Citation Nr: 1322465 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 11-26 856 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for residuals of abdominal hysterectomy and bilateral salpingo-oophorectomy. 2. Entitlement to service connection for a cervical spine disorder. 3. Entitlement to service connection for right lower extremity radiculopathy, to include as secondary to lumbar spine disability. 4. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to lumbar spine disability. 5. Entitlement to service connection for left knee disorder, including patellofemoral syndrome. 6. Entitlement to service connection for a right knee disorder. 7. Entitlement to service connection for an eye disorder/vision loss. 8. Entitlement to service connection for periodontal disease. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The Veteran served on active duty from October 1989 to March 1995. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from an August 2010 rating decision of the VA Regional Office in Columbia, South Carolina that, among other things, denied service connection for residuals of abdominal hysterectomy and bilateral salpingo-oophorectomy, a cervical spine disorder, right lower extremity radiculopathy, left lower extremity radiculopathy, a left knee disorder, a right knee disorder, an eye disorder and periodontal disease. The Veteran was afforded a hearing in May 2012 before the undersigned Acting Veterans Law Judge sitting at Washington, DC. The transcript is of record. In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. The Virtual VA file has been reviewed in conjunction with the disposition of the issues on appeal. FINDINGS OF FACT 1. Abdominal hysterectomy and bilateral salpingo-oophorectomy were performed many years after discharge from active duty and the competent and probative evidence fails to indicate an etiological relationship between these procedures (or any underlying gynecological disease) and the Veteran's service. 2. A cervical spine disorder did not manifest during a period of active duty service and the competent and probative evidence fails to indicate an etiological relationship between any current cervical spine disorder and the Veteran's service. 3. Right lower extremity radiculopathy did not manifest during a period of active duty service and the competent and probative evidence fails to indicate an etiological relationship between any current right lower extremity radiculopathy and the Veteran's service; the evidence also fails to demonstrate a medical nexus between any current right lower extremity radiculopathy and a service-connected disability. 4. Left lower extremity radiculopathy did not manifest during a period of active duty service and the competent and probative evidence fails to indicate an etiological relationship between any current left lower extremity radiculopathy and the Veteran's service; the evidence also fails to demonstrate a medical nexus between any current left lower extremity radiculopathy and a service-connected disability. 5. A chronic left knee disorder, including patellofemoral syndrome, did not manifest during a period of active duty service and the competent and probative evidence fails to indicate an etiological relationship between any current left knee disorder and the Veteran's service. 6. A right knee disorder did not manifest during a period of active duty service and the competent and probative evidence fails to indicate an etiological relationship between any current right knee disorder and the Veteran's service. 7. The Veteran has refractive error of the eyes, including presbyopia and astigmatism that is not an eligible disability for VA compensation; any other eye disorder was first clinically indicated many years after discharge from service and the competent and probative evidence fails to indicate an etiological relationship between any such disorder and the Veteran's service. 8. Periodontal disease is not an eligible disability for VA compensation purposes. CONCLUSIONS OF LAW 1. Residuals of abdominal hysterectomy and bilateral salpingo-oophorectomy were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. Cervical spine disorder was not incurred in or aggravated by service, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 3. Right lower extremity radiculopathy was not incurred in or aggravated by service, may not be presumed to have been in service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 4. Left lower extremity radiculopathy was not incurred in or aggravated by service, may not be presumed to have been in service, and is not proximately due to or the result of a service connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 5. A chronic left knee disorder not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. A right knee disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 7. An eye disorder/vision loss was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 8. Periodontal disease is not subject to compensation under VA regulations. 38 U.S.C.A. §§ 1110, 1131, 1712, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.381, 17.161 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In numerous statements to VA and in testimony on personal hearing on appeal, the Veteran asserts that she has abdominal hysterectomy, a cervical spine disorder, bilateral lower extremity radiculopathy, bilateral knee disorder, a vision disorder and periodontal disease that are of service onset for which service connection should be granted. Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice requirements of the VCAA apply to all elements of a claim for a higher rating including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, the appellant was sent multiple letters over the course of the appeal prior to the initial unfavorable decisions on the claims that informed her of what evidence was required to substantiate the claims and of the appellant and VA's respective duties for obtaining evidence. Notification that included information pertaining to disability ratings and effective dates for an award has also been sent to the appellant. The VA's duty to notify in this case has been satisfied. The Board further finds that the necessary development has been accomplished and that appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384. The appellant has been afforded multiple examinations over the course of the appeal. Voluminous VA and private clinical records have been submitted in support of the claims and carefully reviewed. The extensive evidence of record, including the appellant's statements, has been carefully considered. She was afforded a personal hearing in May 2012 before the undersigned. At the conclusion of the hearing, the appellant's representative noted that the appellant had not been provided VA examinations with respect to the neck, legs, teeth and vision to assist her in developing her claim. The representative stated that if service connection could not be granted based on the evidence of record, the case be remanded for further development as to these aspects of the appeal. VA's duty to assist a veteran in the development of the claim includes providing an examination when indicated. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A (d); 38 C.F.R. § 3.159(c) (4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Board observes that the Veteran was afforded a VA dental examination in May 1995 and the legs were evaluated on VA examination in March 2010. These examinations are determined to be adequate for adjudication purposes. As to the claims for the neck and vision loss, the record does not contain any evidence establishing any pertinent event, injury, or disease in service that might be related to current disability, nor is it shown that there is any reliable nexus between the claimed disabilities and service. The Board finds that the evidence does not satisfy the low threshold of McLendon as neither the second nor the third criterion of the McLendon analysis is met. Additionally, as discussed below, the Board concludes that the Veteran's contentions and testimony do not rise to the level of the "indication of an association" referred to in 38 U.S.C.A. § 5103A or in McLendon. As such, the Board finds that the record, including the lay and medical evidence, is adequate to render a decision as to the claims for neck disability and vision loss, and that a remand for VA examination is unnecessary. The Board is not aware of the existence of any additional or relevant evidence that has not been obtained in this regard. No further notice or assistance to the appellant is required to fulfill VA's duty to assist in the development of the claims under consideration. See 38 U.S.C.A. § 5103A (a) (2); Dela Cruz v. Principi, 15 Vet. App. 143; Smith v. Gober, 14 Vet. App. 227 (2000); aff'd 281 F.3d 1384 (Fed. Cir. 2002); see also Quartuccio v. Principi, 16 Vet. App. 183; Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (2002). As such, the claims are ready to be considered on the merits. Pertinent Law and Regulations Applicable law and regulations provide that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, this requires competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection for certain diseases, such as arthritis and organic disease of the nervous system, including disc disease and radiculopathy, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). Service connection may also be warranted for those diseases found at 38 C.F.R. § 3.309(a) if there is a showing of chronic disease during service with subsequent manifestations of that chronic disease after service that cannot be clearly attributed to intercurrent causes or where the condition is noted in service and there is continuity of symptomatology sufficient to establish chronicity since service. See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Finally, service connection may be granted for disability that is proximately due to or the result of a service-connected disorder. 38 C.F.R. § 3.310 (2012). This includes disability made chronically worse by service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is defined as doubt that 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 (2012). Factual Background The Board has reviewed all of the evidence in the Veteran's claims file and his electronic, paperless Virtual VA file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's discussion of the evidence and its analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). During service, the Veteran had a military occupational specialty of Mobile Subscriber Equipment (MSE) Transmission System Operator with duties that required her to install, operate, supervise, and perform unit level maintenance of MSE radio transmission equipment, radio access units and inoperable devices. The Veteran's service treatment records reflect that on examination in August 1989 for service entrance, she had distant and near vision of 20/20. The genitourinary system, abdomen and viscera, spine, musculoskeletal system, upper and lower extremities, and neurologic status were evaluated as normal and no pertinent defects were recorded. It was noted, however, that she had delivered children in 1984 and 1987 and had a tubal ligation in 1987. In March 1990, the Veteran was treated for a heavy yellow vaginal discharge and a painful bump on the outside of the vagina. On physical examination, the abdomen was firm without masses or tenderness. Following examination, an assessment of rule out GC [gonococcus], NSU [non-specific urethritis] was made and medication was prescribed. The appellant sought treatment in July 1991 for complaints of left knee pain of three days' duration upon coming back from leave. Iliotibial tenderness was elicited. The left knee was negative for effusion, warmth, and laxity. There was a negative drawer sign. Following examination, the assessment was iliotibial band tenderness. Medication was prescribed and she was placed on profile. On gynecological screenings in January 1992, August 1993 and January 1995 the appellant was found to have no masses or other abnormal findings of the uterus, vagina or adnexa. A Pap smear in August 1993 disclosed that trichomonas vaginalis was present. In September 1993, the Veteran was seen for complaints of severe abdominal cramping and heavy bleeding after taking medication. Following examination, an assessment of unusual menstrual cramping was recorded. During service, the Veteran's dental records dating from 1989 reflect that she had many missing teeth and required extensive prophylactic treatment for others affected by heavy scale and a periodontal process. On five-year physical examination in January 1995 prior to discharge from service, the Veteran indicated that she had experienced a tumor, growth, or cyst, and bone, joint or other deformity. These were explained by the examining official as a traumatic benign mass on the left breast since eighth grade, and a left fourth digit injury as a child. She had 20/15 distant vision. The genitourinary system, abdomen and viscera, spine, musculoskeletal system, upper and lower extremities, and neurologic status were evaluated as normal. Post service, the appellant was scheduled for a VA dental examination in May 1995 where she complained of several loose teeth and a loose upper partial denture. It was noted that she had generalized advanced periodontal disease around all remaining teeth and poor oral hygiene, and would probably need full upper and lower dentures in the near future. On a VA general medical examination the following day, the Veteran had various complaints that did not include any of the currently claimed conditions. On physical examination, the neck was supple with full range of motion. Pulses in the extremities were 2+ and equal bilaterally. No diagnosis pertinent to this appeal was rendered following examination. The Veteran underwent a gynecology examination for VA compensation and pension purposes at the South Carolina Medical University in May 1995 for a problem with irregular menses, and a vaginal discharge that she indicated she had had in service. It was noted that a questionable broad-based cervical polyp was found in the posterior lip of the cervix and that biopsies were obtained that disclosed a normal endocervix. The examiner stated that the previous recurrent vaginal discharge for which the appellant seemed to be seeking disability was of undetermined etiology and that none was found on the current occasion. The uterus was normal. The ovaries were present but not palpable. A VA outpatient record dated in January 2005 reflects that the Veteran presented as a new patient and wished to transfer her care to that facility. It was reported that she denied any personal medical history other than tubal ligation. She indicated that she had regular periods but that the flow was heavy. The appellant denied weakness, arthralgias, myalgias, parethesias or anesthesias. On physical examination, the abdomen was soft, nontender, and nondistended. There were no palpable masses. On neurological evaluation, there were no focal deficits and deep tendon reflexes were 2/4 for all four extremities. During a February 2005 physical examination, it was found that the uterus was of irregular shape with fibroid. In June 2005, the Veteran returned for her Pap smear results that were found to be satisfactory but limited due to obscuring inflammation. She denied a history of abnormal pap smears. On physical examination, the neck was without cervical lymphadenopathy. The abdomen had normal contours without masses. A gynecology examination disclosed a large amount of yellow thick discharge. An assessment of vaginitis was provided. At the conclusion of the examination, the examiner noted that the Veteran reported having problems with her glasses. She related that she could see far away but could not read. She indicated that she used over-the-counter reading glasses that helped some but that vision was worsening. An ophthalmology consultation was ordered. An assessment of blurry vision was recorded following eye evaluation in October 2005. In September 2005, the Veteran stated that she had had right knee swelling that had resolved. On musculoskeletal examination, there was some crepitus bilaterally at the knee joints with no effusion. The right knee anterior drawer test was negative. The pulses were equal and adequate in the extremities. A pelvic ultrasound in February 2006 confirmed multiple fibroids. In May 2007, the Veteran sought treatment for light sensitivity and inability to wear her eyeglasses in the sun. Following examination, assessments of photophobia and refractive error change, bilaterally, were rendered. A telephone encounter note dated in September 2007 reflects that the appellant complained of left knee pain of one week's duration with slight swelling and without a history of known trauma. Subsequently received were clinical records from Georgetown Memorial Hospital dated in October 2000 showing that the Veteran was treated on an emergency basis for vaginal irritation and a foul odor with a slight discharge. Following examination and testing, a diagnosis of vaginosis was rendered. Records from McLeod Regional Hospital dated in September 2001 reflect that the Veteran was seen for complaints of low back pain that started on that date. She stated that she worked in the post office pushing packages and mail bins and was used to having some low back pain but that it had gotten worse on that day. On musculoskeletal evaluation, the neck and spine were supple. An assessment of lumbar strain was provided. She continued to be treated for low back complaints but denied numbness, weakness and tingling in the legs in June 2002. Straight leg raising and neurologic status were negative at that time. During a May 2008 VA gynecology consultation, the Veteran related that she had had heavy menstrual bleeding for the past eight years with passing of clots the last seven years or so. She stated that an ultrasound two years before had revealed fibroids. May 2008 VA clinic notes indicate that the appellant was admitted for total abdominal hysterectomy with bilateral salpingo-oophorectomy due to menorrhagia and uterine leiomyoma. An August 2008 VA optometry consultation note reflects that the appellant reported noticing more changes in her distance vision. Following evaluation, the assessment was CHA [complex hyperopic astigmatism] with bilateral presbyopia. Bilateral mild macular pigment changes were also observed. It was noted that she had 20/20 vision in both eyes. New glasses were ordered. In a September 2008 VA outpatient record, the Veteran denied diplopia, cataracts and glaucoma. She related that she had right knee pain for which she had been seen in orthopedics in March 2008. A May 2009 VA clinic notes indicates that the Veteran complained of neck pain and stated that she felt a bulge in the neck. Radiological studies were performed that were interpreted as showing discogenic disease at C4/C5 and C5/C6. Additional views of the cervical spine were ordered that disclosed mild discogenic disease and spondylosis with probable foraminal stenosis for which magnetic resonance imaging (MRI) was recommended. She continued to be treated for neck pain and symptoms. A VA outpatient record dated in June 2009 reflects a diagnosis of cervical stenosis with cord contact at C5/C6 for with physical therapy was authorized. The Veteran filed claims for bilateral knee and neck disabilities in July 2009. Records from Indigo Therapy Specialists dated between July and September 2009 reflect that the Veteran was provided physical therapy for pain in her back and neck. She dated the onset of neck pain/injury back to 1994 while in the military. On VA pain consultation in October 2009, the Veteran indicated that she had had cervical discomfort/occasional radicular components for 20 years. The results of an MRI were interpreted as showing multiple level neural foraminal stenosis with diffuse moderate spinal stenosis from C3/C4 through C6/C7 with no abnormal cord signal. The most severe spinal stenosis was at C5/C6 with cord contact. The Veteran was afforded a VA joints examination in February 2010. The examiner indicated that the claims folder was reviewed. The appellant stated that she had always had problems with her left knee and was told 10-12 years before that she had fluid in that knee. She denied injury to the left knee and said that she had pain when she bent down for more than a minute, with occasional popping, locking and buckling. The appellant related that she worked as a postmaster. The left knee was examined. An X-ray of the left knee was interpreted as normal. Following examination, a pertinent impression of patellofemoral syndrome of the left knee was rendered. The examiner related that review of the claims folder revealed that she had been seen in July 1991 for complaints of left knee pain diagnosed as IT band tenderness but that she had subsequently had a five-year physical in January 1995, several months prior to her release from service, and there was no mention of left knee pain or condition. The examiner stated that "Therefore, it is my opinion that her current patellofemoral syndrome of the left knee is not caused by or the result of her [one] complaint or left knee pain while in service." The Veteran filed claims of service connection for hysterectomy, periodontal disease and a vision problem in March 2010. Subsequently received were clinical records showing that the appellant received extensive dental treatment and surgery between 2008 and 2009, to include extractions of multiple teeth, bone grafts and placement of endosteal implants. The Veteran was afforded a VA examination in March 2010 for evaluation of low back complaints with numbness in the legs. She related that she had numbness and tingling in both posterior lower extremities extending to the toes, as well as occasional pain that radiated down both legs to the toes. Following examination, the impression was chronic lumbosacral spine strain with radiculopathy to the bilateral lower extremities that is considered secondary to her lumbosacral spine condition. In March 2010, VA outpatient records reflect that the Veteran was seen for a routine eye examination and indicated that she was noticing distance vision changes. Following evaluation, the assessment/plan was refractive error change - order new glasses. The Veteran underwent a VA gynecology examination in July 2010 for compensation purposes. She stated that during service she had menstrual cramps and heavy bleeding and was diagnosed as having anemia. She related that three years before, menstrual bleeding had increased, with no relief with medical management, for which she had undergone a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The examiner indicated that the claims folder was reviewed. It was reported that in 1999, an examination by Low Country Gynecology had noted that she had a fibroid uterus at 6-8 weeks in size and in 2000, was having normal menses with no change in the uterus. The examiner stated that he could find no documentation of fibroids in service and that after reviewing the records, found that total abdominal hysterectomy and bilateral salpingo-oophorectomy were not caused by or the result of service. Records received in December 2011 from Low Country Gynecology dating from 1995 reflect that in September 2000, the Veteran was found to have a uterus that was irregular with fibroids of 6-8 weeks size. On personal hearing in May 2012, the appellant testified that when she went into the field during active duty, sometimes for months at a time, she would have no periods, and that when she came out of the field, she would have a heavy flow for seven of more days with discomfort and excruciating pain for which she sought treatment and was prescribed medication. She testified that she did not have these symptoms prior to entering the military and that at one point a uterine cyst was detected. She related that she sought treatment for uterine fibroids within one year of active service for which she had to have a hysterectomy in 2008. Testimony was presented to the effect that the appellant did not have bilateral lower extremity numbness and radiating pain prior to entering service. She related that the condition began when she started physical training and driving long distances and both her legs would tighten up. She said that she began to have leg cramps and charley horses that led to the condition she currently had with her legs. The Veteran related that during active service her duties in communications required her to set up heavy antennas, drums, and other equipment, and that she began to experience discomfort and problems with her neck as the result of the heavy weight involved. She also stated that they had to sleep outside quite a bit on cots and that neck stenosis derived from those conditions as well as from exposure to very cold weather. The Veteran testified that she did not have any problems with her knees prior to active duty, and that her knees gave way as the result of having to remain in the front leading rest position for an extended period. She related that since that time, she had had limitations or issues with the knees, including inability to kneel on any hard surface without a cushion. The appellant stated that she also had calcium buildup in both knees stemming from the in-service incident. The Veteran related that she did not have any vision problem prior to entering the military but that during active duty she was stationed in the Mojave Desert and her eyes would become blurry to the point that she could not see anything. She stated that she had to have her eye checked, was given glasses, and was told by a military doctor that sand filled up the tear ducts and caused the blurriness. She testified that because of her time in the desert, her eyes captured dust and particles that other peoples' eyes did not. The appellant stated that she did not have periodontal disease prior to entering service but that she did have gingivitis, and had had four top and four bottom teeth extracted prior to entering service. She said that due to having to stay in the field in Germany for up to two months with little water except that in her canteen, and having to eat MREs [meals ready to eat] resulted in an inability to maintain good dental hygiene, and made the gingivitis worse that developed into severe periodontal disease for which she had to have all of her teeth extracted. The appellant testified that she was not given any treatment during service to retard her pre-existing gingivitis. She also stated that she broke two teeth on the upper right side as the result of performing the Manual of Arms with an M16 rifle. Legal Analysis 1. Service connection for residuals of abdominal hysterectomy and bilateral salpingo-oophorectomy. As evident from the above discussion, the Veteran underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy in May 2008. The reasons for the surgeries are clearly spelled out in clinical evidence around that time, and included fibroids (leiomyomas) and menorrhagia (abnormally heavy and/or prolonged blood flow). Service treatment records reflect that the appellant had several female-related complaints, including vaginal discharge and trichomonas vaginalis. Her service treatment records also reflect a single occasion in September 1993 when she complained of severe abdominal cramping and heavy bleeding after taking medication, leading to an assessment of unusual menstrual cramping. However, in-service records also reflect that she had a number of gynecology screenings that disclosed no abnormality of the female reproductive system, except for a pre-existing tubal ligation. No masses or other abnormal findings of the uterus, vagina or adnexa were found. Post service, a May 1995 VA gynecology examination shows that the appellant had complaints of irregular menses. It was noted at that time that she had a questionable cervical polyp but that biopsies were obtained that disclosed a normal endocervix. No vaginal discharge or any abnormal findings of the uterus was found on that examination. Private clinical records first record a diagnosis of uterine fibroids in 2000. During a May 2008 VA gynecology consultation, the appellant related that she had had heavy menstrual bleeding for the past eight years. The Board notes that this coincides more or less with the contemporaneous diagnosis of fibroids in 2000. In view of such, the Board finds the earliest onset of fibroids and menorrhagia to be in 2000, approximately five years after discharge from active duty. This finding is supported by contemporaneous lay and medical evidence of record, as discussed above. It was also confirmed by the July 2010 VA examiner who, following a review of the record, wrote that there was no documentation of fibroids during service. The Board recognizes that lay assertions may serve to establish a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d. 1372 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). A layman is competent to report what he experiences through the senses and lay evidence must be considered when a Veteran seeks disability benefits. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran competently testified that she experienced heavy bleeding and cramping throughout her active duty service. The Board, however, does not find such statement credible in view of the other evidence of record. Firstly, there is no clinical evidence of symptoms of fibroids in service treatment records leading to total abdominal hysterectomy and bilateral salpingo-oophorectomy. There is also no showing of any continuity of reported excessive menstrual bleeding dating from service. As indicated previously, evidence of such was first clinically demonstrated five years or so after discharge from active duty. The Veteran herself has also not been a reliable historian. As previously noted, she related a history of heavy menstrual bleeding for only eight years at a May 2008 VA gynecology consultation. Absent some indication of relevant signs or symptoms during service, there must be competent evidence linking the Veteran's total abdominal hysterectomy and bilateral salpingo-oophorectomy (and the underlying conditions of fibroids and menorrhagia) to service. See 38 C.F.R. § 3.303(d). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether the Veteran's post-service menstrual and gynecological symptoms are related to in-service vaginal complaints, this issue falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Here, the only competent and probative evidence of record as to the issue of a medical nexus is the July 2010 VA examination in which the examiner unequivocally opined that total abdominal hysterectomy and bilateral salpingo-oophorectomy were not caused by or the result of service. This opinion was rendered after interview and physical examination of the Veteran; it is also well reasoned and consistent with the historical record. Thus, it will be afforded considerable weight. Given the foregoing, the Board finds that the claim of entitlement to service connection for residuals of total abdominal hysterectomy and bilateral salpingo-oophorectomy must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the competent and probative evidence preponderates against this claim that doctrine is not applicable. 38 U.S.C.A. § 5107(b). 2. Service connection for a cervical spine disorder, right lower extremity radiculopathy, and left lower extremity radiculopathy. Turning to the Veteran's claimed cervical spine and lower extremity disorders, the Board observes that the service treatment records do not document any complaints relating to the cervical spine or neurologic impairment of the lower extremities, to include on examination in January 1995 prior to discharge from service. The appellant did not refer to any problems with the neck or legs on post service VA general medical examination in May 1995 or in ensuing VA outpatient records until May 2009 when she complained of neck pain. In March 2012, she reported numbness and tingling in the lower extremities. Prior to those dates, the extensive VA outpatient records reveal that the neck was consistently found to be patent. She denied any neurologic symptoms affecting the lower extremities and none were found. More recently, the Veteran has ascribed current cervical spine and bilateral lower extremity disability to symptoms she states she experienced during active duty. While she is competent to describe neck and leg symptoms experienced during service, the Board finds such statements lack credibility. In this regard, current diagnoses of discogenic disease of the cervical spine and bilateral lower extremity radiculopathy were not clinically indicated until more than two decades after discharge from active duty. Perhaps more relevantly, however, the Veteran herself expressly denied any neurologic symptoms, to include neck and/or leg pain, on multiple occasions. In this instance, the Board finds that the normal separation examination, the lack of neck or lower extremity complaints at separation, the absence of complaints or treatment for the cervical spine or lower extremities for years after service, as well as the fact that skilled VA clinical professional has determined that bilateral lower extremity radiculopathy is secondary to a back disorder are far more probative than a remote statements of in-service onset and continuity. Therefore, based on the lay and medical evidence, the Board finds that the Veteran's assertions of cervical spine and lower extremity radiculopathy related to service are not credible, and do not provide a basis to establish service connection. In this case, the absence of any neurologic disability affecting the cervical spine and lower extremities for so many years after service militates against a finding that her claims of in-service symptoms and continuity of symptomatology are credible. Additionally, the evidence does not reflect a diagnosis of any cervical spine (disc disease) or lower extremity disability (radiculopathy) consistent with organic disease of the nervous system within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. There is also no competent evidence linking either disability to any in-service incident, injury, or disease, and the Board is of the opinion that the issue of medical nexus for a neurologic disability of the neck or legs falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377. The Board acknowledges that there is evidence, as noted above, and contentions to the effect that that bilateral lower extremity radiculopathy is related to lumbosacral spine disability. The Board points out, however, that as service connection is not in effect for a low back disorder, it is unnecessary to discuss whether bilateral lower extremity radiculopathy is secondary thereto. See 38 C.F.R. § 3.310. Given the foregoing, the Board finds that the claims of entitlement to service connection for a cervical spine disorder and bilateral lower extremity radiculopathy must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the competent and probative evidence preponderates against these claims that doctrine is not applicable. 38 U.S.C.A. § 5107(b). 3. Service connection for a left knee disorder and a right knee disorder. The Veteran asserts that she has disability of both knees that is related service. Service treatment records do indeed reflect that she was treated for left knee complaints of pain in July 1991, assessed as iliotibial band tenderness. However, there is no indication that she sought further treatment for the left knee during service. On examination in January 1995 prior to service discharge, the appellant denied any problem with the left knee and none was detected. The musculoskeletal system and lower extremities were evaluated as normal. Service treatment records do not refer to any right knee complaints or findings. On post-service VA examination in May 1995, the appellant voiced a number of complaints but did not indicate that she had a left or right knee problem. The first post-service clinical record that references a right knee problem was in September 2005. Bilateral crepitus of both knees was elicited at that time. In September 2007, she reported similar complaints affecting the left knee. Left knee patellofemoral syndrome was diagnosed on VA examination in February 2012. As such, indications of left and right knee pathology are not demonstrated for more than two decades after discharge from active duty. The Board has carefully considered the appellant's lay statements, testimony and history to the effect that bilateral knee disability is related to service and duties therein. As previously discussed, a layman is competent to report that she notices symptoms as such come to her through one of the senses. See Layno, supra. The Board points out, however, that while lay evidence must be considered when a Veteran seeks disability benefits, the opinion of the skilled VA clinical professional who reviewed the record and determined that a left knee disorder is not attributable to service is more probative than the appellant's more recent statements and testimony in this regard. The Board thus finds that the Veteran's statements and testimony attributing current right and left knee disorder to service are less probative and do not provide a basis to establish service connection. There is no reliable evidence in the record to show that any left or right knee symptoms in service resulted in a chronic disorder. See 38 C.F.R. § 3.303. Rather, the most probative evidence establishes that current knee disorders developed many years after active duty and are unrelated to service. There is no clinical evidence of record to the contrary. In view of such, the Board finds that service connection for a left knee disorder and a right knee disorder is not warranted. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. 4. Service connection for a vision loss disorder. The service medical records reflect that on examination in January 1995, two months prior to discharge from active duty, the Veteran had 20/15 vision that is well known to be better than average vision of 20/20. Although near vision was not recorded on that occasion, there is no indication that she had any problem in this regard. Service treatment records reflect that she entered active duty with 20/20 near vision do not refer to any complaints or findings regarding near vision impairment during the interim. The service treatment records do not otherwise document any eye complaints, injury or treatment. The post service record reflects that when afforded a VA general medical examination in May 1995, the appellant did not voice any complaints pertaining to vision impairment. VA outpatient records indicate that Veteran has had eye complaints, including blurred vision and photophobia since 2005, and has carried vision-related diagnoses of refractive error changes, and complex hyperopic astigmatism with bilateral presbyopia since that time. However, complex hyperopic astigmatism and refractive changes are considered errors of refraction. See Norris v. West, 11 Vet. App. 219 (1998) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (28th ed. 1994). Bilateral presbyopia is also refractive error due to advancing age. See McNeely v. Principi, 3 Vet. App. 357, 365 (1992); Parker v. Derwinski, 1 Vet. App. 522 (1991). Under 38 C.F.R. § 3.303(c), refractive error of the eye is not considered a disease or injury within the meaning of applicable legislation governing the award of compensation benefits. As indicated previously, there is no documentation of any superimposed trauma to the eyes in the service that might have caused refractive error or any other disease process. The onset of any disability manifested by blurred vision and/or photophobia is first clinically shown many years after discharge from active duty and may not attributed to service. See 38 U.S.C.A. §§ 1110, 1131. There is no evidence of actual eye disease or injury during active service, or a clinical finding that the appellant has current residuals of eye disease or injury during active duty. Her statements and testimony that she developed eye disability/vision loss during active duty are without merit given the findings above. Accordingly, service connection for vision loss and/or eye disability, including refractive changes, complex hyperopic astigmatism, presbyopia, blurred vision and photophobia, etc., is not warranted. The evidence is not in equipoise as to warrant consideration of the benefit-of-the-doubt doctrine. 38 U.S.C.A. § 5107(a). 5. Service connection for periodontal disease. Generally, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses and periodontal disease will be considered service connected solely for the purpose of dental treatment under the provisions of 38 C.F.R. Chapter 17; 38 C.F.R. § 3.381 (2012). In other words, service connection for VA compensation purposes is not permitted for the above conditions. As applicable, a determination will be made as to whether a dental condition is due to combat wounds or other service trauma. 38 C.F.R. § 3.381(e) (2012). The significance of finding that a dental condition is due to service trauma is that a veteran will be eligible for VA outpatient dental treatment, without being subject to the usual restrictions of a timely application and one-time treatment. 38 C.F.R. § 17.161(c) (2012). The Board observes that although the Veteran alleges dental trauma in service, there is no evidence of any injury to the teeth or jaw resulting in periodontal disease in the service treatment records. The available dental records reflect that she entered active duty with many missing teeth and subsequently obtained extensive routine and specialized dental treatment for heavy scale and periodontal disease. VA's General Counsel has held that dental treatment, even extractions during service, does not constitute dental trauma. See VAOPGCPREC 5-97; see also Nielson v. Shinseki, 607 F.3d 802, 808 (Fed. Cir. 2010) (holding that "service trauma" means an injury or wound produced by an external force during the service member's performance of military duties and that the intended result of medical treatment is excluded absent military negligence or malpractice). In this instance, VA and private treatment records reflect that the appellant has a diagnosis of periodontal disease for which she has undergone full-mouth extractions and has had substantial restorative repair, including bone grafts and implants. Periodontal disease is one of a group of pathological conditions that affect the surrounding and supporting tissues and structure of the teeth. See Simington v. West, 11 Vet. App. 41, 42 (1998). Service connection may be established for treatment purposes under 38 C.F.R. § 17.161 (2012) for a dental condition if a veteran meets the basic eligibility requirements. However, applicable regulation clearly prohibits service connection for purposes of compensation where the disability involves periodontal disease such as demonstrated in this case. As such, service connection for periodontal disease for compensation purposes is precluded by law. See 38 C.F.R. § 3.381 (2012). Consequently, there is no legal basis on which the Veteran's claim may be granted. As the law and not the evidence is dispositive in this instance, the claim must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Accordingly, the Board finds that Veteran is not entitled to service connection for periodontal disease for VA compensation purposes. See 38 C.F.R. § 3.381. Conclusion The Board has carefully considered the voluminous evidence of record but concludes that there is no reliable and probative evidence demonstrating that residuals of abdominal hysterectomy and bilateral salpingo-oophorectomy, cervical spine disease, bilateral lower extremity radiculopathy, left and right knee disorders, eye disability/vision loss, and periodontal disease, are related to service, or to any incident therein. The Board thus finds that the preponderance of the evidence is against the claims and service connection is denied in its entirety. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). (CONTINUED ON NEXT PAGE) ORDER Service connection for residuals of abdominal hysterectomy and bilateral salpingo-oophorectomy is denied. Service connection for cervical spine disorder is denied. Service connection for right lower extremity radiculopathy is denied. Service connection for left lower extremity radiculopathy is denied. Service connection for a left knee disorder is denied. Service connection for a right knee disorder is denied. Service connection for an eye disorder/vision loss is denied. Service connection for periodontal disease is denied. ____________________________________________ STEPHANIE L. CAUCUTT Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs