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No. 17 of 2022 Determinations/Veterans' Entitlements as made
This instrument is the Statement of Principles concerning gingivitis (Reasonable Hypothesis).
Administered by: Veterans' Affairs
Registered 04 Jan 2022
Table of contents.

Title: RMA Australian Government Coat of Arms - Description: RMA Australian Government Coat of Arms

 

Statement of Principles

concerning

GINGIVITIS
(Reasonable Hypothesis)

(No. 17 of 2022)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

 

Dated    24 December 2021

 

 

 

 

 

The Common Seal of the
Repatriation Medical Authority
was affixed to this instrument
at the direction of:

 

 

 

Professor Terence Campbell AM

Chairperson

 

 

  

Contents

1          Name........................................................................................................................................... 3

2          Commencement........................................................................................................................ 3

3          Authority..................................................................................................................................... 3

4          Repeal......................................................................................................................................... 3

5          Application................................................................................................................................. 3

6          Definitions.................................................................................................................................. 3

7          Kind of injury, disease or death to which this Statement of Principles relates............... 3

8          Basis for determining the factors........................................................................................... 4

9          Factors that must exist............................................................................................................. 4

10        Relationship to service............................................................................................................. 9

11        Factors referring to an injury or disease covered by another Statement of Principles. 9

Schedule 1 - Dictionary........................................................................................... 10

1          Definitions.................................................................................................................................. 10

 

 


 

1               Name

This is the Statement of Principles concerning gingivitis (Reasonable Hypothesis) (No. 17 of 2022).

2               Commencement

This instrument commences on 31 January 2022.

3               Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning gingivitis No. 45 of 2013 (Federal Register of Legislation No. F2013L01121) made under subsections 196B(2) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about gingivitis and death from gingivitis.

Meaning of gingivitis

(2)          For the purposes of this Statement of Principles, gingivitis:

(a)          means an acute or chronic inflammation of the gums, limited to the mucosal epithelial tissue overlying the alveolar ridge and surrounding the necks of erupted teeth; and

(b)          includes:

(i)            acute necrotising ulcerative gingivitis;

(ii)          desquamative gingivitis;

(iii)        gingival abscess;

(iv)        linear gingival erythema;

(v)          peri-implant mucositis; and

(vi)        plasma cell gingivitis; and

(c)          excludes:

(i)            destructive gingival inflammation extending beyond the gums into the underlying supporting structures of the teeth;

(ii)          gingival hyperplasia and overgrowth;

(iii)        gingival recession; and

(iv)        oral aphthae.

(3)          While gingivitis attracts ICD‑10‑AM code A69.1, K05.0 or K05.1, in applying this Statement of Principles the meaning of gingivitis is that given in subsection (2).

(4)          For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from gingivitis

(5)          For the purposes of this Statement of Principles, gingivitis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's gingivitis.

Note: terminal event is defined in the Schedule 1 - Dictionary.

8               Basis for determining the factors

The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that gingivitis and death from gingivitis can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary.

9               Factors that must exist

At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting gingivitis or death from gingivitis with the circumstances of a person's relevant service:

(1)          being prevented from cleaning the teeth, including toothbrushing and interdental cleansing, for a continuous period of at least 14 days, within the 30 days before the clinical onset of gingivitis;

(2)          having a foreign body embedded in the affected region of the gums at the time of the clinical onset of gingivitis;

Note: Examples of a foreign body embedded in the gums include a fixed orthodontic appliance, an osseointegrated implant or dental prosthesis, particulate materials derived from dental procedures and shrapnel.

(3)          having trauma to the affected region of the gums within the 2 weeks before the clinical onset of gingivitis;

Note: trauma to the affected region of the gums is defined in the Schedule 1 - Dictionary.

(4)          having direct exposure of the affected area to an irritant substance within the 3 days before the clinical onset of gingivitis;

Note: irritant substance is defined in the Schedule 1 - Dictionary.

(5)          having direct exposure of the affected area to an allergen within the 3 days before the clinical onset of gingivitis;

Note: allergen is defined in the Schedule 1 - Dictionary.

(6)          having infection with human immunodeficiency virus at the time of the clinical onset of gingivitis;

(7)          having chronic renal failure at the time of the clinical onset of gingivitis;

Note: chronic renal failure is defined in the Schedule 1 - Dictionary.

(8)          having leukaemia or lymphoma at the time of the clinical onset of gingivitis;

(9)          taking a drug that causes neutropenia or agranulocytosis, at the time of the clinical onset of gingivitis;

Note: Examples of drugs that cause neutropenia or agranulocytosis include clozapine, sulfasalazine, ticlopidine and thioamides such as methimazole, carbimazole and propylthiouracil.

(10)      having severe vitamin C deficiency at the time of the clinical onset of gingivitis;

Note: severe vitamin C deficiency is defined in the Schedule 1 - Dictionary.

(11)      having a solid organ transplant, stem cell transplant or bone marrow transplant before the clinical onset of gingivitis;

(12)      being pregnant at the time of the clinical onset of gingivitis;

(13)      using the combined oral contraceptive pill as specified for a continuous period of at least the 4 weeks before the clinical onset of gingivitis;

Note: combined oral contraceptive pill as specified is defined in the Schedule 1 - Dictionary.

(14)      having an autoimmune or mucocutaneous disease from the specified list of autoimmune or mucocutaneous diseases at the time of the clinical onset of gingivitis;

Note: specified list of autoimmune or mucocutaneous diseases is defined in the Schedule 1 - Dictionary.

(15)      having diabetes mellitus at the time of the clinical onset of gingivitis;

(16)      having infection involving the affected region of the gums at the time of the clinical onset of gingivitis;

Note: Examples of infections that may involve the gums include tuberculosis, gonorrhoea, syphilis, chickenpox, candidiasis, histoplasmosis, herpes simplex and hand, foot and mouth disease.

(17)      experiencing a category 1A stressor or a category 1B stressor within the 14 days before the clinical onset of gingivitis;

Note: category 1A stressor and category 1B stressor are defined in the Schedule 1 - Dictionary.

(18)      for acute necrotising ulcerative gingivitis only:

(a)          having severe malnutrition at the time of the clinical onset of acute necrotising ulcerative gingivitis;

(b)          having smoked tobacco products:

(i)            in an amount of at least 2 pack-years before the clinical onset of acute necrotising ulcerative gingivitis; and

(ii)          if smoking has ceased before the clinical onset of acute necrotising ulcerative gingivitis, then that onset occurred within 3 months of cessation; or

(c)          experiencing a category 2 stressor within the 6 months before the clinical onset of acute necrotising ulcerative gingivitis;

Note 1: A category 2 stressor can arise in a variety of circumstances connected with service. Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation.

Note 2: acute necrotising ulcerative gingivitis, category 2 stressor and one pack-year are defined in the Schedule 1 - Dictionary.

(19)      having depressive disorder at the time of the clinical onset of gingivitis;

(20)      having drug-induced gingival overgrowth at the time of the clinical onset of gingivitis;

Note: Examples of drugs that cause gingival overgrowth include phenytoin, cyclosporine and calcium channel blockers such as nifedipine, diltiazem and verapamil.

(21)      being obese at the time of the clinical onset of gingivitis;

Note: being obese is defined in the Schedule 1 - Dictionary.

(22)      being prevented from cleaning the teeth, including toothbrushing and interdental cleansing, for a continuous period of at least 14 days, within the 30 days before the clinical worsening of gingivitis;

(23)      having a foreign body embedded in the affected region of the gums at the time of the clinical worsening of gingivitis;

Note: Examples of a foreign body embedded in the gums include a fixed orthodontic appliance, an osseointegrated implant or dental prosthesis, particulate materials derived from dental procedures and shrapnel.

(24)      having trauma to the affected region of the gums within the 2 weeks before the clinical worsening of gingivitis;

Note: trauma to the affected region of the gums is defined in the Schedule 1 - Dictionary.

(25)      having direct exposure of the affected area to an irritant substance within the 3 days before the clinical worsening of gingivitis;

Note: irritant substance is defined in the Schedule 1 - Dictionary.

(26)      having direct exposure of the affected area to an allergen within the 3 days before the clinical worsening of gingivitis;

Note: allergen is defined in the Schedule 1 - Dictionary.

(27)      having infection with human immunodeficiency virus at the time of the clinical worsening of gingivitis;

(28)      having chronic renal failure at the time of the clinical worsening of gingivitis;

Note: chronic renal failure is defined in the Schedule 1 - Dictionary.

(29)      having leukaemia or lymphoma at the time of the clinical worsening of gingivitis;

(30)      taking a drug that causes neutropenia or agranulocytosis, at the time of the clinical worsening of gingivitis;

Note: Examples of drugs that cause neutropenia or agranulocytosis include clozapine, sulfasalazine, ticlopidine and thioamides such as methimazole, carbimazole and propylthiouracil.

(31)      having severe vitamin C deficiency at the time of the clinical worsening of gingivitis;

Note: severe vitamin C deficiency is defined in the Schedule 1 - Dictionary.

(32)      having a solid organ transplant, stem cell transplant or bone marrow transplant before the clinical worsening of gingivitis;

(33)      being pregnant at the time of the clinical worsening of gingivitis;

(34)      using the combined oral contraceptive pill as specified for a continuous period of at least the 4 weeks before the clinical worsening of gingivitis;

Note: combined oral contraceptive pill as specified is defined in the Schedule 1 - Dictionary.

(35)      having an autoimmune or mucocutaneous disease from the specified list of autoimmune or mucocutaneous diseases at the time of the clinical worsening of gingivitis;

Note: specified list of autoimmune or mucocutaneous diseases is defined in the Schedule 1 - Dictionary.

(36)      having diabetes mellitus at the time of the clinical worsening of gingivitis;

(37)      having infection involving the affected region of the gums at the time of the clinical worsening of gingivitis;

Note: Examples of infections that may involve the gums include tuberculosis, gonorrhoea, syphilis, chickenpox, candidiasis, histoplasmosis, herpes simplex and hand, foot and mouth disease.

(38)      experiencing a category 1A stressor or a category 1B stressor within the 14 days before the clinical worsening of gingivitis;

Note: category 1A stressor and category 1B stressor are defined in the Schedule 1 - Dictionary.

(39)      for acute necrotising ulcerative gingivitis only:

(a)          having severe malnutrition at the time of the clinical worsening of acute necrotising ulcerative gingivitis;

(b)          having smoked tobacco products:

(i)            in an amount of at least 2 pack-years before the clinical worsening of acute necrotising ulcerative gingivitis; and

(ii)          if smoking has ceased before the clinical worsening of acute necrotising ulcerative gingivitis, then that worsening occurred within 3 months of cessation; or

(c)          experiencing a category 2 stressor within the 6 months before the clinical worsening of acute necrotising ulcerative gingivitis;

Note 1: A category 2 stressor can arise in a variety of circumstances connected with service. Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation.

Note 2: acute necrotising ulcerative gingivitis, category 2 stressor and one pack-year are defined in the Schedule 1 - Dictionary.

(40)      having depressive disorder at the time of the clinical worsening of gingivitis;

(41)      having drug-induced gingival overgrowth at the time of the clinical worsening of gingivitis;

Note: Examples of drugs that cause gingival overgrowth include phenytoin, cyclosporine and calcium channel blockers such as nifedipine, diltiazem and verapamil.

(42)      being obese at the time of the clinical worsening of gingivitis;

Note: being obese is defined in the Schedule 1 - Dictionary.

(43)      inability to obtain appropriate clinical management for gingivitis.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factors set out in subsections 9(22) to 9(43) apply only to material contribution to, or aggravation of, gingivitis where the person's gingivitis was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

 


 

Schedule 1 - Dictionary  

Note: See Section 6

1               Definitions

 In this instrument:

                               acute necrotising ulcerative gingivitis means a painful and rapidly progressive inflammation of the gums characterised by gingival bleeding with interdental soft tissue necrosis and ulceration.

Note: Acute necrotising ulcerative gingivitis is also known as Vincent gingivitis and trench mouth.

                               allergen means an antigenic substance capable of producing an immune response.

                               being obese means:

(a)           having a Body Mass Index (BMI) of 30 or greater; or

(b)          for males, having a waist circumference exceeding 102 centimetres; or

(c)           for females, having a waist circumference exceeding 88 centimetres.

Note: BMI is also defined in the Schedule 1 - Dictionary.

                               BMI means W/H2 where:

(a)           W is the person's weight in kilograms; and

(b)          H is the person's height in metres.

                               category 1A stressor means one of the following severe traumatic events:

(a)           experiencing a life-threatening event;

(b)          being subject to a serious physical attack or assault including rape and sexual molestation; or

(c)           being threatened with a weapon, being held captive, being kidnapped or being tortured.

                               category 1B stressor means one of the following severe traumatic events:

(a)           killing or maiming a person;

(b)          being an eyewitness to a person being killed or critically injured;

(c)           being an eyewitness to atrocities inflicted on another person;

(d)          participating in the clearance of a corpse or a critically injured casualty; or

(e)           viewing a corpse or a critically injured casualty as an eyewitness.

Note: corpse and eyewitness are also defined in the Schedule 1 - Dictionary.

                               category 2 stressor means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel ongoing distress, concern or worry:

(a)           being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;

(b)          experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation or divorce;

(c)           having concerns in the work or school environment including ongoing disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment;

(d)          experiencing serious legal issues including being detained or held in custody, ongoing involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;

(e)           having severe financial hardship including loss of employment, long periods of unemployment, foreclosure on a property or bankruptcy;

(f)           having a family member or significant other experience a major deterioration in their health; or

(g)          being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability.

Note: significant other is also defined in the Schedule 1 - Dictionary.

                               chronic renal failure means:

(a)           having a glomerular filtration rate of less than 15 mL/min/1.73 m2 for a period of at least 3 months; or

(b)          a need for renal replacement therapy (dialysis or transplantation) for treatment of complications of decreased glomerular filtration rate which would otherwise increase the risk of morbidity and mortality; or

(c)           undergoing chronic dialysis.

                               combined oral contraceptive pill as specified means an oral contraceptive pill containing estrogen at a minimum dose of 50 milligrams and a progestogen at a minimum dose of 1 milligram.

                               corpse means the human remains or body parts of one or more persons who have met a violent or horrific death.

Note: Examples of a violent or horrific death may include death due to suicide, gunshot, improvised explosive devices, natural and technological disasters, terrorist attacks or motor vehicle accidents. Seeing a closed body bag or viewing a body in an open-casket coffin are excluded from this definition.

                               eyewitness means a person who experiences an incident first hand and can give direct evidence of it. This excludes persons exposed only to public broadcasting or mass media coverage of the incident.

                               gingivitis—see subsection 7(2).

                               irritant substance means a chemical which causes an inflammatory effect on living tissue by chemical action at the site of contact.

Note: Examples of irritant substances include tooth whitening products, dentrifices and mouthwashes.

                               MRCA means the Military Rehabilitation and Compensation Act 2004.

                               one pack-year means the amount of tobacco consumed in smoking 20 cigarettes per day for a period of 1 year, or an equivalent amount of tobacco products.

Note 1: An equivalent amount of tobacco products is 7,300 grams of smoking tobacco by weight, either in cigarettes, pipe tobacco or cigars, or a combination of same. For pipe tobacco, cigars or combinations of multiple tobacco types, 1 gram of tobacco is considered to be equal to one cigarette.

Note 2: Pack-years are calculated by dividing the number of cigarettes smoked per day by 20 and multiplying this number by the number of years the person has smoked. For example, smoking 10 cigarettes per day for 10 years is equal to 5 pack-years, and smoking 40 cigarettes per day for 10 years is equal to 20 pack-years.

                               relevant service means:

(a)           operational service under the VEA;

(b)          peacekeeping service under the VEA;

(c)           hazardous service under the VEA;

(d)          British nuclear test defence service under the VEA;

(e)           warlike service under the MRCA; or

(f)           non-warlike service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                               severe vitamin C deficiency means symptoms of scurvy or a serum ascorbic acid level of less than 2.5 milligrams per litre.

                               significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.

                               specified list of autoimmune or mucocutaneous diseases means:

(a)           bullous pemphigoid;

(b)          chronic ulcerative stomatitis;

(c)           dermatomyositis;

(d)          discoid lupus erythematosus;

(e)           epidermolysis bullosa acquisita;

(f)           erythema multiforme;

(g)          linear IgA disease;

(h)          mixed connective tissue disease;

(i)            mucous membrane pemphigoid;

(j)            oral lichen planus;

(k)          oral lichenoid lesions;

(l)            pemphigus vulgaris;

(m)        psoriasis;

(n)          Sjögren syndrome; or

(o)          systemic lupus erythematosus.

                               terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)          respiratory failure;

(c)           cardiac arrest;

(d)          circulatory failure; or

(e)           cessation of brain function.

                               trauma to the affected region of the gums means physical injury to the gingival tissues by various mechanisms including thermal, electrical and chemical burns, abrasion, and blunt or penetrating trauma.

Note: Examples of trauma to the gums include tooth fractures, inappropriate teeth cleaning (including toothbrushing or dental flossing), damage to the gums with sharp instruments and thermal burns from the consumption of hot foods or beverages.

                               VEA means the Veterans' Entitlements Act 1986.