
- 12 Mar 2009, Dental examination record, Dental Officer, Garrison dental clinic
- Mar 2009, Gastroscopy report and specialist letter, Gastroenterologist
- 15 Jun 2009, Psychiatric review, Consultant psychiatrist
- 10 Dec 2009, Pre-deployment dental examination, Dental Officer
- Sep 2010, Preventive medicine water quality report, Staging base, Middle East Area of Operations
- Oct 2010, Swimming pool maintenance log, Garrison facility manager
- 12 Oct 2010, Dental presentation record, Dental Officer, Garrison dental clinic
- 02 Nov 2010, Tooth wear assessment and radiographs, Dental Officer
- 10 Jan 2013, Deployed health record and aeromedical evacuation summary, Medical Officer, Solomon Islands
- 12 Apr 2013, Dental review and radiographs, Dental Officer
- May 2013, Prosthodontic consultation, Prosthodontist
- Statement of Principles concerning Tooth Wear (Balance of Probabilities) No. 30 of 2026, Repatriation Medical Authority
- Statement of Principles concerning Tooth Wear (Reasonable Hypothesis) No. 29 of 2026, Repatriation Medical Authority
