Citation Nr: 1237662 Decision Date: 11/02/12 Archive Date: 11/09/12 DOCKET NO. 06-32 558 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to compensation pursuant to the provisions of 38 U.S.C.A. § 1151 (West 2002) for additional disability from residuals of an umbilical hernia repair performed at a as a result of Department of Veterans Affairs medical facility in October 1996. 2. Entitlement to compensation pursuant to the provisions of 38 U.S.C.A. § 1151 (West 2002) for additional disability from dental treatment at a Department of Veterans Affairs medical facility. 3. Entitlement to service connection for a dental condition. 4. Entitlement to service connection for varicose veins. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from May 1951 to May 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The Veteran testified at a hearing in June 2009 before the undersigned. A copy of the transcript has been associated with the claims file. Service connection for varicose veins was initially denied in a March 1999 rating decision which was not timely appealed. Subsequently, relevant service department records were located and associated with the claims file. Therefore the claim will be considered on the merits. 38 C.F.R. § 3.156(c) (2011). In August 2009 and August 2011 the Board remanded this case to the RO via the Appeals Management Center (AMC) for further development. The Veteran's claims for service connection and tinnitus were granted in a November 2010 rating decision and are no longer on appeal. The case was then returned to the Board. After the case was returned to the Board, the Veteran submitted additional lay statements without a waiver of initial RO consideration. 38 C.F.R. § 20.1304(c) (2011). By a September 2012 letter, the Board informed the Veteran that he could chose between signing a waiver or having the case returned to the RO. He was advised if he did not reply to the letter within 30 days, the Board would assume that he waived RO consideration. No response was received and the Board will proceed to adjudicate his claim. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The preponderance of the competent evidence of record shows that the Veteran does not have additional disability from an umbilical hernia repair due to fault on the part of VA in furnishing hospital care, medical or surgical treatment, or examination, nor was it the result of an event not reasonably foreseeable. 2. The preponderance of the competent evidence of record shows that the Veteran does not have additional disability, including periodontal disease, due to fault on the part of VA in furnishing hospital care, medical or surgical treatment, or examination, nor was it the result of an event not reasonably foreseeable. 3. The Veteran was discharged from active service in 1955 with multiple fillings that are not claimed to be the result of dental trauma. He did not receive dental treatment after 180 days of active service. His claim was submitted in 2004. 4. The preponderance of the evidence reflects that the Veteran does not have varicose veins that manifested in service, or are causally or etiologically related to his military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for additional disability as the result of an umbilical hernia repair performed at a VA facility in October 1996 have not been met. 38 U.S.C.A. §§ 1151 , 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. 3.361 (2011). 2. The criteria for entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for additional disability, including periodontal disease, as the result of a deep root cleaning performed at a VA facility have not been met. 38 U.S.C.A. §§ 1151 , 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. 3.361 (2011). 3. The criteria for service connection for a dental disorder, including periodontal disease and post-service tooth extraction, to include for purposes of entitlement to VA outpatient treatment, are not met. 38 U.S.C.A. §§ 1110 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.381, 4.150, 17.161 (2011). 4. The Veteran's varicose veins were not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 ("VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice was not provided prior to the initial adjudication of the claim or if provided, was inadequate or incomplete, such an error can be "cured" by providing any necessary notice and then readjudicating the claim, including in a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given ample 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). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. __ (2009). VA has satisfied its duty to notify by issuing a pre-adjudication notice letter in November 2004. This letter advised the Veteran of what evidence was required to substantiate a service connection claim, and of his and VA's respective duties for obtaining evidence. A follow up letter was issued July 2006; it provided notice of what evidence was required to substantiate a claim for compensation under 38 U.S.C.A. § 1151 (West 2002). The July 2006 letter also provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. The Veteran additionally received a March 2006 letter regarding these two elements. Id. His claims were then readjudicated in the in the January 2009 and August 2012 Supplemental Statements of the Case (SSOC). See Mayfield IV; see also Prickett, 20 Vet. App. at 376. The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records (STRs), reports of post-service medical treatment, a transcript of his June 2009 Board hearing, and reports of VA examinations December 2004, January 2010, and September 2011. The January 2010 and September 2011 examinations were adequate because they were based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder, and appropriate diagnostic tests. The examiners also provided rationales for their opinions. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). This case was remanded in August 2009 so that VA records from the 1950s could be obtained and so the Veteran could undergo dental and hernia examinations. The case was remanded again in August 2011 so that the Veteran could undergo an examination for varicose veins and so an SSOC could be issued after the RO considered additional evidence submitted by the Veteran in March 2011. The RO attempted to obtain records from the 1950s but they were no longer available. The Veteran underwent VA examinations as discussed above. The RO issued an SSOC in August 2012. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2011). Compensation Under 38 U.S.C.A. § 1151 A veteran may be awarded VA compensation for disability caused by VA medical care in the same manner as if that disability was service-connected. 38 U.S.C.A. § 1151. A disability is considered a qualifying disability if it was not the result of the Veteran's willful misconduct and if it was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA and the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or, an event not reasonably foreseeable. Id.; see also VAOPGCPREC 40-97. 38 C.F.R. § 3.361(b) states that to determine whether a veteran has such a disability due to VA medical care, VA compares a veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the condition after such care or treatment. 38 C.F.R. § 3.361(b). VA considers each involved body part or system separately. 38 C.F.R. § 3.361(c) states that claims of disability due to hospital care, medical or surgical treatment, or examination must meet the causation requirements of that paragraph and paragraph (d)(1) or (d)(2) of that section. Actual causation is required. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the Veteran's disability. Merely showing that a veteran received care, treatment, or examination and has an additional disability does not establish causation. Continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished is not considered additional disability unless VA's failure to timely diagnose and/or properly treat the disease or injury proximately caused the continuance or natural progress. Additional disability caused by a veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(d) states that the proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. To establish that VA carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault proximately caused a veteran's additional disability, VA care must be shown to have caused the additional disability (as explained in 38 C.F.R. § 3.361(c)) and there must be evidence that (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (2) VA furnished the hospital care, medical or surgical treatment, or examination without a veteran's (or, in appropriate cases, a veteran's representative's) informed consent. Generally, all patient care furnished by VA shall be carried out only with the full and informed consent of the patient or, in appropriate cases, a representative thereof. In order to give informed consent, the patient must have decision-making capacity and be able to communicate decisions concerning health care. 38 C.F.R. § 17.32(b). The informed consent process must be appropriately documented in the medical record. 38 C.F.R. § 17.32(d) . Whether the proximate cause of a veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of § 17.32. Umbilical Hernia Repair The Veteran contends that in October 1996, VA medical personnel performed the wrong procedure. He asserts that he had an inguinal hernia, not an umbilical hernia. He further asserts that he has never had an umbilical hernia. He contends that because the wrong surgical procedure was performed, he developed a rectus diastasis and accompanying sexual dysfunction. In June 1996, the Veteran went to his first appointment with a new VA primary care provider. He reported having an inguinal hernia and that he subsequently developed hydrocele (a fluid-filled sack in the scrotum). In September 1996, he was noted to have a left hydrocele and an umbilical hernia. In October 1996, he underwent a scrotal ultrasound and was diagnosed with bilateral hydrocele, more on the left side than right. In September 1996, Dr. B., a VA physician, referred him to inpatient surgery because he had an umbilical hernia and the Veteran requested that it be repaired. In September 1996 he was diagnosed with an umbilical hernia and the record noted that the surgery was elective. The Veteran underwent two medical procedures close proximity: a left hydrocele drain on October 9, 1996, and an umbilical hernia repair on October 18, 1996. Prior to his left hydrocele drain, he was informed of the risks of the procedure. It was noted that the informed consent form was signed "willingly by patient." He underwent the procedure without complication and no bleeding was noted. He was ambulatory when discharged to go home with his brother. It was noted that the Veteran "expressed satisfaction" with the removal of fluid. With regard to his umbilical hernia repair, records from October 1996 show that he was informed that the risks of the procedure included infection, recurrence, and bleeding. He signed the informed consent form. During his preadmission testing education, it was noted that the Veteran was able to state the name of the surgical procedure being preformed, his diagnosis, and the reason for the procedure. He understood the need for blood tests, urinalysis, a chest x-ray and an electrocardiogram. He understood that he could not eat or drink prior to the surgery, and that he needed to have another person drive him home. He signed a request for administration of anesthesia. The statement of the request was, "to fix defect in abdominal wall to fix umbilical hernia." The name of the surgical procedure on the form was "repair of umbilical hernia." The full operative report stated that the Veteran underwent an umbilical herniorrhaphy (hernia repair). He was sedated and then local anesthesia was applied. It was noted that he tolerated the procedure well and was transported to the recovery room in stable condition. During the surgery, the problem was identified as a one square centimeter defect in the fascia. The preperitoneal fat was replaced through the defect and it was then closed with sutures. The umbilicus was then tacked back down to the fascia with additional sutures. The incision was closed with steri-strips. The postoperative report noted normal results. The post anesthesia checks were also normal. The Veteran's discharge instructions noted that he underwent an umbilical hernia repair. However, the form sent home with him for his aftercare was for an inguinal hernia repair. At his October 1996 follow up appointment, it was noted that he was status post umbilical hernia repair and that he was doing well. He had no internal complaints. His wound was crusted but otherwise intact. The steri-strips were in place. Records from his November 1996 and February 1997 follow up appointments did not note any additional complaints or abnormalities. In February 1997, a VA record noted that he had a hydrocele drain in October 1996 but that his scrotum was symmetrical without pain and he had no complaints. In May 2004, the Veteran was treated by Dr. D. R., a private physician. He presented with complaints of upper abdominal swelling. The impression was rectus diastasis from the umbilicus to the xiphoid area. Dr. D. R. noted that "[t]here was no obvious hernia in the area." He concluded that the Veteran was "totally asymptomatic" and that it was recommended he wear an abdominal binder when performing activities. Dr. D. R. thought that repair should only be considered if "it increases in size or becomes symptomatic." In April 2009, the Veteran told his VA primary care provider that he wanted to be evaluated for a right inguinal hernia. He reported that he had a mid abdominal umbilical hernia repaired in 1996. He stated that he had no problems with the hernia, but that his lower abdomen still protruded. Upon examination, a mid abdominal hernia was noted. It was not tender, reducible, with no masses, and he had no inguinal hernias. In May 2009, VA treatment records noted that he had a mid abdominal hernia that was reducible. An inguinal hernia was not diagnosed. The Veteran's treatment history provides probative evidence against his claim. The record shows that he was diagnosed with an umbilical hernia, not an inguinal hernia. He was diagnosed with a left hydrocele, but this was treated with no residuals or complications as discussed above. The record shows that the Veteran was aware of the umbilical hernia repair procedure, as his informed consent documents showed that he was able to state his diagnosis, type of procedure, and reason for the procedure. The documentation of both his hydrocele drain and umbilical hernia repair do not note the presence of an inguinal hernia. The operative report for the umbilical hernia repair specifically notes that a fascia defect was corrected and that the Veteran's umbilicus was then tacked to the abdominal wall. His follow up visits showed no abnormalities and he had no complaints. No treatment records show that the procedure caused any complications or residuals. In January 2010, he underwent a VA examination. The examiner noted an umbilical hernia repair in 1996 and a subsequent ventral hernia several years later. The Veteran was unable to state the date of onset of the ventral hernia, but knew that it was many years after the October 1996 umbilical hernia repair. He stated that he was able to have an erection but could not engage in sexual intercourse because of the bulge of the ventral hernia. Upon examination, the examiner noted a ventral hernia that was 8 to 10 centimeters long and non tender and fully reducible. He had a well healed scar over his umbilicus. No umbilical hernia was detected. The examiner concluded that the Veteran had an umbilical hernia repair in October 1996 with "excellent results." He did not have intra operative or post operative complications or residuals. The examiner concluded that the procedure was performed properly. According the claims file, the examiner found that the Veteran was initially seen for a bulge around the umbilicus. He was found to have an umbilical, not an inguinal hernia. He also had a left sided hydrocele. The examiner concluded that the umbilical hernia repair did not cause any defect or split in the abdominal muscles or wall and that instead, it repaired a defect in the fascia. The examiner noted that the first mention of a ventral hernia was in April 2009 and that it was located through the anterior abdominal wall which is "well away from the umbilicus." The examiner concluded that the Veteran had no residuals of the October 1996 umbilical hernia repair, and therefore the Veteran's ventral hernia and sexual dysfunction were not a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. The findings of the VA examiner provide probative evidence against the Veteran's claim. The examiner reviewed his claims file and found that no residuals of his October 1996 umbilical hernia existed and as a result, his subsequently diagnosed ventral hernia was not a result of the surgery. The examiner further noted that the ventral hernia was not located near the umbilicus. The Veteran submitted lay evidence in support of his claim. In September 2008 he stated that he was diagnosed with a right groin hernia in 1998. He noted that he was sent home from the VA Medical Center with inguinal hernia repair aftercare instructions but that the physician performed an umbilical hernia repair. He stated that he signed all of the informed consent forms without reading them because he trusted VA physicians. The Veteran is competent to state that he did not read the informed consent forms. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds that this statement is not credible because his preadmission testing education form noted that he was able to state his diagnosis, the name of the surgical procedure being performed, and the reason for the procedure. This indicates that he read and understood the forms. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Therefore this statement is not probative evidence. In June 2009, the Veteran's wife and son both stated that the Veteran has never had an umbilical hernia. The Veteran's son stated that he had a right groin inguinal hernia that has not been repaired. The Veteran's wife stated that he was supposed to have an operation for an inguinal hernia and that she later found out that an umbilical hernia repair was performed. She stated that the Veteran has "never" had an umbilical hernia and that "sometime later" he developed a large split down his abdominal area from the navel down to his lower abdomen and that it had not been repaired. The Veteran's wife and son are competent to relate observable symptoms such as an abdominal bulge or to re-state what they were told by the Veteran. Layno v. Brown, 6 Vet. App. 465 (1994). However, regarding the statements that the Veteran has "never" had an umbilical hernia, his wife and son are not competent to identify the type of hernia the Veteran had on their own with no input from medical professionals. Laypersons have been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). The Board finds that to the extent the Veteran's wife and son believe that he never had an umbilical hernia, their statements are credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). These lay statement are less probative than the VA treatment records which show that the Veteran was diagnosed with an umbilical hernia. No inguinal hernia was diagnosed in October 1996. The documentation of the surgical procedure is continuously referred to as an umbilical hernia procedure and the informed consent documents note that the Veteran was able to identify the procedure being performed by name as well as his diagnosis and the reason that he was undergoing the procedure. The VA treatment records are more probative than the statements from the Veteran's wife and son. At his June 2009 Travel Board hearing, the Veteran testified that he initially sought VA treatment for groin swelling. He had a drain procedure and was satisfied with the results. When he was diagnosed with a hernia, he sought treatment from the same physician, who declined to do the procedure because it was not his specialty. On the day of his surgery, the Veteran stated that his wife accompanied him, and that VA health care providers gave him medication for his "nerves." He testified that the doctors were "kind of scratching their head with [him]." He stated that he was not operated on in an operating room, but instead the procedure was performed in a hallway. He thought that he had an inguinal hernia because he had previously had such a repair and it was performed under local anesthesia. However, when he was ready to undergo surgery, he was told that he had an umbilical hernia. He stated that he verbally disagreed with the physician and instead stated that he had an inguinal hernia. The Veteran testified that a nurse threatened to "strap [him] down," and that anesthesia was then administered. He concluded that "supposedly, they had done an umbilical hernia [repair] even though I did[] not have one." He asserted that he still had an inguinal hernia that had yet to be repaired. The Veteran is competent to relate what occurred on the day of his surgery. Layno v. Brown, 6 Vet. App. 465 (1994). However, his assertions are contradicted by the record, which clearly indicates that the procedure to be performed was always designated as an umbilical hernia repair. Further, at his two follow up visits, he had no complaints or symptoms, and he did not report that he felt the wrong procedure was performed. His testimony is not considered credible and is not probative evidence in support of his claim. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In March 2011, the Veteran's spouse stated that in October 1996, she and the Veteran thought that the hernia repair was going to be for an inguinal hernia in his groin and that when they arrived at the hospital, "...it appeared as though something was not proper, no one seemed to know what was going on," and that the Veteran was lying on the operation table for "quite some time" with no one tending to him. On the way home from the surgery, she stated that the Veteran told her that the physician did not repair an inguinal hernia, but instead performed an umbilical hernia repair with no prior consultation or preoperative examination. Although the Veteran's spouse is competent to relate situational occurrences such as her conversation with the Veteran on the way home from surgery, her statements regarding the surgical procedure are not credible because they are clearly contradicted by the record. The record shows that prior to undergoing the umbilical hernia repair, the Veteran had a chest x-ray, an examination, and an electrocardiogram. Further, he was not diagnosed with an inguinal hernia. He was diagnosed with a left sided hydrocele and an umbilical hernia. Id. The Veteran's spouse's statement is not probative evidence in support of the Veteran's claim. Lastly, in March 2011 the Veteran stated that he had an inguinal, not an umbilical hernia. He stated that prior to undergoing the surgery, he asked the physician three times not to operate on him, at which point a nurse asked the physician if he wanted her to strap the Veteran to the table. He stated that the physician then ordered anesthesia. He argued that he does not have a ventral hernia. As previously discussed, the Veteran is competent to relate observable symptoms and discuss situations that happened to him. However, his statements are contradicted by the medical evidence of record. The post operative reports show that he had no complaints or complications. If the Veteran was distressed by what he perceived to be an incorrect surgical procedure, it was not reported following the operation or at his two follow up visits. Further, his assertion that he does not have a ventral hernia is contradicted by the findings of the VA examiner who observed an 8 to 10 centimeter long ventral hernia. The Veteran's statement is not credible and is not probative evidence in support of his claim. The competent and credible medical and lay evidence of record does not show that the Veteran has additional disability, to include a ventral hernia, rectus diastasis, or sexual dysfunction as a result of his October 1996 umbilical hernia repair. There is no evidence to suggest that his hernia was misdiagnosed. The operative report shows that an umbilical hernia was located and repaired. The informed consent forms and reports show that the Veteran was capable of stating his diagnosis (umbilical hernia), the name of the procedure (umbilical hernia repair), and the reason for the procedure. Further, The record shows that there were no subsequent complaints or complications following the surgery, and the Veteran reported none at his two follow up appointments in October 1996 and February 1997. Lastly, the VA examiner found that the October 1996 surgery was performed properly and that there was no carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. For these reasons, a grant of disability compensation pursuant to 38 U.S.C.A. §§ 1151 for residuals of an umbilical hernia repair is not in order. Dental Condition The Veteran contends that prior to undergoing a deep root cleaning procedure at a VAMC, his teeth were undamaged. Following the cleaning, he asserts that he developed an infection, leading to periodontal disease and the removal of some of his teeth. It is not clear from the record when the Veteran underwent the cleaning procedure that he believes caused his dental condition. He does not specify a date, only that it occurred during a yearly cleaning that was at least ten years prior to his August 2008 RO hearing. A November 1997 VA dental treatment report shows that tooth number 30 was scheduled to be extracted after the Veteran complained of a lost filling. He was diagnosed with dental caries and periodontal disease. His oral hygiene and gingiva were noted to be abnormal. A November 1997 health questionnaire for dental patients did not note anything abnormal in his personal history; he did not bleed for an unusually long period of time after dental procedures and had not had a mouth sore for more than ten days. He did not fill out the section of the questionnaire that addressed removal of teeth during service. The Veteran's tooth was extracted in December 1997. A December 1997 informed consent form notified the Veteran of the risks associated with a tooth extraction. Specifically, he was notified that tooth number 30 would be extracted with bone recontouring if necessary, and that it could result in possible swelling, pain, dry socket, numbness, bleeding, bone splinters, or infection. The Veteran signed the form. The pathology report from the tooth extraction noted that the tooth was carious. In May 1998 he complained of a toothache. In January 2010, the Veteran underwent a VA dental conditions examination. He claimed that VA treatment caused him to contract gum disease. The examiner noted that the Veteran had 13 missing teeth and that the masticatory surface had been replaced except for tooth number 14, which was replaceable. He also had mild bone loss due to his periodontal condition. The examiner diagnosed the Veteran with 13 missing teeth and concluded that VA was not responsible for the tooth removal because his teeth were carious and extraction was the natural progression of his periodontal disease. The findings of the VA examiner provide probative evidence against the Veteran's claim. In support of his claim, the Veteran testified at a RO hearing in August 2008. He stated that when he entered boot camp in 1951, he was sent to a dental clinic and that his teeth were "perfect" prior to entering service. He stated that the military dentist drilled nearly every tooth in his mouth and installed fillings. He stated that his fillings made a squeaking sound whenever he chewed food. The Veteran stated that he had them all replaced in 1955, after he separated from service. He testified that he had a yearly cleaning at VA and that he was informed that he was going to have a "root scraping" and that following the procedure his gums became infected. As a result of this infection, he asserted that VA had to remove a tooth because it was "full of pus." He stated that the procedure was performed more than ten years prior to the hearing. In a June 2009 statement, he asserted that he had been diagnosed with periodontal disease and that he thought he did not have it until he underwent a "deep root cleaning" at VA. The Veteran is competent to relate observable symptoms such as a toothache or recount that he underwent procedures. To the extent that he believes his periodontal disease was caused by an infection developed after a VA procedure, his statements are also credible. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, they are less probative than the findings of the VA medical examiner, who concluded that his tooth removal was the result of a natural progression of his periodontal disease and not the result of VA treatment. The Veteran's allegation has been investigated by competent medical examination and found not supportable. Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir. 2007). For these reasons, a grant of disability compensation pursuant to 38 U.S.C.A. §§ 1151 for residuals of an umbilical hernia repair is not in order. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Dental Condition The Veteran seeks entitlement to service connection for periodontal disease and post-service tooth extraction. A claim for service connection for a dental disorder is also a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). With regard to periodontal disease, although compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service, the statutes governing compensation benefits provide that periodontal disease may be considered service-connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. 38 U.S.C.A. § 1712; 38 C.F.R. § 3.381. Therefore, the law precludes service connection for periodontal disease for compensation purposes, and the Board is not authorized to grant the benefit. Where a benefit is precluded, the claim must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Although compensation benefits are precluded for periodontal disease, the Court has specifically held that a claim for service connection for a dental disorder is also a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). Service connection of dental conditions will be established under circumstances set forth in 38 C.F.R. § 3.381. This section provides that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. 38 C.F.R. § 3.381. 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. Id. 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. Id. 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 non-restorable 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. 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; and (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. Id. Teeth extracted because of chronic periodontal disease will be service-connected only if they were extracted after 180 days or more of active service. Id. Filling of cavities in the Veteran's teeth in service by military dentists does not constitute "service trauma" within meaning of statute authorizing VA outpatient dental services for "a service-connected dental condition or disability due to combat wounds or other service trauma." VAOPGCPREC 5-97. The Veteran has not alleged that any claimed dental disability was due to trauma in service or incurred in combat. Absent a demonstration of dental trauma, service connection may be considered solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment. See Woodson v. Brown, 8 Vet. App. 352, 354 (1995). The Veteran's May 1951 entrance examination noted cavities on teeth numbers 2-4, 14, 15, 17-20, and 29-31. In June 1951, teeth numbers 4 and 29 were treated. In July 1951, teeth numbers 20 and 30 were treated. At his April 1955 separation examination he had no missing teeth. Teeth numbers 1, 5, 16, 17, 18, and 32 were noted as restorable teeth. Periodontal disease was not diagnosed. The record does not show that the Veteran received dental treatment after 180 days or more of active service. He complained twice of bleeding gums in July 1952 but his STRs do not show that he had carious teeth filled, had old fillings replaced, or had any other dental treatment as a result of his bleeding gums. The Veteran is currently missing 13 teeth, and all of them were extracted following his separation from service in 1955. He has also been diagnosed with periodontal disease, which as noted above, may not be service connected for treatment purposes. 38 C.F.R. § 3.381. The Veteran does not have a dental condition that may be service connected for the purpose of outpatient treatment under 38 C.F.R. § 3.381. Outpatient dental treatment may be authorized by the Chief, Dental Service, for beneficiaries defined in 38 U.S.C.A. § 1712(b) and 38 C.F.R. § 17.93 to the extent prescribed and in accordance with the applicable classification and provisions set forth in 38 C.F.R. § 17.161, which describes several "classes" of dental care. In this case, none of the classes apply to the Veteran. Class I, Class II, and Class II(a) do not apply because, as discussed above, the Veteran does not have a service connected compensable or service connected noncompensable dental disability or condition. Id. Class II(b) does not apply because the Veteran is not homeless or enrolled in a one-time course of dental care under 38 U.S.C.A. § 2062. Class II(c) does not apply because the Veteran was not a prisoner of war. Class IIR (retroactive) does not apply because he did not have teeth extracted during active service. Class III does not apply because his periodontal disease and tooth extractions were not professionally determined to be an aggravating disability from an associated service connected condition. Class IV does not apply because the Veteran's combined disability evaluation is not 100 percent and he is not entitled to a total rating based upon individual unemployability due to service-connected disability. Class V does not apply because he is not participating in a rehabilitation program under 38 U. S. C. A. chapter 31. Lastly, Class VI does not apply because the claimed disabilities were not found to be complicating a medical condition currently under treatment while the Veteran was admitted to or otherwise receiving care and services under 38 U.S.C.A. chapter 17. Under these circumstances, the Veteran has failed to state a claim for service connection for a dental disorder. As such, the claim must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). Varicose Veins At his June 2009 hearing, the Veteran asserted that he has varicose veins in his lower extremities as a result of a horse falling on his legs during service. The Veteran has been diagnosed with varicose veins of the lower extremities, satisfying the first element of a service connection claim. Hickson, 12 Vet. App. at 253. At an April 2009 VA appointment, the Veteran reported lower extremity pain since a horse fell on him in 1951. At his June 2009 hearing, the Veteran testified that while attending electrical school and prior to being assigned to a ship, he went off base to ride a horse. He stated that the horse fell on his legs when he was walking it back to the stable. He thought his leg was broken, and when he stood up he felt as if his legs were heavy. The Veteran testified that he went to sick call but could not recall how long he waited before seeking treatment. He stated that the physician did not believe him when he reported that a horse fell on his legs. He stated that he could not convince the physician that "those weren't natural varicose veins," and so he left the appointment in anger. After the alleged incident, he asserted that he walked with a limp and still had pain a week later. He denied having any other treatment for his legs. He stated that he periodically had aches and pains in his legs while serving aboard ships, but that he did not report it. He stated that he has had pain from his varicose veins since service. He denied receiving current treatment for this condition. In March 2011, the Veteran's spouse stated she noticed his varicose veins in 1962 when they began dating. She stated that he told her he had them because a horse fell on his legs. The STRs are negative for any evidence that the Veteran sought treatment for leg pain or that he had a horse fall on his legs. However, the Veteran and his spouse are competent to relate observable symptoms and recall events such as the incident described above. With regard to occurrence of the in service incident where a horse fell on the Veteran, their statements are also considered credible because of their consistency. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The second element of a service connection claim, an in-service incident, is satisfied. Hickson, 12 Vet. App. at 253. The Veteran has asserted that he has had continued symptoms of his varicose veins since 1951. He is competent to observe that he experienced leg pain. Layno v. Brown, 6 Vet. App. 465 (1994). His STRs, including his April 1955 separation examination, are entirely negative for leg pain or references to any injury to his legs. He filed a claim for service connection for other disabilities in March 1956, shortly after his separation from service. He did not file a claim for service connection for varicose veins at that time. He filed his first claim for varicose veins in December 1997, over 40 years after separation of service. This provides evidence against his assertion of continuity of symptoms. Shaw v. Principi, 3 Vet. App. 365 (1992) (holding that a veteran's delay in asserting a claim can constitute negative evidence that weighs against the claim). Bilateral varicose veins were first noted in his treatment records in June 1998 during a VA examination. Although not dispositive, a lengthy period without complaint or treatment is considered evidence that there has not been a continuity of symptomatology and weighs heavily against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). For these reasons, his statements regarding continuity of symptoms are not credible. Service connection is not warranted based upon continuity of symptomatology. 38 C.F.R. § 3.303(b). Lastly, the nexus element of a service connection claim is not satisfied. The Veteran underwent a VA examination in June 1998 but no etiology opinion was rendered. He underwent a VA joints examination in December 2010. The examiner stated that because there was no record of an injury or treatment in service, he could not provide an etiology opinion without speculating. The examiner did not provide an explanation as to why an opinion could not be rendered. As a result, the December 2010 examination is inadequate and is not probative evidence. Medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. Jones v. Shinseki, 23 Vet. App. 382, 389-90 (2010); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Goss v. Brown, 9 Vet. App. 109, 114 (1996); Obert v. Brown, 5 Vet. App. 30, 33 (1993); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The Veteran underwent a VA examination in September 2011. The examiner found that the date of the onset of the Veteran's varicose veins was "unclear," and that no injury or incident was documented in service. The examiner found that the Veteran's varicose veins were not related to service because a horse falling on the Veteran's legs "can not cause varicose veins." The September 2011 VA examination provides probative evidence against the Veteran's claims. As discussed above, it is more probative than the Veteran's lay assertions. There is no other medical evidence of record that provides a link between the Veteran's in-service incident and his currently diagnosed varicose veins. The third element of a service connection claim is not satisfied. Hickson, 12 Vet. App. at 253. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Service connection for varicose veins is not warranted. ORDER Compensation pursuant to the provisions of 38 U.S.C.A § 1151 for residuals of an umbilical hernia repair is denied. Compensation pursuant to the provisions of 38 U.S.C.A § 1151 for a dental condition is denied. Service connection for a dental condition, to include multiple tooth extractions and periodontal disease is denied. Service connection for varicose veins is denied. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs