Citation Nr: 9903951 Decision Date: 02/11/99 Archive Date: 02/17/99 DOCKET NO. 94-43 932 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to service connection for degenerative disease of the cervical spine. 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to an increased rating for bilateral temporomandibular joint (TMJ) dysfunction as a residual of jaw dislocation, with neck pain and limited motion, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD N. W. Fabian, Counsel INTRODUCTION The veteran had active duty from October 1973 to October 1976. These matters come to the Board of Veterans' Appeals (Board) from a March 1993 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In that rating decision the RO denied entitlement to service connection for neck dysfunction, Eagle's syndrome, hearing loss, and tinnitus as secondary to TMJ dysfunction, and denied entitlement to a disability rating in excess of 10 percent for TMJ dysfunction. The veteran perfected an appeal of that decision. During a January 1995 hearing the veteran withdrew his appeal on the issue of entitlement to service connection for Eagle's syndrome, and the Board finds that the issue is no longer within its jurisdiction. See Hamilton v. Brown, 39 F.3d 1574 (Fed. Cir. 1994) (a notice of disagreement ceases to be valid if withdrawn). In an October 1995 rating decision the RO granted service connection for neck pain transference as secondary to TMJ dysfunction. Subsequent medical evidence indicated that the veteran had degenerative disease of the cervical spine, for which service connection was claimed in December 1996. In an October 1997 rating decision the RO denied entitlement to service connection for degenerative joint disease of the cervical spine. This case was previously before the Board in April 1998, at which time it was remanded to the RO for additional development and to allow the veteran the opportunity to perfect an appeal of the denial of service connection for degenerative disease of the cervical spine. The development has been completed, and the veteran perfected an appeal of the RO's October 1997 rating decision. The case has been returned to the Board for consideration of the merits of the veteran's appeals. The issue of entitlement to service connection for degenerative disease of the cervical spine will be addressed in the remand portion of this decision. The Board finds that the issue of entitlement to an increased rating for TMJ dysfunction is inextricably intertwined with the issue of entitlement to service connection for degenerative disease of the cervical spine, in that the evaluation of disability arising from TMJ dysfunction includes the evaluation of neck pain. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). The issue of entitlement to an increased rating for TMJ dysfunction will, therefore, also be addressed in the remand portion of the decision. During the January 1995 hearing the veteran also raised the issue of entitlement to service connection for headaches as secondary to the service-connected TMJ dysfunction. This issue has not been adjudicated by the RO and is referred to the RO for appropriate action. See Bruce v. West, 11 Vet. App. 405 (1998) (issues that are raised for the first time on appeal should be referred to the RO for appropriate action). Subsequent to the initiation of the veteran's appeals, his case file was transferred to the RO in Boise, Idaho, because the veteran changed his residence to that area. FINDINGS OF FACT 1. The claim of entitlement to service connection for hearing loss is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The tinnitus that is currently documented cannot be dissociated from the tinnitus that was shown in service. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for hearing loss is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. Tinnitus was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background The veteran's service medical records, including those pertaining to his service in the Army Reserves, show that on entry on active duty in August 1973 he had no relevant abnormalities. In January 1974 he incurred a dislocation of the right TMJ from being struck on the right side of the face with a closed fist. The joint was reduced and immobilized for approximately one month, at which time he was shown to be doing well with little deviation of the jaw. The records indicate that in February 1976 the veteran complained of having intermittent tinnitus for the previous three years, and an examination of the ears revealed no abnormalities. In April 1978 and November 1980 the veteran again reported having tinnitus. His hearing was shown to be within normal limits on audiometric testing in March 1976, April 1978, November 1980, and January 1986. In a January 1977 rating decision, service connection was granted for the residuals of dislocation of the jaw and a noncompensable rating was assigned. A February 1990 private medical report shows that the veteran complained of TMJ pain, tinnitus, and dislocation of the jaw. Examination revealed crepitus in the right TMJ and maximum incisal opening of 48 millimeters, but no other abnormalities. In conjunction with a May 1991 VA dental examination the veteran complained of dislocation of his jaw, malalignment of his teeth, daily pain radiating from his jaw to his ears, pain and stiffness in the neck with decreased range of motion, noise and ringing in his ears, headaches, clicking and grinding in his jaw joints, and hearing loss. Examination revealed that opening of the jaws was limited to 35 millimeters due to pain, with 13 millimeters of lateral movement on the right and 12 millimeters on the left; clicking on the left side and grinding on the right; pain on palpation of the jaw muscles and the TMJ on the left; and worn facets. His complaints were assessed as Eagle's syndrome, internal derangement of the left TMJ, crepitus of the right TMJ, and myofascial pain syndrome. The report of a June 1991 VA medical examination indicates that the veteran was provided a night splint in 1976 due to bruxing, which he stopped using in 1980. He complained of popping and pain a few times a month that was related to eating, locking of his jaw twice a year, and aching in his jaw following dental work. The symptoms of pain, bruxing, and locking were assessed as TMJ dysfunction. Based on this evidence, in a July 1991 rating decision the service-connected disorder was re-characterized as TMJ dysfunction, bilateral, residuals of dislocation of the jaw, and the disability rating was increased from zero to 10 percent effective in October 1989. An August 1992 private dental report shows that the veteran continued to complain of his dislocation and pain in the jaw and ringing in his ears, which had gotten worse. He also stated that he had started getting headaches that radiated from the right side of his neck, and of being unable to rotate his head to the right. VA treatment records indicate that in April 1992 the veteran complained of tinnitus, which was related to TMJ dislocation; crepitus in the TMJ; trigeminal nerve pain; and limitation of motion of the neck. Examination revealed markedly decreased range of motion of the neck in all directions, which was attributed to Eagle's syndrome. An X-ray study of the TMJs at that time showed suspected internal derangement on the right, and an X-ray study of the cervical spine revealed some degenerative changes at C5-C6 and C6-C7. In August 1992 the veteran again complained of pain in the right TMJ and pain and stiffness in the neck. Examination revealed a 50 percent reduction in the range of motion of the neck and tenderness at the occipital insertion and trapezius muscles, which were assessed as torticollis secondary to Eagle's syndrome. In an August 1992 statement the veteran reported an increase in the symptoms related to TMJ dysfunction, including frequent popping and cracking of the jaw and neck, headaches, and limited motion of the neck, all of which his physician had attributed to TMJ dysfunction. He also reported receiving pain medication and physical therapy for his symptoms. An August 1992 radiographic report shows that bilateral TMJ tomograms revealed a small spur projecting superiorly from the lateral aspect of the superior tip of the condyle on the left, and no abnormalities on the right. The report of a January 1993 VA audiometric examination indicates that testing revealed puretone decibel thresholds as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 5 5 20 LEFT 10 5 5 10 10 Speech audiometry revealed speech recognition ability of 100 percent in both ears. The report of a January 1993 VA dental examination shows that the veteran complained of ringing in his ears with loud noise; stiffness and decreased range of motion of the neck; crepitus in the neck and jaw; pain in the jaw, neck and face, and occipital area of the head; and intermittent hearing loss. Examination revealed range of movement of the jaw to an opening of 22 millimeters, which was limited due to pain; left lateral movement of three millimeters and right movement of four millimeters; tenderness in the muscles controlling the jaw and in the right TMJ; and worn facets. His previous treatment was noted to include occlusal equilibration, orthodontia, occlusal splint therapy, and physical therapy. Examination revealed popping in both TMJs, and his symptoms were assessed as myofascial pain and malocclusion. The report of a February 1993 VA medical examination indicates that the veteran ate regular food on a regular diet, and that his weight was stable. He reported having been given a TMJ splint due to bruxing at night and physical therapy for his jaw and neck complaints, which had reduced his pain. He also reported having had tinnitus, which had resolved, and his hearing was described as normal. Examination showed that his TMJ opening was to 40 millimeters, which was described as normal; normal range of motion of the neck; and functional range of motion of the jaws with no clicking, crossbite, or pain. The examiner provided a diagnosis of TMJ dysfunction, by history, with degenerative changes in the styloid process requiring the use of a TMJ splint with craniofacial and myofascial discomfort. The examiner also stated that there was insufficient clinical evidence to warrant a diagnosis of a neck disorder. Private treatment records show that the veteran received orthodontic treatment for the alleviation of his malocclusion and TMJ symptoms from August 1992 through April 1993. A September 1993 VA treatment record indicates that examination of the jaw revealed no joint pathology, and it was recommended that the veteran continue orthodontic treatment of the TMJ dysfunction. In his November 1993 notice of disagreement the veteran stated that his TMJ symptoms had become unbearable in August 1992, at which time he sought treatment from a dentist specializing in TMJ syndrome. He said that the symptoms had resolved due to the treatment received from the specialist, including a TMJ splint and orthodontic braces, which had stabilized his jaw and corrected the malalignment. He also stated that the TMJ specialist had told him that his displaced TMJs were pressing against his ear canals and causing his auditory problems, and that the malaligned TMJs were causing increased muscle tension in the muscles of the jaw and neck, causing the pain, stiffness, and decreased range of motion. In a November 1993 report his private orthodontist stated that the limited opening and locking that the veteran had experienced was being alleviated by the orthodontic treatment, which was scheduled to continue until November 1995. A January 1994 VA treatment record indicates that the veteran reported a flare-up of TMJ symptoms, including trigeminal pain, pain that radiated from the jaw to the right scapular area, and limited motion of the neck. He also complained of popping in the jaw, ear pain, and occasional deafness. Examination revealed that opening of the jaw was limited to two-fingers width, limited motion of the neck due to pain, and pain on palpation of the jaw muscles, which were attributed to the orthodontic work being done for the TMJ dysfunction. In an October 1994 report the veteran's physical therapist stated that the veteran's TMJ pain had decreased with successful treatment of his myofascial release and neck exercises. She stated that she had observed a direct relationship between patients with TMJ dysfunction and neck pain and dysfunction. She also stated that TMJ dysfunction frequently caused hearing problems due to increased mandibular pressure on the acoustic nerve and middle ear. She further stated that patients with TMJ dysfunction usually also had a cervical spine dysfunction, as did the veteran, that was normally at the C1 and C2 vertebrae. In a December 1994 report the veteran's private dentist, who was noted to specialize in dentofacial orthopedics and TMJ disorders, stated that in August 1992 the veteran had complained of dislocation of his right TMJ, clicking, and pain in the jaw, right ear, and right side of the neck. Following an examination the veteran's complaints were diagnosed as TMJ dislocation with associated myofascial pain dysfunction of the head, neck, and jaw. He also stated that musculature dysfunction of the jaw spread into the neck, in that the anterior muscles of the neck are attached to the jaw, and that when the anterior muscles of the neck were stressed, the posterior muscles were activated to maintain the head's posture. The result was pain in the neck due to muscle constriction. The veteran's private dentist further stated that the TMJ was controlled by the fifth cranial nerve, which also innervated the Eustachian tube and the tympanic membrane, and that hyperactive nerve impulses in the trigeminal nerve affected the region of the ear. He said that the hyper-muscle activity caused by TMJ dysfunction affected the fifth cranial nerve, including the Eustachian tube and tympanic membrane, and that patients with TMJ frequently complained of ear pain and ringing in the ears. He further stated that it was well known clinically that TMJ dysfunction affected not only the TMJ, but also the head, neck, and ear structures. The treatment of TMJ required, therefore, orthotic jaw splint therapy and physical therapy to the TMJ region. During a January 1995 hearing the veteran testified that in the August 1992 exacerbation of his symptoms he had an increase in headaches; trigeminal nerve pain, which he described as a sharp, shooting pain into his head that occurred when his jaw popped or dislocated; an increase in tinnitus and hearing problems; and decreased motion of the neck. He also testified that he continued to receive orthodontic treatment. He reported having a constant dull ache in the back of his neck, the cervical spine, and the back of his head, with intermittent acute flare-ups. He stated that his jaw periodically dislocated, which he reduced himself, and that he had decreased motion in his neck. He also stated that he had stopped playing the trumpet due to the noise in his ears, and that he had intermittent tinnitus and loss of hearing, which his dentist attributed to the TMJ dysfunction. He testified that the diagnosis of tinnitus had been made, but not hearing loss, because the hearing loss was intermittent. In support of his claim the veteran submitted a number of medical treatises pertaining to TMJ dysfunction. The treatises document a number of studies pertaining to idiosyncratic muscular response patterns to pain, TMJ as a chronic pain illness, the common signs and symptoms of patients with degenerative joint disease of the TMJ, the high rate of otolaryngology symptoms in patients with TMJ, the high rate of incidents of TMJ together with tinnitus, the interrelationship of head posture and occlusion, the interrelationship of TMJ and cervical spine dysfunction, and TMJ as the most common cause of head and neck pain. In conjunction with a June 1995 VA dental examination, the veteran complained of pain in the right side of the face and neck, the ears, the ear canal, the back of the neck and head, and the shoulder, and tinnitus and joint noise. He reported grinding his teeth at night, and was noted to be wearing orthodontic braces. Examination revealed tenderness in the trapezius, preauricular area, external and internal pterygoid and masseter on the right side, the occipitalis muscle at the muscle line, and the temporal area. No crepitus was noted on opening and closing the TMJs. The veteran could open his mouth to 30 millimeters on the initial examination, but with traction applied to the jaw was able to open the joint to 40 millimeters. The examiner noted that at other times during the examination the veteran opened further without any difficulty. The examiner provided the opinion that the TMJs were within normal limits, and attributed the veteran's complaints to myofascial pain dysfunction. He also stated that the variable ability to open the mouth could be due to muscle spasm, or to unknown causes. The examiner noted that all of the veteran's complaints were subjective, and that no objective abnormal findings were noted. The veteran was also provided a VA examination in June 1995 for the purpose of obtaining an opinion on the relationship, if any, between the service-connected TMJ dysfunction and the veteran's neck complaints. During the examination he reported pain in the neck, the upper back, through the trapezius to the shoulder, and in the back of the neck into the head. The examiner stated that his complaints were not consistent with cervical disc or nerve impingement. Examination revealed limited motion of the neck due to stiff neck muscles, localized tender spots, normal reflexes and grip, full range of motion of the shoulders, and no signs of muscle atrophy. The examiner referenced an X-ray study that was reported to reveal no evidence of bony abnormality in the cervical spine. The examiner provided the opinion that the veteran's complaints pertaining to the neck were related to the TMJ dysfunction. As the result of a June 1995 VA neurological examination, the examiner also provided the opinion that the referred pain in the trapezius area was due to the in-service injury and resulting TMJ dysfunction. Based on this evidence, in an October 1995 rating decision the RO re-characterized the service-connected disorder as bilateral TMJ dysfunction, with limitation of motion, dislocation of jaw, and neck pain transference. The service- connected disorder continued to be rated as analogous to Diagnostic Code 9905 for limited motion of the TMJ, and the disability rating was continued at 10 percent. VA treatment records show that in October 1995 the veteran complained of worsening pain in the right side of the neck that radiated to the right shoulder, right arm, and 4th and 5th digits of the hand, and occasionally to the right eye. He also reported a history of dislocation of the right shoulder, with no known residuals. The range of motion of the cervical spine was shown to be normal, with the exception of rotation, which caused an increase in right-sided symptoms. There was decreased sensation in the arm, decreased deep tendon reflexes, and diffuse tenderness in the right paraspinal cervical muscles and the trapezius. The physical therapist assessed the symptoms as disc bulge versus myofascial pain secondary to poor posture, or TMJ dysfunction. A February 1996 VA treatment record indicates that the veteran reported the onset of neck pain and numbness and tingling down his right arm and to the 4th and 5th fingers in October 1995. The treatment record references an X-ray study that revealed mild degenerative joint disease at C5-C6 and C6-C7, unchanged from June 1995. The examiner noted the veteran's history of TMJ dysfunction, with good relief following the orthodontic treatment. An electromyography (EMG) study revealed evidence of right subacute C7 radiculopathy. In conjunction with a November 1996 VA dental examination the veteran reported that the TMJ dysfunction caused popping, locking, neck pain, headaches, myofascial pain, buzzing in his ears, sharp pains in the TMJs, difficulty chewing, and limited jaw movement. He also reported that the frequency and duration of the headaches and myofascial pain had remained the same. Examination revealed that he could open his mouth to 34 millimeters, and move the jaw laterally to 10 millimeters on either side. No TMJ sounds were found on examination, and there was pain to palpation in the right TMJ and muscles. The examiner noted that the veteran had completed a regimen of orthodontic treatment, which had resulted in the reasonable alignment of his bite. The examiner also noted that the veteran had undergone an evaluation for cervical disc disease, which might have been related to the 1974 jaw injury. In a December 1996 statement the veteran reported that his symptoms had varied for the previous three years as the result of the orthodontic treatment that he had received, and that the TMJ splint had alleviated the pain, popping, and headaches in his jaw. He stated that the symptoms worsened when he was not wearing the splint. He also stated that his symptoms had steadily improved over the last two years due to the treatment he had received. He also stated, however, that the problems with his neck had gotten worse, including pain and numbness in the right arm and hand, limited motion of the neck, and crepitus in the neck. He said that his physical therapist had told him that his neck and arm symptoms were due to the TMJ dysfunction. A June 1997 VA treatment record shows that a computerized tomography (CT) scan demonstrated degenerative changes of the cervical spine at C5-C6 and C6-C7 involving the right lateral recess and neuroforamina. There was also evidence of degenerative spurring on the left side at the C5-C6 level. The orthopedist found that the veteran's upper extremity symptoms, including discomfort throughout the dermatomal distribution and a compensatory muscle pattern involving the right trapezius and biceps, were consistent with the narrowing at C5-C6 and C6-C7, with a working diagnosis of radiculopathy at those levels. In a February 1998 medical report that incorporated a review of the veteran's medical file, his VA orthopedist provided the opinion that the muscular dysfunction of the neck, referred to as myofascial pain syndrome, was related to the primary injury to the right TMJ. In response to the veteran's request for an opinion on whether the cervical radiculopathy was related to the service-connected TMJ dysfunction, the orthopedist stated that she was unable to provide an opinion. Criteria & Analysis Hearing Loss The threshold question that must be resolved with regard to the claim is whether the veteran has presented evidence that the claim is well grounded. 38 U.S.C.A. § 5107(a); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). A well grounded claim is a plausible claim, meaning a claim that appears to be meritorious on its own or capable of substantiation. Epps, 126 F.3d at 1468. An allegation of a disorder that is service connected is not sufficient; the veteran must submit evidence in support of the claim that would "justify a belief by a fair and impartial individual that the claim is plausible." Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden depends upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). In order for a claim for service connection to be well grounded, there must be a medical diagnosis of a current disability, medical or lay evidence of the incurrence of a disease or injury in service, and medical evidence of a nexus between the in-service disease or injury and the current disability. Epps, 126 F.3d at 1468. A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. Therefore, if the determinant issue is one of medical etiology or a medical diagnosis, competent medical evidence is generally required to make the claim well grounded. See Grottveit, 5 Vet. App. at 93. A lay person is, however, competent to provide evidence on the occurrence of observable symptoms during and following service. See Savage v. Gober, 10 Vet. App. 488, 496 (1997). If the claimed disability is manifested by observable symptoms, lay evidence may be adequate to show the incurrence of a disease or injury in service and continuing symptomatology since service. Medical evidence is required, however, to show a relationship between the current medical diagnosis and the continuing symptomatology. Sacks v. West, 11 Vet. App. 314 (1998). If the veteran fails to submit evidence showing that his claim is well grounded, VA is under no duty to assist him in any further development of the claim. Epps, 126 F.3d at 1469. VA may, however, dependent on the facts of the case, have a duty to notify him of the evidence needed to support his claim. 38 U.S.C.A. § 5103; see also Robinette v. Brown, 8 Vet. App. 69, 79 (1995). The veteran has not indicated the existence of any evidence that, if obtained, would make his claim well grounded. VA has no further obligation, therefore, to notify him of the evidence needed to support his claim. See McKnight v. Gober, 131 F.3d 1483, 1485 (Fed. Cir. 1997). The threshold for normal hearing is from zero to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). The determination of whether the veteran has a ratable hearing loss is governed by 38 C.F.R. § 3.385, which states that hearing loss shall be considered a disability when the threshold level in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or the thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385. The evidence shows that the veteran has complained of intermittent hearing loss, and that the hearing problems may be related to his service-connected TMJ dysfunction. The audiometric testing in January 1993 indicated that his hearing was within normal limits at all relevant Hertz levels, and none of the evidence shows that he has a hearing loss disability as defined in 38 C.F.R. § 3.385. The veteran's complaints of intermittent hearing loss are not sufficient to establish that he has a hearing loss disability that is subject to service connection. The Board finds, therefore, that the claim for service connection is not supported by competent medical evidence showing a diagnosis of hearing loss linked to service, and that the claim is, therefore, not well grounded. Epps, 126 F.3d at 1468. Tinnitus The Board concludes that the veteran's claim for service connection for tinnitus is well grounded because the evidence shows that it is plausible. VA has a duty, therefore, to assist him in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a); see also Epps, 126 F.3d at 1464. The relevant evidence pertaining to the issue consists of the veteran's service medical records, VA and private treatment records, the reports of VA examinations in February 1993 and June 1995, and the veteran's statements and testimony. The Board concludes that all relevant data have been obtained for determining the merits of the veteran's claim and that VA has fulfilled its obligation to assist him in the development of the facts of his case. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 1131. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303. The report of the veteran's entrance examination in August 1973 does not show that tinnitus was noted on his entry on active duty and he is, therefore, entitled to the presumption of soundness on entering active duty. 38 C.F.R. § 3.304. The service medical records show that in January 1976 he complained of tinnitus of three years duration, and he continued to report having tinnitus in conjunction with exacerbations of TMJ dysfunction after service. The medical evidence indicates that he has tinnitus, and that the tinnitus is related to the TMJ dysfunction, which is a residual of the in-service jaw injury. The Board has determined, therefore, that the evidentiary record supports a grant of entitlement to service connection for tinnitus. ORDER The veteran not having submitted a well grounded claim of entitlement to service connection for hearing loss, the appeal is denied. Entitlement to service connection for tinnitus is granted. REMAND This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the United States Court of Veterans Appeals (Court) for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103- 446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. The veteran contends that the degenerative disease of the cervical spine was caused by the blow to his jaw in January 1974. As an alternative, he claims that the degenerative disease was caused by the TMJ dysfunction, and that the disability rating for TMJ dysfunction should include all of the symptoms resulting from the cervical spine degenerative disease. It is unclear from the evidence of record whether the degenerative disease of the cervical spine is etiologically related to the in-service jaw dislocation or the service- connected TMJ dysfunction. Although the orthopedist in February 1998 provided the opinion, based on a review of the medical evidence, that the myofascial pain syndrome is related to TMJ dysfunction, she was unable to provide an opinion on whether the degenerative disease was caused by the disorder. She recommended that an opinion be obtained from a specialist in TMJ dysfunction. In addition, it is not clear from the evidence of record whether the veteran continues to have any symptoms of myofascial pain syndrome, following the extensive orthodontic treatment that he received. To ensure that VA has met its duty to assist the veteran in developing the facts pertinent to the claim, the issues of entitlement to an increased rating for bilateral TMJ dysfunction as a residual of jaw dislocation, with neck pain and limited motion, and service connection for degenerative disease of the cervical spine are REMANDED to the RO for the following development: 1. The RO should obtain the names and addresses of all medical care providers, inpatient and outpatient, VA and private, who treated the veteran for TMJ dysfunction or a cervical spine disorder since March 1998. After securing any necessary authorization or medical releases, the RO should obtain and associate with the claims file legible copies of the veteran's complete treatment reports from all sources whose records have not previously been secured. Regardless of the veteran's response, the RO should secure all outstanding VA treatment reports. 2. The veteran should be provided a VA medical examination by a specialist in dentofacial injuries for the purpose of determining the severity of the symptoms of TMJ dysfunction and obtaining an opinion on whether the cervical spine degenerative disease is related to the in-service jaw dislocation, or to the service-connected TMJ dysfunction. The claims file and a separate copy of this decision /remand should be made available to and be reviewed by the examiner prior and pursuant to conduction and completion of the examination and the examination report must be annotated in this regard. The examination should include any diagnostic tests or studies, including X- ray studies, that are deemed necessary for an accurate assessment. The examiner should conduct a thorough orthopedic examination of the jaws and neck and provide a diagnosis of any pathology found. In addition, the examiner should describe all of the symptoms attributed to the TMJ dysfunction, including the range of motion of the TMJs and the extent, if any, of myofascial pain. The examiner should provide an opinion on whether and to what extent the veteran's complaints pertaining to the neck are caused by myofascial pain syndrome, which has been shown to be related to the TMJ dysfunction. The examiner should also provide an opinion, based on the available medical evidence and sound medical principles, on whether it is at least as likely as not that the cervical spine degenerative disease was caused by the in-service jaw dislocation or the TMJ dysfunction. The examiner should provide the complete rationale for all opinions given. 3. The RO should then review the claims file to ensure that all of the above requested development has been completed. In particular, the RO should ensure that the requested examination and opinions are responsive to and in complete compliance with the directives of this remand and, if they are not, the RO should take implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 4. After undertaking any additional development deemed appropriate in addition to that requested above, the RO should re-adjudicate the issues of service connection for degenerative disease of the cervical spine and an increased rating for TMJ dysfunction with neck pain and limited motion. In evaluating the TMJ dysfunction, consideration should be given to all of the symptoms related to the disorder, including any documented neck pain. Esteban v. Brown, 6 Vet. App. 259 (1994) (the veteran is entitled to independent ratings where the symptomatology is distinct and separate). If the benefits requested on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, thc case should be returned to the Board for final appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals Department of Veterans Affairs