Diagnostic Assessment — Tooth Loss
Example 1 of 1 · fictitious patient (Veteran DF)
Diagnostic Assessment
Tooth Loss
BOP Code: 30 of 2025 (Tooth Loss)
RH Code: 29 of 2025 (Tooth Loss)
ADF History
Veteran DF, date of birth 22 August 1978, Australian Army, Cavalry Scout (Armoured Corps), enlisted 13 January 1997, medically discharged 28 September 2018. Operational service: Iraq, 15 April 2005 to 30 October 2005 (warlike); Afghanistan, 01 February 2010 to 21 May 2010 (warlike, returned early after injury); Middle East Area of Operations, 08 January 2014 to 20 July 2014 (warlike).
Occupational History
As a cavalry scout the veteran crewed armoured reconnaissance vehicles for long periods, standing in the turret hatch on rough ground, and was exposed to blast, vehicle rollover and blunt facial impact against hatch rims, weapon mounts and sights. He also provided first aid to casualties and was exposed to blood and body fluids.
Deployed and field service involves long periods without access to a dentist, high consumption of sugared and energy drinks, dehydration, irregular oral hygiene and, in the service culture of the period, heavy smoking encouraged by cheap tobacco on deployment. These hazards are associated with dental trauma, dental caries, periodontal disease and tooth loss.
History
Veteran DF, a cavalry scout in the Australian Army, lost teeth 11, 12 and 21 with a fracture of the supporting alveolar bone when his face struck the turret hatch in an improvised explosive device blast in Afghanistan on 14 May 2010. He lost further teeth from caries, pulp and apical disease, periodontitis with abscess, pericoronitis and radiotherapy for a tonsillar cancer between 2011 and 2017, with the loss worsened by lack of dental care on deployment.
Timeline
- 07 Aug 2005 — On warlike service in Iraq the veteran sustained a needle-stick injury from a used cannula while giving first aid to a wounded local national. Baseline blood tests were collected but follow-up hepatitis C serology was not performed before his return to Australia. He was smoking about 25 cigarettes a day, having started heavy smoking on deployment. "needle-stick, first aid casualty"
- 18 Jun 2006 — During a peacetime field exercise the veteran fell from the hull of his vehicle and struck his face. The dental officer found an oblique crown fracture of the upper right lateral incisor, tooth 12, involving enamel and dentine without pulp exposure, and restored it with composite resin. "12 crown fracture, dentine involved"
- 02 Mar 2010 — On warlike service in Afghanistan the veteran reported toothache in the lower right first molar, tooth 46, worse with cold and sugary drinks. The medical officer at the forward operating base noted a large carious cavity. No dentist was available, a temporary dressing was placed and dental evacuation was declined on operational grounds. He was drinking four to six energy drinks a day on patrol. "46 carious, no dentist available"
- 14 May 2010 — An improvised explosive device struck the veteran's vehicle while he was standing in the turret hatch, and his face was thrown against the hatch rim. At the role 3 hospital the maxillofacial surgeon recorded avulsion of tooth 11, lateral luxation of tooth 21 with the crown displaced palatally, loss of the previously restored crown of tooth 12 at the gum line, and a fracture of the anterior maxillary alveolar segment. Tooth 21 was not salvageable and was extracted, and the retained root of 12 was removed. "11 avulsed, 21 luxated, alveolus fractured"
- 03 Feb 2011 — The dental officer found that the caries in tooth 46, untreated since March 2010, had progressed to pulp necrosis with a periapical radiolucency and an acute apical abscess. The tooth was unrestorable and was extracted. "46 necrotic, apical abscess, extracted"
- 12 Mar 2014 — On warlike service in the Middle East the veteran had a swollen gum and trismus around the partially erupted lower left third molar, tooth 38, and a painful swelling at the lower left first molar, tooth 36, which had 7 mm periodontal pockets on charting in 2012. With no dentist at his base for three weeks, the medical officer prescribed antibiotics. On 02 April 2014 a deployed dental officer diagnosed pericoronitis of 38 and decided to extract it, and diagnosed a periodontal abscess on 36 with severe bone loss and extracted both teeth. "38 pericoronitis, 36 periodontal abscess"
- 28 Aug 2015 — The veteran completed a course of radiotherapy, 66 Gy in 33 fractions, for squamous cell carcinoma of the right tonsil, diagnosed in May 2015. The radiation oncologist's plan placed the right mandibular molars, including tooth 47, within the high-dose field. He developed radiation-related dry mouth. "tonsil SCC, RT 66 Gy"
- 10 Nov 2017 — Hepatitis C, genotype 3, had been diagnosed in March 2016 and traced to the 2005 needle-stick injury. On 18 September 2017 a hepatologist commenced sofosbuvir-velpatasvir with ribavirin for 12 weeks. On 10 November 2017, during ribavirin treatment, the lower right second molar, tooth 47, fractured at the gum line from rampant radiation caries and was surgically extracted under antibiotic cover. "47 extracted, on ribavirin"
Symptoms
At onset the veteran had bleeding from the mouth, pain, swelling of the upper lip and gums, and loss of his upper front teeth, with difficulty eating and speaking. After onset he was fitted with an upper partial denture, and over the following years he had episodes of toothache, gum swelling, bad taste and pain on chewing as further teeth were lost.
He now has seven missing permanent teeth (11, 12, 21, 36, 38, 46 and 47), reduced chewing efficiency on both sides, an ill-fitting upper partial denture over a resorbed anterior ridge, dry mouth, and embarrassment about his appearance and speech.
Imaging
- 14 May 2010 — Orthopantomogram and maxillofacial CT, role 3 hospital: "Empty socket of tooth 11, palatally displaced tooth 21, root of 12 retained, and a fracture of the anterior maxillary alveolar process across the sockets of 11 and 21."
- 03 Feb 2011 — Periapical radiograph tooth 46: "Deep caries extending into the pulp chamber with a 5 mm periapical radiolucency at the mesial root."
- 02 Apr 2014 — Orthopantomogram: "Partially erupted, mesioangular tooth 38. Severe vertical bone loss around tooth 36 extending to the apical third of the roots."
- 10 Nov 2017 — Orthopantomogram: "Cervical radiation caries of tooth 47 with fracture of the crown at the gum line. No osteoradionecrosis."
Onset Date
The most likely date of onset of this condition is 14 May 2010.
At that date the veteran was on warlike service in Afghanistan as a cavalry scout, standing in the turret hatch of a reconnaissance vehicle when it struck an improvised explosive device. His face struck the hatch rim, and teeth 11, 12 and 21 were lost that day, by avulsion, luxation and loss of the restored crown, with a fracture of the supporting alveolar bone.
This date is appropriate because his pre-deployment dental examination of 11 January 2010 recorded a full permanent dentition apart from the restored tooth 12, and the loss was recorded by the maxillofacial surgeon on the day of the blast. It falls within his warlike service and within uninterrupted full-time service.
For tooth loss, the clinical onset for each affected tooth is the date that tooth was lost. Teeth 11, 12 and 21 were lost on 14 May 2010; the fracture of tooth 12 involving dentine (18 Jun 2006) and the alveolar fracture (14 May 2010) were present before that loss. Tooth 46 was lost on 03 Feb 2011 with caries and pulp and apical disease present. Teeth 36 and 38 were lost on 02 Apr 2014, with periodontitis, periodontal abscess and pericoronitis present at that time. Tooth 47 was lost on 10 Nov 2017; the 4 years before that loss run from 10 Nov 2013 to 10 Nov 2017 and contain the radiotherapy completed on 28 Aug 2015, and he was taking ribavirin from 18 Sep 2017 to 11 Dec 2017.
For the worsening factor, the condition worsened after onset with each further tooth lost between 03 Feb 2011 and 10 Nov 2017. Before that worsening, untreated caries in tooth 46 from 02 Mar 2010 and the untreated abscess on tooth 36 from 12 Mar 2014 to 02 Apr 2014 reflect an inability to obtain dental care on warlike service.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Tooth Loss (ICD-10-AM K08.1), loss of teeth 11, 12, 21, 36, 38, 46 and 47 of the permanent dentition, under the Statements of Principles concerning tooth loss, Balance of Probabilities No. 30 of 2025 and Reasonable Hypothesis No. 29 of 2025.
Tooth loss is the partial or complete permanent loss of a tooth of the natural secondary dentition, with or without a retained root, and includes loss by surgical extraction. Teeth are lost through trauma, which may avulse or luxate a tooth or fracture the tooth or its supporting alveolar bone, and through disease, chiefly dental caries progressing to pulp necrosis and apical infection, and periodontitis destroying the supporting bone. Radiotherapy to the jaws reduces saliva and blood supply and causes rampant caries, and inflammation around partially erupted third molars leads to their removal. Each lost tooth reduces chewing efficiency and allows the remaining teeth and alveolar bone to drift and resorb.
The condition began with the blast injury on warlike service in Afghanistan on 14 May 2010 and worsened with the loss of four further teeth between 2011 and 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 May 2010.
When did the veteran first present to a health / medical provider for this condition?
14 May 2010.
When was the condition confirmed / formally diagnosed?
14 May 2010.
When did the veteran first present to you (or your practice) for this condition?
26 August 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 clinical examination and imaging on 14 May 2010, when the maxillofacial surgeon recorded the avulsion of tooth 11, the luxation and extraction of tooth 21, the loss of the crown and removal of the root of tooth 12, and an anterior maxillary alveolar fracture, confirmed on orthopantomogram and CT. Each later loss was confirmed by a dental officer at the time of extraction, with radiographs showing the underlying cause: deep caries and periapical disease in 46, severe periodontal bone loss in 36, a partially erupted 38 with pericoronitis, and radiation caries in 47.
The teeth were permanent teeth and the losses were complete and permanent, meeting the Statement of Principles definition of tooth loss. Superficial enamel wear was excluded. A prosthodontist confirmed the seven missing teeth and the resorbed anterior ridge on examination in 2018.
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 14 May 2010, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2005, where the needle-stick injury and heavy smoking began, in Afghanistan in 2010, where the blast injury occurred and caries went untreated, and in the Middle East in 2014, where the periodontal abscess and pericoronitis arose without dental care. The Balance of Probabilities instrument applies to his peacetime service, including the 2006 exercise in which tooth 12 was fractured and his treatment in Australia from 2010 to 2017.
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 Tooth Loss, No. 30 of 2025
Causative factors
Factor 9(1): having dental caries in the affected tooth at the time of clinical onset; — MET
- Tooth 46 had a large carious cavity recorded on 02 March 2010, and on 03 February 2011, when it was extracted, the caries extended into the pulp chamber on the periapical radiograph. The caries developed during service, when the veteran's field diet included four to six energy drinks a day and access to routine dental care was limited, and was present at the clinical onset of the loss of tooth 46.
Factor 9(2): having periodontitis in the periodontium supporting the affected tooth at the time of clinical onset; — MET
- Periodontal charting in 2012 showed 7 mm pockets around tooth 36, and the orthopantomogram of 02 April 2014 showed severe vertical bone loss to the apical third of its roots, which is chronic periodontitis. The periodontitis followed heavy smoking of about 25 cigarettes a day that began during service, and was present when tooth 36 was extracted on 02 April 2014.
Factor 9(3): having periodontal abscess of the affected tooth at the time of clinical onset; — MET
- A deployed dental officer diagnosed a periodontal abscess on tooth 36 on 02 April 2014, three weeks after the swelling began on 12 March 2014, and extracted the tooth the same day because of the abscess and the bone loss beneath it.
Factor 9(4): having dental pulp and apical disease of the affected tooth at the time of clinical onset; — MET
- On 03 February 2011 tooth 46 showed pulp necrosis with a 5 mm periapical radiolucency and an acute apical abscess, which was present when the tooth was extracted that day. The pulp disease followed caries left untreated from March 2010 because no dentist was available on deployment.
Factor 9(5): having a fracture of the affected tooth where the fractures involves the dentine before clinical onset; — MET
- On 18 June 2006, during a peacetime field exercise, the veteran fell from the hull of his vehicle and fractured the crown of tooth 12 through the enamel and dentine, as recorded and restored by the dental officer. The fracture was present before the loss of tooth 12 on 14 May 2010, when the weakened restored crown was lost at the gum line in the blast.
Factor 9(6): having luxation of the affected tooth (partial or complete displacement of the tooth from its alveolar socket) at the time of clinical onset; — MET
- On 14 May 2010 the maxillofacial surgeon recorded lateral luxation of tooth 21, with the crown displaced palatally out of its socket, after the veteran's face struck the turret hatch rim. The tooth was not salvageable and was extracted the same day, so the luxation was present at the clinical onset of its loss.
Factor 9(7): having traumatic avulsion of the affected tooth (total displacement of the tooth out of its alveolar socket) at the time of clinical onset; — MET
- Tooth 11 was completely knocked out of its socket when the veteran's face struck the hatch rim on 14 May 2010, and the orthopantomogram showed an empty socket. The avulsion was the clinical onset of the loss of tooth 11.
Factor 9(8): having a fracture of the alveolar bone supporting the affected tooth before clinical onset; — MET
- The blast impact on 14 May 2010 fractured the anterior maxillary alveolar process across the sockets of teeth 11 and 21, shown on CT, and the fracture occurred before tooth 21 was extracted later that day and contributed to its being unsalvageable.
Factor 9(9): undergoing a course of radiotherapy for head or neck cancer, where the affected tooth was in the field of radiation, within the 4 years before clinical onset; — MET
- The veteran completed radiotherapy of 66 Gy in 33 fractions for squamous cell carcinoma of the right tonsil on 28 August 2015, with tooth 47 inside the high-dose field on the radiation oncologist's plan. Tooth 47 was lost on 10 November 2017, within the 4 years after radiotherapy, from rampant radiation caries. The tonsillar cancer is related to the heavy smoking that began and continued during his service.
Factor 9(10): having pericoronitis of the affected tooth at the time of the dental decision to extract the partially erupted tooth; — MET
- On 02 April 2014 the deployed dental officer diagnosed pericoronitis of the partially erupted lower left third molar, tooth 38, with gum swelling and trismus, and decided at that consultation to extract it. The pericoronitis was present at the time of that decision.
Factor 9(11): taking ribavirin at the time of clinical onset; — MET
- The veteran took ribavirin with sofosbuvir-velpatasvir from 18 September 2017 to 11 December 2017 for hepatitis C acquired from a needle-stick injury while giving first aid on service in 2005. He was taking ribavirin on 10 November 2017, when tooth 47 fractured and was extracted. Ribavirin causes dry mouth and gingival changes that compounded his radiation-related dry mouth.
Worsening factors
Factor 9(12): inability to obtain appropriate clinical management for tooth loss before clinical worsening. — MET
- Before the losses of 2011 and 2014 the veteran could not obtain dental treatment: caries in tooth 46 was found on 02 March 2010 at a forward operating base with no dentist and was left with a temporary dressing until it became unrestorable, and the abscess on tooth 36 went untreated for three weeks from 12 March 2014. Further teeth were lost as a result, worsening the condition. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Tooth Loss, No. 29 of 2025
Causative factors
Factor 9(1): having dental caries in the affected tooth at the time of clinical onset; — MET
- The caries in tooth 46 developed and was first recorded on warlike service in Afghanistan on 02 March 2010, while the veteran drank four to six energy drinks a day on patrol with no access to a dentist, and was present when the tooth was extracted on 03 February 2011.
Factor 9(2): having periodontitis in the periodontium supporting the affected tooth at the time of clinical onset; — MET
- The periodontitis around tooth 36 followed heavy smoking that began on warlike service in Iraq in 2005, and progressed on warlike service in the Middle East in 2014. It was present when tooth 36 was extracted on 02 April 2014.
Factor 9(3): having periodontal abscess of the affected tooth at the time of clinical onset; — MET
- The periodontal abscess on tooth 36 arose on warlike service in the Middle East on 12 March 2014 and was present when the tooth was extracted on 02 April 2014.
Factor 9(4): having dental pulp and apical disease of the affected tooth at the time of clinical onset; — MET
- The pulp necrosis and apical abscess in tooth 46 followed caries left untreated on warlike service in Afghanistan from March 2010, and were present when the tooth was extracted on 03 February 2011.
Factor 9(5): having a fracture of the affected tooth where the fractures involves the dentine before clinical onset; — MET
- The crown of tooth 12 had been fractured through the dentine on 18 June 2006, and the restored, weakened tooth was lost when the veteran's face struck the hatch rim in the blast on warlike service in Afghanistan on 14 May 2010.
Factor 9(6): having luxation of the affected tooth (partial or complete displacement of the tooth from its alveolar socket) at the time of clinical onset; — MET
- Tooth 21 was luxated in the improvised explosive device blast on warlike service in Afghanistan on 14 May 2010 and was extracted the same day.
Factor 9(7): having traumatic avulsion of the affected tooth (total displacement of the tooth out of its alveolar socket) at the time of clinical onset; — MET
- Tooth 11 was avulsed in the improvised explosive device blast on warlike service in Afghanistan on 14 May 2010.
Factor 9(8): having a fracture of the alveolar bone supporting the affected tooth before clinical onset; — MET
- The anterior maxillary alveolar fracture across the sockets of teeth 11 and 21 was sustained in the blast on warlike service in Afghanistan on 14 May 2010, before tooth 21 was extracted.
Factor 9(9): undergoing a course of radiotherapy for head or neck cancer, where the affected tooth was in the field of radiation, within the 4 years before clinical onset; — MET
- The tonsillar cancer treated with radiotherapy completed on 28 August 2015 is related to heavy smoking that began on warlike service in Iraq in 2005. Tooth 47 was in the high-dose field and was lost on 10 November 2017, within the 4 years from 10 November 2013 to 10 November 2017.
Factor 9(10): having pericoronitis of the affected tooth at the time of the dental decision to extract the partially erupted tooth; — MET
- Pericoronitis of the partially erupted tooth 38 arose on warlike service in the Middle East in March 2014, where poor oral hygiene in the field and limited water allowed food and bacteria to collect under the gum flap, and was present when the deployed dental officer decided to extract it on 02 April 2014.
Factor 9(11): taking ribavirin at the time of clinical onset; — MET
- Ribavirin was prescribed from 18 September 2017 for hepatitis C acquired from a needle-stick injury while giving first aid on warlike service in Iraq on 07 August 2005, and he was taking it when tooth 47 was lost on 10 November 2017.
Worsening factors
Factor 9(12): inability to obtain appropriate clinical management for tooth loss before clinical worsening. — MET
- On warlike service in Afghanistan in 2010 and in the Middle East in 2014 no dentist was available: the caries in tooth 46 was left with a temporary dressing from 02 March 2010, and the abscess on tooth 36 was managed with antibiotics alone for three weeks. Both teeth were subsequently lost, worsening the condition.
The % contribution of the causes is 100% and significant.
Sequelae
The tooth loss is a sequela of the veteran's accepted blast injury of 14 May 2010, including the alveolar fracture, and of his accepted tonsillar cancer and hepatitis C through their treatment. The resorption of the anterior alveolar ridge and the reduced chewing efficiency are in turn sequelae of the tooth loss.
Unintended Consequence
Met. The loss of tooth 47 is an unintended consequence of the radiotherapy for the accepted tonsillar cancer, and the dry mouth that hastened it was compounded by ribavirin prescribed for hepatitis C acquired on service. Both treatments were provided 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. On warlike service in Afghanistan from March 2010 the veteran's carious tooth 46 could only be dressed temporarily because no dentist was available and dental evacuation was declined on operational grounds, and the tooth progressed to pulp necrosis and was lost on 03 February 2011. On warlike service in the Middle East the periodontal abscess on tooth 36 went untreated for three weeks from 12 March 2014 before the tooth was extracted. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent timely dental treatment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 07 Aug 2005, Field medical record, needle-stick injury, Medical Officer, Iraq
- 18 Jun 2006, Dental record, Dental Officer
- 11 Jan 2010, Pre-deployment dental examination, Dental Officer
- 02 Mar 2010, Field medical record, Medical Officer, Afghanistan
- 14 May 2010, Maxillofacial assessment, orthopantomogram and CT, Role 3 hospital
- 03 Feb 2011, Dental record and periapical radiograph, Dental Officer
- 02 Apr 2014, Dental record and orthopantomogram, Deployed Dental Officer, Middle East Area of Operations
- 28 Aug 2015, Radiotherapy completion summary, Radiation oncologist
- 18 Sep 2017, Hepatology consultation, Hepatologist
- 10 Nov 2017, Oral surgery record and orthopantomogram, Oral surgeon
- Statement of Principles concerning Tooth Loss (Balance of Probabilities) No. 30 of 2025, Repatriation Medical Authority
- Statement of Principles concerning Tooth Loss (Reasonable Hypothesis) No. 29 of 2025, Repatriation Medical Authority
