CAUSATION – PRE-EXISTING CONDITION. Substantial evidence, including expert medical opinion, supports the compensation judge’s finding that the employee’s work injury was a substantial contributing factor to the employee’s dental condition as it accelerated the need for treatment.
MEDICAL TREATMENT & EXPENSE – REASONABLE & NECESSARY. Substantial evidence, including expert medical opinion, supports the compensation judge’s finding that the proposed treatment plan of implants with dentures for the employee’s dental condition was reasonable and necessary given the employee’s pre-existing condition and the accelerated need for treatment.
MAXIMUM MEDICAL IMPROVEMENT – MULTIPLE CONDITIONS. Where the employee had reached MMI for the work-related orthopedic injuries but had not completed treatment for the work-related dental injury, substantial evidence supports the compensation judge’s finding that the employee had not reached MMI for all work-related injuries.
REHABILITATION – ELIGIBILITY; RULES CONSTRUED – MINN. R. 5220.0100, SUBP. 22. An employee who does not meet the requirements under the definition of a qualified employee for rehabilitation services in Minn. R. 5220.0100, subp. 22, is not entitled to an award of medical management services.
Compensation Judge: Stacy P. Bouman
Attorneys: Vincent Peterson, Law Office of Donald F. Noack, Jr., Mound, Minnesota, for the Respondent. Christine L. Tuft and Susan E. Larson, Arthur, Chapman, Kettering, Smetak & Pikala, P.A., Minneapolis, Minnesota, for the Appellants.
Affirmed in part, modified in part, and reversed in part.
KATHRYN H. CARLSON, Judge
The employer and insurer appeal the compensation judge’s award of dental treatment and vocational rehabilitation benefits to the employee. We affirm in part, modify in part, and reverse in part.
Carlos Alberto Machado-Rivera, the employee, began working for Installed Building Products, the employer, as an insulation installer in 2014. To perform his work, the employee would stand on stilts that could bring him to a height of over 10 feet. He worked full time, but his hours would vary, with summer being his busy season. On September 1, 2020, the employee was on stilts installing plastic over insulation, when he slipped on a cement floor. He fell and hit the floor, striking his chin and mouth. He thought he had lost consciousness, but recalled having spit blood and that he had lost some teeth. He also had pain in his neck and his left arm.
The employee was taken to the Rogers Urgent Care on the date of injury.[1] He reported dizziness, mild headache, back pain, leg pain, pain in his mouth, a loose tooth, and that his dental retainer had broken in the fall. A CT scan of his lumbar spine did not show acute fracture. He began treating with a chiropractor on September 2, 2020, and was taken off work.
On September 11, 2020, the employee was seen by Dr. William Leon at Inka Dental. At that visit, Dr. Leon assessed the employee as having advanced periodontitis and missing teeth numbered 4, 5, 7, 8, 15, 18, 19, 20, 21, 23, 24, 29, 30, and 31. He had severe mobility of teeth 1/31 and 3/28 on the left side of his mouth. A CT scan showed a fracture of the alveolar bone.[2] Dr. Leon stabilized some of the teeth (specific teeth unknown) and recommended surgical intervention that included a bone graft of the mandible and maxilla, followed by dental implants. Dr. Leon then wrote a treatment plan outlining the phases of dental treatment that he was recommending, which included stabilization, surgical, and prosthetic phases. The plan provided for a total of 24 new implants, 12 upper and 12 lower, to restore the minimum area for a good function of mastication. (Ex. 20.)
The employee had been previously seen by Dr. Leon on March 4, 2020, prior to the work injury. At that visit, the employee was diagnosed with advanced periodontitis, cavities at teeth numbered 1, 16, 17, and 32, and missing teeth numbered 4, 5, 7, 8, 9, 15, 18, 19, 20, 21, 24, 25, 29, 30, and 31.[3] At that time, Dr. Leon was recommending treatment options including 1) extraction of all teeth and dentures, 2) extraction and periodontal treatment with composited and upper dentures, or 3) four implants with overdentures. The employee opted for the second option but did not pursue further treatment at that time due to limited insurance coverage. (Ex. 20.)
On September 21, 2020, Dr. Leon extracted teeth numbered 2, 3, and 15[4] and noted again that the employee had severe bone loss and precarious, poor periodontal condition. On October 3, 2020, the employee underwent a bone graft procedure of the maxilla and mandible for the purpose of having sufficient bone to secure the posts for the next phase of treatment. After that procedure, a representative for the insurer called the office of Dr. Leon and advised that all treatment should be halted.
The employer and insurer requested a peer review by Dr. Todd Wiener, who wrote a report dated December 10, 2020. Dr. Wiener viewed the employee’s x-rays and noted a mandibular alveolar fracture on the left side. After reviewing the employee’s dental records, Dr. Wiener opined that the employee was a candidate for full mouth extraction prior to the work injury as all teeth showed marked bone loss to the point where the teeth were not savable, that the treatment recommended by Dr. Leon was not appropriate due to the employee’s poor dental history, and that any dental treatment would not be related to the work injury given his pre-existing dental condition. As a result of that opinion, the employer and insurer denied all additional dental treatment. At the time of the hearing, the employee had already had the bone graft, all but a few teeth had been removed, and posts were implanted into the bone for eventual placement of 24 implants.
Dr. Nelson Rhodus prepared three record review reports at the request of the employer and insurer. Dr. Rhodus was also deposed and his testimony was admitted into evidence at the hearing. Dr. Rhodus opined that there was no evidence that the employee’s dental condition was worse following the work injury. The findings on films and diagnosis before and after the injury, he opined, were the same, as was the treatment plan. He noted that if there had been significant injury to the mouth as a result of the injury, that he would have expected the emergency room records from the date of injury to show more than a loose tooth, perhaps bruising, swelling, cuts, or an emergent need for dental treatment. Instead, the employee waited 10 days to receive dental treatment. Dr. Rhodus conceded that the work injury could have exacerbated the employee’s pre-existing dental condition. He noted that it was conceivable that a fall that resulted in the employee’s retainer being broken could also cause damage to existing teeth, such as additional or worsened loose teeth, and to his gums. He agreed that when a patient develops severely loose teeth, something needs to be done to fix them. With regard to the treatment proposed by Dr. Leon, he agreed that it was medically necessary that the employee have treatment, but that implants were not necessary. He opined that the employee could instead have his remaining teeth extracted and use traditional dentures, which would be more appropriate given the high level of dental hygiene necessary to care for implants and the employee’s history of poor dental hygiene. He agreed in his reports and in his testimony that implants were an option, albeit elaborate and elective.
Dr. Leon issued a narrative report and testified on the employee’s behalf. He testified that although the employee had several missing and loose teeth in March 2020, several teeth were severely loose after the work injury, and that the employee’s bottom teeth likely hit his top teeth when he fell. He opined that the work injury exacerbated the dental condition, and noted that following the injury, the employee was unable to chew due to loose teeth. With regard to the treatment plan, he explained that the bone graft was needed to support the posts for the implants and as the bone graft and posts have already been completed, they cannot be removed.[5] He opined that implants are the best treatment option for the employee as they are tighter, give better support, and do not require daily removal for cleaning.
The employee had filed a claim petition in January 2021 seeking payment of past temporary partial disability benefits, permanent partial disability benefits to be determined, medical and dental benefits, and vocational rehabilitation benefits. The employee returned to his pre-injury work for the employer full time in July 2021. After a hearing held on January 31 and June 29, 2023, the compensation judge found that the employee’s work injury aggravated the employee’s pre-existing dental condition, accelerating his previous plans for dental work, and awarded the claimed dental expenses. The compensation judge also found that the employee is entitled to vocational rehabilitation benefits in the form of medical management. The judge further found that the employee’s injuries to his neck, back, and left knee had resolved as of July 2021, and denied his claims for temporary partial disability and permanent partial disability benefits. In addition, the judge found that the employee had not yet reached maximum medical improvement (MMI) from the effects of all his injuries. The employer and insurer appeal the partial finding of MMI, the award of payment for the employee’s dental treatment expenses, and the award of vocational rehabilitation benefits.
On appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.” Minn. Stat. § 176.421, subd. 1(3). Substantial evidence supports the findings if, in the context of the entire record, “they are supported by evidence that a reasonable mind might accept as adequate.” Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of evidence or not reasonably supported by the evidence as a whole.” Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
A decision which rests upon the application of a statute or rule to essentially undisputed facts generally involves a question of law which the Workers’ Compensation Court of Appeals may consider de novo. Krovchuk v. Koch Oil Refinery, 48 W.C.D. 607, 608 (W.C.C.A. 1993), summarily aff’d (Minn. June 3, 1993).
The central issues in this case are whether the employee’s work injury is a substantial contributing cause of his need for dental treatment, and if so, whether the proposed treatment is reasonable and necessary to treat that condition. We find that there is substantial evidence of record to support the compensation judge’s findings on these issues as well as the finding that the employee is not at MMI for all of his work injuries. With regard to the issue of whether the employee is entitled to vocational rehabilitation services in the form of medical management services, we conclude there is no evidence that he is a qualified employee.
The compensation judge found that the September 1, 2020, injury aggravated the employee’s pre-existing dental condition and accelerated his need for dental treatment, including the previously recommended dental treatment. The employer and insurer argue that the compensation judge’s award of past and ongoing dental treatment should be overturned on the basis that Dr. Leon’s records and information provided to the insurer were not accurate or forthcoming, and therefore his opinions should be disqualified. The compensation judge, as trier of fact, has discretion to choose between competing and conflicting medical experts’ reports and opinions. Gianotti v. Indep. Sch. Dist. 152, 889 N.W.2d 796, 803, 77 W.C. D. 117, 126 (Minn. 2017); Ruether v. State of Minn., 455 N.W.2d 475, 478, 42 W.C.D. 1118, 1123-24 (Minn. 1990); Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985). The nature and extent of an injury is an issue of ultimate fact to be decided by a compensation judge. Abed v. ERA Venture Capital, 79 W.C.D. 707 (W.C.C.A. 2019) (citing Felton v. Anton Chevrolet, 513 N.W.2d 457, 459, 50 W.C.D. 181, 184 (Minn. 1994)), summarily aff’d (Minn. Nov. 20, 2019); see also Domarus v. Yule Transp., No. WC20-6387 (W.C.C.A. June 29, 2021). A compensation judge’s decision to adopt the opinion of an expert must be upheld if the opinion has adequate foundation, absent an abuse of discretion. Mattick v. Hy-Vee Foods Stores, 898 N.W.2d 616, 621, 77 W.C.D. 617, 624 (Minn. 2017). “An expert opinion lacks adequate foundation when the opinion does not include the facts upon which the expert is relying in forming the opinion, there is no explanation of the basis for the opinion, or the facts assumed by the expert are not supported by the evidence.” Erickson v. Grand Itasca Clinic & Hosp., No. WC21-6413 (W.C.C.A. Nov. 16, 2021) (citing Hudson v. Trillium Staffing, 896 N.W.2d 536, 540, 77 W.C.D. 437, 442 (Minn. 2017)). Dr. Leon has examined the employee on multiple occasions, has created a treatment plan, and has explained his opinions in his report, his treatment records, and his testimony; his opinion has adequate foundation.
It is undisputed that the employee had a serious dental condition prior to the work injury. Records from Inka Dental from March 2020 show that the employee had numerous missing teeth, loose teeth, and advanced periodontitis at the time of that visit. He also had a retainer device for three missing front teeth that did not fit well. Dr. Leon provided treatment options including full dentures or implants, which the employee chose not to pursue at that time for financial reasons. Following the work injury, the medical and dental records show a worsened condition. The urgent care record from the date of injury shows a loosened incisor and that his dental retainer had broken. When he saw Dr. Leon on September 11, 2020, the records show that several of his teeth were severely loose to the extent that he was not able to brush his teeth or chew. He was diagnosed as having a fracture of the alveolar bone, along with alveolar bone atrophy, as seen on a CT scan. Dr. Leon opined that the work injury loosened the employee’s teeth even more, and Dr. Rhodus agreed that it was possible that the fall worsened his dental condition, especially since the force of the fall caused his retainer to break. Both Dr. Leon and Dr. Rhodus agreed that once teeth become severely loose, dental treatment is necessary.
Dr. Leon stabilized a few teeth on September 11, 2020, and then proceeded with the dental plan of bone grafts and placement of posts over the next several months. The compensation judge, in appealed Finding 14, found “[t]he employee required a graft to fix the fracture.” We note, however, that the undisputed medical evidence shows that the bone grafts were for the purpose of implanting the posts, rather than to fix the fracture. (T. 136, Ex. 21 at p. 40.) As such, consistent with the record, Finding 14 is modified to state: “The employee required a graft for the purpose of implanting the surgical endosteal posts.”
The employer and insurer also point out that the dental plan calls for replacement of numerous teeth that were actually missing before the injury. Although the missing teeth may have needed to be replaced at some point, the work injury accelerated the need to replace the teeth that were missing before the injury. As explained by Dr. Rhodus, “once you start missing a few teeth, then there are open spaces and the teeth become malaligned with the opposing teeth.” (Ex. 21 at p. 24.) He added that the misalignment results in malocclusion, and the teeth will not function properly. Dr. Leon opined that 24 implants would restore the minimum area “for a good function of mastication.” (Ex. 20.) These expert opinions provide sufficient evidence to support the finding that the work injury aggravated the employee’s dental condition and accelerated his need for the proposed dental treatment. Substantial evidence supports the compensation judge’s finding that the September 1, 2020, work injury aggravated the employee’s pre-existing dental condition and accelerated his need for dental treatment, and we affirm.
The employer and insurer also argue that Dr. Leon’s treatment plan is not reasonable and necessary, and that two experts are of the opinion that the most appropriate treatment is full dentures rather than implants, partly based on concerns regarding the viability of full-mouth dental implants. All experts who provided opinions in this case agree that for implants to be successful, good oral hygiene is necessary. Since the employee has a history of poor oral hygiene, there is concern about his ability to properly care for implants. Dr. Leon testified that the employee has been educated on how to care for his mouth, and that the employee’s habits had improved since the injury through the date of hearing. Also, both Dr. Leon and Dr. Rhodus agreed that numerous patients who have poor dental hygiene have received implants. Another concern is the cost of the dental implants, which are significantly more expensive than traditional dentures. Dr. Rhodus testified that dentures cost approximately $15,000, compared to dental implants, which cost approximately $100,000. (Ex. 21 at p. 60.) In this case, the estimated cost of the dental implants is more than $100,000. (Ex. 20.) While those are valid concerns, the reasonableness and necessity of medical treatment constitutes a fact question for the compensation judge. See Hopp v. Grist Mill, 499 N.W.2d 812, 48 W.C.D. 450 (Minn. 1993).
As noted above, Dr. Leon and Dr. Rhodus agreed that treatment was necessary given that at least some teeth were severely loose after the injury. Dr. Rhodus recommended that appropriate treatment would involve extracting the employee’s remaining teeth and providing full dentures. This recommendation does not address the endosteal posts which have been implanted in the employee’s jaw. Dr. Leon indicated that these implants would need to be surgically removed for the employee to use traditional dentures. While Dr. Rhodus stated that the treatment plan for placement of 24 implants was elaborate and excessive, he agreed that it was a reasonable treatment option. (Ex. 21 at p. 37.) Dr. Leon provided testimony, which the compensation judge specifically accepted as credible, that implants, rather than dentures, provide more support and result in less bone loss. (Finding 36.) The compensation judge adopted Dr. Leon’s opinion as more persuasive and consistent with the record as a whole. Substantial evidence supports the compensation judge’s finding that the proposed dental treatment recommended by Dr. Leon[6] is reasonable and necessary, and under these unique circumstances, we affirm.
The compensation judge found that although the employee has reached MMI from his neck, back and left knee injuries, that he has not reached MMI from all injuries sustained as a result of the September 1, 2020, work injury. Since the evidence shows that the employee has not yet completed the treatment necessary for his dental issues, and that treatment is substantially related to his work injury, the compensation judge’s finding that he has not reached MMI for all injuries is affirmed.
The compensation judge found that the employee is entitled to vocational rehabilitation benefits in the form of medical management services. An injured worker must be determined to be a “qualified employee” to be entitled to rehabilitation benefits. Minn. R. 5220.0130, subp. 1 (a rehabilitation consultation is used to make a determination of whether an employee is a qualified employee). A qualified employee is defined by Minn. R 5220.0100, subp. 22, as:
an employee who, because of the effects of a work-related injury or disease, whether or not combined with the effects of a prior injury or disability:A. is permanently precluded or is likely to be permanently precluded from engaging in the employee’s usual and customary occupation or from engaging in the job the employee held at the time of the injury;
B. cannot reasonably be expected to return to suitable gainful employment with the date-of-injury employer; and
C. can reasonably be expected to return to suitable gainful employment through the provision of rehabilitation services, considering the treating physician’s opinion of the employee’s work ability.
In this matter, there is no evidence that a rehabilitation consultation has been completed or that the employee has been determined to be a qualified employee. To the contrary, the compensation judge found that the employee has not lost wages or job assignments because of the work injury. (Findings 25 and 26.) At the time of the hearing, the employee was still employed by the employer and was performing his same duties at no wage loss related to the work injury. There is no evidence that the employee has any restrictions on his work activities relative to his dental needs. The compensation judge’s finding that the employee is entitled to rehabilitation services at this time is not supported by substantial evidence in the record. We therefore reverse the compensation judge’s finding on this issue.
[1] The employee does not speak English and a co-worker who brought the employee to urgent care served as his interpreter for that visit.
[2] The alveolar bone is the part of the jaw where teeth arise. Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/alveolar (accessed Apr. 29, 2024).
[3] The employee’s dental records have inconsistencies. For example, tooth number 31 was noted to be missing on March 4, 2020, and then noted to be avulsed or to have severe immobility on September 11, 2020, and teeth numbered 9 and 25 were noted as missing in March 2020, but not in September 2020.
[4] The office note of September 29 indicates that tooth number 14, rather than number 15, was actually extracted, which is consistent with the records and films of March 1, 2020, and September 11, 2020, which show that tooth number 15 was missing.
[5] The issue of whether the dental treatment was pre-approved was discussed at the hearing. Dr. Leon testified that he spoke with someone he believed to be from the insurer who authorized the treatment plan. Throughout the course of the two-day hearing, it became apparent that Dr. Leon, or someone in his office, actually spoke with a representative of the employer. As such, counsel for the employee withdrew the pre-approval claim. At oral argument, counsel for the employee confirmed that pre-approval was not at issue on appeal.
[6] The employer and insurer request a remand for clarification of the compensation judge’s award of dental expenses because the order refers to dentures rather than implants. The compensation judge awarded payment of “the medical expenses incident to the employee’s dental condition and replacement dentures as outlined by Dr. Leon.” (Order 3.) We note that the compensation judge adopted Dr. Leon’s opinions, in which he clearly recommends implants. In addition, the choice between the recommended treatments had been described as dentures without implants versus dentures with implants. (Finding 36.) We decline to remand this issue.