Citation Nr: 1301209 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 10-37 679 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a cervical spine disorder. 2. Entitlement to service connection for a dental disorder. 3. Entitlement to an initial compensable evaluation (rating) for service-connected perianal cyst/abscess. REPRESENTATION Veteran represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from September 1986 to September 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2010 and May 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board has reviewed the Veteran's physical claims file, as well as the Veteran's electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. The issues of: (1) entitlement to service connection for a cervical spine disorder and (2) entitlement to service connection for a dental disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. For the portion of the claim/appeal period prior to June 8, 2010, there is evidence of constant minor serous drainage from the perianal cyst/abscess that is analogous to constant slight or occasional moderate leakage due to impaired sphincter control. 2. For the portion of the claim/appeal period from June 8, 2010 forward, the Veteran's perianal cyst/abscess generally has no leakage or wetness. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for a 10 percent rating for service-connected perianal cyst/abscess are approximated for the portion of the claim/appeal period prior to June 8, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.27, 4.114, Diagnostic Code 7399-7335 (2012). 2. The criteria for a compensable rating for service-connected perianal cyst/abscess are not met or approximated for the portion of the claim/appeal period from June 8, 2010 forward. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.27, 4.114, Diagnostic Code 7399-7335 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, in Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) stated that a claim for service connection included the potential downstream questions of disability rating and effective date. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a statement of the case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Regarding the Veteran's initial rating appeal for perianal cyst/abscess, the Veteran challenges the initial noncompensable (0 percent) rating assigned following the grant of service connection in the April 2010 rating decision. The Court has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has in fact been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. at 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a Notice of Disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). For this reason no further notice, beyond that afforded in the context of the Veteran's initial claim for service connection, is needed under the VCAA with regard to the initial rating appeal. The Veteran has been provided with copies of the above rating decisions, the August 2010 SOC, and the January 2012 SSOC, which collectively include discussion of the facts of the initial rating claim, pertinent laws and regulations, notification of the basis for the decision, and a summary of the evidence considered. In view of the foregoing, the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's statutory duty to assist in claims development, the RO afforded the Veteran with medical examinations in August 2008, March 2010, and December 2011 in connection with the initial rating appeal. The medical examination reports include all relevant history, complaints, and findings needed to evaluate rate the disability. Collectively, the medical examination reports are adequate for rating purposes; therefore, there is no need for further medical examination or opinion. Also, the Veteran's service treatment records (STRs) are included in the physical claims folder. Several post-service treatment records adequately identified as relevant to the Veteran's claim have also been obtained to the extent possible, or otherwise submitted, and are associated with the record. There are additional VA treatment records pertinent to the Veteran's claims found in his Virtual VA folder, which have been considered by the RO in the first instance. See Evidence listed in the January 2012 SSOC. Although treatment records pertaining to the Veteran's June 2010 fistulectomy are not included in the record, the Veteran adequately described his perianal cyst symptomatology since the surgery at the December 2011 VA medical examination. Indeed, he stated that he generally had no leakage or wetness and only very occasionally felt some wetness in the area of the surgery. The Veteran has not made the RO or the Board aware of any other evidence relevant to his appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claim decided herein. In view of the foregoing, the Board will proceed with appellate review. Initial Rating for Perianal Cyst/Abscess It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). The Board has thoroughly reviewed all the evidence in this case. 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) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below 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) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of the veteran's condition. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In an appeal for a higher initial rating after an award of service connection, all of the evidence submitted in support of a veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. The Veteran seeks a higher (compensable) initial disability rating for his service-connected perianal cyst/abscess. The disability was initially rated as 0 percent disabling (i.e., noncompensable) under the criteria found at 38 C.F.R § 4.114, DC 7335, as a condition analogous to an anal fistula. The rating criteria provide that the disability should be rated as impairment of sphincter control under Diagnostic Code 7332. Under Diagnostic Code 7332, a noncompensable (i.e., 0 percent) disability rating for impairment of sphincter control is assigned when there is evidence of healed or slight impairment of sphincter control without leakage. A 10 percent rating is assigned for constant slight, or occasional moderate leakage. A 30 percent rating is assigned for impairment of sphincter control characterized by occasional involuntary bowel movements, necessitating wearing a pad. A 60 percent rating is assigned when there is extensive leakage and fairly frequent involuntary bowel movements and a 100 percent rating is assigned for complete loss of sphincter control. 38 C.F.R. § 4.114. In order for the Veteran to receive the next higher rating of 10 percent rating under DC 7332, the disability picture associated with his service-connected perianal cyst/abscess must more nearly approximate constant slight or occasional moderate leakage due to impairment of sphincter control. 38 C.F.R. § 4.114. Preliminarily, the Board notes that the Veteran does not contend, and the evidence does not show, that he has experienced any fecal leakage due to impaired sphincter control during the claim/appeal period. For example, at the August 2008 VA examination, the Veteran reported no problems with the anal canal or rectum, and no relevant problems were noted on examination. After performing a physical examination of the Veteran at the March 2010 VA medical examination, the VA medical examiner wrote that no stool was coming from the area. The Veteran also told the examiner that he had not seen any stool from that area. In addition, the December 2011 VA medical examiner wrote that there was no leakage of fecal material or wetness shown on physical examination at that time. While the Veteran told a treating VA medical provider in November 2011 that he had noticed stool changes over the last one to two years and had frequent loose stools 4 or 5 times per day, the medical provider did not attribute such reported symptomatology to the Veteran's perianal cyst disability. Also, the Board observes that the Veteran had previously denied having any diarrhea or constipation when receiving medical treatment for other disabilities in February 2011. He additionally did not mention having such symptoms to the December 2011 VA medical examiner when undergoing examination in connection with the initial rating claim. Therefore, the preponderance of the evidence weighs against finding fecal leakage due to impaired sphincter control throughout the claim/appeal period. Nonetheless, the Veteran's perianal cyst/abscess is rated by analogy to impairment of sphincter control of the rectum and anus. In September 2009, the Veteran wrote that he had recurrent perianal cysts that began in service and had recently experienced another recurrence in July 2009. He reported that the perianal cysts had not caused a great deal of pain but had caused discomfort and drained on their own. He also wrote that his then-current perianal cyst was constantly draining. When the Veteran underwent medical examination in March 2010 in connection with his claim, he reported that his abscess drained constantly and occasionally was foul smelling. He also stated that he would occasionally have a blood streak on toilet paper when wiping over the abscessed area. On physical examination, the examiner noted that the Veteran demonstrated a slightly indurated, reddened area measuring about 2 centimeters by 2 centimeters in his anus, which had some minor serous drainage. In February 2010, the Veteran told a treating VA medical provider that he had had recurrent perianal cysts with drainage and inflammation intermittently since stationed in Qatar in 2007 but the condition had become worse over the past 8 or 9 months. On the September 2010 VA Form 9, the Veteran wrote that he believed that he met the 10 percent disability rating and referenced the fact that the March 2010 VA medical examiner noted some minor serous drainage on examination. He asserted that his minor serous drainage amounts to occasional moderate leakage so as to warrant a 10 percent disability rating. Rating Period prior to June 8, 2010 In consideration of the above evidence, both lay and medical, the Board resolves reasonable doubt in the Veteran's favor in finding that his perianal cyst disability more closely approximates impaired sphincter control manifested by constant slight leakage so as to warrant a 10 percent rating for the portion of the appeal period prior to June 8, 2010, the date of the fistulectomy. Although the evidence does not demonstrate fecal leakage during this portion of the appeal period, the Veteran has competently reported experiencing constant drainage from the site of the anal cyst, and there is no indication that his account of such symptomatology is not credible. Indeed, he objectively demonstrated minor serous drainage at the March 2010 VA medical examination, which provides further support for the Veteran's description of his symptomatology. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that for this period manifestations of the Veteran's perianal cyst disability are analogous to constant slight leakage due to impairment of sphincter control of the rectum and anus under Diagnostic Code 7332. 38 C.F.R. §§ 4.3.4.7. The Board finds that the criteria for the next higher disability rating of 30 percent have not been met or more nearly approximated the initial rating appeal period prior to June 8, 2010. Although the Veteran has asserted that the manifestations more closely approximate occasional moderate leakage, there is no evidence to support finding that the leakage demonstrated is greater than slight. The examiner specifically noted that the serous drainage demonstrated at the March 2010 VA medical examination was minor. Regardless, a 10 percent rating under Diagnostic Code 7332, and no more, would be assigned. The Veteran does not contend that he had occasional involuntary bowel movements necessitating wearing a pad for this period. There is also no evidence to show that the Veteran's symptomatology more closely approximated the schedular criteria for a 30 percent rating. He merely asserts that he is entitled to a 10 percent rating under Diagnostic Code 7332 for the manifestation of minor serous drainage of the perianal cyst; a 10 percent rating has been granted for the portion of the appeal period prior to June 8, 2010. Rating Period from June 8, 2010 The Board next finds that, for the portion of the appeal period from June 8, 2010 forward, the evidence does not show that a compensable rating is warranted under Diagnostic Code 7332. For the portion of the appeal period from June 8, 2010 forward, the evidence shows that the Veteran's perianal cyst/abscess generally has manifested no leakage or wetness. When the Veteran underwent a medical examination in connection with his claim/appeal in December 2011, he told the examiner that his symptoms had progressed since the last examination and, as a result, a fistulectomy was performed on June 8, 2010. He also told the examiner that he only experienced some wetness in the area of the surgery very occasionally at that point in time. He further stated that there was no smell and no fecal material when he wiped the area and, generally, there was no leakage of fecal material and no wetness. On physical examination in December 2011, the VA examiner noted no soiling, leakage, or wetness, and found the anal canal to be normal. The VA examiner further noted that the Veteran's tone in the anal sphincter was firm, and no lumps or masses were palpable. The VA examiner diagnosed two anterior fistulae in the anus that had been treated surgically. Although records pertaining to the Veteran's fistulectomy and treatment thereafter are not included in the claims file, the Veteran indicated at the December 2011 VA medical examination that he has only had very occasional wetness in the area of the perianal cyst since the surgery. He stated that there was generally no fecal leakage or wetness. Thus, even assuming the credibility of the Veteran's statement, the manifestations of his perianal cyst disability amount to no more than healed or slight impairment, with no leakage. There is no indication of moderate leakage from the surgical site. Moreover, while the Veteran has reported that he had very occasional wetness, it is clear that such symptomatology is not characteristic of his disability for the portion of the claim/appeal period following the June 8, 2010 fistulectomy. He specifically stated that there was no fecal leakage or wetness generally. For these reasons, the Board concludes that a preponderance of the evidence weighs against finding that the assignment of a compensable disability rating for the portion of the appeal period from June 8, 2010 forward. 38 C.F.R. §§ 4.3.4.7. The Board has also considered whether the Veteran's perianal cyst is more appropriately evaluated under any other diagnostic code and/or rating schedule. However, upon review, the Board finds no other diagnostic code under which it would be more appropriate to evaluate the Veteran's disability. Even if the Veteran's perianal cyst disability were to be evaluated under the potentially applicable Diagnostic Code 7804 for unstable or painful scars, the Veteran would be entitled to no more than a 10 percent rating for one or two scar(s) that is/are painful or unstable prior to his June 2010 surgery. In the absence of evidence of pain or instability after the surgery, the Veteran's perianal cyst would similarly not be entitled to a compensable rating under that diagnostic code for the portion of the appeal period from June 8, 2010 forward. Extraschedular Considerations Furthermore, the Board has considered whether an extraschedular evaluation would have been warranted for the perianal cyst/abscess. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's perianal cyst/abscess is adequately contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's perianal cyst/abscess is rated by analogy to impairment of sphincter control of the rectum and anus. See 38 C.F.R. § 4.20 (2012). While the rating criteria does not specifically contemplate constant minor serous drainage from the perianal cyst, the Board specifically contemplated the symptomatology as reported by the Veteran and objectively demonstrated at the March 2010 VA medical examination in awarding the 10 percent disability rating for the disability for the portion of the claim/appeal period prior to June 8, 2010. For the initial rating period prior to June 8, 2010, the Board resolved reasonable doubt in the Veteran's favor in finding that his perianal cyst was manifested by constant minor serous drainage and that such manifestation was analogous to constant slight fecal leakage due to impaired sphincter control. For the initial rating period from June 8, 2010, the Board concluded that the evidence showed that the Veteran's perianal cyst had generally not been manifested by leakage or wetness and, consequently, was analogous to healed or slight impairment of sphincter control of the rectum and anus. As the schedular evaluation adequately contemplates the claimant's level of disability and symptomatology, there is no need to proceed further with the analysis under Thun. ORDER An initial rating for service-connected perianal cyst/abscess of 10 percent, but no higher, for the appeal period prior to June 8, 2010, is granted; a compensable rating for the appeal period from June 8, 2010 forward is denied. REMAND Service Connection for Dental Disorder The issue of entitlement to service connection for a dental disorder must be remanded for further evidentiary development. As a preliminary matter, the Board recognizes that a claim for service connection of a dental disorder is generally considered to be a claim for VA outpatient dental treatment as well as for compensation purposes. Mays v. Brown, 5 Vet. App. 302 (1993). However, in this case, the Veteran has specifically stated that he is only seeking service connection for a dental disorder for compensation purposes. See September 2009 Report of Contact. Under current VA regulations, compensation is available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. 38 U.S.C.A. § 1712 (West 2002); 38 C.F.R. §§ 3.381, 17.161 (2012). The Veteran contends that he is entitled to service-connected compensation benefits due to a dental trauma incident while on active duty in 1990 resulting in replaceable teeth. Service dental records show that the Veteran suffered a fractured maxilla secondary to a racquetball injury in November 1990. The records show that the injury resulted in significant fractures at Tooth #8, Tooth #9, and Tooth #10. Tooth #7 and Tooth #9 were also noted to be "severely traumatized" and showing multiple fracture lines. The dental clinic provided endodontic treatment and prosthetic dental repair to the teeth. It is unclear whether the fracture of the maxilla in service has resulted in impairment of the mandible, loss of a portion of the ramus, or loss of a portion of the maxilla. The Veteran has not yet been afforded a dental examination in connection with his claim/appeal, and the current record is insufficient to resolve the medical question. For these reasons, the Board finds that a remand is warranted. Service Connection for Cervical Spine Disorder The issue of entitlement to service connection for a cervical spine disorder must also be remanded for further evidentiary development. The Veteran contends that his current cervical spine disorder was caused by several sports-related injuries, as indicated by neck pain experienced during service. He alternatively contends that he developed degenerative disc disease during the presumptive period after retiring from service in 2008. See September 2010 VA Form 9. The evidence shows that the Veteran currently suffers from a cervical spine disability. When the Veteran underwent the VA medical examination in May 2010, the VA examiner diagnosed degenerative disc disease and degenerative joint disease of the cervical spine. Service treatment records also show that the Veteran received medical treatment for neck pain on three occasions. In September 1994, the Veteran presented for medical treatment with complaint of a sore neck for two weeks. He told the service medical examiner that he had been on an airplane trip two weeks before, had slept "wrong," and had a crick in his neck. He further stated that he had played softball the day before and turned his head fast, and now could not turn his head due to pain. After performing a physical examination of the Veteran, the service medical examiner diagnosed trapezius strain/spasm, to be treated with medication (i.e., Robaxin and Motrin), warm compresses four times a day, and follow up as needed. In June 1998 during service, the Veteran again presented for medical treatment of a sore neck following a car accident that had occurred one month before. He stated that his neck pain had occurred approximately two weeks before. It does not appear, however, that the service medical examiner made an assessment pertaining to the Veteran's complaints of neck pain at that time. Approximately six years later, in August 2002 during service, the Veteran presented with complaint of a sore neck radiating down his back and shoulders having lasted for one week. After physically examining the Veteran, the service medical examiner assessed overuse syndrome of the left arm and shoulder. The Veteran has not been provided with an adequate medical examination or medical opinion in connection with his claim for service connection for cervical spine disorder. Although the Veteran underwent medical examination in May 2010, the VA medical examiner concluded that chronicity of the Veteran's neck pain could not be established from the service treatment records while the Veteran was on active duty and no opinion could be offered without resorting to speculation. The VA medical examiner provided no supporting rationale as to why a medical opinion could not be provided and did not specifically address the likelihood of whether the neck pain and/or the sports-related injuries noted in service later could have caused the Veteran to develop a cervical spine disorder. Consequently, the Board finds that further medical examination and medical opinion are needed. Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) (when the record is not clear on whether a medical examiner could offer a nonspeculative opinion given the correct facts, "it is the Board's duty to remand for further development"). Accordingly, the issues of service connection for dental disorder and service connection for cervical spine disorder are REMANDED for the following actions: 1. Ask the Veteran to identify any VA or non-VA treatment received for a dental disorder or a cervical spine disorder from October 1, 2008 to the present. After securing the necessary releases, obtain the identified treatment records. Any documents received by VA should be associated with the record. If no records are available or the search yields negative results, make specific note of that fact in the claims file and follow the procedures outlined in 38 C.F.R. §3.159(e) regarding notification of the inability to obtain records. 2. Schedule the Veteran for a VA dental examination. All relevant documents (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) should be made available to and reviewed by the examiner in rendering the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE should be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate in the examination report that the record was reviewed. a. Based on review of appropriate records, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50 percent degree of probability) that the dental trauma sustained by the Veteran in November 1990 from a racquetball injury caused any impairment of the mandible, loss of a portion of the ramus, or loss of a portion of the maxilla? If so, please fully describe the extent of such impairment. b. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. c. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based should be set forth in the report. If the examiner cannot answer any question posed without resorting to unsupported speculation, the examiner should so state, and explain why that is so. 3. Schedule the Veteran for appropriate VA compensation examination for the claimed cervical spine disorder by a medical examiner who has not previously examined the Veteran. All relevant documents (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be made available to and reviewed by the examiner in rendering the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE should be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should confirm that the record was reviewed in the examination report. a. Based on review of appropriate records, for each diagnosis of a cervical spine disorder, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50 percent degree of probability) that any cervical spine disorder had its onset during active military service or is otherwise causally or etiologically related to service? For the purpose of providing the opinion, consider and discuss the following STR entries: 1) trapezius strain/spasm in September 1994; 2) neck pain in June 1998; and 3) overuse syndrome of the left arm and shoulder in August 2002. b. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. c. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based should be set forth in the report. If the examiner/reviewer cannot answer any question posed without resorting to unsupported speculation, the examiner/reviewer should so state, and explain why that is so. 4. Thereafter, the Veteran's claims for service connection for dental disorder and service connection for cervical spine disorder should be readjudicated. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with an appropriate time for response. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The purpose of this REMAND is to assist the Veteran in the development of his claims. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2012). 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. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs