Citation Nr: 1314209 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 11-26 918 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for a skin condition of the back and chest, to include as secondary to contaminated water at Camp Lejeune and/or as secondary to a service-connected disability. 2. Entitlement to service connection for a respiratory disorder, to include as secondary to contaminated water at Camp Lejeune. 3. Entitlement to service connection for tooth loss, to include as secondary to contaminated water at Camp Lejeune. 4. Entitlement to a rating in excess of 80 percent for residual scarring from discoid lupus erythematosus with generalized eczematoid dermatitis, resulting in disfigurement of the head, neck and face. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel INTRODUCTION The Veteran had service from August 1970 to November 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the August 2006 and September 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. While these rating decisions were issued by the Cleveland RO, in light of evidence indicating that the Veteran was stationed in Camp Lejeune sometime between 1957 to 1987, the Veteran's claims file was transferred to the RO in Louisville, Kentucky, and his claims were subsequently certified for appeal at the Louisville RO. A brief historical overview reflects that the Veteran was initially granted service connection for generalized eczematoid dermatitis, which was evaluated as 10 percent disabling, effective November 28, 1972, in the February 1973 rating decision. In the September 1978 rating decision, the RO increased the disability rating for the service-connected skin disorder to 30 percent, effective February 22, 1978. In the July 1996 rating decision, RO granted the Veteran's claim for service connection for discoid lupus erythematosus of the face, neck, and scalp, evaluating it as 10 percent disabling, effective June 4, 1992. A subsequent rating decision, dated in July 1997, indicates the disability rating for service-connected discoid lupus erythematosus of the face, neck, and scalp was increased to 30 percent, effective June 2, 1997. In May 2006, the Veteran sought a higher rating for both the above-referenced disorders, and in the August 2006 rating decision, the RO continued the 30 percent rating for his generalized eczematoid dermatitis and for his discoid lupus erythematosus of the face, neck, and scalp. After receiving notice of this determination, the Veteran filed a notice of disagreement (NOD) with the continued 30 percent rating awarded for both service-connected disorders. He then perfected a timely appeal with respect to the August 2006 rating decision. Before the case was certified to the Board, and after additional evidentiary development was completed, in the December 2009 rating decision, the RO combined the service-connected residual scarring from discoid lupus erythematosus with the generalized eczematoid dermatitis resulting in disfigurement of the head, face, and neck, and evaluated this disability as 80 percent disabling, effective May 18, 2006 (date of receipt of claim). The 30 percent disability rating for the Veteran's generalized eczematoid dermatitis was no longer effective after May 18, 2006. Although a higher rating has been assigned for the Veteran's skin disorder, the issue remains in appellate status as the maximum rating has not been assigned. AB v. Brown, 6 Vet. App. 35, 38 (1993) (a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In his August 2010 claim, the Veteran sought service connection for emphysema, and the September 2010 rating decision denied this issue. Competent medical evidence of record, however, not only reflects a diagnosis of emphysema but also shows diagnoses of bronchitis, and chronic obstructive pulmonary disease (COPD), all medical diagnoses which could fall under the category of a respiratory disorder. Prior to this appeal, the United States Court of Appeals for Veterans Claims (Court) addressed the scope of a claim in regard to a claimed disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons the Court held that, in determining the scope of a claim, the Board must consider the veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. Id. at 5. In light of the Court's decision in Clemons and the varying diagnoses recounted above, the Board has recharacterized this issue as is stated on the title page of this decision. This will provide the most favorable review of the Veteran's claim in keeping with the Court's holding in Clemons. In March 2012, the Veteran testified at a hearing conducted at the Board in Washington, DC before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the claim folder. The Board notes that the Veteran completed a VA Form 21-22a in favor of a private attorney in June 2009. However, in a July 2011 letter, and subsequent letters dated in September 2011 and February 2012, the Veteran's attorney indicated that he was no longer representing the Veteran, and in effect, withdrew as his representative. This was completed prior to the certification of the appeal to the Board, which took place on November 4, 2011. During the March 2012 hearing, the Veteran indicated that he was aware his attorney had withdrawn as his representative and wished to proceed with his hearing without any representation. The claims for an increased rating for the residual scarring from discoid lupus erythematosus with generalized eczematoid dermatitis, and the claims for service connection for a skin condition of the back and chest and for tooth loss, 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. FINDING OF FACT A respiratory disability, which has been diagnosed as COPD, was first identified many years after active duty and is not related to any injury, disease or event incurred in service, to include exposure to contaminated water at Camp Lejeune. CONCLUSION OF LAW The Veteran does not have a respiratory disability that is the result of disease or injury incurred in or aggravated during active military service; nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION A. Duties To Notify And To Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. Further, in Dingess v. Nicholson, 19 Vet. Ap. 473 (2006), the Court held that, upon receipt of an application for a service connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. With respect to the Veteran's claim seeking service connection for a respiratory disorder, the Board notes that the RO issued to the Veteran a letter dated in August 2010 prior to the appealed September 2010 rating decision. Therefore, the timing requirement of the notice has been met and to decide the appeal would not be prejudicial to the claimant. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The August 2010 letter satisfied the duty to notify provisions concerning his claim of service connection for a respiratory disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. Specifically, this letter apprised him of what the evidence must show to establish entitlement to the benefits sought, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. The August 2010 letter also informed the Veteran that his claimed disability may be considered secondary to his exposure to contaminated water during his period of service in Camp Lejeune, and that he had to option to submit additional evidence that established a connection between his claimed disability and his exposure to certain contaminants in the water supply at Camp Lejeune. The Veteran was also informed of the type of evidence he could submit that could substantiate a possible relationship between his claimed condition and his exposure to certain contaminants in the water at Camp Lejeune. The letter also provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective date. The Board also finds VA's duty to assist has been satisfied. The Veteran's service treatment records, as well as all post-service private treatment records, VA medical records, and VA examination reports are in the claims file and were reviewed by both the RO and the Board in connection with the claim adjudicated herein. Also, medical records used in the adjudication of his claim for disability benefits from the Social Security Administration (SSA) were obtained and associated with his claims file. Indeed, at no time has the Veteran referenced outstanding records that he wanted VA to obtain or that he felt were relevant to his claim. Finally, the duty to assist includes obtaining a medical examination/opinion when such is necessary to make a decision on the claim, as defined by law. The Veteran was afforded a VA examination for his respiratory disorder in July 2011. Pursuant to VBA Fast Letters No. 11-03 dated on January 11, 2011 and April 27, 2011, and in light of the Veteran's possible exposure to contaminated drinking water while stationed in Camp Lejeune, the Veteran's claims file was sent to the Louisville, Kentucky RO for additional development. These letters specifically instruct the AOJ to provide the designated VA medical examiner with appendices containing medical information and literature articles designed to assist the examiner with his or her assessment of the Veteran. Appendix A lists a number of internet websites pertaining to the issue of contaminated water at Camp Lejeune. Appendix B lists the diseases potentially associated with exposure to contaminants present in the Camp Lejeune water supply between 1957 and 1987. Appendix C provides a number of internet websites describing the potential health effects of exposure to chemical contaminants present in the water supply of Camp Lejeune between 1957 and 1987. Finally, Appendix D provides a notification letter to examiners evaluating claims based on service at Camp Lejeune. A review of the record reflects that the RO initiated a request to schedule the Veteran for a VA examination, and provided the VA examiner evaluating the Veteran in connection to his claimed respiratory disorder with the above-referenced appendices. The examination was conducted in July 2011, and included a review and discussion of the Veteran's claims file and existing medical records, an interview with the Veteran including a discussion regarding his medical history, and a thorough physical examination of the Veteran's respiratory system. Based on a review of the Veteran's claims file and an evaluation of the Veteran, the same examiner provided an etiological opinion concerning the Veteran's claimed disorder and service, and included the rationale upon which the opinion was based. The Board finds the opinion to be adequate, as it is predicated on a reading of the service and post-service medical records in the Veteran's claims file. It considered all the pertinent evidence of record, to include the Veteran's service and post-service records, statements of the Veteran, as well as the requisite appendices, and provides a complete rationale for the opinions stated, relying on and citing to the records reviewed. As such, there is adequate medical evidence of record to make a determination in this case. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). B. Service Connection Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Generally, establishment of direct service connection for a disorder requires evidence of (1) a current disability; (2) in-service incurrence of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Subsection (a) also refers to "each disabling condition...for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." Id. Also, the Court of Appeals for the Federal Circuit (Federal Circuit) held that, unlike §3.303(a) which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. Certain chronic diseases, including bronchiectasis, may be presumed to have been incurred during service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012). 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); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Here, the Veteran claims that he developed a respiratory disorder as a result of his exposure to contaminated water while stationed at Camp Lejeune. Initially, and in this regard, the Board notes that the Veteran's service treatment and service personnel records reflect that he was intermittently stationed in Camp Lejeune, North Carolina in 1970 until the time of his discharge in November 1972. Turning to the service treatment records, on the August 1970 examination conducted pursuant to the Veteran's enlistment, the clinical evaluation of his lung and chest was shown to be normal. In addition, the Veteran denied any respiratory or pulmonary problems in his medical history report and had a physical profile of 'P1' at the time of this examination. Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the 'PULHES' profile reflects the overall physical and psychiatric condition of the Veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). A number of the service treatment records reflect ongoing complaints of, and treatment provided for, respiratory problems. The Veteran was first seen at sick call with complaints of a sore throat, runny nose and cough in November 1970. He was subsequently seen again several months later (January 1971) with complaints of a cold of three weeks duration. During this visit, he reported symptoms of head congestion, as well as a headache and runny nose. Sick call records dated in May and June 1971 reflect the Veteran's ongoing complaints of a sore throat, chest pain and cough. During the June 1971 treatment visit, it was noted that the Veteran had been assessed with bronchitis the day before. However, the physical examination of his chest had been clear for any abnormalities and his temperature was shown to be within normal limits. Another physical examination of the chest was conducted at the June 1971 visit, the results of which were clear for any abnormalities. He also complained of pain that spread to his back and sides. The treatment provider did not diagnose the Veteran with a respiratory disorder but did refer him to another military healthcare provider for further inspection. The Veteran presented at sick call again, on what appears to be the same day, with complaints of sharp pain in his right upper quadrant that travelled to the right side of the back and flared up especially when he was working or laughing. He also reported a mild non-productive cough of three days duration. It does not appear that the treatment provider diagnosed the Veteran with any form of respiratory disability. Lastly, in November 1971, he presented at the Emergency room at the Naval Hospital for complaints of coughing and wheezing. He was assessed with an asthmatic attack. During a one-month admission to the Naval Hospital, the Veteran reported a childhood history of asthma, but added that he had not had any recurrences since he was eight or nine. The remainder of the Veteran's service treatment records is clear for any complaints or signs of respiratory problems. The Board finds that the weight of the evidence demonstrates that during the Veteran's service there was no combination of manifestations sufficient to identify a respiratory disability so as to establish chronicity of such claimed disorders during service. 38 C.F.R. § 3.303(b). While service treatment records reflect treatment for respiratory problems, an assessment of asthmatic attack, and a possible assessment of bronchitis, there were no actual clinical findings of a respiratory disability. The June 1971 treatment provider referred to a previous assessment of bronchitis the day before, but the service treatment records do not contain documentation demonstrating this assessment. Moreover, the June 1971 treatment provider evaluated the Veteran and did not assess him with a respiratory disability. Thus, while the Veteran was treated for respiratory problems during service, the service treatment records do not indicate that he was diagnosed with a chronic respiratory disorder. To the contrary, the evidence indicates that the respiratory symptoms experienced during active duty service were of an acute and transitory nature. The Veteran's August 1970 entrance examination is completely negative for any complaints or previous diagnoses of a respiratory disability. Indeed, the only evidence indicating that the Veteran had a respiratory disability prior to his enlistment consists exclusively of statements made by the Veteran during an in-service treatment consultation, wherein he reported a childhood history of asthma. The Board observes that lay statements, standing alone, are insufficient to rebut the presumption of soundness which arose when the Veteran was accepted for service. See Crowe v. Brown, 7 Vet. App. 238 (1994) (supporting medical evidence is needed to establish the presence of a pre-existing condition). As such, the Board is not persuaded that there is objective evidence demonstrating that the Veteran's current respiratory disability existed prior to service. Indeed, the post-service record on appeal is similarly negative for any complaints, treatment or diagnosis of a respiratory disability until several decades after service. In fact, the first post-service medical evidence of record pertaining to the Veteran's respiratory system is a March 2000 private emergency treatment report reflecting the Veteran's complaints of shortness of breath. This treatment report is dated nearly twenty-eight years after the Veteran's separation from service. During this treatment visit, the Veteran reported a history of shortness of breath and some coughing for several weeks prior to his arrival. He also reported previous chest pain, but denied currently experiencing similar symptoms. After undergoing an electrocardiogram (EKG) and rhythm strip, and being observed for several hours, the Veteran was assessed with chest wall pain. A July 2000 VA outpatient note reflects that the Veteran contacted the twenty-four hour hotline and reported to have shortness of breath upon exertion and an uncontrollable cough. The Veteran reported that he currently smokes one pack per day, and has smoked for most of his life. He scheduled an appointment to visit with his physician one week later. During the August 2000 appointment, Veteran reported that he was a smoker, and complained of a stuffy nose, hoarseness, shortness of breath, and a productive cough. Upon physical examination of the Veteran, the treatment provider noted that the Veteran's nose was congested and his throat exhibited signs of erythema. The Veteran underwent a chest X-ray, the results of which were negative for active pulmonary pathology and cardiac enlargement. Based on his evaluation of the Veteran, the treatment provider diagnosed the Veteran with bronchitis and possible emphysema. In April 2005, the Veteran was seen at the VA Community Based Outpatient Clinic (CBOC), at which time he relayed a six-month history of near syncopal episodes. According to the Veteran, his symptoms occurred approximately once a week and lasted nearly thirty seconds. In November 2005, the Veteran presented at the VA CBOC with complaints of chest congestion, wheezing, a scratchy throat, fatigue and a productive cough - symptoms that had reportedly persisted for two weeks. He was assessed with an upper respiratory infection. VA treatment records dated from January 2006 to August 2007 reflect the Veteran's complaints of shortness of breath and occasional chest discomfort, as well as ongoing diagnoses of bronchitis, an upper respiratory infection, sinusitis and COPD. The Veteran was afforded a VA respiratory examination in July 2011, at which time, he provided his medical history, and described an "insidious onset of a chronic cough" that began in the 1970s. The Veteran also reported to develop increasing dyspnea on exertion over the past several years, and stated that he has to stop ambulating after one block or climbing a staircase after one flight. In reviewing the Veteran's medical records, the examiner acknowledged the Veteran's diagnoses of COPD and emphysema, and noted that he was being treated with an albuteral inhaler, which he reportedly uses one to two times a day, and up to four times a day during increasingly warm and hot weather. The examiner also noted that the Veteran had been a smoker for the past fifty years, and had a documented history of tobacco abuse. On physical examination, the Veteran was not shown to be in respiratory distress, and his lungs were clear throughout his evaluation. Pulmonary function tests (PFTs) were also conducted, the results of which were consistent with COPD. Based on his review of the Veteran's claims file, as well as his discussion with, and evaluation of the Veteran, the examiner diagnosed the Veteran with COPD. The examiner also concluded that it is less likely than not that the Veteran's COPD is related to his exposure to contaminated drinking water while stationed at Camp Lejeune. According to the examiner, there is no direct or causal relationship between the Veteran's COPD and his exposure to the contaminated drinking water at Camp Lejeune documented in current medical literature. Additionally, the examiner found that it is more likely than not that the Veteran's COPD is related to his 50+ year history of tobacco abuse. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a respiratory disability. First, there is no evidence that the Veteran's COPD first manifested within the first post-service year after the Veteran's discharge from service in November 1972, nor has the Veteran so contended. As such, service connection on a presumptive basis is not warranted for a respiratory disorder (bronchiectasis). With respect to direct service connection, the competent medical evidence of record does not relate the Veteran's COPD to service. In the July 2011 VA medical opinion, the examiner reviewed the Veteran's service and post-service treatment records, as well as the necessary appendices providing background information and medical literature articles concerning the contaminated water supply at Camp Lejeune between 1957 and 1987, the potential health effects due to exposure to chemical contaminants present in this water supply, and diseases potentially associated with exposure to contaminants present in the Camp Lejeune water supply during this time period. Based on his review of this evidence and medical literature, as well as his evaluation of the Veteran, the examiner found there to be no direct or causal connection between the Veteran's COPD and his exposure to contaminated drinking water while stationed at Camp Lejeune. According to the VA examiner, the Veteran's respiratory disability, namely his COPD, was not related to his service, but instead attributed to his 50+ year history of smoking. In reaching this conclusion, the examiner referenced evidence in the claims file documenting the Veteran's smoking history. The VA examiner also took note of the Veteran's claim that his respiratory symptoms had their onset in service and had continued since, and still found nothing that would support a connection between his current respiratory disability and his military service. Thus, the Board finds that the July 2011 VA examiner's opinion is entitled to more probative weight than the Veteran's assertions that his respiratory disorder was causally related to service, to include his exposure to contaminated water while stationed in Camp Lejeune. The Board acknowledges the fact that the July 2011 VA examiner did not provide a medical opinion as to whether the Veteran's previously diagnosed respiratory disabilities, namely his bronchitis, emphysema, and upper respiratory infection, were related to service. However, the Board finds that a medical opinion concerning the etiology of these disorders is not necessary. Evidence must show that the Veteran has had the disability for which benefits are being claimed at some point during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim). The Veteran filed a claim for a respiratory disorder in August 2010, and the only respiratory disorder he has been diagnosed with during the pendency of this appeal is his COPD. The Board has also considered the lay statements of record. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter 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"). In this case, however, although the Veteran is competent to describe symptoms congruent to a respiratory problem, he is not competent to comment on the etiology of such a disorder. While a layperson can provide evidence as to some questions of etiology or diagnosis, the question of a medical relationship between a respiratory condition and service, which would require more than direct observation to resolve, is not in the category of questions that lend themselves to resolution by lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), Barr v. Nicholson, 21 Vet. App. 303, 309 (2007), Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). Here, the Veteran is competent to report symptoms of a respiratory condition because such actions come to him through his senses and, as such, require only personal knowledge rather than medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran is not competent to opine on the question of etiology and, therefore, his statements asserting a relationship between his respiratory condition and service do not constitute competent medical evidence on which the Board can make a service connection determination. As for the Veteran's complaints of continuing respiratory symptoms since service, the Board notes that it may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints of or treatment for the relevant condition or symptoms. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37. Notwithstanding that fact, the lack of contemporaneous medical records is something that the Board can consider and weigh against a Veteran's lay evidence. Id. According to the Veteran's statements, his respiratory problems had their onset in service, and he has continued to experience symptoms associated with this disability since that time. Even if the Veteran's contentions could be read as claiming continuity of symptomatology since service, the evidence does not show that the Veteran sought treatment for his respiratory problems for many years after service. Indeed, the earliest post-service evidence of record reflecting a diagnosis of a respiratory disability (bronchitis and possible emphysema) is dated in August 2000, nearly twenty-eight years after the Veteran's separation from service. The earliest post-service evidence of record reflecting a diagnosis of COPD is dated in May 2006, nearly thirty-four years after service. In the absence of any objective evidence to support complaints of continuity of symptomatology in the years since service, the initial demonstration of the disability diagnosed during the pendency of the appeal, thirty-four years after service, is too remote from service to be taken as evidence of continuity of symptoms since service, and diminishes the reliability of the Veteran's current recollections. Maxson v. Gober, 230 F.3d 1130 (Fed. Cir. 2000) (holding, in an aggravation context, that the Board may consider a prolonged period without medical complaint when deciding a claim). Moreover, during the March 2012 hearing, the Veteran testified that he was diagnosed with emphysema in the nineties, and began experiencing respiratory symptoms, such as shortness of breath, one year later. See March 2012 Hearing Transcript., p. 8. This weighs again his claim that his respiratory symptoms have existed since service. In addition, the Board notes that the Veteran had the opportunity to file a claim for this disability given the fact that he filed a claim for his skin condition in 1972; however, no such claim was filed until August 2010, nearly thirty-eight years after his separation from service. In addition, the Veteran began receiving treatment for his skin condition at VA treatment facilities in Youngstown, Wade Park, Canton, and Brecksville, Ohio, very soon after service, but failed to mention or discuss any manifestations of a respiratory condition until March 2000. The fact that the Veteran had the opportunity to file a claim and receive medical treatment for his respiratory disability closer in time to his discharge from service, but did not do so, weighs against any contentions of continuing symptoms since service. Accordingly, and based on this evidentiary posture, the Board concludes that service connection for a respiratory disability based on continuity of symptomatology is not warranted. After considering the probative value of the evidence in this case, the Board finds the evidence against the Veteran's claim for a respiratory disability to be more persuasive than the evidence in favor of the claim. Without evidence of sufficient probative value to support a relationship between his COPD and service, there is a lack of persuasive medical evidence to support his claim. As noted above, there is at a minimum a twenty-eight year gap without any objective clinical evidence to support an assertion of continuing symptomatology, the Veteran's own statements have been contradictory as to whether he has experienced respiratory symptoms since service, and the persuasive objective medical evidence of record does not relate the Veteran's current COPD to service. The preponderance of the evidence is against the claim. As such, service connection for a disability manifested by poor circulation is not warranted. ORDER Entitlement to service connection for a respiratory disorder is denied. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); 38 C.F.R. § 3.159(c)(4) (2012). A medical opinion is considered adequate only "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl, 21 Vet. App. at 123, quoting Ardison, supra. The opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions," id. at 124-25, and the "examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two," Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Thus, while there is no requirement imposed on a medical examiner to provide a statement of reasons or bases in support of his or her opinion, Ardison v. Brown, 6 Vet. App. 405, 407 (1994), the clinician must support his of her medical findings with adequate medical analysis. Stefl and Nieves-Rodriguez, both supra. A. Increased Rating for Residual Scarring from Discoid Lupus Erythematosus with Generalized Eczematoid Dermatitis, resulting in Disfigurement of the Head, Face and Neck Preliminarily, the Board notes that additional evidence in the form of VA outpatient records and examination reports have been associated with the claims file and/or scanned into the Virtual VA Claims processing system after the issuance of the most recent Supplemental Statement of the Case (SSOC) in connection to this disorder (in April 2009). These records reflect outpatient treatment for, and examinations of, the Veteran's service-connected skin disability and residual health complications arising therefrom. The Veteran has not specifically stated that he was waiving consideration of the additional evidence by the AOJ. Pursuant to 38 C.F.R. § 20.1304(c), any pertinent evidence submitted by the Veteran must be referred to the AOJ for initial review, unless this procedural right is waived by the appellant or his representative, or unless the Board determines the benefit sought can be allowed on appeal without such a referral. Therefore, the Board may not properly consider this evidence or issue a decision at this time, and must remand the case to allow the AOJ opportunity to review this evidence and readjudicate the Veteran's claim. See 38 C.F.R. § 19.31 B. Service Connection for Skin Condition of the Back and Chest The Veteran contends that he developed a skin condition on his back and chest as a result of his exposure to contaminated water while stationed in Camp Lejeune during his period of service, and/or secondary to his service-connected residual scarring from discoid lupus erythematosus with generalized eczematoid dermatitis. During his hearing, the Veteran testified that the skin problems on his back and chest began towards the end of his service, and have continued to bother him since his separation from service. See Hearing Transcript, p. 4. Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). A review of the service treatment records reflects that the Veteran was treated for ongoing dermatitis that spread throughout his face, arms, and neck during his period of service. A March 1972 discharge summary reflects that the Veteran was hospitalized for his skin problems at the U.S. Naval Hospital in February 1972. A recitation of his medical history indicated that in July 1971, two months after reporting to his duty station at Guantanamo Bay, Cuba, the Veteran noticed the onset of a small, pruritic patch on the flexor aspect of his right forearm which spread to both arms, legs, neck, axillae, ankles and midthigh level. Upon physical examination of the Veteran, the chief of dermatology, F.E., M.D., observed that the skin eruption was located on the face and neck, as well as the region of the arms below the mid-upper arm level, and the region of the legs beginning slightly below the knees and extending above the ankles bilaterally. According to Dr. F.E., the eruption consisted of "hyperpigmented, lichenified plaque-like lesions with scaling and was fairly confluent in the above mentioned areas." The record reflects that the Veteran was treated with systemic and topical steroids with marked improvement. He was subsequently discharged from the hospital with a diagnosis of probable allergic photodermatitis. Unfortunately, the Veteran continued to experience a recurring rash after his discharge and in September 1972, he appeared before the medical board for the purpose of discharge as his condition was not improving with treatment, and rendered him unable to perform some of his military duties. In the September 1972 medical board report, the Veteran was diagnosed with atopic dermatitis, and found unfit for duty. The Veteran's post-service treatment records encompass nearly forty-years worth of medical treatment provided for his skin condition, to include his dermatitis, eczema, and discoid lupus lesions. The medical records indicate that the Veteran's service-connected skin lesions and rash were primarily located on or near his face, neck and arms after his discharge from service. However, during a December 2006 treatment visit, the Veteran's private physician, Dr. P.S., discovered areas of eczematous change and hyperpigmentation on his back and abdomen. The Veteran was afforded a VA skin examination in June 2009, at which time the examiner detected the presence of cirrhosis and dry flaky skin in the upper anteroposterior chest region. Based on her evaluation of the Veteran, she assessed him with residual scarring from discoid lupus erythematosus of the face, scalp and neck, and eczema. The January 2010 dermatology note also noted findings of a "fine scale on [the] neck, upper chest and upper back." At the March 2010 VA examination, the VA examiner, upon reviewing the Veteran's claims file, acknowledged his ongoing diagnoses of eczema, discoid lupus, seborrheic dermatitis and discoid lupus erythematosus. According to the examiner, the Veteran's xerosis and seborrheic dermatitis affects five percent of the exposed areas. The examiner also noted that the Veteran's xerosis affects 80 percent of the entire body, and his seborrheic dermatitis affects less than one percent of the entire body. Further, the examiner did not observe any scarring and/or disfigurement due to the Veteran's xerosis and seborrheic dermatitis. Based on his evaluation of the Veteran, the examiner assessed the Veteran with residual scarring, but did not identify active discoid lupus erythematosus lesions. The examiner also diagnosed the Veteran with xerosis and seborrheic dermatitis. According to the examiner, the Veteran's xerosis and seborrheic dermatitis were not related to his military service or secondary to his already service-connected skin disability. He explained that xerosis and seborrheic dermatitis are separate dermatological conditions. The Veteran was afforded another VA skin examination in July 2011, at which time, he reported occasional flare-ups of his discoid lesions as well as the dermatitis surrounding his head, scalp, neck and back area. Based on his evaluation of the Veteran, the examiner diagnosed him with discoid lupus skin lesions and eczematous dermatitis. According to the examiner, it is less likely than not that the Veteran's two chronic skin conditions are related to his exposure to contaminated drinking water while stationed at Camp Lejeune. The examiner explained that there is no direct or causal relationship between the contaminated drinking water and the Veteran's claimed skin disorder. Based on the most recent VA examination, the Board is left to question whether the Veteran's skin condition on his back and chest is an extension of his already service-connected skin disorder, or a separate and distinct skin disorder altogether. The July 2011 VA examiner diagnosed the Veteran with skin disorders analogous to what he was already service-connected for, and did not specify what region or area(s) of the Veteran's body these diagnosed disorders were located on. In addition, the examiner did not discuss whether the Veteran's skin condition of the back and chest was secondary to his service-connected skin disability. On the other hand, the March 2010 VA examiner determined that the Veteran's diagnoses of xerosis and seborrheic dermatitis were separate dermatologic conditions that were neither related to his military service, nor secondary to his already service-connected skin disability. Unfortunately, the Board is still unclear as to whether xerosis and seborrheic dermatitis are separate dermatologic conditions diagnoses and/or separate from the Veteran's already service-connected skin disability. In addition, although this examiner provided the requested opinion, he provided no justification for his opinion. As noted above, to be adequate, an opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl, 21 Vet. App. at 124. The value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." See Bloom v. West, 12 Vet. App. 185, 187 (1999). A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. Brown, 11 Vet. App. 345, 348 (1998). A supporting rationale is especially important in a case such as this where there is evidence indicating the possibility that the Veteran's skin condition of the back and chest could have been incurred in service. Moreover, the March 2010 examiner did not have access to the designated appendices providing background information regarding the relationship between certain diseases and the exposure to certain contaminants located in the water supply in Camp Lejeune, North Carolina between 1957 and 1987, which must be provided to VA medical examiners pursuant to VBA Fast Letter No. 11-03 (April 27, 2011). Furthermore, the March 2010 examiner did not address whether the Veteran's xerosis and seborrheic dermatitis were aggravated by his service-connected skin disorder. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). As such, both examination reports are inadequate for rating purposes and the Veteran's claim should be remanded so he can be afforded another VA medical examination to determine the nature and etiology of his skin condition of the back and chest. 38 C.F.R. § 3.159(c)(4)(i). In addition, during his hearing, the Veteran testified that he has continued receiving treatment for his skin condition at the Cleveland VA Medical Center (VAMC), to include treatment facilities located in Wade Park, Brecksville, and Youngstown, Ohio. As this matter is being returned for further development, an effort should be made to obtain any medical records pertaining to ongoing treatment the Veteran has received for his skin condition that are not already on file. 38 U.S.C.A. § 5103A(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). C. Service Connection for Tooth Loss The Veteran contends that his dental condition, namely the loss of his teeth, is due to his exposure to contaminated water during his period of service in Camp Lejeune, North Carolina. During his hearing, the Veteran testified that his teeth started to fall out sometime between 1987 and 1988. See March 2012 Hearing Transcript, p. 10. The Board notes that VA compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. The types of dental conditions covered are: loss of teeth due to bone loss of the body of the maxilla or the mandible due to trauma or disease such as osteomyelitis, but not periodontal disease. See 38 C.F.R. §§ 4.150, Diagnostic Code 9913; 17.161(a). Otherwise, a veteran may be entitled to service connection for dental conditions including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal (i.e., gum) disease, for the sole purposes of receiving VA outpatient dental services and treatment, if certain criteria are met. See 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 17.161. The rating activity should 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 and, when applicable, to determine whether the condition is due to combat or other in-service trauma, or whether the Veteran was interned as a prisoner of war. See 38 C.F.R. § 3.381(b). The Veteran's service treatment records indicate that his dental condition was acceptable during his August 1970 enlistment examination, and there were no subjective or objective abnormalities noted of the mouth and teeth. However, in May 1971, the Veteran presented at sick call with complaints of soreness in his left jaw and left sub mandibular region of one week duration. On physical examination, the treatment provider noted that the Veteran appeared to have an abscess behind his tooth and an "enlarged tender left submand node." He was referred to an oral surgeon for further treatment. The remainder of the Veteran's service treatment records, to include his dental examination reports, are clear for any abnormalities. The Veteran was afforded a VA examination in connection to his dental claim in July 2011. During the examination, the Veteran reported that he took care of his teeth and does not understand why they decayed. Upon physical examination of the Veteran's dental condition, the examiner observed no limitation of maximum opening, adding that the exact number could not be recorded due to the absence of the Veteran's teeth. The examiner further noted no evidence of pain, deviation or limitation of mouth opening. With respect to the extent of any bone loss of the mandible, maxilla or hard palate, the examiner wrote that there was a "loss of the alveolar bone where teeth are missing." It does not appear that any diagnostic tests were conducted to determine the extent of the bone tissue loss. Based on his evaluation of the Veteran, the VA examiner determined that the loss of teeth present was neither caused by, nor the result of, the Veteran's exposure to contaminated water at Camp Lejeune. The examiner attributed the loss of the Veteran's teeth to decay, noting that the Veteran was "fully dentate" during service. According to the examiner, there is no evidence that the contaminated water in Camp Lejeune "resulted directly or indirectly in the loss of teeth observed." The Board finds the basis of the examiner's opinion to be somewhat unclear from the examination report. While the examiner attributed the loss of the Veteran's teeth to decay, the report contains no discussion of what specific post-service medical or lifestyle factors may have contributed or led to the Veteran's decaying teeth. The Veteran indicated at the examination that he brushed and took care of his teeth. A medical opinion is considered adequate only "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one.'" See Stefl v. Nicholson, 21 Vet. App. 120, 122 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Without a discussion of the specific post-service factors that the examiner has determined to be the cause of the Veteran's decaying teeth and subsequent tooth loss, the Board cannot conclude that the examiner's opinion is based on more than just mere conjecture. Additionally, it does not appear as though the examiner took note of the May 1971 clinical record documenting the Veteran's in-service treatment for an abscess behind his tooth when arriving at his conclusion. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). Further, the record remains unclear whether a dental condition for which disability compensation may be provided has been diagnosed - specifically, loss of teeth due to loss of substance of the body of maxilla or mandible due to trauma or disease such as osteomyelitis. While the examiner noted the loss of the alveolar bone where the teeth are missing, there is no additional medical information as to the relationship between the alveolar bone and the body of the maxilla or the mandible. As such, the Board is unclear as to whether the alveolar bone involves the body of the maxilla or mandible, and if so, whether the bone loss of the alveolar bone extended to the body of the maxilla or the mandible and was due to a disease such as osteomyelitis. Accordingly, the Board finds that the Veteran's claim of service connection for tooth loss must be remanded so the AOJ can schedule the Veteran for another VA examination to determine the nature and etiology of his tooth loss. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination, it must provide an adequate one). In addition, during the March 2012 hearing, the Veteran testified that he received dental treatment from a private dentist during the 1980's. The Veteran identified the private dentist as "Dr. Chung." See Hearing Transcript, p. 10. However, the specified treatment records have not been associated with the claims file, nor has any attempt been made to obtain the specified treatment records. Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to make a reasonable effort to obtain identified private treatment records. See 38 C.F.R. § 3.159(c)(1). As such, on remand, the AOJ should to attempt to obtain the specified treatment records. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with a corrective VCAA notice letter informing him of the information and evidence needed to substantiate the claim for service connection for a skin condition of the back and chest, to include as secondary to a service-connected disability. 2. Ask the Veteran to provide the full name and address for his previous private dentist, Dr. Chung, as well as any other non-VA dental health-care providers, and the specific dates in which he received treatment with these providers. After acquiring this information, instruct the Veteran to complete a release form authorizing VA to request his private medical records from any of these health-care providers. After securing the appropriate release form from the Veteran, attempt to obtain any clinical or medical records, to include progress notes, evaluations and X-ray reports, regarding any treatment the Veteran received from any of the specified dental treatments providers, from 1980 until the present time. If any records are not obtained, inform the Veteran and provide him an opportunity to submit the records. All such available documents should be associated with the Veteran's claims folder. 3. Request records of relevant skin and dental treatment that the Veteran may have received at the Cleveland VAMC, to include the Youngstown VA Outpatient Clinic and any VA treatment facilities located in the Wade Park and Brecksville campus, since February 2012. Copies of such records which are available should be associated with the claims folder. 4. Once these records have been obtained, then, make arrangements with the appropriate VA facility for the Veteran to be afforded a dermatological examination to determine the nature and etiology of any skin condition on the back and chest that may be present. The claims file, all medical records on Virtual VA, a copy of this REMAND, and Appendices A - D pursuant to VBA Fast Letter No. 11-03 (April 27, 2011), must be made available to the examiner for review, and the examination report should reflect that the claims file was reviewed in conjunction with the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, and all pertinent pathology should be noted in the examination report. After reviewing the record and examining the Veteran, the examiner should specify the nature of any current skin disability located on the Veteran's chest and/or back and provide diagnoses for all identified skin disabilities. For any diagnosed skin disorder of the chest and back separate from the skin disability the Veteran is already service-connected for (discoid lupus erythematosus with generalized eczematoid dermatitis), the examiner should express an opinion as to whether it is at least as likely as not, i.e., a 50 percent probability or greater, that such disorder had its clinical onset in service or is otherwise related to the Veteran's conceded in-service exposure to contaminated water during his period of service in Camp Lejeune, North Carolina. In answering this question, the examiner should address the Veteran's competent assertions that he has experienced a skin condition on his back and chest since service, and should set forth the medical reasons for accepting or rejecting the Veteran's statements regarding continuity of symptoms since his military service. If the examiner finds that the Veteran's disability(ies) is(are) not related to his service, then he or she must provide a complete rationale upon which his or her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. If the examiner finds that it is unlikely the Veteran's skin disorder(s) of the chest and back had its (their) onset in service or is(are) otherwise etiologically related to the Veteran's military service, then the examiner should also express an opinion as to whether it is at least as likely as not, i.e., a 50 percent probability or greater, that any skin disorder(s) of the chest and back currently present [other than the skin disability the Veteran is already service-connected for] was(were) caused and/or aggravated (permanently worsened beyond normal progression) by the Veteran's service-connected residual scarring from discoid lupus erythematosus with generalized eczematoid dermatitis, resulting in disfigurement of the head, face, and neck. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it. All opinions expressed must be supported by complete rationale. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 5. Then, the Veteran should be scheduled for another VA dental examination with a VA dentist or oral surgeon to determine the nature and etiology of any dental condition that may be present. The claims file, all medical records on Virtual VA, a copy of this REMAND, and Appendices A - D pursuant to VBA Fast Letter No. 11-03 (April 27, 2011) must be made available to the examiner for review, and the examination report should reflect that the claims file was reviewed in conjunction with the examination. Any and all studies, tests, and evaluations, to include diagnostic testing, deemed necessary by the examiner should be performed, and all pertinent pathology should be noted in the examination report. [The examiner should specifically take into consideration the May 1971 sick call note reflecting in-service treatment for the Veteran's dental/mouth condition.] The examiner is asked to: a. Identify any current dental condition, to include any missing teeth (listed by tooth number). State whether there is chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible; loss of the mandible, nonunion or malunion of the mandible; temporomandibular articulation or limited jaw motion; loss of the ramus; loss of the condyloid process; loss of the hard palate; loss of the maxilla, or malunion or nonunion of the maxilla. See 38 C.F.R. § 4.150.) b. For any diagnosed dental disorder, opine as to whether it is at least as likely as not, i.e., a 50 percent probability or greater, that such disorder had its clinical onset in service or is otherwise related to the Veteran's conceded in-service exposure to contaminated water during his period of service in Camp Lejeune, North Carolina. In particular: i. For any missing tooth, it is at least as likely as not, i.e., a 50 percent probability or greater, that such was the result of an in-service disease such as osteomyelitis? ii. Additionally, is it at least as likely as not, i.e., a 50 percent probability or greater, that the loss of any given tooth was the result of loss of substance of the body of the maxilla or mandible due to a disease such as osteomyelitis? iii. Alternatively, is the loss of any given tooth due to periodontal disease? iv. For any missing tooth, state whether the loss of that tooth (or lost masticatory surface) can be replaced by suitable prosthesis, such as dentures. If the examiner finds that the Veteran's dental disorder(s) is(are) not related to his service, then he or she must provide a complete rationale upon which his or her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. Specifically, the examiner should discuss what post-service medical or lifestyle factors may have contributed to the Veteran's tooth loss. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it. All opinions expressed must be supported by complete rationale. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 6. Then, readjudicate the issues on appeal, as are listed on the title page of this decision/remand. If any of the benefits remaining on appeal are not granted, the Veteran should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2012). 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). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs