Title: INOCENCIO RAMOS V. STATE OF WYOMING, ex rel., WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION

State: wyoming

Issuer: Wyoming Supreme Court

Document:

INOCENCIO RAMOS V. STATE OF WYOMING, ex rel., WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2007 WY 85158 P.3d 670Case Number: 06-100Decided: 05/22/2007
APRIL TERM, A.D. 2007

 
 
INOCENCIO 
RAMOS,

 
 
Appellant

(Petitioner),

 
 
v.

 
 
STATE OFWYOMING, ex rel., WYOMING WORKERS' SAFETY 
AND COMPENSATION DIVISION,

 
 
Appellee

(Respondent).

 
 
Appeal 
from the DistrictCourtofConverseCounty

 
 

Representing 
Appellant:

Hampton M. 
Young, Jr., Casper, Wyoming

 
 

Representing 
Appellee:

Patrick 
J. Crank, Wyoming Attorney General; John W. Renneisen, Deputy Attorney General; 
Steven R. Czoschke, Senior Assistant Attorney General; Kristi M. Radosevich, 
Assistant Attorney General

 
 
Before 
VOIGT, C.J., and GOLDEN, HILL, KITE, BURKE, JJ.

 
 

GOLDEN, 
Justice.

 
 
[¶1]      Over ten years 
before Inocencio Ramos sustained facial bone fractures in a work-related 
accident on August 26, 2003, as an employee of Knighten Well Service, he had 
periodontal disease and had been advised by a dentist to have his teeth 
extracted and replaced with dentures, but he had decided not to do so.  Following his work-related injury, he 
was evaluated by another dentist for chronic jaw pain and had his teeth 
extracted and replaced with dentures to relieve that pain.  The Wyoming Workers' Compensation 
Division (Division) denied payment of three bills totaling $2,470.00 for that 
dental treatment; Mr. Ramos requested a hearing; and, after the hearing, the 
Office of Administrative Hearings (OAH) hearing examiner upheld the Division's 
denial.  The district court affirmed 
the hearing examiner's decision.

 
 
[¶2]      On appeal, Mr. 
Ramos contends that the hearing examiner's decision was arbitrary and capricious 
and not in accordance with the law as it failed to consider whether the 
work-related injury combined with the preexisting periodontal disease 
necessitated the dental treatment for which compensation was sought.  Responding to those contentions, the 
Division asserts that substantial evidence supports the hearing examiner's 
decision that the dental treatment in question was necessitated by Mr. Ramos' 
preexisting periodontal disease, not the work-related injury. 

 
 
[¶3]      Applying the 
arbitrary and capricious standard of review, we hold that the hearing examiner's 
decision must be reversed, that Mr. Ramos proved by a preponderance of the 
evidence that his work-related injury combined with his preexisting periodontal 
disease necessitated the dental treatment in question, and that this case is 
remanded with instructions that the hearing examiner's order be vacated and a 
new order be entered awarding payment of the dental bills in 
question.

 
 

FACTS

 
 

I.          
Procedural 
History

 
 
[¶4]      On September 4, 
2003, Mr. Ramos filed an injury report with the Division in which he reported he 
sustained injury to his face and jaw on August 26, 2003, when a work tool struck 
him on the right side of his face while working for Knighten Well Service.  The Division paid for medical treatment 
related to this injury.  On May 14, 
2004, the Division received three bills totaling $2,470.00 from Dr. Arnie G. 
Sybrant for teeth extractions and dentures replacement he performed on Mr. Ramos 
in April and May 2004.  On June 8, 
2004, the Division issued three Final Determination letters to Dr. Sybrant in 
which it denied payment of those bills for the reason that the dental services 
were not related to the August 26, 2003, work-related injury.  On June 10, 2004, Mr. Ramos requested a 
contested case hearing, and two weeks later the Division referred the case to 
the OAH.  On December 9, 2004, the 
hearing examiner conducted the hearing.

 
 
[¶5]      At the outset of 
the hearing, the hearing examiner explained that both Mr. Ramos and the Division 
had the same or similar exhibits which included Dr. Sybrant's notes and records 
and the Division's denial letters; the hearing examiner admitted these exhibits 
into evidence without objection.  
Mr. Ramos' counsel made an opening statement and the Division's counsel 
waived opening statement. Mr. Ramos' counsel presented three witnesses, namely, 
Dr. Sybrant, Mrs. Ramos, and Mr. Ramos, and the Division's counsel 
cross-examined them. Following the presentation of Mr. Ramos' evidence, the 
Division's counsel moved for a directed verdict, which the hearing examiner 
denied.  The Division did not 
present any witnesses.  The hearing 
examiner declared the evidence closed and invited counsel's closing 
arguments.  Mr. Ramos' counsel made 
no closing argument, having previously argued against the Division's motion for 
directed verdict. The Division's counsel made a closing argument, after which 
the hearing examiner took the matter under advisement.  On January 5, 2005, the hearing examiner 
issued his decision in the form of an order denying payment for Dr. Sybrant's 
three bills, finding and concluding that Mr. Ramos had not proven that his 
work-related injury caused the need for Dr. Sybrant's dental treatment and that 
the need for that dental treatment was Mr. Ramos' preexisting periodontal 
disease which had been diagnosed a decade before the work-related 
injury.

 
 
[¶6]      On February 24, 
2006, the district court affirmed the hearing examiner's order, determining that 
substantial evidence supported that order.  
Mr. Ramos timely filed his notice of appeal.  

 
 

II.         
Hearing Facts 

 
 
[¶7]      About ten years 
before Mr. Ramos sustained the work-related facial injuries working for Knighten 
Well Service, Mr. Ramos was told by a dentist named Dr. Mathisen that he needed 
to have all of his teeth removed because he had advanced periodontal 
disease.  Dr. Sybrant testified that 
periodontal disease is the result of the buildup of bacterial plaque on the 
surface of the teeth which, over time, causes degeneration of the soft gum 
tissues around the teeth and eventually loss of the bone structures that support 
the teeth; in the advanced stages, the teeth become abscessed because there is 
so much infection from the bacteria around them, and, at that point, once the 
teeth have lost a substantial amount of bone, the only treatment for it is to 
have the teeth removed. According to Dr. Sybrant, the cause of the disease is 
lack of good home care and regular professional care.  

 
 
[¶8]      According to Mr. 
Ramos, in the years between Dr. Mathisen's advice and the work accident some of 
his teeth were loose and fell out, his jaw structure was normal, he had no 
difficulty eating, and he had no problems being able to open his mouth.  According to Mrs. Ramos, before the work 
accident her husband had some loose teeth and had no problem eating steak or 
jerky, he had no problem talking, and rarely had headaches. 

 
 
[¶9]      On August 26, 
2003, while working for Knighten Well Service, Mr. Ramos was using a pipe wrench 
and cheater bar when the pipe wrench slipped and the cheater bar struck him in 
the face.  Mr. Ramos' injuries were 
a depressed fracture of the right zygoma with an undisplaced fracture of the 
zygomatic arch and a blowout of the orbit along the neurovascular canal.  Mrs. Ramos testified that the work 
accident broke the right side of her husband's face in six places under the eye 
socket, down the cheekbone, down toward the jaw and a plate was put in to pull 
the bone together.  According to 
Mrs. Ramos, right after her husband's work accident, he could not open his mouth 
far enough to see inside and he could only eat soft "liquidy" foods; his problem 
with eating was he could not open his jaw; it was a jaw problem, not a teeth 
problem.  She testified her husband 
had severe pain in his face and jaw on the right side. According to Mr. Ramos, 
after the work accident he was unable to open his jaw and talk well and was 
having pain in his jaw.  

 
 
[¶10]   Dr. Joseph Vigneri surgically 
repaired Mr. Ramos' facial injuries, and the Division paid for that medical 
treatment.  On January 20, 2004, Dr. 
Vigneri referred Mr. Ramos to Dr. Sybrant for evaluation of the chronic pain 
that Mr. Ramos was experiencing on the right side of his face.  Dr. Sybrant's notes of his examination 
of Mr. Ramos on that initial visit reveal in pertinent 
part:

 
 
. . . 
can't open mouth & has pain all the time upper right side teeth.  Can't push on face tender under 
eye.  Constant headaches on right 
side, feels sick all the time, dizzy but goes away.  Advised patient to stop chewing gum . . 
. . Missing teeth #24-26, 17-19, 13, 9 & 10.  MSO = 23.8 mm.  Pt. needs teeth stabilized before 
anything could be done.  Several 
loose teeth . . . . Patient has advance perio, all teeth mobile . . . . Good 
reason to suspect that he has pain due to periodontal abscesses.  Possible that if dentures can be made 
with his limited MSO, it could alleviate a lot of his pain.  Pt. told to chew gum as therapy.  I told him to stop due to perio as well 
as TMJ symptoms.  Dental conditions 
must be dealt with first then see what can be done about limited opening 
ability & TMJ symptoms. 

 
 
On 
January 28, 2004, Dr. Sybrant wrote to the Division outlining the problems and 
possible treatment alternatives for Mr. Ramos.  In pertinent part, Dr. Sybrant 
wrote:

 
 
I 
explained to Mr. Ramos how temporomandibular dysfunction (TMD) is treated but in 
his case there are other factors that must be considered.

 
 
            
In order to treat any TMD, a stable intraoral environment is 
required.  In this case, it appears 
Mr. Ramos will require serial extraction of his teeth and fabrication of 
dentures.  He was informed by his 
former dentist, over ten years ago, that he needed to have all of his teeth 
removed due to advanced periodontal disease.  Treatment for TMD entails careful 
determination of the proper bite relationship.  I hope to determine the best bite for 
correction of Mr. Ramos TMD symptoms and incorporate that into the immediate 
dentures.  The result should be a 
correction for his dental problems as well as stabilization of his TMD 
symptoms.

 
 
            
There is also the possibility that his pain is partially due to the 
infection from the periodontal disease.  
Removal of his remaining teeth could alleviate a significant portion of 
his pain symptoms.

 
 
            
Initially, I need to do a Panoramic Radiograph.  This xray will be necessary for both 
dental and TMD treatment.  The xray 
plus a dental examination will determine the extent of his periodontal 
disease.  At that point the best 
solution will be prescribed.  In 
stabilization of the stomatognathic relationship can be obtained concomitant 
with the fabrication of full dentures, then the patient could possibly be 
treated with less time and effort.  

 
 
[¶11]   At the contested case hearing, both 
Mr. Ramos' counsel and the Division's counsel questioned Dr. Sybrant.  On direct examination by Mr. Ramos' 
counsel, Dr. Sybrant explained Dr. Vigneri's referral for pain evaluation, 
recounted Mr. Ramos' significant advanced periodontal disease, and commented on 
Mr. Ramos' limited ability to open his jaw and the pain associated with his 
effort to open his mouth.  When 
asked if Mr. Ramos' headaches could have been the result of an unstable jaw, Dr. 
Sybrant answered:

 
 
            
I think that a lot of the pain he was going through, the physical pain, 
was from the infection from the periodontal disease.  Normally that will cause a lot of pain 
in the facial area, simply because there is so much 
infection.

 
 
            
His symptoms were somewhat limited to the right-hand side of his face, 
where apparently he had had some damage.  
But at the same time, I have no reason to believe that the advanced 
periodontal condition would not at least be a contributing factor in how much 
discomfort he was going through. 

 
 
When 
asked whether, as a medical probability, the facial injury could have increased 
the pain with the periodontal disease, Dr. Sybrant 
answered:

 
 
            
From what I can determine, he had a rather substantial injury, which was 
apparently repaired by Dr. Vigneri.  
That could have triggered the infection to become worse in these areas, 
because he had to have the surgery.

 
 
* * * 
*

 
 
            
The periodontal  disease is 
obviously connected very closely to the bones and areas where he was having the 
surgery done, and it could have just kind of stirred everything up at that point 
and made it a lot worse for him suddenly.  
The problem was there before, but that may have set it off and caused it 
to become more of a problem.  

 
 
When 
asked in cross-examination by the Division's counsel if it would be speculating 
to say that the work accident caused "more of this problem" (referring to 
advanced periodontal disease), Dr. Sybrant answered:

 
 
            
I think I would have to say yes to that.  My opinion was, I wanted to treat his 
dental problems, because we had no choice but to do that before we could even go 
on.

 
 
* * * 
*

            
We had to get a stable dental environment before we could even consider 
doing anything as far as evaluating the jaw situation.

 
 
Q. 
[Division's counsel]  And he didn't 
have a stable dental environment even before the accident, did 
he?

 
 
A.        Not [at] 
that point.  The hope was . . . to 
be able to correct both simultaneously.  
The hope was to thereby stabilize the jaw, give more support for the jaw 
joint mechanism where he was getting a lot of pain.

 
 
Q.        But 
this pre-existing periodontal disease was going to require him to have his teeth 
removed

 
 
A.        
Yes.

 
 
Q.        
--which should actually have been done years 
before?

 
 
A.        That 
was recommended to him in the past, yes.

 
 
On 
redirect examination by Mr. Ramos' counsel, this exchange 
followed:

 
 
Q. [Mr. 
Ramos' counsel]  Could you have 
treated him for the jaw injury without treating him for the periodontal 
disease?

 
 
A.        
No.

 
 
Q.        And 
when you say both problems, by replacing the dentures will cure both problems, 
you mean it would also help with the joint problem in allowing him to open his 
mouth?

 
 
A.        
Yes.  My determination was 
that, because he had the  such amount of loose teeth in his mouth, that when 
the denture was made it gave him a more stable bite structure.  That was going to take stress off this 
area where he had damage in the joint area on the right upper side.  And my hope was, in the process of 
taking care of the teeth  which had to be replaced, anyway  that would give 
more joint stability, and thereby take stress off the mechanism where he had the 
injury. 

 
 
[¶12]   Mr. Ramos testified that, because 
of Dr. Sybrant's dental treatment, he feels pretty good and can eat.  Mrs. Ramos testified that, after Dr. 
Sybrant's dental work, her husband's face and jaw didn't hurt as much, his 
headaches were less, he can eat most any food except jerky, and he has no 
problem opening his mouth and chewing. 

 
 
[¶13]   After the Ramoses testified, the 
Division moved for a directed verdict, arguing Mr. Ramos had failed to prove 
that the work accident materially aggravated the preexisting advanced 
periodontal disease.  In response to 
that motion, Mr. Ramos' counsel conceded the existence of the preexisting 
disease but asserted that it was not the cause of his inability to open and 
close his mouth and if he had not had his jaw stabilized with Dr. Sybrant's 
dental treatment he would not have been able to open and close his mouth.  In conclusion, Mr. Ramos' counsel stated 
a material aggravation existed and it was "a combination of both the periodontal 
disease and the accident which would create the TMJ or the TMD in this case." 

 
 
[¶14]   The hearing examiner denied the 
Division's motion for directed verdict; the Division did not present witnesses; 
the hearing examiner declared the evidence closed and asked for any additional 
closing statements.  Mr. Ramos' 
counsel declined additional remarks; the Division's counsel reiterated its 
position, adding that Dr. Sybrant testified it would be speculating to say there 
was a material aggravation.  The 
Division's counsel concluded, saying there was no question Mr. Ramos had a jaw 
problem where he could not open his mouth, that was different than removal of 
his teeth and periodontal disease, and the Division was not obligated to pay for 
the dental work that had always been needed. 

 
 
[¶15]   The hearing examiner took the 
matter under advisement and closed the hearing.  On January 5, 2005, the hearing examiner 
issued its order denying payment of Dr. Sybrant's dental bills.  Of the order's nine findings-of-fact 
paragraphs, paragraphs eight and nine are the focus of Mr. Ramos' appeal.  They read:

 
 
8.         
Dr. Sybrant testified APD [advanced periodontal disease] affects the 
entire mouth.  Dr. Sybrant also 
testified he believed Ramos' continued mouth pain was more associated with the 
APD than with the work injury.  Dr. 
Sybrant testified Ramos had needed the complete teeth extraction for several 
years prior to the August 26, 2003 injury.  
Finally, Dr. Sybrant testified he would be speculating to conclude the 
August 26, 2003 work-related injury caused the need for Ramos to finally have 
his teeth removed and dentures fitted.

 
 
9.         
While this Office is sympathetic to Ramos' situation, this Office cannot 
find Ramos has proven, by a preponderance of the evidence, his August 26, 2003 
work injured [sic] caused the need for his teeth extractions and denture 
fabrication.  This Office finds 
Ramos' need for the extractions and dentures was a preexisting condition which 
was diagnosed more than a decade before the work injury.  Ramos' own dentist admitted the APD was 
not caused by the work injury and to even associate Ramos' mouth pain with the 
accident would be mere speculation.  
Thus, this Office must find the Division's June 8, 2004 Final 
Determinations denying coverage for the extractions and dentures must be upheld. 

 
 
Of the 
order's seven conclusions-of-law paragraphs, paragraph seven, which is identical 
to paragraph nine of the findings of fact, is the focus of Mr. Ramos' 
appeal.

 
 

STANDARD 
OF REVIEW

 
 
[¶16]   The principles of this Court's 
standard of review of a hearing examiner's order in a contested case are 
well-known:

 
 
            
1.         
The scope of our view is governed by Wyo. Stat. Ann. § 16-3-114(c) 
(LexisNexis 2005).

 
 
            
2.         
We review the order as if it came directly to us from the hearing 
examiner, giving no deference to the district court's decision on the petition 
for review; we review the hearing examiner's conclusions of law de novo.  State of Wyoming ex rel. Wyoming Workers' 
Comp. Div. v. Slaymaker, 2007 WY 65, ¶¶ 9, 11, 156 P.3d 977, 980-81 (Wyo. 
2007).

 
 
            
3.         
Where the record is clear that only the party with the burden of proof 
submitted evidence in the contested case hearing and that party did not 
ultimately prevail, as in Mr. Ramos' case, the arbitrary or capricious standard 
governs the judicial review of the hearing examiner's order.  Newman v. State of Wyoming ex rel. Wyoming 
Workers' Comp. Div., 2002 WY 91, ¶ 22,  
49 P.3d 163, 171 (Wyo. 2002).

 
 
            
4.         
Applying the arbitrary or capricious standard, we review the entire 
record to determine whether the hearing examiner reasonably could have made his 
findings and order based upon all the evidence before him; a non-exhaustive list 
of examples of agency decisions reflecting arbitrary or capricious action 
includes an agency's internally inconsistent findings of fact and conclusions of 
law, entering incomplete findings of fact, or failing to provide findings of 
fact or conclusions of law.  Newman, ¶¶ 19-23, 49 P.3d  at 
170-72.

 
 

DISCUSSION

 
 
[¶17]   The principles governing a 
claimant's burden of proof are well known:

 
 
            
In order to be eligible to receive worker's compensation benefits, a 
claimant must have sustained an "injury" as defined by Wyo. Stat. Ann. § 
27-14-102(a)(xi) (LexisNexis 2001).  
"Injury' means any harmful change in the human organism other than 
normal aging . . . arising out of and in the course of employment while at work. 
. . ."  To demonstrate that an 
injury arose out of the course of employment, the claimant must establish a 
causal connection between the work-related incident and the injury.  Hanks v. City of Casper , 2001 WY 4, ¶ 
6, 16 P.3d 710, 711 (Wyo. 2001).  
The claimant bears the burden of proving this causal connection by a 
preponderance of the evidence.  Clark v. State ex rel. Wyoming Workers' 
Safety and Compensation Div., 2001 WY 132, ¶ 19, 36 P.3d 1145, 1150 (Wyo. 
2001).  "A preponderence of the 
evidence' is defined as proof which leads the trier of fact to find that the 
existence of the contested fact is more probable than its non-existence.'"  Matter of Worker's Compensation Claim of 
Thornberg, 913 P.2d 863, 866 (Wyo. 1996) 
(quoting Scherling v. Kilgore, 599 P.2d 1352, 1359 (Wyo. 1979)).

 
 

Anastos 
v. General Chemical Soda Ash, 2005 
WY 122, ¶ 20, 120 P.3d 658, 665-66 (Wyo. 2005).

 
 
"Injury," 
as the term is defined in Wyo. Stat. Ann. § 27-14-102(a)(xi) (LexisNexis 2003) 
of the Wyoming Workers' Compensation Act, does not include any injury or 
condition preexisting at the time employment begins with the employer against 
whom a claim is made.  However, "in 
Wyoming an 
employer takes the employee as he finds him."  Lindbloom v. Teton International, 684 P.2d 1388, 1389 (Wyo. 1984).  If an employee suffers from a 
preexisting condition, that employee may still recover if his employment 
substantially or materially aggravates that condition.  Id.  In Lindbloom, we cited with approval the 
widely accepted treatise, Larson's Workmen's Compensation Law, for the 
proposition that:

 
 
"Preexisting 
disease or infirmity of the employee does not disqualify a claim under the 
arising out of employment' requirement if the employment aggravated, 
accelerated, or combined with the disease or infirmity to produce the death or 
disability for which compensation is sought."

 
 
1 
Larson's Workmen's Compensation Law, § 12.20, p. 273-276.  Larson goes on to 
say:

 
 
"Since 
the rule of law stated at the beginning of this section is so widely accepted, 
in practice most of the problems in this area are medical rather than legal. * * 
* * It will be found then that denials of compensation in this category are 
almost entirely the result of holdings that the evidence did not support a 
finding that the employment contributed to the final result.  Whether the employment aggravated, 
accelerated, or combined with the internal weakness or disease to produce the 
disability is a question of fact, not law, and a finding of fact on this point . 
. . based on any medical testimony . . . will not be disturbed on 
appeal."

 
 

Id., § 
12.20, p. 313-16.

 
 

Boyce v. 
State ex rel. Wyoming Workers' Safety & Comp. Div., 2005 
WY 9, ¶ 10, 105 P.3d 451, 454-55 (Wyo. 2005). 

 
 
[¶18]   Expert opinion testimony ordinarily 
will be required to establish the link between the employee's work activity or 
injury and the preexisting disease or condition; the expert need not state with 
specificity that the work activities or injury materially or substantially 
aggravated, accelerated, or combined with the preexisting disease or condition 
to necessitate the medical treatment for which compensation is sought; and the 
expert need not apportion between the work activity or injury and the 
preexisting disease or condition; the relative contribution of the work activity 
or injury and the preexisting disease or condition is not weighed.  Boyce, ¶¶ 11, 16, 105 P.3d  at 455, 
456.

 
 
[¶19]   Mr. Ramos does not challenge the 
findings of fact that he had long-standing periodontal disease and had elected 
years before his work-related injury not to have his teeth extracted and 
replaced with dentures.  Rather, he 
does challenge those findings of fact in paragraphs 8 and 9 of the hearing 
examiner's decision which state:

 
 
-- Dr. 
Sybrant testified he believed Mr. Ramos' continued mouth pain was more 
associated with the APD than with the work injury;

 
 
-- Dr. 
Sybrant testified he would be speculating to conclude the August 26, 2003, 
work-related injury caused the need for Mr. Ramos to finally have his teeth 
removed and dentures fitted;

 
 
-- Mr. 
Ramos' own dentist admitted that to even associate Mr. Ramos' mouth pain with 
the accident would be mere speculation.

 
 
[¶20]   Moreover, Mr. Ramos challenges the 
hearing examiner's findings of fact for what has been omitted from them when one 
reviews the whole record.  In this 
regard, he points to the following undisputed evidence:

 
 
-- 
before the work injury, even with his advanced periodontal disease, his jaw 
structure was normal, he had no problems being able to open his mouth, he had no 
difficulty eating steak or jerky, he had no problem talking, and he rarely had 
headaches;

 
 
-- as a 
result of the work injury and before Dr. Sybrant evaluated his mouth and jaw, he 
could not open his mouth and jaw, he felt severe pain in the right facial and 
jaw area, and he could eat only soft "liquidy" food;

 
 
-- after 
Dr. Sybrant's dental treatment, he feels pretty good and he can eat solid foods 
again with the exception of jerky, his face and jaw do not hurt as much, he has 
fewer headaches, and he has no problem opening his mouth and jaw and 
chewing;

 
 
-- the 
only point on which Dr. Sybrant testified he would be speculating was, in answer 
to the Division counsel's question, it would be speculating to say that the work 
injury caused "more of this problem" which was referring to the advanced 
periodontal disease;

 
 
-- Dr. 
Sybrant's notes, records, and testimony established that while Mr. Ramos' 
advanced periodontal disease was at least a contributing factor in the amount of 
Mr. Ramos' discomfort and pain, his pain symptoms were somewhat limited to the 
right-hand side of his face where he sustained some damage from the work injury; 
Dr. Sybrant determined that Mr. Ramos had advanced periodontal disease and also 
temporomandibular dysfunction (TMD); Dr. Sybrant explained to Mr. Ramos how TMD 
is treated; to treat TMD, a stable introral environment is required and Mr. 
Ramos did not have that because of his advanced periodontal disease; treatment 
for TMD entails careful determination of the proper bite relationship; to 
correct Mr. Ramos' dental problems and stabilize his TMD symptoms, Dr. Sybrant 
would extract Mr. Ramos' teeth, determine the best bite for correction of his 
TMD symptoms and incorporate that into the dentures; Dr. Sybrant's hope was to 
correct both the dental problems and the TMD simultaneously to stabilize the jaw 
and give more support for the jaw joint mechanism where he was getting a lot of 
his pain; Dr. Sybrant could not have treated Mr. Ramos' jaw injury without 
treating him for the periodontal disease; replacing Mr. Ramos' teeth with 
dentures would treat the disease and also help with the jaw joint problem in 
allowing him to open his mouth; the dentures gave Mr. Ramos a more stable bite 
structure which took stress off the upper right side jaw joint area where he had 
damage; Dr. Sybrant's hope was that taking care of the teeth which had to be 
replaced anyway would give more joint stability and, thereby, take stress off 
the mechanism where the injury was located.

 
 
[¶21]   Countering Mr. Ramos' contentions, 
the Division asserts that substantial evidence supports the hearing examiner's 
decision that Mr. Ramos' long-standing preexisting periodontal disease, not the 
work-related injury, was the reason for Dr. Sybrant's dental treatment.  In particular, the Division claims that, 
according to Dr. Sybrant, Mr. Ramos' periodontal disease caused his pain and it 
would be speculation to say his work-related injury caused more of the 
periodontal problem.

 
 
[¶22]   Based upon a thorough review of the 
entire record and applying the applicable standard of review, we agree with Mr. 
Ramos' contentions and, accordingly, hold that the hearing examiner's decision 
was arbitrary and capricious and not in accordance with the law.  With respect to paragraph 8 of the 
hearing examiner's findings of fact, Dr. Sybrant did not testify that Mr. Ramos' 
mouth pain was more associated with his periodontal disease than with his 
work-related injury.  Dr. Sybrant 
did testify that Mr. Ramos had pain all the time in the upper right side teeth, 
his right face was tender under the eye, he had right side headaches, a lot of 
his pain was due to the periodontal disease infection, his symptoms were 
somewhat limited to the right side of his face where he had had some damage from 
the work-related accident, the periodontal disease was at least a contributing 
factor in his discomfort, and the substantial work-related injury of fractured 
facial bones is connected very closely to the periodontal disease.  In Dr. Sybrant's testimony, we do not 
see an opinion that the pain was more associated with the periodontal disease 
than the work-related injury.  It is 
clear the pain was associated with both.

 
 
[¶23]   Again with respect to paragraph 8 
of the hearing examiner's findings of fact, Dr. Sybrant did not testify that he 
would be speculating to conclude that the work-related injury caused the need 
for Mr. Ramos to finally have his teeth removed and dentures fitted.  Our careful reading of Dr. Sybrant's 
testimony, notes, and records reveals no such statement.  The only instance in which Dr. Sybrant's 
testimony is associated with the term "speculation" appears in his affirmative 
answer to the Division counsel's question that it would be speculating to say 
that the work-related injury caused more of the periodontal 
problem.

 
 
[¶24]   Importantly, Dr. Sybrant did 
connect the work-related injury to the dental treatment when he testified that 
Mr. Ramos had both periodontal disease and a TMD jaw problem and Dr. Sybrant 
would extract his teeth and fit him for dentures to correct the dental problems 
and stabilize his TMD symptoms.  Dr. 
Sybrant testified that he could not have treated Mr. Ramos' jaw injury without 
treating his periodontal disease.  
He testified that extracting the teeth and fitting dentures would treat 
the disease and help the jaw joint problem allowing him to open his mouth; the 
dentures stabilized his bite structure which in turn took stress off the upper 
right side jaw joint area where the work-related injury damage was 
located.

 
 
[¶25]   With respect to paragraph 9 of the 
hearing examiner's findings of fact, Dr. Sybrant did not admit "to even 
associate Ramos' mouth pain with the [work-related] accident would be mere 
speculation."  Our careful reading 
of Dr. Sybrant's testimony, notes, and records reveals no such statement.  We note that paragraph 7 of the hearing 
examiner's conclusions of law also contains this erroneous 
attribution.

 
 
[¶26]   Based upon our review of the entire 
record, Mr. Ramos proved by a preponderance of the evidence that his 
work-related injury substantially combined with his preexisting periodontal 
disease necessitated Dr. Sybrant's dental treatment.  That combination is preponderantly 
evident from the Ramoses' and Dr. Sybrant's testimony.  Our case law does not require Dr. 
Sybrant to apportion the combination between the work-related injury and the 
preexisting periodontal disease.  We 
do not weigh the relative contribution of the work-related injury and the 
preexisting disease.  Boyce, ¶ 11, 105 P.3d  at 
455.

 
 
[¶27]   We reverse the hearing examiner's 
order and remand to the district court for further proceedings consistent with 
this opinion.