SUMMARY
DECISION NO. 303/99
Health care (dental aid); Board Directives and Guidelines (health care) (dental aid) (abutment teeth).
The worker was struck in the face, suffering a cracked tooth and damage to a preexisting dental bridge. The worker appealed a decision of the Appeals Officer finding that the worker was entitled to a new upper denture but denying reimbursement for extraction of teeth.
The worker's dentist originally planned to replace the existing bridge but it was discovered that the teeth which had been used as the abutment teeth would not support the new bridge. As a result, the worker required a new upper denture which required extraction of additional teeth. Prior to the accident, the abutment teeth were stable. The accident caused the need for the denture which required the further extractions.
The worker was entitled to reimbursement for the extractions in accordance with Board policy which provides for dental service if the number of teeth requiring restoration is increased due to preexisting condition of the mouth. [6 pages]
DECIDED BY: Sajtos; Anderson; Young DATE: 24/03/99
ACT: WCA
APPEALS TRIBUNAL
DECISION NO. 303/99
[1] This appeal was heard in Windsor on February 11, 1999, by a Tribunal Panel consisting of :
E.J. Sajtos : Vice-Chair,
B.M. Young : Member representative of employers, J. Anderson : Member representative of workers. THE APPEAL PROCEEDINGS
[2] The worker appeals the decision of K. Boland, Appeals Officer, dated July 31, 1997, which was
further clarified in a letter dated January 8, 1998. That decision concluded that the worker was entitled to benefits for a complete immediate upper denture and realignment of the complete upper denture, but did not allow reimbursement for extraction of teeth that were unrelated to the compensable accident.
[3] The worker appeared and represented himself. The employer was notified and chose not to
attend, but did provide written submissions.
[4] On January 1, 1998, the Workplace Safety and Insurance Act (WSIA) took effect. This
legislation amends portions of the Workers’ Compensation Act (WCA), which continues to apply to the injuries that occurred before January 1, 1998. All references to “the Act” in this decision refer to the Workers’ Compensation Act as it read on December 31, 1997, unless otherwise stated.
[5] A change relevant to this appeal is that the Appeals Tribunal is required to apply Board policy in
accordance with sections 112 and 126 of the WSIA. The Tribunal previously considered Board policy although this was not specifically set out in the Act. In addition, the jurisdiction of the Appeals Tribunal is now described by section 123 of the WSIA, with necessary modifications.
THE EVIDENCE
[6] The Panel had before it as exhibits the Case Record and two Addenda prepared by the Tribunal
Counsel Office.
[7] The Panel also heard oral evidence from the worker. Submissions were made by the worker.
The employer provided written submission from its representative, M.C. Warren and Associates Inc.
THE ISSUES
[8] The Panel must determine whether the worker is entitled to benefits for the extraction of teeth.
Page: 2 Decision No. 303/99
THE REASONS
(i) Background
[9] There is no dispute concerning the following facts in this case which the Panel has relied on in
reaching its decision:
• The worker was employed as a warehouse helper on February 5, 1996, when he was struck in the face causing a cracked front tooth and damaged a pre-existing dental bridge.
• The worker’s dentist, Dr. Sacilotto, in a report of February 20, 1996, provided the Board with a treatment plan, which stated that two teeth needed extraction. The plan also stated “Treatment plan may be altered when bridge is removed as we don’t know what is under it”.
• On March 21, 1996, Dr. Sacilotto, wrote that teeth “#12 and 22 need extraction due to perio involvement. They will most likely come out when present bridge is removed. The bridge is ajar due to the blow to the mouth and loosened the porcelain and fractures on Buccal surfaces also.” In a report of May 6, 1996, the dentist indicated that the worker is a strong gagger and he may not be able to wear a full denture. Therefore a bridge would restore function and aesthetics without compromise.
• A Board dental consultant, Dr. Calzonetti, in a memorandum of March 29, 1996, stated that teeth 1.2 and 2.3 were “hopeless periodontaly prior to the accident” and a fixed bridge was denied due to the condition of the remaining teeth.
• The Board dentist, Dr. Anco, in a memorandum of April 22, 1997 stated:
In support of Dr. Calzonetti’s memo to replace the existing bridge after the necessary extractions, with a cast partial upper denture is reasonable due to the pre-accident condition of severe horizontal bone loss throughout the upper arch. However, if the IW and dentist opt for the fixed bridge, it appears eligible on a once only basis.
• In a report of June 2, 1997, Dr. Sacilotto, noted that there had been a change in the treatment plan because when the old bridge was removed the worker was not in a condition to proceed with the new bridge and a denture was the only alternative.
• The Board dentist, Dr. Anco, in a memorandum of June 13, 1997, noted the change of treatment plan requiring a complete upper denture with removal of all remaining teeth due to the pre-accident peridontal condition. He recommended allowance for a complete immediate upper denture and a reline in six months.
• Two dental bills from Dr. Paul George indicate that work was done on June 4 and July 4, 1997, in the amount of $285 and $159.
• The Appeals Officer in her decision of July 21, 1997, found that the costs associated with the worker’s claim were significantly enhanced due to his pre-existing periodontal problems, which were reported to have been evident for 15 years prior to the accident.
• In a memorandum dated August 25, 1997, it is noted that the worker claimed lost time for June 4, 5, and 6, July 4, 7, 8 and 11, 1997. The Board confirmed on September 19, 1997 that the employer was reimbursed for the days it paid the worker.
• Dr. Anco, from the Board, in a memorandum of September 11, 1997, stated that extraction of peridontally involved teeth which were not accident related; i.e., 17, 16, 23, 24, 24, 26 and 27 were the worker’s responsibility.
• In correspondence from the employer dated September 23, 1997, it is noted that the worker lost the following time from work: June 4, 5, 6 and July 7, 1997, which were paid by his employer as a “personal paid holiday”.
(ii) The worker’s testimony and party submissions
[10] The worker testified that the employer paid for four of his accident related lost time days out of
his holiday pay. He requested that he be reimbursed for this time lost time by way of compensation benefits.
[11] The worker stated that when he was injured, the dentist tried to fix his pre-existing bridge but due
to the condition of his teeth, he was forced to obtain a new denture plate instead. When the Board refused to pay for the removal of his teeth, he forwarded his receipts to his insurance company and was repaid for part of the services, but still requires payment for the extractions done on July 4, 1997, in the amount of $285.
[12] It was the worker’s position that he had been going to a peridontist regularly for 15 years and his
top teeth were not loose prior to the workplace accident. It was submitted that the Board’s denial of the claim did not make sense, as it is impossible to obtain a denture without first extracting ones teeth. Therefore, the worker submitted payment should be allowed for the extractions, as this work would not have been required but for the accident.
[13] The employer submitted that the worker had been paid for lost time from his sick credits and that
it was not within the Panel’s jurisdiction to deal with this issue. Rather, the worker should address payment of time off directly with his employer.
[14] It was further argued that due to the worker’s ongoing peridontal disease, he should be
responsible for payment for the extraction of teeth not covered by the claim. The employer felt that the worker’s dental health condition, as a result of the compensable injury and repairs, was now better than pre-injury and the costs of achieving this improvement should be borne by the worker.
(iii) Law and Policy
[15] The Board, in accordance with section 126 of the WSIA, provided the Panel with Board policy.
[16] In Operational Policy Manual, Document # 06-02-04, the Board provides the following
treatment fees, in the event of a workplace injury:
Dental entitlement is limited to the treatment of an oral injury or industrial disease which is directly related to a work related disability.
The Board’s responsibility is to restore, as nearly as possible, the health and chewing function existing prior to the compensable disability or onset of industrial disease.
Page: 4 Decision No. 303/99
When some of the worker’s teeth are damaged, but the number of teeth to be restored is increased due to the pre-existing condition of the mouth, the worker may receive dental service but this may complete the entitlement.
When some teeth are damaged and the remainder in the same arch show evidence of severe dental disease which existed prior to the accident, and the recommended treatment is extraction of all teeth, payment will be made only for the extraction of injured teeth. This may complete treatment.
(iv) The Panel’s reasons
[17] The worker has asked that he be reimbursed for four days of lost time in June and July 1997,
which were deducted from his personal holiday time by his employer. In the correspondence on file, the employer confirms that it did deduct four vacation days from the worker’s bank of accrued holiday time, in lieu of compensation benefits. The Board appears to have paid the employer directly for the payments, which were made to the worker in advance.
[18] The employer’s submissions, which were provided to the Panel in writing by a representative,
mistakenly state that the worker was paid from his sick day credits for the four days in question. However, based on direct information from the employer and the worker, the Panel has concluded that the deduction was made from holiday and not sick time benefits accrued.
[19] The Panel has determined that the payment for the four days in question is a labour relations
matter and should be appropriately determined in another forum. The worker may choose to proceed with this matter accordingly. However, the Panel has concluded that the four days of lost time were due to a compensable injury and this finding may be a factor in determining whether or not the worker was appropriately paid for his lost time from his accrued holiday time.
[20] Payment for the extraction of the worker’s teeth, which then allowed the placement of the upper
denture is the next consideration the Panel must make. It is noted that Board policy provides that it is the Board’s responsibility to restore, as nearly as possible, the worker’s health and chewing function, which existed prior to the compensable disability.
[21] It was the worker’s dentist’s original intention to replace his pre-existing fixed bridge. However,
when this procedure was attempted, it was discovered that teeth 12 and 22, which had been originally used as abutments for the existing bridge, would not support the new bridge. As a result, the worker required a upper denture, which meant that additional teeth had to be extracted. The Board denied allowance for the extractions, reasoning that the worker’s pre-existing periodontal state was such that the dentist was unable to repair the damage caused by the workplace injury.
[22] The Panel is unable to agree with the Appeals Officer’s decision. The worker testified that he
attended his peridontist regularly for 15 years and that his teeth were stable prior to the accident. It was the workplace accident which caused the need for the upper denture and this could only be provided if extractions were performed. Board policy specifically speaks to such an occurrence by acknowledging that if the number of teeth requiring restoration is increased due to the pre-existing condition of the mouth, the worker may receive dental service when a workplace accident occurs.
[23] Had the worker not been injured on the job, he would not have required the upper denture.
Neither the worker’s dentist, nor the Board physician’s indicate that the pre-existing periodontal condition required immediate treatment. But for the accident, the extractions would not have been required at that time. As the Panel has determined that the accident was a significant contributing factor for the extraction of the worker’s teeth, payment for this procedure is allowed.
THE DECISION
[24] The appeal is allowed in part. The worker is entitled to benefits for the teeth that were extracted
on July 4, 1997.
DATED: March 24, 1999
