Citation Nr: 1210504 Decision Date: 03/21/12 Archive Date: 03/30/12 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 extraschedular evaluation for trigeminal nerve injury. 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 S. B. Mays, 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 hearing at the VA Central Office in Washington, DC. The hearing transcript has been associated with the claims file and has been reviewed. 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. In September 2009, the Board denied the Veteran's service connection claim for dental trauma and determined that the criteria for a 30 percent evaluation for intractable sural nerve entrapment syndrome of the left ankle had been met. The Veteran appealed the September 2009 Board's decision that denied service connection for dental trauma to the United States Court of Appeals for Veterans Claims (Court). In a September 2011 Memorandum Decision, the Court vacated the Board's denial of service connection for dental trauma and remanded it to the Board for additional consideration. The Court found that because the uncontroverted evidence indicated that the Veteran was eligible for secondary service connection for his chronic periodontal disease and because the Board made that determination in its decision on appeal, the Court reversed the Board's decision with respect to service connection and instructed the Board to grant service connection for the Veteran's periodontal disease, originally claimed as "dental trauma" as secondary to the Veteran's service-connected trigeminal nerve injury. The Court noted that service connection did not establish entitlement to disability compensation, but only established that the Veteran may be entitled to dental treatment under 38 C.F.R. § 17.161. The Court found that the Board failed to address whether the Veteran's service-connected trigeminal nerve injury could be considered a "service trauma" for the purposes of 38 C.F.R. § 17.161(c) (Class II(a) VA outpatient dental treatment), and remanded the case for consideration of this matter. The Court also found that the Board failed to address whether the Veteran might be entitled to Class VI outpatient dental treatment and directed the Board to consider this issue. Finally, the Court noted that although the RO determined that the award of a 50 percent disability evaluation (the highest available schedular rating) for the Veteran's trigeminal nerve injury was a complete grant of benefits and closed the Veteran's appeal as to that issue, the RO failed to consider the possibility of a higher rating through extraschedular consideration. See March 2008 RO rating decision. The case was remanded so that the Board could consider whether the Veteran's condition required a referral for an extraschedular rating for his service-connected trigeminal nerve injury. Finally, the Board notes that on appeal to the Court, the Veteran did not present argument on his increased rating claim for nerve impairment of the left ankle that was adjudicated in the September 2009 decision and therefore that claim was deemed abandoned. In reviewing this case, the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. As will be discussed in further below, the Court in its 2011 Memorandum Decision remanded to the Board the issue of entitlement to an extraschedular evaluation for trigeminal nerve injury. As such, that issue 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. The Veteran sustained injury to his trigeminal nerve during service and such injury constitutes 'service trauma'. 2. The medical evidence shows that the Veteran's trigeminal nerve injury results in the inability to maintain good oral hygiene and, as a result, has led to his chronic periodontal disease. CONCLUSION OF LAW Chronic periodontal disease is proximately due to the Veteran's service-connected trigeminal nerve injury, and the criteria for Class II(a) VA outpatient dental treatment are met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.381, 17.161 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Background The record reflects that the Veteran served for more than 180 days, from December 1999 to February 2004, and he was honorably discharged. 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 tooth 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. 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. VA treatment records dated in June 2007 show that the Veteran has current diagnoses of periodontitis and chronic gingivitis. 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. 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 history as provided by the Veteran. 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. 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. The Veteran also testified during his January 2009 Central Office 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 April 2010, the Veteran underwent an additional authorized examination in connection with a separate claim. He reported gum and inner cheek numbness of the lower half of the right side of his face. The Veteran's diagnosis of trigeminal nerve injury remained the same. In June 2011, the Veteran underwent an additional authorized dental examination. The loss of teeth did not accompany loss of masticatory surface. There was plaque buildup and the gingival were inflamed and showed poor oral hygiene. The Veteran had speech difficulties because of his dental condition. He was not able to control how his tongue moved or feel where it is in the mouth. II. Legal Criteria General Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). 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) (2011). 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. Dental Conditions In the VA benefits system, dental disabilities are treated differently from medical disabilities. The Court has held that a claim for service connection for dental compensation is also a claim for service connection for outpatient dental treatment purposes. Mays v. Brown, 5 Vet. App. 302 (1993). 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 as provided in § 17.161 of this chapter. 38 C.F.R. § 3.381(a) (2011). 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 line of duty during active service. When applicable, the rating activity will determine whether the condition is due to combat or other in-service trauma, or whether the Veteran was interned as a prisoner of war. 38 C.F.R. § 3.381(b). In determining service connection, the condition of teeth and periodontal tissues at the time of entry into active duty will be considered. Treatment during service, including filling or extraction of a tooth, or placement of a prosthesis, will not be considered evidence of aggravation of a condition that was noted at entry, unless additional pathology developed after 180 days or more of active service. 38 C.F.R. § 3.381(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 considered service connected for treatment purposes: (1) calculus; (2) acute periodontal disease; (3) third 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). 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(f). Certain dental conditions, including periodontal disease, treatable carious teeth, and replaceable missing teeth (i.e. with a bridge or denture), are not considered disabling, and may be service connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment under the provisions of 38 C.F.R. §§ 17.120 or 17.123, but not for purposes of compensation. The provisions of 38 U.S.C.A. § 1712(a)(1) provide that outpatient dental services and treatment, and related dental appliances, will be furnished only for a dental condition or disability which is service-connected and compensable in degree; or is service-connected, but not compensable in degree, if the Veteran qualifies under one of the categories outlined in subsection (b) of 38 U.S.C.A. § 1712 and in 38 C.F.R. § 17.161 (2011). The provisions of 38 U.S.C.A. § 1712(a)(1) provide that outpatient dental services and treatment, and related dental appliances, will be furnished only for a dental condition or disability which: (A) is service-connected and compensable in degree; or (B) is service-connected, but not compensable in degree, if : (i) the dental condition or disability is shown to have been in existence at the time of the Veteran's discharge or release from active military, naval, or air service; (ii) the Veteran had served on active duty for a period of not less than 180 days or, (iii) application for treatment is made within 90 days after such discharge or release, except that (I) in the date of such Veteran's subsequent discharge or release from such service, and (II) if a disqualifying discharge or release has been corrected by competent authority, application may be made within 90 days after the date of correction; and (iv) the Veteran's certificate of discharge or release from active duty does not bear a certification that the Veteran was provided, within the 90-day period immediately before the date of such discharge or release, a complete dental examination (including dental x- rays) and all appropriate dental services and treatment indicated by the examination to be needed; (C) is a service-connected dental condition or disability due to combat wounds or other service trauma, or of a former POW; (D) is associated with and is aggravating a disability resulting from some other disease or injury which was incurred in or aggravated by active military, naval, or air service; (E) is a non-service-connected condition or disability of a Veteran for which treatment was begun while such Veteran was receiving hospital care under this chapter and such services and treatment are reasonably necessary to complete such treatment; or where, (F) the Veteran is a former POW who was detained or interned for a period of not less than 90 days; (G) the Veteran has a service-connected disability rated as total; or where, (H) the dental treatment is medically necessary (i) in preparation for hospital admission, or (ii) for a Veteran otherwise receiving care or services under this chapter. 38 U.S.C.A. § 1712(a)(1),(2). Under 38 C.F.R. § 17.161 (2011), outpatient dental treatment may be authorized if the claimant falls into one of several enumerated classes. See also 38 U.S.C.A. § 1712(b) (West 2002); 38 C.F.R. § 17.93. Under Class I, those having a service-connected compensable dental disability or condition may be authorized any dental treatment indicated as reasonably necessary to maintain oral health and masticatory function. There is no time limitation for making an application for treatment and no restriction as to the number of repeat episodes of treatment. 38 C.F.R. § 17.161(a). Under Class II, those having a service-connected noncompensable dental condition or disability shown to have been in existence at the time of discharge or release from active service, which took place after September 30, 1981, may be authorized any treatment indicated as reasonably necessary for the one-time correction of the service- connected noncompensable condition, but only if: (i) they served on active duty during the Persian Gulf War and were discharged or released, under conditions other than dishonorable, for a period of active military, naval, or air service of not less than 90 days, or they were discharged or released under conditions other than dishonorable from any other period of active military, naval, or air service of not less than 180 days; (ii) application for treatment is made within 90 days of such discharge or release; (iii) the certificate of discharge or release does not bear a certification that the Veteran was provided, within the 90 day period immediately before such discharge or release, a complete dental examination (including dental X-rays) and all appropriate dental treatment indicated by the examination to be needed; and (iv) a VA dental examination is completed within six months after discharge or release, unless delayed through no fault of the Veteran. Those Veterans discharged from their final period of service after August 12, 1981 who reentered active military service within 90 days after the date of a discharge or release from a prior period of active military service may apply for treatment of service-connected noncompensable dental conditions relating to any such periods of service within 90 days from the date of their final discharge or release. If competent authority has corrected a disqualifying discharge or release, application may be made within 90 days after the date of correction. 38 C.F.R. § 17.161(b)(1). Class II also includes those Veterans having a service- connected noncompensable dental condition or disability shown to have been in existence at the time of discharge or release from active service which took place before October 1, 1981 in certain cases. Such Veterans may be authorized treatment indicated as reasonably necessary for the one-time correction of the service-connected noncompensable condition, but only if: (i) they were discharged or released, under conditions other than dishonorable, from a period of active military, naval, or air service of not less than 180 days; (ii) application for treatment is made within one year after such discharge or release; and (iii) a VA dental examination is completed within 14 months after discharge or release, unless delayed through no fault of the Veteran. Those Veterans discharged from their final period of service before August 13, 1981, who had reentered active military service within one year from the date of a prior discharge or release, may apply for treatment of service-connected noncompensable dental conditions relating to any such prior periods of service within one year of their final discharge or release. If a disqualifying discharge or release has been corrected by competent authority, application may be made within one year after the date of correction. 38 C.F.R. § 17.161(b)(2). Under Class II(a), those having a service-connected noncompensable dental condition or disability adjudicated as resulting from combat wounds or service trauma may be authorized any treatment indicated as reasonably necessary for the correction of such service-connected noncompensable condition or disability. 38 C.F.R. § 17.161(c). Under Class II(b), those having a service-connected noncompensable dental condition or disability and who had been detained or interned as prisoners of war for a period of less than 90 days may be authorized any treatment as reasonably necessary for the correction of such service- connected dental condition or disability. 38 C.F.R. § 17.161(d). Under Class II(c), those who were prisoners of war for 90 days or more, as determined by the concerned military service department, may be authorized any needed dental treatment. 38 C.F.R. § 17.161(e). Under Class IIR, any Veteran who had made prior application for and received dental treatment from the VA for noncompensable dental conditions, but was denied replacement of missing teeth which were lost during any period of service prior to his/her last period of service may be authorized such previously denied benefits under the following conditions: (i) an application for such retroactive benefits is made within one year of April 5, 1983; and (ii) existing VA records reflect a prior denial of the claim. 38 C.F.R. § 17.161(f). Under Class III, those having a dental condition professionally determined to be aggravating disability from an associated service-connected condition or disability may be authorized dental treatment for only those dental conditions which, in sound professional judgment, are having a direct and material detrimental effect upon the associated basic condition or disability. 38 C.F.R. § 17.161(g). Under Class IV, those whose service-connected disabilities are rated at 100 percent by schedular evaluation, or those who are entitled to the 100 percent rate by reason of individual unemployability, may be authorized any needed dental treatment. 38 C.F.R. § 17.161(h). Under Class V, a Veteran who is participating in a rehabilitation program under 38 U.S.C.A., Chapter 31, may be authorized dental services as are professionally determined to be necessary for any of the reasons enumerated in 38 C.F.R. § 17.47(g) (2011). 38 C.F.R. § 17.161(i). Under Class VI, any Veterans scheduled for admission or are otherwise receiving care and service under 38 U.S.C.A., Chapter 17, may receive outpatient dental care which is medically necessary (i.e., for a dental condition clinically determined to be complicating a medical condition currently under treatment). 38 C.F.R. § 17.161(j). The Board notes that in essence, the significance of a finding that a noncompensable service-connected dental condition is due to dental trauma, as opposed to other causes, is that VA provides any reasonably necessary dental treatment, without time limitations, for conditions which are attributable to the service trauma, whereas other service-connected noncompensable dental conditions are typically subject to limitations of one-time treatment and timely application after service. 38 U.S.C.A. § 1712; 38 C.F.R. § 17.161 (2011). III. Analysis The Veteran seeks service connection for dental trauma. In this decision, the Board grants service connection for chronic periodontal disease as secondary to his service-connected trigeminal nerve injury, which represents a complete grant of the benefits sought on appeal. As such, no discussion of VA's duty to notify and assist is necessary. As indicated, the Veteran indicates that after undergoing surgery during service to extract his impacted third molars, he developed numbness in his tongue. The Veteran, as a layperson, is competent to report observable symptoms. The Board finds that the Veteran is both competent to report his medical history, and credible in his reports. The Veteran's lay history is well-supported by medical evidence of record. There is competent medical evidence of a current disability. In this regard, VA and private treatment records show that the Veteran has current diagnoses of periodontitis and chronic gingivitis. 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 Board recognizes that Dr. C.N.B. indicated that the Veteran had "dental problems (caries/periodontitis)", however this diagnosis was not associated with a dental examination. Moreover, a March 2008 VA authorized dental examination which included x-rays, did not reflect any current dental caries, and during a December 2008 dental examination, Dr. S.B. stated that there were no carious lesions detected. The preponderance of the medical evidence therefore does not show that the Veteran has current carious teeth. Accordingly, the Board finds that the Veteran's only currently diagnosed dental disabilities are periodontitis and chronic gingivitis. Significantly, the competent medical evidence of record shows that the Veteran's chronic periodontal disease is proximately due 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.) Indeed, the Court, in its 2011 Memorandum Decision indicated that there is uncontroverted evidence that the Veteran is eligible for secondary service connection for his chronic periodontal disease. However, because chronic periodontal disease is noncompensable and therefore does not fall under the categories of compensable dental conditions as set forth in 38 C.F.R. § 4.150, the Veteran is not entitled to VA compensation for his periodontal disease. Importantly however the grant of service connection for chronic periodontal disease establishes that the Veteran may be entitled to outpatient dental treatment under 38 C.F.R. § 17.161 (2011). As indicated, the Veteran's chronic periodontal disease is not a disorder for which service connection can be granted for compensation because this is precluded by regulation. Therefore, service connection for the purposes of Class I treatment is not warranted. However, on review, the Board concludes that the Veteran is entitled to Class II (a) outpatient dental treatment. The Veteran does not contend that the trauma incurred during service is the extraction of his teeth; indeed, dental extractions during service are not tantamount to dental "trauma". See VAOPGCPREC 5- 97 (January 22, 1997). Rather, the Veteran maintains that the trauma suffered during service is the injury to his trigeminal nerve. Thus the dispositive question is whether the Veteran's trigeminal nerve injury constitutes 'service trauma' as contemplated by the controlling regulations and case law. Pertaining to dental compensation claims, the United States Court of Appeals for the Federal Circuit (Federal Circuit) defined "service trauma" as "an injury or wound produced by an external force during the service member's performance of military duties." See Nielson v. Shinseki, 607 F.3d 802, 808 (Fed. Cir. 2010). The definition excluded "the intended result of proper medical treatment." Id. However, in Nielson, the Federal Circuit specifically noted, "We do not, however, suggest that an unintended result of medical treatment due to military negligence or malpractice could not be a 'service trauma'..." Id. The injury to the Veteran's trigeminal nerve was an unintended result of the dental surgery and therefore could reasonably be considered a trauma during service. Indeed, service connection for the trigeminal nerve injury was granted on the basis that it was incurred during service. Thus, in light of the Veteran's competent and credible statements of in-service injury, the holding in Nielson, and with resolution of any doubt in the Veteran's favor, the Board believes that the evidence establishes that the trigeminal nerve injury during service was a "service trauma', and that secondary service connection for periodontal disease, as a noncompensable disability, is established. In light of the Board's grant of service connection for chronic periodontal disease, the Veteran is thereby entitled to Class II(a) outpatient dental treatment. The appeal is accordingly allowed. The Board acknowledges the Veteran's alternative argument that he is entitled to Class VI outpatient dental treatment pursuant to 38 C.F.R. § 17.161(i) (2011); however, as eligibility for Class II(a) outpatient dental treatment is already established, further analysis is unnecessary. ORDER Service connection for chronic periodontal disease secondary to service-connected trigeminal nerve injury is granted solely for purposes of entitlement to VA outpatient dental treatment, and the criteria for Class II(a) VA outpatient dental treatment are met; the appeal is granted. REMAND The Veteran is in receipt of a 50 percent evaluation, the highest schedular evaluation available, for his trigeminal nerve injury. As noted above, service connection for chronic periodontal disease is granted herein as secondary to the trigeminal nerve disability. Significantly, the Court in its September 2011 Memorandum Decision, indicated that the Veteran's chronic periodontal disease may have had a significant negative effect on his earning capacity, and requires frequent, highly specialized treatment often under anesthesia. Consequently, the Court remanded to the Board the issue of entitlement to an extraschedular evaluation for the Veteran's trigeminal nerve injury. In light of the September 2011 Court's Memorandum Decision, the Board finds that the issue of entitlement to an increased rating for trigeminal nerve injury should be remanded to the RO for referral to the Director of Compensation and Pension for extraschedular consideration. Accordingly, the case is REMANDED for the following action: Refer the issue of entitlement to an increased rating for service-connected trigeminal nerve injury in excess of 50 percent to the Director of Compensation and Pension for extraschedular consideration. The Director is asked to consider the highly specialized treatment necessary to treat the Veteran's secondarily service-connected chronic periodontal disease and comment on any effect that the Veteran's chronic periodontal disease will have on his earning capacity. Any determination should be reconciled with the evidence of record, to include the June 2011 VA authorized examination report. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the Veteran and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 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. 2011). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs