Citation Nr: 1318584 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 10-13 737 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to an initial compensable disability evaluation for residuals of dental surgery (tooth #10). 4. Entitlement to an initial disability evaluation (rating) in excess of 10 percent for a septal deviation. 5. Entitlement to a higher initial disability evaluation (rating) for sinusitis with sinus headaches associated with septal deviation, in excess of 10 percent from July 19, 2007, and in excess of 30 percent from March 27, 2012. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is also the appellant, had active service from January 1967 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Cleveland, Ohio. Thereafter, the RO in Chicago, Illinois, assumed jurisdiction. In February 2013, the Veteran appeared at a Board videoconference hearing at the RO before the undersigned Veterans Law Judge in Washington, DC. A transcript of the hearing is of record. The matter is now ready for appellate review. The Board has also reviewed the file in Virtual VA to ensure a complete review, but has found no additional relevant evidence. FINDINGS OF FACT 1. At the time of the February 2013 videoconference hearing, the Veteran specifically withdrew the issues of entitlement to higher initial disability evaluations for a septal deviation and sinusitis with sinus headaches. 2. The Veteran was exposed to some loud noises during service from small arms fire during basic training and heavy equipment, and had post-service loud noise exposure working in trucking and with heavy equipment and recreational noise exposure. 3. Tinnitus did not begin in service. 4. The current tinnitus is not causally or etiologically related to service. 5. Symptoms of sensorineural hearing loss were not chronic in service. 6. Hearing loss did not manifest to a compensable degree within one year of service separation. 7. Symptoms of sensorineural hearing loss were not continuous since service. 8. Current hearing loss disability is not causally or etiologically related to service, including the loud noise exposure during service. 9. The loss of tooth 10 was not due to loss of substance of body of mandible or maxilla without loss of continuity. 10. The Veteran does not have loss of any part of the mandible, mandibular ramus, or maxilla. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran of the issues of higher initial disability evaluations for a septal deviation and sinusitis with sinus headaches have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Supp. 2012); 38 C.F.R. § 20.204 (2012). 2. Tinnitus was not incurred in active service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 3. Hearing loss was not incurred in active service nor may it be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. The criteria for an initial compensable evaluation for residuals of dental surgery (tooth #10) have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.21, 4.150, Diagnostic Codes 9913, 9915 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal of Initial Rating Issues Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn in writing or in testimony at a hearing. 38 C.F.R. § 20.204. In this case, at the time of his February 2013 videoconference hearing, the Veteran withdrew the issues of higher initial disability evaluations for a septal deviation and sinusitis with sinus headaches; hence, there remain no allegations of errors of fact or law for appellate consideration as it relates to these issues. Accordingly, the Board does not have jurisdiction to review the appeal, and it is dismissed without prejudice as it relates to these issues. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 has been amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). The Court has also held that that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With regard to the residuals of dental surgery (Tooth #10) claim, because the Veteran's appeal arises from his disagreement with the initial rating following the grant of service connection no additional notice is required. The United States Court of Appeals for Veterans Claims (Court) and the United States Court of Appeals for the Federal Circuit (Federal Circuit) have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (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). As it relates to the claims of service connection for hearing loss and tinnitus, the Board observes that in a December 2007 letter the RO provided the Veteran with notice that informed him of the evidence needed to substantiate his claims. The letter also told him what evidence he was responsible for obtaining and what evidence VA would undertake to obtain. The letter further told him to submit relevant evidence in his possession. The December 2007 letter also provided the Veteran with notice as to the disability rating and effective date elements of the claim. As to all issues, the Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, VA examination reports, and lay evidence, to include hearing testimony. No additional pertinent evidence has been identified by the claimant. The Board further notes that as it relates to the claims for hearing loss and tinnitus, the Veteran was afforded a VA examination in April 2008. At the time of the examination, the examiner rendered opinions as to the relationship between any claimed hearing loss and tinnitus and the Veteran's period of service and provided rationale to support the opinions. As to the claim for an increased evaluation for residuals of the dental surgery, the Veteran was afforded VA examinations in April 2008 and April 2012. Information obtained from all the examinations, which included detailed history, statements from the Veteran, and testing results, provided sufficient information to properly rate the Veteran's claims. As such, the Board finds that additional VA examinations are not warranted as there is otherwise sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). The Veteran also appeared at a videoconference hearing before the undersigned Veterans Law Judge in February 2013 in support of his claim. At the time of the hearing, the Veterans Law Judge set forth the issues on appeal. Furthermore, information was obtained regarding the symptoms related to the Veteran's claimed disorders. Therefore, not only were the issues explained in terms of the scope of the claim for benefits, but the outstanding issues material to substantiating the claims were also fully explained. The Veterans Law Judge advised the Veteran that there was a negative medical nexus opinion of record, and that he could obtain and submit a medical nexus opinion relating the current disabilities to the noise exposure service. Following the hearing, the Veteran was afforded the opportunity to submit additional evidence and has chosen not to do so. The Board finds that the Veterans Law Judge complied with the duties set forth in 38 C.F.R.§ 3.103(c)(2). The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments presented by his representative. As noted above, he also appeared at a videoconference hearing before the undersigned Veterans Law Judge in February 2013. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Service Connection for Tinnitus Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Tinnitus is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) do not apply to the non-chronic disease. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran maintains that he was exposed to acoustic trauma in service of small arms fire during basic training and heavy equipment (bulldozer and truck), and that this noise exposure caused his current tinnitus. He maintains that his tinnitus started in service and has continued to the present day. At the time of the February 2013 Board hearing, the Veteran testified that he first experienced ringing in his ears after basic training; he operated heavy equipment in service without ear protection and other noise exposures; the ringing in his ears had continued since service; and he currently wore ear protection when in loud areas; and that he now has constant ringing in his ears. After a review of all the evidence, the Board finds that the Veteran was exposed to some loud noises during service from small arms fire during basic training and heavy equipment, and also had post-service loud noise exposure working in trucking and with heavy equipment and recreational noise exposure. At the October 2007 VA audiology examination, the Veteran presented a thorough history of both service and post-service loud noise exposure. The Veteran reported that his military noise exposure included combat training, firearms, heavy equipment, and service as a mail man. He also reported having occupational noise exposure as a result of being a truck driver, horse manager, and heavy equipment operator, with inconsistent use of hearing protection devices. Recreational noise exposure included power tools, shop equipment, chainsaw with hearing protection devices, firearms, and motorcycles without hearing protective devices. At an April 2008 VA examination, the Veteran reported that while in the military he was a heavy equipment operator, that he operated a bulldozer and truck, and had noise exposure during basic training. He reported that in the fourth week of training at Fort Jackson they had night fire and he was exposed to noise (more on the right) from training exercises. The Veteran stated that he was not provided with any hearing protection for any of his job duties. The Veteran also reported that following discharge from the service, the Veteran worked in trucking and heavy equipment. The Board recognizes the competency of a lay person to report symptoms of tinnitus (ringing in the ears) at any time. See Charles v. Principi, 16 Vet. App. 370 (2002) (stating that tinnitus is the type of disorder associated with symptoms capable of lay observation, as it may be diagnosed by its unique and readily identifiable features, so is not "medical in nature"). The Veteran filed the claim for service connection for hearing loss and tinnitus in September 2007. At the October 2007 VA compensation examination, the Veteran presented a history of tinnitus since 1967, which would be during the time he was in service. At the Board personal hearing in February 2013, the Veteran testified, among other things, that he first experienced ringing in his ears after basic training, and that the ringing in his ears had continued since service. After reviewing all the evidence, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience tinnitus during service, that is, that tinnitus did not begin during service. In this case, the Board finds Veteran not to be credible in the more recent reporting of symptoms of tinnitus during service and after service. The weight of the competent and credible evidence shows no tinnitus (also referred to as ringing in the ears) in service or during the years immediately following service; tinnitus is not shown for 38 years after service until 2007. The first objective finding of tinnitus subsequent to service was not until a VA examination in October 2007, when the Veteran was seen with complaints of tinnitus. The Board finds that the Veteran's more recent histories and testimony to the effect that he had tinnitus in service and for the years after service prior to 2007, which he made pursuant to the current claim for service connection (compensation), are inconsistent with, and outweighed by, other more contemporaneous evidence that shows no tinnitus in service or for years after service. The unfavorable evidence includes that the service treatment records do not reveal any complaints or findings of tinnitus. At the time of the August 1969 service separation examination, normal findings were reported for the ears. While the Veteran checked the "yes" box on his August 1969 report of medical history when asked if he had or had ever had ear, nose, or throat trouble, it was indicated in the physician's summary statement that he had seasonal throat trouble, rather than an ear problem; therefore, both the lay history/complaints and medical findings show no tinnitus in service. The Veteran did not give a history of tinnitus in service, and there was no reference to any ear problems or ringing of the ears during service. While the Veteran has indicated that he went to an ENT within one year following service and reported having tinnitus, these records are not available for review. The Veteran also did not claim service connection for tinnitus for many decades following service, including at the time he filed a claim for service connection for other disabilities in July 2007, but did not claim service connection for hearing loss or tinnitus at that time. At the time of an April 2008 VA examination, the Veteran reported a history of noise exposure in service without hearing protection, that he had had tinnitus since basic training and had reported his tinnitus to an ENT a year after he was discharged, but these records were not in the file because the physician had passed away. Inconsistent with the Veteran's report in April 2008 of always using ear protection at work after service, the VA examiner noted that ear protection was found to be used inconsistently at the time of the October 2007 outpatient consultation. The VA examiner further noted the other types of (post-service) occupational and recreational noise exposure that were reported at the time of the October 2007 audiological consultation, and noted that the Veteran did not report these activities at the time of the examination. The Board next finds that the weight of the evidence demonstrates that the Veteran's current tinnitus is not related to service, including to the in-service loud noise exposure. Following examination in April 2008, the VA examiner rendered an opinion that the Veteran's tinnitus was less likely as not caused by or a result of his military service. The examiner accurately noted that the Veteran's military occupational specialty was a forklift operator which would expose him to some noise; however, the VA examiner also indicated that a Department of Defense (DOD) study concluded that there was no scientific basis for delayed or late-onset of noise-induced hearing loss. The VA examiner also referred to the American Tinnitus Association, "Noise, Its Effects on Hearing and Tinnitus," for the proposition that many patients who have a history of noise exposure have tinnitus. The same ATA report indicates that noise is "by far the most probable cause of tinnitus which may or may not occur with associated hearing loss." As to the Veteran's belief that he has tinnitus related to his period of active service, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The Veteran has not been shown to have the requisite training or expertise to render an opinion as to the etiology of any tinnitus and its relationship, if any, to his period of service. Moreover, there are many complex factors or contributors to tinnitus, such as heredity disorders, medications, or other factors which may cause tinnitus not necessarily related to acoustic trauma, which the Veteran also does not have the requisite training to address. The Veteran has also been notified of the necessity to provide a competent nexus opinion between any claimed tinnitus and service and has not provided such a nexus. Moreover, there have been no post-service treatment records associated with the claims folder which demonstrate any evidence of a relationship between any claimed tinnitus and any period of active service. The Board finds the opinion provided by the April 2008 VA examiner that it was less likely than not that the Veteran's tinnitus was related to his period of service to be of high probative value. When evaluating the weight of medical evidence, the Board is guided by the principle that the probative value of a medical opinion largely rests upon the extent to which such opinion is based upon a thorough evaluation of the Veteran's medical history, including but not limited to the medical evidence contained in the claims file. See, e.g. Miller v. West, 11 Vet. App. 345, 348. The Board may examine the factual foundation of a medical opinion, including whether the physician had access to relevant information of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). The April 2008 VA examiner's opinion was based upon a thorough review of the accurate facts, including as obtained from the claims folder, and a comprehensive examination of the Veteran. The examiner provided rationale in support of his opinion. The Veteran's entire claims file, which at the time included his service treatment records, VA treatment records, and statements from the Veteran, was reviewed. Based on all of the evidence, the examiner rendered an opinion that was supported by rationale. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he relied upon anything other than accurate facts; thus, the Board finds the April 2008 VA examiner's opinion to be the most probative evidence of record on the question of nexus between current tinnitus and service. In sum, the preponderance of the evidence weighs against a finding that tinnitus is related to service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Hearing Loss Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The disorder at issue, namely hearing loss, sensorineural in nature, is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker, 708 F.3d 1331. Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as organic disease of the nervous system (which includes sensorineural hearing loss), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The provisions of 38 C.F.R. § 3.385 do not require that hearing loss be shown as defined in that regulation at the time of separation from service, if there is sufficient evidence to demonstrate a relationship between a veteran's service and his current disability. Hensley v. Brown, 5 Vet. App. 155 (1993). The Veteran maintains that he was exposed to acoustic trauma in service that caused his current hearing loss. He contends that his hearing loss started during a night fire exercise during service. After a review of all the evidence, the Board finds that the Veteran was exposed to some loud noises during service from small arms fire during basic training and heavy equipment, and had post-service loud noise exposure working in trucking and with heavy equipment and recreational noise exposure. The weight of the evidence shows that symptoms of sensorineural hearing loss were not chronic in service. A review of the Veteran's service treatment records does not reveal any complaints or findings of hearing loss. At the time of the Veteran's January 1967 enlistment examination, he was found to have decibel level readings of -5, -5, -5, -, and -5 for the right ear and 10, -5, -5, - and -5 for the left ear at 500, 1000, 2000, 3000, and 4000 Hertz. Normal findings for the ears were reported at that time. Any military audiograms conducted prior to November 1967 must be converted from ASA to ISO units. Essentially, that means adding 10 decibels to the reported findings in most frequencies, the exceptions being adding 15 decibels at 250 and 500 Hertz and 5 decibels at 4000 Hertz. Therefore, as converted to ISO units, the induction examination showed findings of 10, 5, 5, -, and 0 in the right ear and 20, 5, 5, -, and 0 in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz. Normal findings were reported for the ears. At the time of the August 1969 service separation examination, the Veteran was found to have decibel level readings of 5, 0, 5, -, and 5 in the right ear and 5, 0, 5, -, and 5 in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz. Normal findings for the ears were also reported at that time. On the August 1969 service separation report of medical history, the Veteran checked the "no" box when asked if he had or had ever had hearing loss. While the Veteran did check the "yes" box when asked if he had ear, nose, or throat trouble, as noted above, he reported having seasonal throat trouble. The weight of the evidence also demonstrates that symptoms of bilateral sensorineural hearing loss were not continuous after service separation, including that hearing loss did not manifest to a compensable degree within one year of service separation. The evidence of record also does not reveal symptoms, findings, or diagnosis of hearing loss in the years immediately following service. The first objective medical finding of hearing loss was not until October 2007, when the Veteran was found to have hearing loss at the time of an audiological consultation. At the October 2007 audiological consultation, the Veteran reported that his military noise exposure included combat training, firearms, heavy equipment, and duties as a mail man. He also reported having occupational noise exposure as a result of being a truck driver, horse manager, and heavy equipment operator with inconsistent use of hearing protection devices. The Veteran reported recreational noise exposure that included power tools, shop equipment, chainsaw with hearing protection devices, firearms, and motorcycles without hearing protective devices. Testing performed at the time of the October 2007 consultation revealed bilateral sensorineural hearing loss. The Veteran was afforded a VA examination in April 2008. At the time of the examination, the Veteran reported having difficulty understanding speech when it was quiet or with background noise. He also noted having difficulty listening to the television or hearing people on the telephone. The examiner observed that the Veteran's entrance and exit examinations revealed normal hearing results. He noted that the Veteran listed throat trouble and denied any other medical or surgical diseases. The Veteran indicated that he was a heavy equipment operator while in service, which was confirmed in the claims folder. He reported that he was then transferred to Europe where he was on mail duty. The Veteran stated that it was his belief that his hearing loss was the result of basic training. He reported that in the fourth week at Ft. Jackson they had night fire and he was exposed to noise. The Veteran stated that he was not provided with hearing protection for any of his jobs. The examiner indicated that following discharge from service, the Veteran worked in trucking and heavy equipment. He noted always using ear protection but the examiner observed, as noted above, that the Veteran's use of ear protection was reported as inconsistent at the time of the October 2007 audiological consult. Audiological testing revealed puretone thresholds of 20, 30, 30, 50, and 80 in the right ear and 15, 20, 20, 40, and 55 in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz. Speech recognition testing was 68 percent in the right ear and 80 percent in the left ear. The examiner diagnosed mild to profound sensorineural hearing loss in the right ear and mild to moderately severe sensorineural hearing loss in the left ear. The VA examiner in April 2008 opined that the Veteran's hearing loss was not caused by or the result of his military service. He observed that the Veteran had normal hearing at separation examination and did not have a significant change in hearing thresholds between service induction and service separation. The VA examiner further observed that the Department of Defense, in a recent study, had indicated that there was no basis for delayed or late onset hearing loss. It was further noted that the October 2007 audiology report documented that the Veteran's hearing protection for occupational use was inconsistent and that he had also had exposure to firearms and motorcycles without hearing protection. In a September 2008 notice of disagreement, the Veteran indicated that he went to Ft. Lenerwood for heavy equipment training which consisted of running a D-9 dozer, scraper, and grader, and a six wheel dump truck, all without ear protection. He indicated that he never drove a forklift and that when he was stationed at Ft. Benning he drove a six wheel dump truck every day. In his March 2010 substantive appeal, the Veteran reported that he had a hearing examination three months post discharge which showed he had a 30 percent hearing loss. At the February 2013 Board hearing, the Veteran testified that his MOS was heavy equipment operator. He reported that he was not issued any hearing protection. The Veteran stated that he never ran a forklift but did run all the other heavy equipment. The Veteran also noted spending time on the firing range with no ear protection. He testified as to seeking medical attention for his hearing loss within one year of service. The Veteran stated that he had a trucking business for awhile after he got out of service. He noted that he currently wore hearing protection when in loud areas. The Veteran reported that he went to an ear doctor in Elgin, Illinois, in 1970 and was told that he had lost 20 to 30 percent of his hearing. He reported that those records were not available as the physician was deceased. He indicated that he had had gradual hearing loss since that time. While the Veteran has reported seeing a physician within one year of service and being told that he had a 20 to 30 percent hearing loss, there is no record of this. The first objective medical finding of hearing loss following service was not until October 2007. Therefore, the weight of the credible evidence reflects no chronic symptoms of hearing loss during service or continuity of symptomatology of hearing loss since service. As such, the 38 C.F.R. § 3.303(b) presumptions have not been met. The Board finds that the Veteran's histories and testimony of having had hearing loss in service and for the years after service prior to 2007, made pursuant to the claim for service connection (compensation), are inconsistent with, and outweighed by, other more contemporaneous evidence that shows no hearing loss in service or for years after service. The unfavorable evidence includes that the service treatment records do not reveal any complaints or findings of hearing loss, including at service separation. At the time of the Veteran's August 1969 service separation examination, normal findings were reported for the ears. While the Veteran checked the "yes" box on his August 1969 report of medical history when asked if he had or had ever had ear, nose, or throat trouble, it was indicated in the physician's summary statement that he had seasonal throat trouble, rather than an ear problem; therefore, there is no lay or medical evidence of hearing loss in service, as the Veteran did not give a history of hearing loss in service, and there was no reference to any ear problems difficulty hearing. While the Veteran has indicated that he went to an ENT within one year following service and reported having hearing loss, these records are not available for review. Such assertion of treatment soon after service is also inconsistent with the other evidence of record, including normal hearing with no complaints at service separation, and no claims, complaints, or treatment for hearing loss for decades after service. The Veteran did not claim service connection for hearing loss for many decades following service. At the time he filed a claim for service connection for other disabilities in July 2007, but did not claim service connection for hearing loss at that time. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). If the Veteran had been having problems with hearing loss throughout the years, it is more probable that he would have filed a claim for benefits earlier than 37 years following service. The above evidence is more probative than his recent assertions that his current hearing loss problems had their onset in service, voiced many years after service and in connection with the current claim for disability benefits. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). At the time of the April 2008 VA examination, the Veteran reported a history of noise exposure in service without hearing protection, that he had had hearing loss since basic training and had reported his hearing loss to an ENT a year after he was discharged, but these records were not in the file because the physician had passed away. Inconsistent with the Veteran's report of always using ear protection at work after service, the VA examiner noted that ear protection was found to be used inconsistently at the time of the October 2007 outpatient consultation. The examiner further noted the other types of occupational and recreational noise exposure that were reported at the time of the October 2007 audiological consultation, and noted that the Veteran did not report these activities at the time of the examination. For the above reasons, continuity of symptoms since service has not here been established, either through the clinical record or through the Veteran's own statements. See 38 C.F.R. § 3.303(b). The Board further finds that the weight of the evidence demonstrates that the Veteran's current hearing loss is not otherwise related to service. See 38 C.F.R. § 3.303(d) (service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service); Hensley, 5 Vet. App. 155 (provisions of 38 C.F.R. § 3.385 do not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service). As to the Veteran's belief that his current hearing loss is related to his period of service, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The Veteran has not been shown to have the requisite expertise or training to interpret hearing loss scores or comment on the etiology of any hearing loss. Moreover, there are many complex factors/contributors to hearing loss such as age, post-service noise exposure, etc., which the Veteran also does not have the requisite training to address. Service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints. The Veteran was informed of the necessity to submit evidence showing a relationship between any claimed hearing loss and his period of service. In addition to VCAA notice, at the Board hearing, the Veterans Law Judge [ ]. The Veteran has not obtained or submitted such evidence tending to show a relationship between current hearing loss and noise exposure during service. The Board finds the opinion provided by the April 2008 VA examiner that the Veteran's current hearing loss was not caused by or the result of his period of service to be of high probative value. The examiner's opinion was based upon a thorough review of the claims folder and a comprehensive examination of the Veteran. The examiner provided detailed rationale in support of his opinion. The Veteran's entire claims file, which at the time included his service treatment records, VA treatment records, and statements from the Veteran, was reviewed. Based on all of the evidence, the examiner rendered an opinion that was supported by detailed and complete rationale. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Thus, the Board finds the April 2008 VA examiner's opinion weighing against a finding of relationship of hearing loss to service to be the most probative evidence of record. In sum, the preponderance of the evidence weighs against a finding that bilateral hearing loss is related to the Veteran's period of service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Initial Rating for Tooth Number 10 Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The rating schedule provides that loss of teeth due to loss of substance of the body of the maxilla or mandible, without loss of continuity, will be rated as noncompensable when the loss of masticatory surface can be restored by a suitable prosthesis. A 10 percent rating is permitted when the lost masticatory surface cannot be restored by suitable prosthesis in all upper anterior teeth, all lower anterior teeth, or all upper and lower teeth on one side. Such a rating applies only to bone loss through trauma or disease such as osteomyelitis, and not to loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling. 38 C.F.R. § 4.150, Diagnostic Code 9913. When there is loss of less than 25 percent of the maxilla that cannot be replaced by a prosthesis a 20 percent evaluation can be assigned. When this loss can be replaced by a prosthesis only a noncompensable evaluation is warranted. 38 C.F.R. § 4.150, Diagnostic Code 9915. In connection with his claim, the Veteran was afforded a VA examination in April 2008. The examiner noted that the Veteran had restorations placed in several teeth and in June 1967, he had a direct pulp cap performed on tooth 10 . Subsequent treatment was performed on tooth 10, at which time a dental instrument called a reamer broke off in the canal of the tooth. The instrument was bypassed and a apicalectomy was to be performed. While the surgery is not of record, the Veteran was seen in July 1967 for swelling in the area of the apicalectomy tooth 10. Physical examination performed in April 2008 revealed bone defect in the anterior maxillary alveolus in area #9-10 with bluish pigmented mucosa which is usually called the "amalgam tattoo" usually due to placing amalgam at the site of an apicalectomy procedure. The area was slightly painful during palpation in area of maxillary bone defect. There was no loss of functional impairment or loss of motion or masticatory function. The examiner indicated that the Veteran had had a private dentist place a fixed bridge. Tooth 10 was missing and it was unclear as to when it had been extracted. The fixed bridge appeared intact and functioned well. Teeth 7 and 9 were also missing but they were noted to have been missing at the time of entrance. The examiner further observed that there was moderate buccal bone missing in the area of 9-10 and the examiner could not substantiate if some bone was lost when tooth 10 was extracted. The examiner indicated that there was some discomfort in the area of the maxilla during the examination, including on palpation of this area, and that this discomfort was at least as likely as not probably due to the apicalectomy performed on tooth 10 with subsequent postoperative swelling occurring in the service for approximately five days. The Veteran expressed disagreement with the assigned disability evaluation in his notice of disagreement and substantive appeal, indicating that the symptomatology associated with the dental surgery was worse than the noncompensable disability evaluation. The Veteran was afforded an additional VA examination in April 2012. The examiner indicated that the Veteran had not lost any part of the mandible or mandibular ramus. He further stated that the Veteran had not had any injury resulting in malunion or nonunion of the mandible. The examiner also indicated that the Veteran had not lost any part of the maxilla. He further reported that the loss of teeth was not due to loss of substance of body of maxilla or mandible without loss of continuity. He noted that all the teeth which were missing were missing at the time of the Veteran's entry into service with the exception of tooth 10. The examiner further indicated that the Veteran did not have any disfiguring scars or a mouth injury that resulted in impairment of mastication. The examiner noted that panographic x-rays revealed some slight loss of bone in the 9-10 area. The examiner also noted that there was a gingival amalgam tatoo gingiva area of nonattached mucos at 9-10. The examiner reported that the Veteran's dental condition did not have any impact on his ability to work. He observed that while the Veteran stated that he had discomfort in the upper jaw area, pointing to the 9-10 area; there were no signs of swelling or infection. At the February 2013 Board hearing, the Veteran reported that he would have swelling on the area of tooth 10 which would occur 4 to 5 times per week. He stated that it hindered his eating a little bit and his ability to have a cold or hot beverage when it was swollen. He indicated that when it was in this stage he would take over-the-counter pain killers for it. He noted that it did not interfere with talking. In order to find the Veteran entitled to an initial compensable evaluation for dental surgery, specifically relating to tooth #10, the Board is required to find that the loss of teeth was due to loss of substance of body of maxilla or mandible without loss of continuity. At the time of the most recent VA examination, the examiner specifically checked the "no" box when asked if the loss of teeth was due to loss of substance of body of mandible or maxilla without loss of continuity. Moreover, for a 10 percent evaluation under this rating code, loss of all upper anterior teeth missing, all lower anterior teeth missing, or all upper and lower teeth on one side missing had to be shown. 38 C.F.R. § 4.150, Diagnostic Code 9913. Such is not the case here. Although the Veteran's complaints of swelling, difficulty drinking hot and cold drinks when swollen, and slight interference with chewing are credible, it is the conclusion of the Board that, even with consideration of the stated functional impairment, the Veteran's subjective complaints are not closely analogous to loss of all anterior top or bottom teeth or all top and bottom teeth on one side and therefore the functional limitation does not provide a basis for the next higher (compensable) evaluation of 10 percent. The Board has reviewed the schedule of rating for dental and oral conditions, 38 C.F.R. § 4.150, and finds no basis for an award of a compensable evaluation under another diagnostic code. Given the evidence of slight bone loss in the area of teeth numbers 9 and 10, the Board considered applicability of Diagnostic Code 9915 which pertains to loss of bone of the maxilla. However while there is evidence of bone loss around teeth numbers 9 and 10, the examiner specifically indicated that the Veteran did not have loss of any part of the mandible, mandibular ramus, or maxilla. As such, a compensable disability evaluation would not be warranted under DC 9915. Upon review of the other potentially applicable diagnostic criteria pertaining to dental disabilities, there is no evidence of nonunion of the maxilla. The Veteran has contended that he has swelling in the tooth 9-10 area and he has stated that as a result he has slight difficulty eating and difficulty drinking beverages when in a swollen state. However, he has not specifically claimed that he has limitation of motion of the jaw and in any event and no limitation of motion of the jaw due to the service connected disability is shown by the probative evidence of record. Accordingly, the preponderance of the evidence is against the claim for an initial compensable evaluation for residuals of dental surgery (tooth #10); thus, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for the Veteran's residuals of dental surgery (tooth 10). In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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. In this case, as it relates to the Veteran's residuals of dental surgery (tooth #10), comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, there is a higher rating available under the codes addressed in this decision, but the Veteran's disorder is not productive of the manifestations that would warrant the higher rating. As such, the available schedular evaluations for the service-connected residuals of dental surgery (tooth #10) at issue here are adequate. For this reason, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's residuals of dental surgery (tooth #10) and no referral for an extraschedular rating is required. Moreover, the April 2012 VA examiner specifically indicated that the Veteran's residuals of dental surgery would have no impact on his employability. ORDER Service connection for tinnitus is denied. Service connection for bilateral hearing loss is denied. A higher (compensable) initial disability evaluation (rating) for residuals of dental surgery (tooth #10) is denied. The appeal for an initial disability evaluation in excess of 10 percent for a septal deviation is dismissed. The appeal for a higher initial disability evaluation for sinusitis with sinus headaches associated with septal deviation, in excess of 10 percent from July 19, 2007, and in excess of 30 percent from March 27, 2012, is dismissed. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs