Citation Nr: 1300357 Decision Date: 01/04/13 Archive Date: 01/11/13 DOCKET NO. 04-22 434 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Cheyenne, Wyoming THE ISSUE Entitlement to service connection for cracked teeth, to include as secondary to the service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD H. Seesel, Counsel INTRODUCTION The Veteran had active service from May 1977 until May 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2003 rating decision from the RO. The Board previously considered this appeal in June 2009, November 2009 and August 2011 and remanded the claim for additional development. As will be explained in detail hereinbelow, the Board finds that, although the directives were not fully complied with, the record is now sufficient to provide a favorable decision on the claim. See 38 C.F.R. § 3.159(c) (2) and (3). Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination "more than substantially complied with the Board's remand order"). Accordingly, another remand for strict compliance is not necessary. FINDING OF FACT The Veteran is not shown to have sustained cracked teeth or any tooth loss where the masticatory surface could not be restored due to bone loss through trauma or disease attributable to the service-connected PTSD; any loss of teeth due to the loss or alveolar process as the result of periodontal disease is not deemed to be disabling. CONCLUSION OF LAW The Veteran does not have a disability manifested by cracked teeth or any tooth loss that is proximately due to or the result of the service-connected PTSD. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In this case, notice has been provided to the Veteran by way of letters in September 2002, March 2003, December 2009 and September 2011. Additionally, the record includes service treatment and personnel records, VA treatment records, records from the Social Security Administration and reports from VA examinations. Additionally, the Veteran provided testimony in support of his claim at two Board hearings. The Board notes that although the Veteran reported he had dental treatment at VA facilities, there are few VA records which document such treatment. Additionally, the August 2011 Board remand directed that the RO obtain a VA examination to provide an opinion as to whether it was at least as likely as not that any current disability manifested by cracked teeth or bruxism was caused or aggravated by the service-connected PTSD. The October 2011 VA examination noted there was insufficient evidence to provide an opinion as to the relationship between the dental condition and PTSD, but the July 2012 addendum concluded it was less likely the dental condition was the result of bruxism. Thus, remanding the claim another time in this case, which has been pending since 2003, would not of assistance in this matter and only result in further delay of adjudication. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). The Merits of the Claim The Veteran seeks service connection for cracked teeth. Specifically, he contends that stress related to his service-connected posttraumatic stress disorder (PTSD) resulted in him clenching his jaw and grinding his teeth. Service connection will be granted if it is shown that a Veteran has a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty in the active military, naval or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury incurred in service alone is not enough. There must be chronic disability resulting from that injury. 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). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to prove service connection, the record must contain: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and a disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In certain cases, competent lay evidence may demonstrate the presence of any of these elements. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). The law provides that secondary service connection shall be awarded when a disability is "proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310(a). See Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (en banc). Establishing service connection on a secondary basis therefore requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. The record reflects the Veteran was diagnosed as having bruxism due to PTSD in an April 2003 VA outpatient treatment visit. Furthermore, the Veteran is competent to describe symptoms such as grinding and clenching of his teeth as well as the cracking or loss of a tooth. See Barr v. Nicholson, 21 Vet. App. 303 (2007) Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (recognizing that lay testimony is "competent" if it discusses matters that the witness has actually observed or sensed and is within his "personal knowledge"); Dorland's Illustrated Medical Dictionary 257 (30th ed. 2003) (defining bruxism as involuntary, nonfunctional, rhythmic or spasmodic gnashing, grinding, and clenching of teeth (not including chewing movement of the mandible), usually during sleep, sometimes leading to occlusal trauma). Significantly, the Veteran has not identified a specific tooth that has been lost to bruxism or other trauma attributable to the service-connected PTSD. While the recent VA examination showed that the Veteran had a number of missing teeth, he was generally noted to have poor oral hygiene due to periodontal disease with associated bone loss that required the extraction of all of his remaining teeth. The loss of these teeth due to periodontal disease is not considered to be disabling for compensation purposes. Moreover, with respect to those teeth noted to be absent at the time of the recent examination, the evidence does not show that the Veteran experienced any bone loss due to trauma or disease caused by the service-connected PTSD. The Veteran has provided several lay statements in support of his claim over the course of the appeal. In April 2003, he related that he had a dental condition from clenching his teeth during stressful moments related to PTSD. He explained he had split, cracked and shred a good number of teeth and had had some removed. He reported the only dental work he had done was performed at VA. In other statements the Veteran related that he ground his teeth when under stress. He explained he had cracked, chipped and broken most of his teeth and had three teeth that were broken off at the gum line. However, the Veteran's lay assertions alone are not sufficient to establish that he has a current dental disability for compensation purposes. Accordingly, the Veteran is not found to have current disability manifested by cracked or lost teeth for which disability compensation is payable in this case. See McClain v. Nicholson, 21Vet. App. 319 (2007) (finding that the requirement for a current disability is satisfied if the claimant has a disability at the time a claim was filed or at any time during the pendency of the appeal, even if the disability resolves prior to the Secretary's adjudication of the claim). By "competent medical evidence" is meant in part that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). To the extent that the April 2003 VA outpatient treatment note indicated the Veteran was experiencing dental pain due to broken teeth/clenching/bruxism secondary to PTSD, the probative value of the statement is significantly diminished due to the lack of specificity. Bloom v. West, 12 Vet. App. 185, 187 (1999). The Veteran was afforded a VA examination in October 2011 to assess the nature and etiology of the bruxism or cracked teeth. As noted, the examination reflected several missing teeth, several caries and several dental restorations. After review of the file the examiner reported that examination and x-ray study showed the Veteran had very poor oral hygiene and a build up of plaque and calculus on all teeth. He was missing all mandibular posterior teeth and most of the remaining teeth were decayed and nonrestorable. Two teeth had apical abscesses. In addition, the Veteran had generalized severe periodontal disease with associated horizontal bone loss. He had full mouth extractions, and teeth 6 and 7 were emergent. The examiner opined that there was insufficient evidence to render a judgment as to whether or not the Veteran's current dental condition was caused or aggravated by PTSD. A July 2012 addendum to the VA examination explained that the Veteran first presented to the clinic in October 2011 and had very poor oral care, calculus and plaque build-up on all teeth. He had multiple broken teeth, extensive decay, dental infection and severe periodontal disease. Significantly, the examiner opined that, in spite of the significant dental problems, it did not appear that the remaining teeth had extensive wear from bruxism. Therefore, in his professional opinion, the examiner concluded that the Veteran's dental condition was less likely than not the result of bruxism. The examiner added that, as the result of the October 2011 VA examination, the Veteran had two teeth extracted on an emergent basis due to significant infection and the remaining teeth were extracted in January 2012 for humanitarian and health concerns. The Veteran was noted to now be edentulous. Accordingly, on this record, the Board finds that service connection for cracked teeth or lost teeth as due to the service-connected PTSD must be denied. ORDER Service connection for cracked teeth to include as secondary to the service-connected posttraumatic stress disorder is denied. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs