Lee v Insurance Australia Limited t/as NRMA Insurance
[2023] NSWPICMP 339
•19 July 2023
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Lee v Insurance Australia Limited t/as NRMA Insurance [2023] NSWPICMP 339 |
| CLAIMANT: | Hyeok Ja Lee |
INSURER: | Insurance Australia Ltd t/as NRMA |
| REVIEW Panel | |
| PRINCIPAL MEMBER: | John Harris |
| MEDICAL ASSESSOR: | Shane Moloney |
MEDICAL ASSESSOR: | David Sykes |
| DATE OF DECISION: | 19 July 2023 |
| CATCHWORDS: | MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; pedestrian injury on 24 June 2017 falling to the ground; issue of permanent impairment of mastication, original medical assessor found no restriction in diet with no assessable impairment; claimant accepted that she did not notice teeth pain until approximately two months post-accident; teeth pain should have been noticed when eating if injured despite claimant suffering lumbar fracture; finding that tenderness at tooth 24 likely due to pre-existing condition; claimant’s diet not limited to soft or semi-solid foods; Panel not satisfied of any permanent impairment due to mastication; Held – original assessment confirmed. |
| DETERMINATIONS MADE: | PERMANENT IMPAIRMENT WHETHER THE DEGREE OF permanent impairment OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10%. THE ASSESSMENT MADE BY THE REVIEW PANEL UNDER S 63(4) IS AS FOLLOWS: The Panel confirms the certificate of Medical Assessor Nicholls dated 26 August 2022. . |
REASONS
BACKGROUND
Ms Lee (the claimant) was involved in a motor accident on 24 June 2017. Ms Lee was walking across a street when she was struck by the insured vehicle.[1]
[1] Claimant’s bundle, p 22.
The insurer is liable to pay Ms Lee any damages under the Motor Accidents Compensation Act 1999 (the MAC Act).
Section 57 of the MAC Act defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Section 58 of the MAC Act provides that a disagreement between a claimant and an insurer on three distinct matters is referred to as “medical assessment matters”. A medical assessment matter includes “whether the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident is greater than 10%”.
Section 60 of the MAC Act provides that either party may refer a medical dispute to the President who is to arrange for the dispute to be referred to one or more Medical Assessors.
A medical assessment matter is determined in accordance with Part 3.4 of the MAC Act. This means that the matter is determined at first instance by a Medical Assessor[2] and, pursuant to s 63 of the MAC Act, on review by a review panel.
[2] Section 60 of the MAC Act.
The medical dispute before the Panel is the assessment of permanent impairment of mastication by reason of injury caused by the motor accident to four teeth. The claimant has otherwise been assessed at 10% impairment for the injury to the lumbar spine.
MEDICAL ASSESSMENT
Medical Assessor Nichols issued a Medical Assessment Certificate dated 20 August 2022 (the Medical Assessment).[3]
[3] Claimant’s bundle, p 6.
The Medical Assessor noted there was no pre-accident dental records, and it was likely the subject teeth were not normal, suffering from vertical fracture from para functional bruxing. The claimant had lost the lower first and second molars and tooth 35 many years previously, causing her to posture her mandible forward to eat and brux.
The Medical Assessor opined that there were no restrictions to mastication or diet albeit that the claimant could not bite on the front teeth due to pain. On examination the Medical Assessor noted that teeth 21, 22, 23 and 24 had been expertly restored and showed vertical internal fractures (bruxing) which were not horizontal. The incisal edges were worn from parafunctional bruxing.
The Medical Assessor noted there was no mention of the teeth in the hospital report although Dr Tateossian had examined the claimant on 11 September 2017 and noted that teeth 21, 22, 23 and 24 were chipped and broken on the incisal tips and corners.
The Medical Assessor accepted that the motor accident caused minor fractures to teeth 21, 22, 23 and 24 and that tooth 22 was non vital. He found that there was no masticatory dysfunction and no dietary restriction and assessed permanent impairment at 0%.
THE REVIEW
The application for referral of the medical assessment to a review panel were made by the claimant within 28 days after the parties were issued with the certificate for the medical assessment for which the review is sought.[4]
[4] Section 63(7) of the MAC Act.
The President’s delegate referred the medical assessments to the Review Panel (the Panel) as they were satisfied that there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application.[5]
[5] Section 63(2B) of the MAC Act.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.[6]
[6] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application.[7]
[7] Rule 128 of the PIC Rules.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.[8]
[8] Section 63(3A) of the MAC Act.
The Panel issued a direction to the parties requesting a provision of respective bundles.
STATUTORY PROVISIONS/GUIDELINES
Section 44(1)(c) of the MAC Act provides that the Authority may issue guidelines with respect to the assessment of the degree of permanent impairment of an injured person as a result of an injury caused by a motor accident.
The Motor Accident Permanent Impairment Guidelines (the Guidelines) were issued pursuant to s 44(1)(c) for the assessment of permanent impairment. The Guidelines adopt the fourth edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA 4). Where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.[9]
[9] Clause 1.2 of the Guidelines.
Clauses 1.5-1.7 of the Guidelines relate to the assessment of permanent impairment and provide:
“1.5 An assessment of the degree of permanent impairment is a medical assessment matter under Section 58 (1)(d) of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person’s impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or claims assessor) in considering such issues.
1.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
‘Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.’
This, therefore, involves a medical decision and a non-medical informed judgement.
1.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question ‘Would this injury (or impairment) have occurred if not for the accident?’ may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
The provisions of the Civil Liability Act 2002 (the CL Act) apply to the MAC Act in determining issues of causation. Particularly ss 5D and 5E of the CL Act apply to the MAC Act.[10] In Raina v CIC Allianz Insurance Ltd[11] Campbell J stated:
“One may accept that a review panel is engaged in a process of dispute resolution by expert assessment of medical issues arising under the Act. However, the questions arise in a legal context and it is incumbent upon the panel, medical practitioners they may be, to correctly apply the law including the law of causation in the exercise of their powers. This includes the provisions of Division 3 of Part 1A of the Civil Liability Act 2002(NSW), ss5D and 5E: see s 3B(2)(a) of that Act. Although it may be expected that questions about the appropriate scope of liability will arise but rarely.”
[10] See s 3B(2) of the CL Act.
[11] [2021] NSWSC 13 (Raina) at [65].
MATERIAL BEFORE THE REVIEW PANEL
The parties filed bundles of documents for the Panel’s consideration.
Pre-accident records
There are no pre-accident dental records.
Initial medical treatment following the motor accident
The ambulance notes for the motor accident referred to head and spinal injuries.[12]
[12] Claimant’s bundle, p 18.
The police report refers to the claimant stepping off the footpath into the side of a passing motor vehicle being knocked over and falling onto the roadway.[13]
[13] Insurer’s bundle, p 13.
Ms Lee was admitted to Katoomba Hospital reporting the motor accident which caused the claimant to fall backwards onto her back/legs and with head strike. A CT scan of the lumbar spine identified a fracture at L5 with no spinal cord or nerve impingement.[14]
[14] Claimant’s bundle, p 23.
The emergency department assessment noted the claimant had lower back pain and a haematoma on the back of the head.[15]
[15] Insurer’s bundle, p 166.
The clinical notes of the general practitioner dated 29 June 2017 refer to low back injury.[16] The first clinical note of the general practitioner referring to the teeth is dated 1 December 2017.[17] A medical certificate was completed at that time.
[16] Insurer’s bundle, p 194.
[17] Insurer’s bundle, p 199.
Dr Tateossian provided a report noting that he had seen the claimant on 11 September 2017 when he treated the claimant for a bridge from teeth 13 to 15.[18] At that time the doctor noted that teeth 21, 22, 23 and 24 were chipped and broken on the incisal tips and corners. Restoration work was to be undertaken at another time.
[18] Claimant’s bundle, p 61.
The doctor stated that restoration of teeth 21, 22, 23, and 24 was undertaken on 16 November 2017 when there was no indication of further damage to the nerves. The doctor noted that the teeth required monitoring on a regular basis to ascertain if any of the chips showed signs of deep idolisation which may be caused by the trauma noting that trauma causes disruption of the blood supply to the tooth which can cause its death requiring root canal treatment and possibly crowns.
A medical certificate dated 1 December 2017 referred to the motor accident causing injuries to the low back (L5 fracture), depression, haematoma in the cervical region and dental injury.[19]
[19] Claimant’s bundle, p 17.
Dr Bill Kim provided a report dated 11 October 2021.[20] The doctor noted a history that the claimant was struck by a car as a pedestrian in June 2017 and since then had complained of symptoms such as pain and difficulty with chewing in the front teeth. The doctor noted that there was a lack of posterior support so most of her main mastication is done on the front teeth.
[20] Claimant’s bundle, p 16.
The doctor noted a superficial crack on tooth 21 running from the incisal tip of the tooth to the subgingival line, darkening of tooth shade noted on tooth 22 which indicated necrotic pulp, nonvital nerve on tooth 22 confirmed with vitality testing and vertical crack on tooth 24 on the distal marginal ridge. Dr Kim noted that the condition of the claimant’s teeth was consistent with the injury that occurred on 24 June 2017 and that the conditions had deteriorated since that time.
In his clinical notes the doctor noted “symptoms such as pain and difficulty with chewing on front teeth” which were “getting weaker by the day experiencing increased tenderness when pressure is applied on upper teeth”.[21]
[21] Insurer’s bundle, p 294.
Qualified opinions
Mr Michael Griffiths, bio-mechanical engineer provided a report dated 3 March 2022.[22] After analysing the description of the motor accident, Mr Griffiths also provided an opinion based on a summary of the contemporaneous records. He stated:[23]
“Based on the lack of contemporaneous reporting any dental trauma and taking account that the impact was reported to be on the left rear region, it is deduced that there does not appear to be a valid causal link between the chipped teeth and the incident under review here.”
[22] Insurer’s bundle, p 105.
[23] Insurer’s bundle, p 136.
Statement
The claimant provided a statement dated 14 November 2022.[24] The claimant stated:
“In paragraph 12 Assessor Nichols notes ‘she has no restrictions to mastication or diet how she can’t bite on her front teeth due to pain.’ This is contrary to what we discussed when he examined me and I specifically told him that I can’t enjoy the same diet I had prior to the motor accident because due to the full cracked teeth and pain I cannot masticate any hard foodstuffs including meat, dried foods and hard fruit. As I have a few missing molars I am completely reliant on my front and canine teeth when I eat. Therefore discomfort in front teeth greatly affect chewing.”
[24] Claimant’s bundle, p 4.
The claimant stated that she had in fact returned to see Dr Kim but could not afford the cost of the treatment which was in the order of $6,650.
Other medical assessments
Medical Assessor Nichols issued a prior certificate dated 31 January 2020.[25] The Medical Assessor held that the motor accident caused injury to the teeth number 21, 22, 23 and 24 but that it had no impact on mastication or deglutition. The Medical Assessor held that the subject teeth showed vertical internal fractures which had been successfully restored.
[25] Insurer’s bundle, p 75.
Medical Assessor Cameron issued a certificate dated 17 March 2020 when he assessed the lumbar spine impairment at 10%.[26] He otherwise found the claimant suffered a soft tissue head injury which had resolved.
[26] Claimant’s bundle, p 78.
Medical Assessor Home issued a certificate dated 25 October 2022. The Medical Assessor again assessed the lumbar spine impairment at 10%.[27] The Medical Assessor issued a combined certificate dated 31 October 2022 assessing the overall impairment at 13% due to the combination of the lumbar spine assessment and facial and right hip leg scarring assessed by Medical Assessor Curtin on 3 September 2022.[28]
[27] Claimant’s bundle, p 84.
[28] Claimant’s bundle, p 93.
SUBMISSIONS
Claimant’s submissions dated 15 November 2022[29]
[29] Claimant’s bundle, p 2.
These submissions sought a review of the Medical Assessment.
The claimant submitted that the Medical Assessor found that the claimant suffered injury to four teeth caused by the motor accident. It was noted that teeth 21, 22 and 24 required repair which included full coverage crowns for three of the teeth.
The claimant noted that, pursuant to clause 1.195 of the Guidelines, damage to teeth can only be assessed where there is permanent impact on mastication and deglutition. Further clause 1.197 amends the assessment of impairment of mastication for the first category to a range of between 0 to 19%.
The claimant disputed the history recorded by Medical Assessor Nicholls concerning the history recorded of her diet restrictions.
Insurer’s submissions dated 12 May 2022[30]
[30] Insurer’s bundle, p 4.
The insurer noted that the claim was originally managed by GIO when the claimant was assessed by Medical Assessor Nicholls and Medical Assessor Cameron. In relation to the teeth injury the insurer noted the reports of Dr Tateossian and Dr Kim.
The insurer referred to the opinion of Dr Robert Mitchell dated 9 December 2021 and the report of Mr Michael Griffiths dated 3 March 2022.
Mr Griffiths concluded that based on the lack of contemporaneous reporting of any dental trauma and that the impact was to the head at the left rear region, there was not a valid causal link between the chipped teeth in the motor accident.
The insurer submitted that it was evident that there was no impact to the jaw or mouth area in the motor accident and a lack of contemporaneous reporting of any dental trauma and submitted that the dental injuries were not causally related to the motor accident.
Insurer’s submissions dated 5 December 2022[31]
[31] Insurer’s bundle, p 2.
These submissions were filed opposing the application to review the medical assessment submitting that in order to meet the first category under AMA 4, diet must be limited to semisolid or soft foods. The claimant’s reported limitation was that she was able to eat solid food and therefore did not satisfy the criteria for the first category.
The insurer otherwise submitted that the Medical Assessor was experienced and would have probably recorded the examination findings. Even if the teeth had not been restored, this did not impact on the question of mastication.
RE-EXAMINATION
The claimant was examined by Medical Assessor Sykes on behalf of the Panel. The examination report is as follows:
“Ms Lee was examined by Medical Assessor Sykes on 12 July 2023 and attended alone. Dr Sykes explained the purpose of the re-assessment and advised that he was not able to provide any clinical advice. The examination report is as follows:
HISTORY
Ms Lee reported that she was a pedestrian on a quiet street in Katoomba on 24 July, 2017 with a friend behind her. A car approached and turned to avoid the friend but apparently did not see her. The car hit Ms Lee and knocked her into the air. Ms Lee landed on the ground on her left side hitting her face and back of head. Ms Lee could not get off the ground. An ambulance was called and the officers lifted her off the ground onto a stretcher and took her to Katoomba hospital.
X-rays were taken at the hospital and a CT found a compression fracture in the lumbar spine. Ms Lee stayed in hospital for 3-4 days. She had not noticed any problem with her teeth at this stage.
Ms Lee reported that she was in much back pain after the accident and did not really notice any problem with her teeth until, perhaps, September, 2017 (2 months post-accident). She attended her usual dentist, Dr John Tateossian, in September who noticed four cracked teeth.
Ms Lee reported that she was beginning to experience pain on the upper right and upper left area. She is aware that Dr Tateossian has reported that he successfully restored these teeth but Ms Lee believes an upper front incisor remains cracked and has not been restored. She attended Dr Bill Kim in 2021 as it was easier to get to his surgery. Dr Kim pointed out that the upper left incisor had not been restored and that there were other cracked fillings on the upper left. She agreed that Dr Kim had only seen her after some 4 years after the accident. Dr Kim has not carried out any treatment to date.
Ms Lee advised that she was having some biting tenderness on a tooth on the upper left and indicated the upper left first premolar. This is an intermittent problem and occurs especially when she is tired or forgets to brush her teeth. However, she is afraid to bite on this side as a result. She feels she has to bite on her front teeth as she has missing back teeth. Thus, she self-restricts her diet to reduce pressure on these front teeth. She cuts food up small but she can eat meat if she does. She can eat well-cooked vegetables, boiled chicken, bananas, and mangoes. This history was somewhat different from that recorded by Assessor Nichols in that she did not assert that a dietary change has occurred since the accident other than that she had self-regulated in order to reduce the pressure on her front teeth.
Ms Lee does not experience any jaw joint noises. She has been to a dentist to have her jaw joints checked and was told that that they were good. She is not aware of a tooth grinding (bruxing) habit.
EXAMINATION
TOOTH NUMBERING
The FDI tooth numbering system is used throughout this report. An explanation of the system is provided below:
A two digit system is used to identify individual teeth. The first number refers to the quadrant and second number refers to the actual tooth. The quadrants are numbered this way:
Upper Right (Quadrant 1) Upper Left (Quadrant 2)
[image unable to render]
Lower Right (Quadrant 4) Lower Left (Quadrant 3)
Each individual tooth is numbered from the midline back. In explanation: Tooth 26 (pronounced two six) refers to the upper left (quadrant 2), sixth tooth from the midline. Tooth 43 (pronounced four three) refers to the lower right quadrant (quadrant 4), third tooth from the midline.
Extra-oral examination revealed no jaw joint noises or masticatory muscle tenderness. Maximum jaw opening was measured at the incisors as 51mm (normal range 40-45mm).
Intra-oral examination revealed some xerostomia (low saliva volume). The oral hygiene was only fair with plaque retention and gingival inflammation around the lower incisors and tooth 38. There was periodontal pocketing of 1-3mm pocketing generally but 5mm on the mesial of tooth 38. Subgingival calculus was present at tooth 38 and all upper molars. These findings indicated the presence of chronic, localised, moderate periodontal disease. This condition is not accident related.
There was a Class I occlusal relationship with a compromised tooth alignment. Teeth 18/48 were in crossbite and tooth 26 overupted. Teeth 18, 14, 28, 37, 36, 35, 46 and 47 were missing. There was a dental bridge between teeth 15-13 made by Dr Tateossian. There was a large amalgam restoration in tooth 26 but, otherwise, mostly small restorations in the other teeth. There was a small composite resin restoration on the distal of tooth 23 with a leaking margin and a mesio-occlusal composite resin restoration in tooth 24, also with a leaking margin. This tooth also exhibited an, apparently, minor hairline crack on the distal marginal ridge but also a clear functional wear facet on the palatal cusp.
The leaking restoration margins should not really be described as cracks and are NOT, in my view, accident related.
The functional (chewing) contacts were limited to teeth 15-24 and their lower opposing teeth due to the missing molar teeth. The missing teeth pre-existed the subject accident. Such a span of functional contacts is termed a shortened dental arch and is recognised as being a number of functioning teeth that can be sufficient for adequate chewing function in the long term.
Tooth 21 exhibited a hairline crack in the mid-buccal region aligning with a very small enamel chip on the mid-incisal edge (see attached photograph). This tooth has not been restored. Tooth 22 was mildly discoloured and exhibited a composite restoration in the cingulum area.
Pulp testing of all the upper front teeth was inconclusive in that only tooth 24 reacted to the cold stimulation.
A peri-apical x-ray was taken of teeth 11, 21, 22 which did not show any apical pathology (signs of an abscess).
DIAGNOSIS
There is a localised chronic periodontal disease condition and partial edentulism (missing teeth) that are not accident related. There are failing composite restorations at teeth 23, 24 which also are not accident related and are not ‘trauma-induced cracks’.
Tooth 24 has a moderate restoration and a minor hairline crack on the distal marginal ridge with a significant functional wear facet on the palatal cusp. The tooth may well exhibit a mesio-distal crack under the restoration which would be a very common finding in such a tooth in Ms Lee’s age group caused by years of normal function and weakening of the tooth due to the restoration. It is highly likely, if the crack is present as I suspect that it is, to be the cause of her tenderness on biting on this tooth. There is no evidence that such a crack was caused by the subject accident other than a report from Dr Tateossian suggesting that he noted chips and broken corners on teeth 21, 22, 23, 24 which were restored at a later time.
There is no evidence of any pathology or nerve death in any of teeth 11, 21.
REASONS
The review is a new assessment of all matters with which the medical assessment is concerned. Our role is not to correct error in the decision of the Medical Assessor. The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: Insurance Australia Group Ltd v Keen[32] and Insurance Australia Ltd v Marsh.[33]
[32] [2021] NSWCA 287 at [40], [41] and [45].
[33] [2022] NSWCA 31 at [11], [21], [64].
The Panel adopts the examination report of Medical Assessor Sykes and adds the following reasons.
We do not have Dr Tateossian’s clinical notes showing the state of the claimant’s teeth prior to the motor accident. We have the doctor’s report which then noted that teeth 21, 22, 23, 24 were chipped and broken on the incisal tips and corners.
Medical Assessor Sykes could not see any such chips or where exactly they have been restored except at tooth 21 on the incisal edge. That tooth has not been restored.
The claimant candidly admitted to Medical Assessor Sykes that she did not notice teeth pain at hospital and did not notice any pain in the teeth until approximately two months after the motor accident. Accordingly, there is not only an absence of contemporaneous complaint, but an absence of symptoms noted by the claimant. Whilst the claimant had significant back pain, teeth pain should have been noted especially when either eating or drinking if the motor accident had caused significant teeth injury.
The tenderness on biting at tooth 24 is likely to be a crack under the present filling which was created by function over the years on this tooth and the weakening of the tooth created by the pre-existing filling.
The crack in tooth 21 is very superficial and quite likely was present before the motor accident. Such a crack is very common from normal wear and tear.
The contemporaneous clinical notes otherwise do not support injury to the left upper region of the mouth.
The review is restricted to an assessment of permanent impairment of the teeth. Ms Lee, by consistent report to various clinicians, is not limited to soft or semisolid foods and self-restricts by cutting her food up small.
The claimant reported to Medical Assessor Sykes that her pain was intermittent and seemed to be restricted to the area of tooth 24. That sensitivity is probably due to a crack under the existing filling that is not motor accident related. The crack can only be investigated by removal of the filling.
Whilst there is a pre-existing masticatory change due to the missing back teeth, we are not satisfied that the claimant’s diet is restricted to soft or semi-solid foods that is caused by the accident and which requires an assessable impairment. We are of the opinion that the permanent impairment under 9.3b, Table 6 of AMA 4 is 0%.
These findings are different from that opined by Dr Kim who based his opinion in part on a complaint of contemporaneous symptoms. We have explained why we have differed from his conclusion based on the clinical findings of Medical Assessor Sykes and the history obtained from the claimant.
We otherwise do not consider the opinion of Mr Griffiths, the bio-mechanical engineer qualified by the insurer, of any assistance in determining the extent of any teeth injury as he is providing an opinion outside his area of expertise.
CONCLUSION
The Medical Assessment Certificate dated 26 August 2022 is confirmed.
Attachments
Periapical x-ray of teeth 11, 21, 22 showing no pathology or sign of nerve death.
[image unble to render]
Photo of upper front teeth showing superficial crack at tooth 21 and minor enamel chip on incisal edge
[image unble to render]
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