Citation Nr: 0934037 Decision Date: 09/11/09 Archive Date: 09/17/09 DOCKET NO. 05-06 752A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for dental trauma. 2. Entitlement to an initial evaluation in excess of 20 percent for intractable sural nerve entrapment syndrome, left ankle. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant, L.S., and Dr. C.N.B. ATTORNEY FOR THE BOARD Christine C. Kung, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1999 to February 2004. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a July 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office in Roanoke, Virginia (RO). In that decision, the RO denied service connection for dental trauma, and granted service connection for sural nerve entrapment syndrome of the left ankle, with a 0 percent (non-compensable) evaluation effective March 1, 2004. In a subsequent March 2005 rating decision, the RO granted an increased 20 percent evaluation for sural nerve entrapment syndrome, left ankle, effective March 1, 2004. The Veteran testified at a January 2009 Board hearing. The hearing transcript has been associated with the claims file. The Veteran submitted a March 2009 motion to modify his hearing transcript; the Veteran identified typographical errors and misspelled names in the transcript and provided corrections. The Board has accepted the Veteran's transcription of the hearing with his corrections and has reviewed the transcript accordingly. The evidence of record reasonably raises claims of entitlement to service connection for (1) limited temporomandibular articulation (Diagnostic Code 9905), (2) complex regional pain syndrome (CPRS), (3) bruxism, and (4) a TMJ disorder, all claims to be considered as secondary to a service-connected injury of the lingual and mandibular branches of the 5th cranial nerve. These issues are not currently on appeal and are referred to the RO for further action. The evidence of record reasonably raises a claim of entitlement to Class III outpatient dental treatment. The issue of entitlement to Class III outpatient dental treatment has not been adjudicated by VA, and is not inextricably intertwined with the Veteran's claim for service connection for dental trauma. See Kellar v. Brown, 6 Vet. App. 157 (1994). The Board notes that claims for eligibility for VA outpatient dental treatment are processed at the VA Medical Center (VAMC) Medical Administrative Service (MAS) and not the RO. The RO should refer the matter to of the nearest VAMC/MAS for appropriate action. FINDINGS OF FACT 1. The Veteran's dental disability is not a result of combat wounds or other trauma during his active military service. 2. Periodontal disease is not a disorder for which service connection can be granted for compensation purposes. 3. The Veteran's intractable sural nerve entrapment syndrome, left ankle, results in severe incomplete paralysis of the ankle and foot. The Veteran is not shown to have complete paralysis of the sural nerve. CONCLUSIONS OF LAW 1. The criteria for service-connected compensation for dental trauma have not met. 38 U.S.C.A. §§ 1110, 1131, 1721, 5103, 5103A, 5107 (West & Supp. 2009); 38 C.F.R. §§ 3.303, 3.381, 17.161 (2008). 2. The criteria for a 30 percent evaluation for intractable sural nerve entrapment syndrome, left ankle have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. § 4.124a, Diagnostic Code 8521 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2008). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). In a May 2004 letter, VA informed the Veteran of the evidence necessary to substantiate his claim, evidence VA would reasonably seek to obtain, and information and evidence for which the Veteran was responsible. A July 2006 letter provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). This notice was not received prior to the initial rating decision. Despite the inadequate timing of this notice, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The RO cured any VCAA notice deficiency by issuing the corrective notice in July 2006. The RO readjudicated the case in July 2007 and March 2008 supplemental statements of the case (SSOC). The United States Court of Appeals for the Federal Circuit (Federal Circuit) held that a statement of the case (SOC) or SSOC can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. Id. There is no indication that any notice deficiency reasonably affects the outcome of this case. The Veteran's service treatment records, VA and private treatment records, and VA examinations have been associated with the claims file. VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claim, and to respond to VA notices. The Board notes specifically that the Veteran was afforded a VA dental examination in March 2008; he was afforded rating examinations in October 2006 and February 2008. 38 C.F.R. § 3.159(c) (4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As set forth in greater detail below, the Board finds that the VA examinations obtained in this case are adequate as they are predicated on a review of the medical evidence of record; contain a description of the history of the disability at issue; document and consider the Veteran's complaints and symptoms; and include an adequate examination of the Veteran. The Veteran's rating examinations fully address the relevant rating criteria; and contain a discussion of the effects of the Veteran's service- connected disability on his occupational and daily activities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Veteran and his representative have not made the Board aware of any additional evidence that needs to be obtained prior to appellate review. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record is complete and the case is ready for review. B. Law and Analysis 1. Dental Trauma The Veteran filed his initial claim for service connection for a dental disability in March 2004. The United States Court of Appeals for Veterans Claims (CAVC or Court) has specifically held that a claim for service connection for a dental disorder is also a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). In the VA benefits system, dental disabilities are treated differently from medical disabilities. VA regulations provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment, not for compensation purposes. 38 C.F.R. § 3.381 (a). The rating activity will consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in the line of duty during active service. When applicable, a determination will be made as to whether it is due to a combat wound or other service trauma, or whether the veteran was interned as a prisoner of war (POW). 38 C.F.R. § 3.381(b). The significance of finding that a dental condition is due to service trauma is that a veteran will be eligible for VA dental treatment for the condition without the usual restrictions of timely application and one-time treatment. 38 C.F.R. § 17.161(c). The following principles apply to dental conditions noted at entry and treated during service: (1) teeth noted as normal at entry will be service connected if they were filled or extracted after 180 days or more of active service. (2) Teeth noted as filled at entry will be service connected if they were extracted or if the existing filling was replaced after 180 days or more of active service. (3) Teeth noted as carious but restorable at entry will not be service connected on the basis that they were filled during service. However, new caries that developed 180 days or more after such a tooth was filled will be service connected. (4) Teeth noted as carious but restorable at entry, whether or not filled, will be service connected if extraction was required after 180 days or more of active service. (5) Teeth noted at entry as nonrestorable will not be service connected regardless of treatment during service. (6) Teeth noted as missing at entry will not be service connected regardless of treatment during service. 38 C.F.R. § 3.381(d). The following will not be service connected for treatment purposes: (1) calculus; (2) acute periodontal disease; (3) 3rd molars, unless disease or pathology of the tooth developed after 180 days or more of active service, or was due to combat or in-service trauma; (4) impacted or malposed teeth, and other developmental defects, unless disease or pathology of these teeth developed after 180 days or more of active service. It is important to note that teeth extracted because of chronic periodontal disease will be service-connected only if they were extracted after 180 days or more of active service. 38 C.F.R. § 3.381(e). Legal authority describes various categories of eligibility for VA outpatient dental treatment, to include veterans having a compensable service-connected dental condition (Class I eligibility); one-time treatment for veterans having a noncompensable service-connected dental condition, provided they apply for treatment within a year after service (Class II eligibility); those having a noncompensable service- connected dental condition adjudicated as resulting from a combat wound or other service trauma (Class II(a) eligibility); those who were detained as a POW (Class II(b) and Class II(c) eligibility); those who made prior applications for, and received, dental treatment from VA for noncompensable dental conditions but were denied replacement of missing teeth that were lost during any period of service prior to his or her last period of service (Class IIR (Retroactive) eligibility); those having a dental condition professionally determined to be aggravating disability from an associated service-connected condition or disability (Class III eligibility); those whose service-connected disabilities are rated at 100 percent by schedular evaluation or who are entitled to the 100 percent rating by reason of individual unemployability (Class IV eligibility); those who participate in a rehabilitation program under 38 U.S.C. chapter 31 (Class V eligibility); and those who are scheduled for admission or who are otherwise receiving care and services under chapter 17 of 38 U.S.C. (Class VI eligibility). 38 U.S.C.A. § 1712; 38 C.F.R. § 17.161. VA's General Counsel has held that merely to have had dental extractions during service is not tantamount to dental "trauma", because trauma of teeth, even extractions, in and of itself, does not constitute dental trauma. VAOPGCPREC 5- 97 (January 22, 1997). For the purposes of determining whether a veteran has Class IIa eligibility for dental care under 17 C.F.R. § 17.123(c), the term "service trauma" does not include the intended effects of treatment provided during the veteran's military service. Id. The Board is bound by this opinion. 38 U.S.C.A. § 7104(c). Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service- connected disease or injury. 38 C.F.R. § 3.310(a) (2006). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The provisions of 38 C.F.R. § 3.310 were amended, effective from October 10, 2006; however, the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744-47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen, the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. Thus, in order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). It is possible to establish secondary service-connection for a dental disability, but the basic service connection rules for dental disorders still apply. If the condition is for a non-compensable dental disorder, (such as treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease), a veteran can only be service-connected for treatment purposes. See 38 C.F.R. § 3.381 (a). The Board notes that third molars will not be service-connected for treatment purposes unless disease or pathology of the tooth developed after 180 days or more of active service, or disability was due to combat or in-service trauma. § 3.381(e). The Veteran's records and DD Form 214 shows that he served for more than 180 days, from December 1999 to February 2004, and he was given an honorable discharge. Service treatment records show that the Veteran was evaluated in July 2001 for impaction of his third molars. The Veteran had partial bony impaction of teeth numbers 1, 16, and 17. He had full bony impaction of number 32. The Veteran's third molars (teeth numbers 1, 16, 17, and 32) were extracted in September 2001. Following surgery, the Veteran had progressive right sided tongue numbness and was found to have an injury to the lingual and mandibular nerves, which are currently service- connected. Service treatment records do not reflect any dental trauma in service and there is no indication of bone loss through trauma or disease. VA treatment records dated in June 2007 show that the Veteran has current diagnoses of periodontitis and chronic gingivitis. A July 2005 evaluation by a VA staff periodontist shows that dental carries and periodontitis may develop on the right side of the mandible because the Veteran is unable brush the teeth or gums on this side. An October 2007 treatment note from Dr. C.N.B. diagnosed the Veteran with dental problems, specifically caries and periodontitis, due to his dysfunctional tongue and associated saliva secretion. In a December 2008 treatment report, Dr. S.B., a general and cosmetic dentist, also indicated that the Veteran would not be able to maintain his oral hygiene due to damage to the lingual and buccal branches of the mandibular division of the trigeminal nerve, and as a result dental caries and periodontal disease may develop. A March 2008 VA authorized dental examination included an interview of the Veteran and a review of the Veteran's specific history for a Sunderland grade IV-V injury to the branches of the lingual and mandibular branches of the 5th cranial nerve. The VA examiner relied in part on a history as provided by the Veteran. The Board finds that the Veteran is both competent to report his medical history, and credible in his reports. The history provided by the Veteran during examination is well supported by medical evidence of record. The VA examiner noted the history of paralysis due to damage to the lingual and mandibular branches of the trigeminal nerve. Examination of the mandible, maxilla, ramus, and palates revealed no abnormal findings. Examination of temporomandibular articulation revealed an inter-incisional motion within a range of 11 to 20 centimeters. There was a range of right and left lateral excursion of 0 to 4 millimeters. Examination of the teeth showed loss of four wisdom teeth. The loss of teeth did not accompany loss of masticatory surface. The loss of teeth was due to the removal of wisdom teeth. Panoramic x-ray results were within normal limits. The examiner stated that the Veteran had documentation from qualified experts that he has permanent damage to the mandibular and lingual branches of the trigeminal nerve with associated chronic pain. The examiner stated that this condition made it very painful for the Veteran to properly care for his teeth, and that this would lead to serious dental problems and tooth loss in the future. The Veteran also testified during his January 2009 Board hearing that he could not brush his teeth due to pain and sensitivity in the right side of his mouth due to his service-connected injury. In general, treatable carious teeth and replaceable missing teeth are not considered a disability for purposes of compensation. 38 C.F.R. § 3.381. The exceptions to the general rule are listed under 38 C.F.R. § 4.150, Diagnostic Codes 9900 through 9916. Missing teeth may be compensable for rating purposes under Diagnostic Code 9913. However, the Note immediately following states, "these ratings apply only to bone loss through trauma or disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling." See 38 C.F.R. § 4.150, Diagnostic Code 9913 (2008). In this case, service treatment records show that the Veteran had his third molars extracted after 180 days of service. Missing teeth may be compensable for rating purposes only where there is bone loss through trauma or disease such as osteomyelitis. See 38 C.F.R. § 4.150, Diagnostic Code 9913 (2008). Although the Veteran has missing third molars, his missing teeth are not shown to be due to bone loss of the body of the maxilla or the mandible due to trauma or disease. The March 2008 VA authorized dental examination shows that the loss of teeth were due to extraction, and not trauma, and the loss of teeth did not accompany loss of masticatory surface. Service treatment records do not reflect bone loss through trauma or disease. Therefore, the criteria for compensable service-connected dental condition under 38 C.F.R. § 4.150 have not been met. There is no evidence that the Veteran suffers from any other disability listed under 38 C.F.R. § 4.150. A veteran can receive Class I treatment for a compensable service-connected dental condition. Service treatment records do not reflect any dental trauma in service. As noted above, dental extractions during service are not tantamount to dental "trauma". See VAOPGCPREC 5- 97 (January 22, 1997). The extraction of the Veteran's teeth is not shown to be due to bone loss through trauma or disease such as osteomyelitis. Therefore, service connection for the purposes of Class I treatment is not warranted on a direct basis. VA and private treatment records show that the Veteran has current diagnoses of periodontitis and chronic gingivitis. Non-compensable dental disorders, such as treatable carious teeth and periodontal disease can only be service-connected for treatment purposes. See 38 C.F.R. § 3.381 (a). Periodontal disease is any of a group of pathological conditions that affect the surrounding and supporting tissues of the teeth. See Simington v. West, 11 Vet. App. 41, 42 (1998). Gingivitis is a form of periodontal disease. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY at 768 (30th ed. 2003). The preponderance of the medical evidence does not show that the Veteran has current carious teeth. Although Dr. C.N.B. indicated that the Veteran had "dental problems (caries/periodontitis)" this diagnosis was not associated with a dental examination. A recent March 2008 VA authorized dental examination, which included x-rays, did not reflect any current dental caries. During a December 2008 dental examination, Dr. S.B. stated that there were no carious lesions detected. Therefore the Board finds that the Veteran's only currently diagnosed dental disabilities are periodontitis and chronic gingivitis. Competent medical evidence indicates that the Veteran's periodontal disease (periodontitis and chronic gingivitis) is secondary to his service-connected Sunderland grade IV-V injury to the lingual and mandibular branches of the 5th cranial (trigeminal) nerve. (See July 2005 VA Dental Treatment Report; December 2008 Treatment Report from Dr. S.B.; and March 2008 VA Dental Examination Report, indicating that damage to the mandibular and lingual branches of the trigeminal nerve with associated chronic pain would likely result in periodontal disease, dental carries, and tooth loss in the future.) Although secondary service-connection can be established for a dental disability, the basic service connection rules for dental disorders still apply. Unfortunately, periodontal disease is not a disorder for which service connection can be granted for compensation purposes. See 38 C.F.R. § 3.381 (a). Therefore, service connection for the purposes of Class I treatment is not warranted on a secondary basis. As noted in the introduction, eligibility for VA outpatient dental treatment for a non-compensable dental disorder has not been adjudicated by VA and is therefore, not on appeal before the Board. Claims for adjunct dental treatment are separate from the RO, and are adjudicated at the MAS/VAMC. This matter has been referred for consideration by the MAS. 2. Sural Nerve Entrapment Syndrome, Left Ankle Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2008). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2008). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2008). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether staged ratings are for consideration; however, the evidence of record does not establish distinct time periods where the Veteran's service-connected disability results in symptoms that would warrant different ratings. Rating by analogy is appropriate for an unlisted condition where a closely related condition, which approximates the anatomical localization, symptomatology, and functional impairment, is available. 38 C.F.R. § 4.20 (2008). The Veteran was assigned a 20 percent evaluation for sural nerve entrapment syndrome, under Diagnostic Code 8521 for paralysis/incomplete paralysis of the external popliteal nerve (common peroneal). A higher 30 percent rating is assigned for incomplete paralysis which is severe in degree. 38 C.F.R. § 4.124(a), Diagnostic Code 8521 (2008). A 40 percent evaluation requires complete paralysis of the external popliteal nerve, manifested by foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes. Id. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at "Diseases of the Peripheral Nerves," 38 C.F.R. § 4.124(a) (2008). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2003). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). An October 2006 VA authorized examination shows that due to sural nerve entrapment syndrome, the Veteran had tingling and numbness, weakness, and constant pain in the affected parts. The symptoms affected the Veteran's ability to run, drive a car, and disrupted sleep. Pain was constant and traveled up the leg to the head. On a 1 to 10 scale, pain level was at an 8. The Veteran had shocking sharp pain when the left foot was touched. The Veteran had 20 degrees dorsiflexion and 45 degrees plantar flexion in the left ankle. Neurological examination shows that there was sural nerve involvement revealing findings of paresthesia and sensory dysfunction. The Veteran was very sensitive to light touch and had severe paresthesia to light touch. He withdrew his leg because of this on examination. Motor function was within normal limits. Sensory function was abnormal with findings of sural nerve paresthesia. An October 2007 evaluation completed by Dr. C.N.B. reflects pain and numbness in the left foot and decreased ankle reflex. The Veteran had left foot strength of 1/5 on dorsiflexion, 4/5 on plantar flexion, and 1/5 on eversion; strength was limited due to pain. The Veteran walked with a limp and used a cane. A February 2008 VA authorized examination shows that due to sural nerve entrapment syndrome, the Veteran had tingling and numbness, abnormal sensation, anesthesia, weakness and constant pain in the affected parts, and limp reflexes. There was no paralysis of the affected parts. Range of motion at the left ankle was limited. Repetitive motions were further limited due to pain. On a 1 to 10 scale, pain level was at a 10. Pain was constant, and the Veteran had little improvement with medications. The Veteran had 15 degrees dorsiflexion and 40 degrees plantar flexion in the left ankle. Motor and sensory function was normal in the lower extremities. A November 2008 treatment report from Dr. P.G.B. at Neurology Services, Inc. shows that the Veteran had chronic and persistent pain in the left sural nerve distribution and left ankle. He had limitation of movement at the ankle and progressive swelling of the left foot and ankle. He walked with a cane and had difficulty with walking and standing. The Veteran had heightened sensitivity to touch. Dr. P.G.B. stated that the Veteran had muscle wasting of the left foot and incomplete paralysis of sensation of high severity. He had pain on any kind of movement involving the left foot. In a January 2009 treatment report, Dr. C.N.B. stated that the Veteran had a weak painful left foot, not useful for ambulation. The Veteran had 3+/5 strength in his foot dorsiflexors with 10 degrees plantar dorsiflexion. He used a cane for ambulation. The left lateral toes were discolored and swollen and his foot was warm to touch. The Veteran's sural nerve entrapment syndrome has been rated as analogous to paralysis/incomplete paralysis of the external popliteal nerve (common peroneal) under Diagnostic Code 8521. There is no specific Diagnostic Code which addresses the sural nerve. The Board finds that a rating under Diagnostic Code 8521 is appropriate for the external popliteal nerve where is most closely approximates the anatomical localization, symptomatology, and functional impairment of the Veteran's disability. See 38 C.F.R. § 4.20 (2008). The Board finds that increased a 30 percent evaluation is warranted for sural nerve entrapment syndrome under Diagnostic Code 8521. Medical evidence of record shows that the Veteran's disability has increased in severity. The Veteran's disability is manifested by constant pain, tingling and numbness, abnormal sensation, anesthesia, weakness, limitation of motion, and heightened sensitivity to touch. An October 2006 VA authorized examination reflects severe paresthesia to light touch. Dr. P.G.B. stated that the Veteran had incomplete paralysis of sensation of high severity. Medical evidence shows that the Veteran's sural nerve entrapment syndrome results in incomplete paralysis which is severe in degree. A Note to the ratings for "Diseases of the Peripheral Nerves" provides that a rating should be moderate at most, when involvement is wholly sensory. See 38 C.F.R. § 4.124(a) (2008). In the present case, involvement of the sural nerve is not wholly sensory where medical evidence shows that the Veteran's disability is also manifested by limitation of motion, weakness, swelling, and muscle wasting. The Board finds that the presented symptomatology more nearly approximates a 30 percent evaluation for incomplete paralysis of the sural nerve which is severe in degree. See 38 C.F.R. § 4.124(a), Diagnostic Code 8521 (2008). The Board finds that a higher 40 percent evaluation is not warranted where the Veteran is not shown to have complete paralysis of the sural nerve. The Veteran's disability is not manifested by foot drop and slight droop of first phalanges of all toes, inability to dorsiflex the foot, loss of extension of proximal phalanges of toes, loss of abduction of the foot, weakened adduction, and anesthesia of the entire dorsum of foot and toes. A February 2008 VA authorized examination shows that there was no paralysis of the effected parts. Although range of motion was limited in the ankle, VA and private treatment records do not reflect complete paralysis of the foot or ankle. A 40 percent evaluation is the maximum available under Diagnostic Code 8521. Medical evidence of record, in this case, simply does not establish complete paralysis of the foot or ankle to warrant such a rating. The Board has considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show that the Veteran's sural nerve entrapment syndrome presents such an exceptional disability picture that the available schedular evaluation is inadequate. A comparison between the level of severity and symptomatology of the Veteran's sural nerve entrapment with the established criteria found in the rating schedule shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology as discussed above. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for his disability. There is no objective evidence in the record to indicate that this service-connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Further, 38 C.F.R. § 4.1 specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned herein. What the evidence in this case does not show is that the manifestations of the Veteran's service-connected disability have resulted in unusual disability or impairment that has rendered the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate. Accordingly, consideration of 38 C.F.R. § 3.321(b)(1) is not warranted in this case. C. Conclusion The Veteran's dental disability is not a result of combat wounds or other trauma during his active military service. The Veteran has been diagnosed with periodontal disease, to include periodontitis and chronic gingivitis; however, periodontal disease is not a dental disorder for which service connection can be granted for compensation purposes. Therefore, the criteria for service-connected compensation for dental trauma have not met. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) regarding benefit of the doubt, but there is not such a state of equipoise of positive and negative evidence to otherwise grant the Veteran's claim. The Board concludes that the evidence supports a 30 percent rating for intractable sural nerve entrapment syndrome of the left ankle. ORDER Service connection for dental trauma is denied. A 30 percent rating, but no more, is granted for intractable sural nerve entrapment syndrome, left ankle, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs