Citation Nr: 1100372 Decision Date: 01/04/11 Archive Date: 01/11/11 DOCKET NO. 06-09 896 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to June 14, 2010. 2. Entitlement to a rating in excess of 70 percent for PTSD from June 14, 2010. 3. Whether new and material evidence has been submitted to reopen a claim for service connection for loss of teeth due to injury. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michael J. Skaltsounis, Counsel INTRODUCTION The Veteran had active service from June 1966 to June 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which denied an application to reopen a claim for service connection for loss of teeth due to injury and granted service connection and assigned a 30 percent rating for PTSD, effective from November 30, 2004. A July 2010 rating decision has recently increased the rating for PTSD to 70 percent, effective from June 14, 2010. The Veteran has continued his appeal. Jurisdiction over the claims lies with the RO in Boston, Massachusetts. In March 2009, a hearing was held before the undersigned Veterans Law Judge making this decision. See 38 U.S.C.A. § 7107(c) (West 2002). In June 2009, the Board remanded the claims for procedural and evidentiary considerations. The Board also determined that the issues of entitlement to service connection for shrapnel fragments of the neck and erectile dysfunction had been raised by the record, but had not yet been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board determined that it did not have jurisdiction over them, and they were referred to the AOJ for appropriate action. As the Board's review of the record does not reveal that the AOJ took any action with respect to these claims, the Board will once again refer these matters for appropriate consideration. Finally, the Board finds that as a result of a July 2009 Vet Center social worker's report and VA PTSD examination results from June 2010, the record has raised a claim for TDIU as an included claim within the Veteran's currently pending increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, this issue has been added as an additional subject for current appellate consideration. However, additional development is required with respect to this claim. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Before June 14, 2010, the Veteran's PTSD was manifested by symptoms that more nearly approximated occupational and social impairment, with deficiencies in most areas, but not total occupational and social impairment. 2. Since June 14, 2010, the Veteran's PTSD was manifested by symptoms that more nearly approximated occupational and social impairment, with deficiencies in most areas, but not total occupational and social impairment. 3. A claim for service connection for loss of teeth due to injury was denied by a September 1982 rating decision that was not appealed. 4. The evidence submitted since the September 1982 rating decision pertinent to the claim for service connection for loss of teeth due to injury is either cumulative or redundant, does not relate to an unestablished fact necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. For the period prior to June 14, 2010, the criteria for an initial 70 percent rating, but not greater, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.7, 4.130, Diagnostic Code 9411 (2010). 2. Since June 14, 2010, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.7, 4.130, Diagnostic Code 9411 (2010). 3. The September 1982 rating decision, which denied the Veteran's claim for service connection for loss of teeth due to injury, is final. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. §§ 3.104, 3.156, 20.1103 (2010). 4. New and material evidence has not been submitted since the September 1982 rating decision pertinent to the claim for service connection for loss of teeth due to injury, and the claim is not reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veteran's increased rating claims arise from the Veteran's disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlop v. Nicholson, 21 Vet. App. 112 (2007). With respect to the Veteran's new and material claim, the Veterans Claims Assistance Act of 2000 (VCAA), (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010)), imposes obligations on VA in terms of its duty to notify and assist claimants. Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice must be provided prior to the initial unfavorable adjudication by the RO. Id. at 120. VCAA notice requirements apply to all five elements of a service connection claim. Those five elements include: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Prior to the adjudication of the application to reopen the claim for service connection for loss of teeth due to injury, a January 2005 letter advised the Veteran of the evidence necessary to substantiate a claim for service connection, including the type of evidence required to reopen his previously denied claim, advised of his and VA's respective duties, and asked to submit information and/or evidence, which would include that in his possession, to the RO. The content of this and more complete notice provided in September 2009 complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), and Kent v. Nicholson, 20 Vet. App. 1 (2006). A March 2006 letter and the September 2009 letter also advised the Veteran of the bases for assigning ratings and effective dates, and were respectively followed by readjudication of the claim in a November 2006 statement of the case and July 2010 supplemental statement of the case. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent post-service treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained all available service and VA treatment records. The Veteran was also afforded multiple VA examinations to support his increased rating claim, and the Veteran has not argued that the most recent VA examination was inadequate for rating purposes. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Although the Veteran was not afforded an examination and etiological opinion with respect to his application to reopen the claim for service connection for loss of teeth due to injury, since 38 C.F.R. § 3.159(c)(4) does not apply to finally adjudicated claims unless new and material evidence has been received, and the Board has concluded that such evidence has not been received as to the application to reopen a claim for service connection for loss of teeth due to injury, the Board finds that an examination and etiological opinion is not warranted as to this claim. See 38 C.F.R. § 3.159(c)(4)(C)(iii). The Board therefore finds that VA has satisfied its duty to notify and the duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103 (West 2002); 38 C.F.R. §§ 3.159(b), 20.1102 (2009); Dingess v. Nicholson, 19 Vet. App. 473 (2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Veteran has also not claimed that VA has failed to comply with the requirements of the VCAA. II. Increased Rating Claim Service-connected disabilities are rated in accordance with VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (Schedule), which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. When after considering carefully all procurable and assembled data a reasonable doubt arises regarding the degree of disability, the Board shall resolve such doubt in favor of the claimant. 38 C.F.R. § 4.3. In all such claims, separate ratings for separate periods of time, as the evidence may show, is considered. See Fenderson v. West, 12 Vet. App. 119 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim, or whether a preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As was noted previously, in May 2005, the RO granted service connection for PTSD and assigned an initial 30 percent rating, from November 2004. In July 2010, the RO assigned an evaluation of 70 percent for PTSD, effective June 14, 2010. PTSD is rated under Diagnostic Code 9411, which provides for a 50 percent rating where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long- term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of the Veteran's close relatives, own occupation, or own name. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service- connected mental condition that affect the level of occupational or social impairment. Id. at 443. Under the Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) (DSM-IV), global assessment of functioning (GAF) scale scores of 51 to 60 generally reflect some moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores from 41 to 50 reflect serious symptoms (suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). VA PTSD examination in February 2005 revealed that the Veteran had not received any treatment at VA over the previous ten years, but had treated at the Vet Center two years earlier. He denied any relevant hospitalizations and was currently employed with the fire department, where he had been employed for 23 years. He voiced the belief that his time at the fire department would not continue much longer due to severe arthritis in the knees. He had been married since 1971 and had one son. He denied socializing much and leisure activities were reportedly limited. He did watch television and occasionally went on trips with his wife. Mental status examination revealed no evidence of a thought disorder. The Veteran denied delusions or ideas of reference. He did state that he had "images" of Vietnam nearly every day that appeared to the examiner to be short flashbacks on further description. The Veteran indicated that he had been suicidal in the past but never had a plan and currently denied suicidal or homicidal ideation. He was able to maintain his activities of daily living, and was oriented in all spheres. The Veteran reported that his memory was poor for dates and names, and that he had to write things down in order to remember them. He also reported panic attacks in the past but none recently. He endorsed depression which he stated occurred "in phases off and on." His sleep was described as fitful and he arose at night to check the doors and windows. The Axis I diagnosis was PTSD, chronic and moderate to severe, and the Veteran was assigned a global assessment of functioning (GAF) scale score of 47. At the Veteran's hearing before the Board in March 2009, the Veteran testified that he was recently retired from the fire department, where he had been employed for 25 years (transcript (T.) at p. 4). When he was on the job, he worked two 14 hour shifts at night followed by a day off, and he would have difficulty sleeping during the night (T. at pp. 5-6). He had also previously abused alcohol but did not do so currently (T. at p. 6). While he characterized his marriage as decent, he stated that he was easily agitated, anxious, and depressed (T. at p. 7). Vet Center records for the period of March to December 2009 reflect that in March 2009, the Veteran's PTSD symptoms included memory loss, illogical speech, disorganized thinking, and difficulty concentrating. During the same time period as his last VA examination in 2005, the Veteran took early retirement, and reported that his PTSD was a major factor in addition to stroke. Symptoms of PTSD included memory loss, illogical language, recurrent distressing images, hypervigilance, unprovoked outbursts of irritability, and diminished social network (now only combat veterans). In early May 2009, the Veteran was noted to have a limited affect. It was also noted that the plan included specifying unemployability in a letter supporting increased VA compensation. In a July 2009 medical statement from the Veteran's most recent treating social worker at the Vet Center, the Veteran's social worker indicated that the Veteran reported that his chronic sleep problems had worsened since his retirement from the fire department in 2005. The Veteran reported awakening every two hours. He also stated that he had nightmares regularly. This examiner also noted that the Veteran expressed having constant thoughts of killing himself, and reported panic attacks and only feeling safe when he was alone. His spouse also stated that since the Veteran's retirement, he had been neglecting his personal care. In conclusion, this examiner stated that the Veteran had chronic PTSD related to his two combat-tours in Vietnam, and that he was permanently unemployable due to his PTSD. The examiner further commented that his only social connection was his wife and that he did not trust other people. An August 2009 VA outpatient consultation record indicates that the Veteran had been struggling with sleep problems for the previous 40 years, and that his symptoms worsened after he received early retirement due to arthritis about four years earlier. Over the previous few months, the Veteran described his mood as "irritable." He denied feelings of hopelessness/helplessness. He also denied suicidal/homicidal ideation. The Veteran indicated that his activities had been limited since he had a stroke in 2007. He further mentioned being "depressed" in the past along with missing occasional days from work due to his symptoms and thoughts of hurting himself without any specific plan. The Veteran denied having symptoms of mania/hypomania such as elevated mood, decreased need for sleep, increased energy, or taking part in risk taking behaviors. He also denied psychotic symptoms such as hallucinations, panic attacks, excessively worrying, or obsessive-compulsive behavior. Mental status examination revealed that the Veteran was alert and attentive. He was somewhat disheveled and had poor hygiene. His mood was described as "okay" and affect was mood-congruent and appropriate. The Veteran was not considered delusional and insight and judgment were described as good. The Axis I diagnosis was PTSD, chronic, alcohol abuse, in remission, cognitive disorder not otherwise specified, rule out mood disorder to general medical condition, such as cerebrovascular accident, and rule out history of major depressive episode. The Veteran was assigned a GAF of 45. This examiner summarized that the Veteran had a history of PTSD, alcohol abuse (in remission) along with other medical comorbidities including cerebrovascular accident, who was being evaluated for PTSD. He further stated that psychosocial stressors such as the Veteran's early retirement from gainful employment due to arthritis and history of stroke in 2007 may have worsened his symptoms, leading him to seek further help. A VA outpatient record entry dated at the end of August 2009 reflects that certain medication had helped him to fall asleep but that he would awaken once during the night and go back to sleep in approximately one hour. The Veteran was noted to be well-dressed as compared with his previous consultation. In September 2009, it was noted that the Veteran indicated having increased sleep and denied having worsening symptoms of PTSD. The Veteran was again assigned a GAF of 45. In October 2009, however, it was noted that the Veteran's sleep continued to be disrupted in the middle of the night and that he experienced an increase in intrusive memories. The Veteran was assigned a GAF of 48. In December 2009, the Veteran stated that he felt less irritable and that the relationship with his wife was improving. The Veteran was assigned a GAF of 50. In a medical statement, dated in December 2009, the Veteran's most recent treating social worker at the Vet Center indicated that the Veteran had severe PTSD and should be rated at 70 percent. VA treatment records further reflect that while the Veteran was assigned GAFs of 55 over the period of January to May 2010, in June 2010, it was noted that he endorsed suicidal ideation and was assigned a GAF of 45. The Veteran then stated that the last occasion he had suicidal thoughts was about six months earlier. He denied homicidal thoughts. The Veteran also continued to be forgetful and had panic attacks once or twice a year. He also endorsed depression but was unable to rate his level of depression. Additionally, the Veteran continued to suffer with sleep impairment. There was also evidence of hypervigilance and irritability. The Axis I diagnosis was PTSD, chronic and moderately severe, and alcohol abuse, in full remission. The Veteran again noted that his PTSD had worsened since his retirement, and that his irritability and difficulty in getting along with others contributed to his retirement, although the examiner noted there were also issues of physical problems from arthritis. VA PTSD examination in June 2010 was conducted by the same examiner who conducted the Veteran's last VA PTSD examination in February 2005. It was noted that the Veteran continued to receive monthly treatment at VA, and was also attending a Vet Center, where he saw a counselor at the rate of approximately twice a month. The examiner noted that the records indicated that the Veteran retired from the fire department in part because of advancing arthritis but also because of the stress. The Veteran thereafter worked briefly as a plumber but then had a stroke a year later, and had not been able to work at all since that time. Mental status examination revealed that the Veteran was cooperative and casually dressed, and showed no overt evidence of a thought disorder. He walked with a cane. He denied delusions or ideas of reference. He endorsed suicidal ideation, the last time being about six months earlier. He denied homicidal thoughts. He was able to maintain the activities of daily living. His short-term memory was poor and the Veteran was forgetful. He also reported panic attacks at the rate of once or twice a year. He continued to have depression and a chronic sleep impairment, with difficulty falling asleep and then maintaining sleep. The examiner commented that the Veteran reported that his PTSD symptoms had worsened since his retirement, with sleep walking and increased hypervigilance. The Veteran also reported increased irritability. The Axis I diagnosis was PTSD, chronic and moderately severe, and alcohol abuse, in full remission. The Veteran was assigned a GAF of 45. The examiner noted that while the Veteran reported that his irritability and difficulty getting along with people contributed to his retirement, there were also issues of physical problems with arthritis, and the Veteran worked briefly as a plumber before having a stroke. Turning first to the period prior to June 14, 2010, the medical evidence documenting the level of severity of the Veteran's PTSD for this period begins with the February 2005 VA PTSD examination results and thereafter is not supported by additional documentary evidence until March 2009. However, the same examiner conducted both VA examinations and despite the fact that he noted the Veteran's report of worsening symptoms since the Veteran's retirement (2006), the Axis I diagnosis in February 2005 of chronic, moderate to severe PTSD, was, in essence, the same diagnosis provided in June 2010 of chronic, moderately severe PTSD; the respective GAF scores of 47 and 45 were both representative of serious occupational and social impairment and consistent with the majority of the other GAF scores of record; and the Veteran's most prevalent continuing symptoms of disrupted sleep, impaired short-term memory, intermittent depression, intermittent panic attacks, estrangement from others, daily flashbacks, and intermittently poor hygiene have continued throughout the entire time frame on appeal. Therefore, giving the Veteran the benefit of the doubt, the Board finds that the criteria for a 70 percent rating have been met since the establishment of service connection for this disorder. On the other hand, turning to the issue of entitlement to a 100 percent schedular rating at any stage during the time frame on appeal, in addition to the fact that the Veteran did not retire until after he filed his claim for service connection for PTSD, the Board's review of the evidence as a whole reflects that with the exception of the Veteran's most recent social worker in July 2009, no examiner has found that the Veteran had total occupational impairment as the sole result of his PTSD. Instead, other examiners have simply noted the Veteran's statements of other contributing factors such as the Veteran's stroke in 2007 and his arthritis, which are not service-connected disabilities. In addition, to the extent that the Veteran's most recent social worker found the Veteran unemployable solely due to his PTSD, a review of the facts contained within that report reflects an assessment of symptoms that is inflated in comparison with all of the other treatment and examination of records. More specifically, in describing the Veteran's symptoms of PTSD, the social worker's statements indicating that the Veteran awakened every two hours at night, was experiencing constant suicidal thoughts, only felt safe when at home, and neglected his personal care, are all found to be overstatements of the more frequent reports of awakening once in the middle of the night, panic attacks at the rate of one or twice a year, periodically diminished personal hygiene, and periodic passive suicidal ideation. It should also be noted that a 100 percent rating requires total social and occupational impairment, and with the Veteran clearly able to work until 2006, and the fact that of the criteria for a 100 percent rating only some impairment in thought processes and periodically poor personal hygiene were demonstrated during this period, the Board finds that at no stage during the entire time frame on appeal was the Veteran's PTSD ever manifested by symptoms that more nearly approximated total occupational and social impairment. In addition, the Board would point out that the rating schedule represents as far as practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2010). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate. Second, if the schedular rating does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional 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. During the entire time frame on appeal, the Veteran's symptoms associated with his service-connected PTSD were moderately severe and made it difficult for the Veteran to carry on work-related activities. Such impairment is contemplated by the applicable rating criteria. The rating criteria reasonably describe the Veteran's disability. Referral for consideration of an extraschedular rating for the time period relevant on appeal is, therefore, not warranted. III. New and Material Claim Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). The record with respect to this claim reflects that the September 1982 rating decision denied service connection for loss of teeth due to injury, and that the Veteran did not file a timely notice of disagreement as to that decision. Accordingly, it became final. Evans v. Brown, 9 Vet. App. 273, 285 (1996). As such, the Veteran's claim for service connection for loss of teeth due to injury may only be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108; 38 C.F.R. 3.156. Evidence is new if it has not been previously submitted to agency decision makers. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. In this regard, the Board notes that, in a recent case, the Court clarified that the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Shade v. Shinseki, No. 08-3548 (U.S. Vet. App. Nov. 2, 2010). Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. For purposes of determining whether VA has received new and material evidence sufficient to reopen a previously-denied claim, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992); see also Madden v. Gober, 125 F.3d 1477, 1481 (1997); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). With respect to the claim for service connection for loss of teeth due to injury, based on the grounds stated for the denial in the September 1982 rating decision, new and material evidence to reopen the claim for service connection for loss of teeth due to injury would be evidence of injury to the jaw that resulted in the loss of teeth. In this regard, additional evidence received since the September 1982 rating decision includes additional VA treatment and examination records documenting some scarring on the Veteran's upper lip, and additional statements and testimony from the Veteran regarding the circumstances of the in-service dental trauma that resulted in the loss of teeth. However, the Board cannot conclude that such evidence constitutes new and material evidence to reopen the claim. More specifically, although the Veteran may have sustained some trauma to his upper lip, there is still no competent evidence linking tooth loss and/or an identifiable dental disability to an injury to the Veteran's jaw during service (see 38 C.F.R. § 4.150, Diagnostic Code 9913 (2010). In addition, the Veteran's statements about being struck by a board on the face during service are cumulative of statements made at the time of the last final denial in September 1982. It should also be remembered that the term "service trauma" does not include the intended effects of therapy or restorative dental care and treatment provided during a Veteran's military service (see 38 C.F.R. § 3.306(b)(1) (2010); VAOGCPREC 5-97), and that absent a demonstration of dental trauma, service connection may be considered solely for the purpose of determining entitlement to VA dental examinations or outpatient dental treatment. Woodson v. Brown, 8 Vet. App. 352, 354 (1995). Therefore, the Board finds that it has no alternative but to conclude that the additional evidence received in this case as to the claim for service connection for loss of teeth due to injury does not relate to an unestablished fact necessary to substantiate the claim and thus is not material. It is also not material because it is essentially redundant of assertions maintained at the time of the previous final denial in September 1982, and does not raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2010). ORDER Entitlement to an initial 70 percent rating, but not greater, for PTSD prior to June 14, 2010, is granted, subject to the statutes and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 70 percent for PTSD since June 14, 2010, is denied. New and material evidence not having been submitted, the application to reopen the claim for service connection for loss of teeth due to injury is denied. REMAND As was noted previously, as a result of a July 2009 Vet Center social worker's report and VA PTSD examination results from June 2010, the Board finds that the record has raised an additional claim for TDIU as an included claim within the Veteran's claim for an increased rating for his PTSD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the Board finds that the Veteran should be provided with an examination and opinion as to whether the Veteran's service-connected disabilities render him unable to secure or follow substantially gainful employment. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran about (1) the information and evidence not of record that is necessary to substantiate his claim for a TDIU; (2) the information and evidence that VA will seek to obtain on his behalf; and (3) the information or evidence that he is expected to provide. A copy of this notification must be associated with the claims folder. 2. Thereafter, schedule the Veteran for appropriate VA examination to determine the impact that his service-connected disabilities have on his ability to secure or follow substantially gainful employment. The claims folder should be made available to and reviewed by the examiner. All indicated studies should be conducted. The examiner should state the degree to which the Veteran's service-connected disabilities of PTSD, diabetes mellitus, type II, malaria, tinnitus, and bilateral hearing loss affect his ability to secure or follow substantially gainful employment. All opinions must be supported by a clear rationale. 3. Read the medical opinion obtained to ensure that the remand directives have been accomplished, and return the case to the examiner if all questions posed are not answered. 4. Finally, adjudicate the claim for a TDIU. If the benefit sought on appeal is not granted in full, a supplemental statement of the case should be issued and the Veteran and his representative provided an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs