Citation Nr: 1002702 Decision Date: 01/19/10 Archive Date: 02/01/10 DOCKET NO. 07-23 592 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for burn scars on the feet. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to service connection for a left knee disorder, including as secondary to the right knee disorder. 4. Entitlement to service connection for a dental disorder, including as a residual of trauma for outpatient treatment purposes. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Biswajit Chatterjee, Associate Counsel INTRODUCTION The Veteran served on active duty in the military from September 1979 to August 1985. This appeal to the Board of Veterans' Appeals (Board) is from July and August 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. As support for her claims, the Veteran testified at a hearing at the RO in October 2009 before the undersigned Veterans Law Judge of the Board, also commonly referred to as a Travel Board hearing. FINDINGS OF FACT 1. The Veteran does not currently have burns scars of either foot. 2. X-rays confirm she has degenerative joint disease (DJD), i.e., arthritis in her knees, so bilaterally. 3. But there was no complaint, treatment, or diagnosis of any right knee disorder during her military service. She had an acute and transitory left knee injury in a fall in 1982, but there is no indication she had resultant DJD in either knee during service or even within one year following her discharge from service or for many years after, or that any current left knee disorder - including the DJD, is attributable to her military service, such as to that injury. 4. To the contrary, the report of her January 2009 VA compensation examination is competent medical evidence specifically discounting this notion that the DJD in her knees is etiologically linked to her military service, including to that injury. 5. There is no probative (competent and credible) evidence refuting this VA examiner's unfavorable opinion. 6. The Veteran does not have a compensable dental condition. She does not have a dental condition or disability as a result of combat wounds or other trauma during her active military service, and she does not otherwise meet the requirements for service connection for the limited purpose of receiving VA outpatient dental treatment. CONCLUSIONS OF LAW 1. A burn scar disability involving the feet was not incurred in or aggravated by her military service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 and Supp. 2009); 38 C.F.R. §§ 3.102, 3.303 (2009). 2. The Veteran's right knee disorder was not incurred in or aggravated by her military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002 and Supp. 2009); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2009). 3. The Veteran's left knee disorder also was not incurred in or aggravated by her military service, may not be presumed to have been incurred in service, and is not proximately due to, the result of, or chronically aggravated by a service- connected disability - in particular, her right knee disorder inasmuch as it, too, is not service connected. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002 and Supp. 2009); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310(a) and (b) (2009). 4. The criteria are not met for service connection for a dental disorder, for purposes of compensation or outpatient dental treatment. 38 U.S.C.A. §§ 1131, 1721, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.381, 4.150, 17.161 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In the interest of clarity, the Board will initially discuss whether the claims have been properly developed for appellate review. The Board will then address the claims on their merits, providing relevant VA laws and regulations, the relevant factual background, and an analysis of its decision. I. The Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties 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) (2009). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373- 74 (2002). These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In Shinseki v. Sanders, 129 S. Ct. 1696 (2009), the United States Supreme Court made clear that a reviewing court, in considering the rule of prejudicial error, is precluded from applying a mandatory presumption of prejudice rather than assessing whether, based on the facts of each case, the error was outcome determinative. In Sanders, the Supreme Court rejected the lower Federal Circuit's framework (see Sanders v. Nicholson, 487 F. 3d 881, 889 (Fed. Cir. 2007)) that all VA notice errors are presumptively prejudicial, in part, because it was "complex, rigid, and mandatory." Id., at 1704. The Supreme Court rejected the Federal Circuit's analysis because it imposed an unreasonable evidentiary burden on VA to rebut the presumption and because it required VA to demonstrate why the error was harmless, rather than requiring the appellant - as the pleading party, to show the error was harmful. Id., at 1705-06. The Supreme Court stated that it had "warned against courts' determining whether an error is harmless through the use of mandatory presumptions and rigid rules rather than case-specific application of judgment, based upon examination of the record." Id., at 1704-05. Thus, it is clear from the Supreme Court's analysis that, while the Veterans