DECISION NUMBER:

20220071

OBJECTING PARTY:

WORKER

REPRESENTED by:

WORKER REPRESENTATIVE

RESPONDENT:

EMPLOYER (NOT PARTICIPATING)

REPRESENTED by:

NONE

HEARING:

HEARING IN WRITING

HEARD by:

H. MOHAMED, APPEALS RESOLUTION OFFICER

DATED:

MAY 16, 2022

ISSUES

The worker representative, on behalf of the worker, objects to the Case Manager’s (CM) decision dated October 6, 2020, which denied initial entitlement to dental fractures.

BACKGROUND

On October 5, 2018, this now 53-year-old driver was pulling a tarp on a trailer when they fell approximately three feet and landed on an outstretched left hand. The worker sustained a comminuted left radial head fracture, a small coronoid fracture, and a lateral collateral ligament tear. The worker underwent surgical correction on October 11, 2018, and remained off work until November 14, 2018, when they returned to modified duties.

The worker contacted the CM on November 29, 2018, to advise that the week prior they had lost a piece of their tooth and questioned whether it could be related to the workplace injury. The worker was verbally advised to put a claim through their employer’s dental plan, as there was no information to support that the tooth injury was work related.

Two years later, the worker representative submitted a letter requesting entitlement to two broken teeth (tooth #11 and #22) under this claim. The representative provided a medical report to support this request.

In a decision dated October 6, 2020, the CM denied entitlement to the two teeth on the basis that it could not be established that the tooth injuries were related to the workplace accident. The worker representative has objected to this decision.

Accordingly, the only issue to be determined in this appeal is whether the worker has initial entitlement to dental injuries in this claim.

AUTHORITY

Operational Policy Manual

Published

11-01-01 Adjudicative Process

November 3, 2008

ANALYSIS

For the reasons that follow, I find there is insufficient evidence to support that the two broken teeth were caused by the workplace accident.

The worker representative (WR) submits that the worker fell from full height to the ground landing on their left upper extremity and face. The fact that the worker ended up fracturing their left elbow supports that the worker was unable to break the fall with their outstretched left arm and likely struck their face on the ground when they fell forward. As such, the WR believes that the broken teeth are likely compatible with the accident history under this claim. The WR submits that the worker’s dental injuries were not immediately addressed because the focus was on a severely injured left arm. The intense recovery program of the left arm consumed the worker’s attention for several weeks preventing the worker from going to the dentist for what appeared to be a minor issue at first. The WR points out that the worker did contact the CM a few weeks after the injury to report dental issues but the CM dismissed these concerns and directed the worker to contact their private insurance carrier. The worker eventually saw a dentist in December 2019 and a report was provided which indicated that the fractured teeth were caused by a fall at work. Finally, the WR points out that aside from the work-related injury, there was no other intervening incident or event that could have caused the worker to sustain tooth fractures. Accordingly, the WR submits that entitlement should be accepted.

The employer has chosen not to participate in the appeals process.

Policy 11-01-01 titled “Adjudicative Process” states that a five-point check system is used to adjudicate initial entitlement claims. Each point must be satisfied for initial entitlement to be allowed. There must be an employer, a worker, a personal work-related injury, proof of accident and compatibility of the diagnosis to the accident or disablement history. With respect to proof of accident, the policy asks the decision maker to consider the following:

• whether an accident situation exists;

• whether there are witnesses;

• whether there are discrepancies in the date of accident and the date the worker stopped working; and

• whether there is any delay in the onset of symptoms, or in seeking medical attention

It is important to understand that the four considerations listed above are not absolutes. Failure to meet one of the considerations does not result in failure to establish proof accident. The considerations should not be seen as a check list that must be met before entitlement to be considered. If there are reasonable explanations as to delays in seeking medical attention then proof of accident can still be said to be present. Therefore, a ruling on proof of accident requires careful consideration of the whole of the evidence relating to the happening of the accident, including the worker’s statement, evidence of continuity, the reporting to the employer and to the WSIB and the medical reports. Any delays should be carefully considered and the reasons for them weighed as to reasonableness.

According to the Employer’s Report of Injury, the worker slipped and fell off a catwalk and struck their left arm. There was no mention of any facial injuries. The Emergency Record (ER) dated October 5, 2018, documented the presenting complaint as “LT ARM/HEAD INJURY- FALL.” However, the attending physician (Dr. Khanna), documented that the worker fell on an outstretched hand sustaining a left wrist injury. More importantly, Dr. Khanna clearly documented that the worker had not sustained a head injury. As a result, no imaging studies or treatment of any head injury was prescribed or recommended. Instead, the worker was sent for an x-ray of the left upper extremity which revealed an elbow fracture.

Subsequent medical reports on file make no mention of any facial or head injuries. There is also no mention of any injury to the teeth.

The CM took a detailed statement from the worker on November 9, 2018, but there was no mention of head or facial injuries documented during this conversation. The worker was asked to complete and submit a Worker’s Report of Injury (Form 6). During a follow-up conversation on November 15, 2018, the worker said they had completed a Form 6 and submitted it by mail. Again, the worker made no mention of any facial or head injuries during this conversation. (I note the Form 6 was never received. The worker eventually completed another Form 6 on October 21, 2020, more than two years after the work accident, indicating that they had injured their head and teeth in the accident).

It was not until November 29, 2018, that the worker called to report that they had “lost a piece of (their) tooth last week” and questioned whether this should be put through WSIB or through their dental plan. The worker was told to go through their private dental plan as there was no information on file regarding any tooth injury caused by the work accident.

Despite reporting that they had lost a part of their tooth sometime in November 2018, the worker did not seek any medical attention regarding this tooth until December 23, 2019 – more than one year after the fact. The dentist report dated September 3, 2020, indicates the worker was seen on December 23, 2019 and reported they had fallen at work resulting in two broken teeth (tooth 11 and 22). The dentist recommended extracting both teeth and replacing them with a cast partial denture.

Having reviewed the case record, I find there is insufficient evidence to support that the two fractured teeth were caused by the workplace accident. None of the medical reports for up to one year post- accident make any mention of the worker sustaining any facial injuries as a result of the workplace accident. Any injury that might have resulted in two fractured teeth would have left significant facial injuries that would have been documented by the ER physician as well as the worker’s family physician. No facial or head injuries were reported to the employer or the WSIB in the days and weeks following the workplace injury. As such, I am not persuaded the worker sustained any facial injuries.

The WR submits that the dentist report corroborates that the worker had fractured their teeth due to a fall at work. Based on my review of the report, I find the dentist does not provide a specific opinion on causation but simply reiterates what the worker reported. While the worker said they lost a piece of their tooth on November 29, 2018, it is unclear whether this was related to tooth 11, tooth 22, or a different tooth altogether. Unfortunately, the dentist did not complete a detailed report outlining specifically which tooth the worker was referring to in November 2018. There is also insufficient information as to the nature of the fracture (split tooth, vertical root fracture, fractured cusp, craze line etc.) or any documentation regarding the overall state and health of the worker’s teeth prior to the workplace injury. According to medical literature, the most common causes of tooth fractures is grinding teeth, age over 50, biting hard on food, and trauma. The paucity of information makes it difficult to establish causality.

Additionally, there is a seven-week gap from the date of accident and when the worker said they lost a piece of their tooth. Assuming the worker struck their face, no medical explanation or opinion has been provided as to why it would take more than seven weeks post- trauma for a piece of tooth to fall out. I

also find the delay of over 14 months in seeking medical attention significant. According to medical literature, a fractured tooth that is significant enough to require extraction would be quite painful. It is difficult to accept the worker sustained two fractured teeth that did not produce any symptoms necessitating treatment or healthcare until more than 14 months after the fact. While I realize the worker’s primary focus post-accident was the elbow fracture, that might help explain a delay of 1-2 months not 14 months. Besides, the worker’s recovery post-surgery went well and the worker went back to work within a few months. As such, I do not accept the argument that the preoccupation with the left elbow injury was so significant that it either masked the pain from the tooth fractures or prevented the worker from seeking medical attention within a reasonable timeframe.

For all of these reasons, I find that proof of accident for dental injuries has not been established.

CONCLUSION

The worker does not have initial entitlement to dental injuries under this claim. The worker’s appeal is denied.

DATED May 16, 2022

Mr. H. Mohamed

Appeals Resolution Officer Appeals Services Division