Court may conclude generally that a specific type of error is more likely to prejudice an appellant, the error must nonetheless be examined in the context of the facts of the particular case. Id. The Veterans Court held in Vazquez-Flores v. Peake, 22 Vet. App. 37, 48 (2008), since overturned on other grounds in Vazquez-Flores v. Shinseki, 2009 WL 2835434 (Fed.Cir.), that prejudicial deficiencies in the timing or content of a VCAA notice can be cured by showing the essential fairness of the adjudication will not be affected because: (1) the defect was cured by actual knowledge on the part of the claimant ("Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrates an awareness of what was necessary to substantiate his or her claim.") (citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007)); (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Sanders, 487 F. 3d at 889. Additionally, consideration also should be given to "whether the post- adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre-adjudicatory section 5103(a) notice error non- prejudicial." Vazquez-Flores, 22 Vet. App. at 46. See also Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding the Board had erred by relying on various post-decisional documents for concluding adequate 38 U.S.C.A. § 5103(a) notice had been provided to the appellant, the Veterans Court nonetheless determined the evidence established the Veteran was afforded a meaningful opportunity to participate effectively in the adjudication of his claims, and therefore found the error harmless). In this case, a letter satisfying the notice requirements under 38 C.F.R. § 3.159(b)(1) was sent to the Veteran in April 2006. This letter informed her of the evidence required to substantiate her claims, and of her and VA's respective responsibilities in obtaining supporting evidence. Note also that the April 2006 letter complied with Dingess by discussing the downstream disability rating and effective date elements of the claims. And of equal or greater significance, all VCAA notice sent was provided prior to the RO's initial unfavorable decisions on the claims in July and August 2006. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). See also Mayfield IV and Prickett, supra. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of her claims that is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran submitted private treatment records, personal statements and hearing testimony. The RO obtained her service treatment records (STRs), service personnel records (SPRs), and arranged for a VA compensation examination for a medical nexus opinion concerning the cause of her right and left knee disorders - including, in particular, in terms of whether it is attributable to her military service. McLendon v. Nicholson, 20 Vet. App. 79 (2006), 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Further, a VA compensation examination is not necessary to decide the bilateral foot burn scar or dental disorder claims as the standards of the Court's decision in McLendon v. Nicholson, 20 Vet. App. 79 (2006), have not been met. It is significant that the Veteran's post-service medical records are unremarkable for a bilateral foot disorder, especially any current diagnosis of a burn scar. The VA is not obligated to provide an examination for a medical nexus opinion where, as here, the supporting evidence of record consists only of lay statements. See Duenas v. Principi, 18 Vet. App. 512, 519 (2004). And the Veteran does not contend any in-service dental trauma outside the course of normal dental treatment, precluding the possibility of service connection for VA outpatient dental treatment purposes. Significantly, the appellant has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. The Board is therefore satisfied that VA has provided all assistance required by the VCAA. 38 U.S.C.A. § 5103A. II. Analysis-Entitlement to Service Connection for Burn Scars of Both Feet, Right and Left Knee Disorders She asserts that both her feet were scalded with boiling water, during a field exercise in Germany in 1984. The condition was then allegedly treated for several months at Kaiserslaughten and Manheim hospitals in Germany. She claims that she continues to have painful scars. She claims that her right knee was injured, with an open wound, in a fall during Army night operations in 1982. She testified that that this was on a long-range firing range, and she scraped her knee during the fall. The injured knee and resulting scar are still painful. The Veteran further contends that her left knee disorder is secondarily related to her right knee disorder. Specifically, she states she has overuse damage in the left knee from overcompensating for loss of use of the right knee. Service connection is granted if it is shown the Veteran has disability resulting from an injury sustained or a disease contracted in the line of duty, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1131, 1153 (West 2002 and Supp. 2009); 38 C.F.R. §§ 3.303, 3.306 (2008). To establish service connection, there must be: (1) a medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996). Certain chronic diseases such as degenerative joint disease (DJD) (i.e., arthritis) will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Further, disability that is proximately due to, the result of, or chronically aggravated by a service-connected disease or injury is considered service-connected, and when thus established, this secondary condition is considered a part of the original condition. 38 C.F.R. § 3.310(a) and (b) (2009). In this regard, 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) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). See, too, Wallin v. West, 11 Vet. App. 509, 512 (1998) and Velez v. West, 11 Vet. App. 148, 158 (1998). When determining service connection, all theories of entitlement, direct and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). Thus, the Board will address service connection for the left knee disorder on both a direct and secondary basis in this appeal. Concerning the burn scar claim, a review of her STRs shows that the Veteran did, in fact, receive a 2nd degree burn to the top of her left foot from hot water in January 1985. There are several treatments during January and February 1985, but it appears that her left foot burn healed. Indeed, the STRs from that period note observations that this foot burn was "healing well;" the wound was clean and "looks great;" and that the left foot area was pink, but "nontender to the touch," with no drainage noted. However, there are no STRs documenting any complaints, treatment, or diagnosis, for a burn of the right foot. Her July 1985 separation examination is silent for a burn scar disability of either foot, or any foot disorder for that matter. So, her in-service complaint of foot pain appears to have been an acute and transitory condition that was limited to only her left foot for a portion of her active duty service. Indeed, following separation, there are no further records of foot treatment, especially for burn scars. Unfortunately, most fatal to the burn scar claim is that there simply is no medical evidence confirming the Veteran has any current disability from burn scars to her feet. Proof of current disability is perhaps the most fundamental requirement for establishing entitlement to service connection. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997) (holding that compensation only may be awarded to an applicant who has disability on the date of her application, not for past disability). See, too, Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000) and Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating that, in the absence of proof of current disability, there can be no valid claim since service connection presupposes a current diagnosis of the condition claimed). See also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of current disability is satisfied when the claimant has disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that he may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). The Board emphasizes that here, though, there is no such evidence or indication. Concerning this, the Veteran's post-service private medical records are completely unremarkable for any documented complaint, treatment, or diagnosis of a burn scar disorder of her feet. Rather, the competent evidence of record specifically discounts the notion of an existing burn scar disorder of her feet. The January 2009 VA examination report recorded the Veteran's complaints of an accidental burn to both feet, with the left the worst. Quite significantly, though, the VA examiner nonetheless objectively found that "[t]here are no burn scars present." Further objective findings for either foot showed no tenderness, painful motion, weakness, edema, heat, redness, instability, atrophy or disturbed circulation. Palpation of the plantar surface of the feet revealed no tenderness. Other objective findings on that examination also failed to show that either foot had any other disorder. As mentioned, the Veteran asserts she suffers from continued pain on her feet where she was burned by boiling water during active duty. But mere pain, alone, without a diagnosed or identifiable underlying malady or condition, is not generally considered a disability and cannot substantiate a claim for service connection. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The Veteran is certainly competent, even as a layman, to comment on any symptoms within her five senses, especially that involving her feet pain. On the other hand, she is not competent to provide a probative opinion concerning the appropriate diagnosis of the underlying conditions causing her pain. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). See also 38 C.F.R. § 3.159(a)(2) and Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In fact, following service, no doctor has ever provided a clinical diagnosis that the Veteran has a bilateral foot disorder, especially burn scars of the feet. So obviously there is no possible means of attributing a non-existent condition to her military service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). Simply stated, the medical record outweighs the Veteran's personal belief that she has a bilateral burn scar disability of her feet due to military service. Thus, absent current disability, service connection for a burn scar disorder of the feet cannot be granted. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed). Regarding the knee disorders, the Veteran's contentions simply do not match the evidence of record. Contrary to her testimony of an in-service right knee injury, there are no STRs confirming any complaint, treatment, or diagnosis of a right knee disorder during service. On the other hand, STRs do confirm that her left knee was injured in a fall in November 1982, when she twisted her knee. She received emergency, albeit nonurgent, treatment for the left knee injury. A November 1982 emergency treatment report diagnosed her left knee as normal and stable. As a result, she was returned to duty without any indication of any further treatment for this knee until separation. Her February 1985 physical examination and July 1985 separation examination reports were silent for any disorder for either knee. At the outset, there is no disputing that the Veteran shows proof of the existence of a current disability. X-ray results from recent private treatment records and the January 2009 VA examination report confirm the Veteran is diagnosed with degenerative joint disease (DJD). Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Consequently, the determinative issue is whether her current right and left knee disorders are somehow attributable to her military service. In this critical respect, her claims fail. There is simply no competent medical evidence that etiologically links any current knee disorder to her period of active duty. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). Instead, the competent evidence of record specifically discounts the notion that her bilateral knee DJD is attributable to her active duty service. The January 2009 VA examiner stated, "[i]njuries sustained during military have not likely led to DJD of the knees." Id. Moreover, despite her contentions to the contrary, the Veteran's STRs are completely unremarkable for any complaint, treatment, or diagnosis of a right knee disorder during service, providing highly probative evidence against that claim. See Struck v. Brown, 9 Vet. App. 145 (1996). In addition, the lapse of so many years between an in-service knee injury (1982) and the first documented complaints of knee pain over a decade after service (1996) provides highly probative evidence against these claims. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). Furthermore, there also is no alternative basis for a nexus in the form of evidence of a chronic disorder in service or any continuity of symptomatology after service. See 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.303(b); 3.307; 3.309; Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Following separation, there are no further records of treatment for either knee until over a decade later in 1996, and degenerative disease changes do not appear to have been diagnosed until 2001. Therefore, service connection for her right and left knees may not be established based on chronicity in service, including on a presumptive basis for arthritis. Id. As for the claimed feet disability, there is not a documented history of complaint or treatment, not to mention diagnosis, of a bilateral burn scar foot disorder, either in service or until many years after. Id. As a layman, the Veteran generally is not competent to give a probative opinion on a diagnosis or etiology of a disorder, especially when, as here, there is contradictory medical evidence of record. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 494-95 (1991). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson generally is not capable of opining on matters requiring medical knowledge"). The Board acknowledges her personal hearing testimony that her feet and knees are sore and swell. In that regard, as mentioned, she is competent even as a layman to report symptoms of pain on her feet and other symptoms within her five senses. Still, this competent evidence of pain is insufficient to establish a diagnosed underlying disorder or etiological link to her military service, especially given the significant passage of so many years in any documentation of her complaints of pain in the knees until over a decade following service. Indeed, the first documented complaint of pain in the feet post- service appears to be the Veteran's February 2006 claim for a bilateral foot disability. And most importantly, no physician of record has associated the Veteran's feet pain with a diagnosed, underlying disorder of her feet, let alone attributed any foot pain to trauma during service, such as from a burn injury. Nor has any physician attributed any knee pain to trauma during service, such as from injury in a fall. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). See also Barr v. Nicholson, 21 Vet. App. 303 (2007). Furthermore, the Veteran's competency to make this claim must be distinguished from the weight and credibility of her lay testimony, which are factual determinations going to the ultimate probative value of this evidence. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Thus, even were the Board to assume the competency of her assertions of etiology to a burn injury of her feet during service, her statements nonetheless lack credibility due to lack of corroboration by the record. A review of her claims file does not confirm any current diagnosed foot disorder, especially burn scars or residuals of burn scars, which undercuts the credibility of her assertions. Also, she claimed in-service burns to both feet, while the STRs only confirm a burn to her left foot, and acute and transitory at that. Id. Moreover, a review of her claims file does not confirm any right knee injury in service, which undercuts the credibility of her assertions that an accidental fall during service directly caused her current right knee pain, in addition to secondarily damaging her left knee through overuse. Instead, her STRs only confirm an isolated left knee injury in 1982, which appears to have resolved by separation, in the absence of any follow-up treatment. To the extent her claimed right and left knee pain is traumatic in origin, there is no competent and credible, i.e., ultimately probative, evidence indicating the trauma occurred during or coincident with her military service, including in the manner alleged, as opposed to in incidents long after her service had ended. Id. Regarding the question of secondary service connection, an underlying disease or injury must first be service connected for the Veteran to claim secondary service connection. 38 C.F.R. 3.310. Here, the Board is denying service connection for a right knee disorder, which the Veteran claims to be the underlying disorder to which her left knee disorder is allegedly etiologically linked. So, without service connection in effect for the underlying right knee disorder, there is no service-connected disorder for which her left knee disorder may be secondary to. 38 C.F.R. 3.310. (In the event the Veteran was confused and inadvertently switched references to the right and left knees, the Board also finds no basis to establish direct service incurrence for a left knee disorder, so also precluding service connection for a right knee disorder, i.e., as secondary to the left knee.) Even assuming, but not conceding, for sake of argument, that a right knee disorder was service-connected, there is still no medical evidence of a nexus (i.e., link) between the right and left knee disorders (or even vice versa). Velez, 11 Vet. App. at 158. See also Wallin v. West, 11 Vet. App. 509, 512 (1998) and McQueen v. West, 13 Vet. App. 237 (1999) (both indicating, like Velez, that competent medical nexus evidence is required to associate the pancreatic disorder with the service-connected disability). Accordingly, the Board finds that the preponderance of the evidence is against service connection for burn scars of both feet, and right and left knee disorders. So there is no reasonable doubt to resolve in the Veteran's favor, and these claims must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Entitlement to Service Connection for a Dental Disorder The Veteran contends that "[dental] work was being done to provide [her] partial dental plates when [she] was released from the Army." She testified at her personal hearing that during service, approximately eight of her teeth were pulled out due to a root canal and other dental problems. She added the missing teeth were never replaced with dentures or fake teeth Essentially, she seeks service connection for the purpose of receiving VA outpatient dental treatment, to finish her allegedly incomplete dental work during military service. See 38 C.F.R. §§ 3.381, 4.150 (2009); see also 64 Fed. Reg. 30,392 (June 8, 1999); personal hearing transcript, at 7. Under the holding in Mays v. Brown, 5 Vet. App. 302, 306 (1993), a claim for service connection is also considered a claim for VA outpatient dental treatment. So the Board will consider her entitlement to service connection for both compensation and outpatient dental treatment. Service connection for compensation purposes can only be established for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150 (2009), such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. Compensation is available for loss of teeth only if due to loss of substance of the body of the maxilla or mandible. See Simmington v. West, 11 Vet. App. 41 (1998). For loss of teeth, bone loss through trauma or disease such as to osteomyelitis must be shown for purposes of compensability. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See Note to Diagnostic Code 9913, 38 C.F.R. § 4.150. Her dental STRs confirm her contention that she received extensive dental care during her period of active duty. The dental STRs indicate several teeth were removed, although the exact number is difficult to determine. Importantly, her dental STRs fail to show, nor does she contend, any dental trauma during service. Her separation examination was silent for any dental or jaw disorder. Here, the Veteran's dental records in service and other STRs fail to show that she sustained any damage to her maxilla (upper jaw bone) or mandible (lower jaw bone) during service. It follows that entitlement to compensation benefits for the loss of the body of the maxilla or mandible also is not shown. Thus, service connection may not be established for compensation purposes for missing or damaged teeth, as here. Id. Accordingly, the Board finds that entitlement to VA compensation benefits for a dental disorder is not warranted as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board must also alternatively consider whether service connection may be established for the purpose of outpatient dental treatment, based on the criteria set forth in 38 C.F.R. § 3.381. See Mays v. Brown, 5 Vet. App. 302 (1993); see also Douglas v. Derwinski, 2 Vet. App. 435, 440 (1992) (en banc) (holding that the Board is required to consider a Veteran's claim under all applicable provisions of law and regulation whether or not the claimant specifically raises the applicable provision); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The determination of whether service connection may be established for the purpose of outpatient dental treatment is based on the criteria set forth in 38 C.F.R. § 3.381. As provided by VA regulations, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses and periodontal disease are not considered to be disabling conditions, but may be considered service connected solely for the purpose of establishing eligibility for VA outpatient dental treatment. See 38 U.S.C.A. § 1712 (West 2002); 38 C.F.R. § 3.381(a), 17.161 (2009). Service connection may be granted for a dental condition of each tooth and periodontal tissue shown by the evidence to have been incurred in or aggravated by 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. 38 C.F.R. § 3.381(e). 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). There are various categories of eligibility for VA outpatient dental treatment, including Veterans having a compensable service-connected dental condition (Class I eligibility); one-time treatment for Veterans having a noncompensable service-connected dental condition (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 her 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. The Veteran does not qualify for Class I eligibility for VA dental treatment because, as discussed above, there is no basis for establishing service connection for any dental disorder for compensation purposes (Class I eligibility). The Veteran also fails to establish eligibility for Class II treatment, one-time dental treatment for Veterans having a noncompensable service-connected dental condition or disability in existence at the time of discharge. Class II eligibility requires that, for Veterans discharged after September 31, 1981, an application for treatment must be made within 180 days after discharge from service. See 73 FR 58875 (Oct. 8, 2008). The Veteran is ineligible for Class II treatment since she first applied for dental treatment in February 2006, over two decades after her separation from active duty service in August 1985, so far later than the requisite 180 days. Nor is there any indication the Veteran is a prisoner of war (POW), precluding entitlement to Class II(b) and Class II(c) treatment. See 38 C.F.R. § 17.161(d), (e). Nor is there any suggestion that she is entitled to Class IIR retroactive eligibility pursuant to 38 C.F.R. § 17.161(f). There is also no indication in the record that she has a dental condition that impairs or aggravates a service- connected condition (Class III eligibility), see 38 C.F.R. § 17.161(g); that she has disabilities rated as 100 percent disabling by schedular evaluation or due to individual unemployability (Class IV eligibility), or that she is a Chapter 31 vocational rehabilitation trainee (Class V eligibility). See 38 C.F.R. § 17.161(h), (i). Nor is she receiving or due to receive VA care and treatment under Chapter 17 (Class VI eligibility). See 38 C.F.R. § 17.161(j). The Board concedes the Veteran's assertion that several of her teeth were pulled out during the course of in-service dental treatment. Importantly, though, this simply cannot constitute dental trauma for establishing outpatient treatment purposes, as a matter of law. Therapeutic and restorative dental treatment, for example, fillings, bridges, and extractions, almost always involves physical impact of the teeth. The intended effect of dental treatment performed in service, including extractions of teeth, is not considered dental "trauma" as the term is defined in 38 C.F.R. §§ 3.381 and 17.161 (and former § 17.123(c)). See also 38 U.S.C.A. § 7104(c) (2008); Smith v. West, 11 Vet. App. 134 (1998). 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, 62 Fed. Reg. 15,566 (1997). Therefore, as the Veteran does not allege any injury to her teeth outside of the normal course of in-service dental treatment, the Board finds the Veteran did not suffer dental "trauma." 38 C.F.R. §§ 3.381 and 17.161. In summary, there is no basis to grant service connection for a dental disorder for VA compensation or outpatient treatment purposes as a matter of law. The Board is sympathetic to the Veteran's arguments but, unfortunately, is unable to provide a legal remedy. See Owings v. Brown, 8 Vet. App. 17, 23 (1995), quoting Kelly v. Derwinski, 3 Vet. App. 171, 172 (1992) ("This Court must interpret the law as it exists, and cannot 'extend . . . benefits out of sympathy for a particular [claimant].'"). Since the Veteran's claim fails because of absence of legal merit or lack of entitlement under the law, the claim must be denied. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). ORDER The claim for service connection for burn scars on the feet is denied. The claim for service connection for a right knee disorder is denied. The claim for service connection for a left knee disorder, including secondary to the right knee disorder, is denied. The claim for service connection for a dental disorder, for compensation and/or treatment purposes, is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs