Citation Nr: 1324969 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 09-19 925 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a right knee disability, to include arthritis, including as due to a service-connected left foot fracture. 2. Entitlement to service connection for a dental disability, including as due to service-connected residuals of a left mandible fracture, for purposes of outpatient treatment only. 3. Entitlement to service connection for an acquired psychiatric disability other than posttraumatic stress disorder (PTSD), to include depression, including as due to service-connected residuals of a left mandible fracture. 4. Entitlement to service connection for headaches, including as due to service-connected residuals of a left mandible fracture. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from April 1971 to May 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which denied, in pertinent part, the Veteran's claim of service connection for a dental disability, including as due to service-connected residuals of a left mandible fracture, for purposes of outpatient treatment only, and determined that, as new and material evidence had not been received, the Veteran's previously denied claim of service connection for a right knee disability, including as due to a service-connected left foot fracture, would not be reopened. This matter also is on appeal from a December 2008 rating decision in which the RO denied, in pertinent part, the Veteran's claim of service connection for headaches (which were characterized as migraine headaches) and for an acquired psychiatric disability other PTSD, to include depression, each including as due to service-connected residuals of a left mandible fracture (which was characterized as depression, to include as due to temporomandibular joint (TMJ) dysfunction). A Travel Board hearing was held at the RO in August 2011 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. Having reviewed the evidence of record, the Board finds that the issues on appeal are characterized more appropriately as stated on the title page of this decision. In November 2012, the Board, in pertinent part, reopened the Veteran's previously denied service connection for a right knee disability, including as due to a service-connected left foot fracture. The Board also remanded this reopened claim and the Veteran's other currently appealed claims to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the RO/AMC to obtain the Veteran's up-to-date VA and private outpatient treatment records. These records subsequently were associated with the Veteran's claims file. The Board next directed the RO/AMC to obtain the Veteran's Social Security Administration (SSA) records. After contacting SSA and being informed by SSA in January 2013 that these records had been destroyed and were no longer available, the RO/AMC documented its efforts to obtain them in the Veteran's claims file in a formal memorandum for the record. The Board finally directed the RO/AMC to schedule the Veteran for updated VA examinations. These examinations occurred in January and February 2013. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The issue of entitlement to service connection for PTSD, to include as due to an in-service personal assault, has been raised by the record but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). The Veteran filed this claim in statements on a March 2013 VA Form 21-4138 which was date-stamped as received by VA in April 2013. Therefore, the Board does not have jurisdiction over this claim and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's right knee disability is not attributable to active service or any incident of service; it was not caused or aggravated by his service-connected left foot fracture. 2. The Veteran did not experience any in-service dental trauma or bone loss that resulted in any teeth loss or extractions. 3. The Veteran does not experience any current dental disability which could be attributed to active service or any incident of service, including as due to his service-connected left foot fracture. 4. The Veteran's depression is related to active service. 5. The Veteran's headaches were not related to active service or any incident of service, nor were they caused or aggravated by his service-connected residuals of a left mandible fracture. CONCLUSIONS OF LAW 1. A right knee disability was not incurred in or aggravated by active service, or caused, proximately due to, or aggravated by the service-connected left foot fracture; nor may arthritis of the right knee be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a dental disability, for purposes of outpatient treatment only, including as due to service-connected residuals of a left mandible fracture, have not been met. 38 U.S.C.A. §§ 1110, 1721, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.304, 3.304, 3.310, 3.381, 4.150, 17.161 (2012). 3. The Veteran's depression was incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 4. Headaches were not incurred in or aggravated by active service, or caused by, proximately due to, or aggravated by the service-connected residuals of a left mandible fracture. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. Given the favorable disposition of the action here with respect to the Veteran's service connection claim for an acquired psychiatric disability other than PTSD, which is not prejudicial to him, the Board need not assess VA's compliance with the VCAA with respect to this claim. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). With respect to the Veteran's other currently appealed claims, the Board notes that, in letters issued in September 2007, and in September, October and November 2008, VA notified him of the information and evidence needed to substantiate and complete those claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence relating the claimed disabilities to active service and noted other types of evidence the Veteran could submit in support of his claims. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied the requirement that the Veteran be advised to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service-connection claim was provided in all of the VCAA notice letters issued during the pendency of this appeal, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As will be explained below in greater detail, the evidence does not support granting service connection for a right knee disability, including as due to a service-connected left foot fracture, or for a dental disability or for headaches, each including as due to service-connected residuals of a left mandible fracture. Because the Veteran was fully informed of the evidence needed to substantiate these claims, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). With respect to the Veteran's service connection claims for a dental disability and for a right knee disability, the September 2007 VCAA notice letter was issued prior to the currently appealed rating decision issued in February 2008; thus, this notice was timely. The remaining VCAA notice was provided prior to the other currently appealed rating decision issued in December 2008; thus, this notice also was timely. Because the Veteran's claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. And any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the Board. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file also has been reviewed. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the basis of the prior determination and noted the element of the claims that was lacking to substantiate the claims for benefits. The VLJ specifically noted the issues on appeal included all of the issues listed on the title page of this decision. The Veteran was assisted at the hearing by an accredited representative from the Oregon Department of Veterans Affairs. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of his claims. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. The representative specifically asked the Veteran about continuity of his right knee, dental, acquired psychiatric, and headache symptomatology since active service. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the element necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the element necessary to substantiate his claims for benefits. The Veteran's representative and the VLJ asked questions to draw out the evidence which related the Veteran's right knee, dental disability, acquired psychiatric disability, and headaches to active service, the only element of the claims in question. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error. Pursuant to the Board's November 2012 remand, the RO attempted to obtain the Veteran's complete Social Security Administration (SSA) records. SSA informed VA in January 2013 that no records were available for the Veteran because they had been destroyed. Following SSA's negative response in January 2013, the RO sent the Veteran a letter in February 2013 requesting that he provide VA with any copies of his SSA records that were in his possession. There is no record of a response from the Veteran. In March 2013, the RO formally determined that the Veteran's SSA records were not available for review and further attempts to obtain them would be futile. The Board agrees; no additional action is required. The Veteran has been provided with VA examinations which address the contended causal relationship between the claimed disabilities and active service. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Service Connection Claims The Veteran contends that he incurred a right knee disability, a dental disability, an acquired psychiatric disability other than PTSD, and headaches during active service. He alternatively contends that his service-connected left foot fracture caused or contributed to his current right knee disability. He also contends alternatively that his service-connected residuals of a left mandible fracture caused or contributed to his dental disability, acquired psychiatric disability other than PTSD (which he characterizes as depression), and headaches. Law and Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claim in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection also may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a)-(b); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993) (explaining 38 C.F.R. § 3.310(a)); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. § 3.310(b)). Under 38 U.S.C.A. § 1712, outpatient dental services and treatment, and related dental supplies, may be furnished for a dental condition or disability when certain enumerated conditions are met. A claim for service connection also is considered a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306 (1993). Service connection may be awarded for missing teeth due to dental trauma or bone loss in service. The law and regulations also provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are considered non-disabling conditions and may be considered service-connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. See 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 17.161 (emphasis added); see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). The term "service trauma" does not include the intended effects of therapy or restorative dental care and treatment provided during a Veteran's active service. See 38 C.F.R. § 3.306(b)(1) (2012); VAOGCPREC 5-97. Dental disabilities which may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes (DC's) 9900-9916. To establish entitlement to service connection for a tooth, the Veteran must have sustained a combat wound or other in-service trauma. 38 U.S.C.A. § 1712; 38 C.F.R. § 3.381(b). The significance of finding that a dental condition is due to in- 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). Mere dental treatment or cracking a tooth while eating is not sufficient to establish eligibility for treatment. Similarly, broken bridgework due to injury is not dental trauma because it must be the injury of a natural tooth. If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a). Because a dental disability, an acquired psychiatric disability, and headaches are not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to these claims. By contrast, because arthritis is considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating the Veteran's claim of service connection for right knee arthritis. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. 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 one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background The Veteran's service treatment records show that, at his enlistment physical examination in April 1971, he denied all relevant pre-service medical history. On outpatient treatment on July 1, 1972, the Veteran complained that he was struck in the jaw earlier that day and had pain the left mandible and just to the right of the midline of the mandible. Physical examination showed tenderness in the left mandible area with freely movable distal or anterior mandible and inner gingival tenderness in the anterior mandible when moving the mandible. The impression was most probable fracture of the mandible in two places. This injury was considered to have been incurred in the line of duty. The Veteran was sent to a U.S. Army Hospital for further treatment. A "Narrative Summary" dated on July 31, 1972, shows that the Veteran was hospitalized for one month for pain in the left mandible. He had been "involved in a fist fight with his roommate" in their barracks when "he was struck in the left face once, but experienced no loss of consciousness." X-rays taken at a clinical dispensary which revealed a mandible fracture. On admission to a U.S. Army hospital, the Veteran was stable and ambulatory "but in slight distress from the pain from his fracture." Physical examination showed swelling and tenderness over the left angle of the mandible, stable occlusion, and intact dentition. X-rays showed an undisplaced fracture of the mandible "after reduction." While in the hospital, the Veteran had closed reduction surgery on the mandible on July 3, 1972. The post-operative course was unremarkable. The mandible was mobilized on July 28, 1972, "by removal of the intermaxillary wires. The [Veteran] immediately demonstrated a vertical opening of 2.5 [centimeters]." All wires were removed on July 31, 1972, "and the mandible wire appeared clinically healed. The range of motion of the jaw was within normal limits and he was able to masticate a normal diet without difficulty. He returned to duty doing well." The final diagnosis was an open undisplaced fracture of the left angle of the mandible. A Discharge Summary dated in July 1972 showed that the Veteran was hospitalized for one month for an open, non-displaced fracture of the left mandible. It was noted that this fracture was "treated + healed." The Veteran had been struck in the left face during an altercation. He had closed reduction surgery with IV loops and intermaxillary wires to immobilize his mandible on July 3, 1972. His mandible was mobilized again on July 28, 1972. At discharge, his fracture was healed clinically and his mandible range of motion was within normal limits. He also was able to masticate a normal diet without difficulty and was doing well. At his separation physical examination in January 1974, clinical evaluation was normal except for a tattoo and a scar on the right thumb. The Veteran stated that he was in good health. The Veteran certified in May 1974 that there had been no change in his medical condition since his separation physical examination. A review of the Veteran's service dental records shows that, on July 1, 1972, it was noted that he had been injured in an altercation but had not lost consciousness. Oral examination showed slight swelling and discomfort in the left angle of the mandible, stable occlusion, and cross-bite tooth # 8 "edge to edge" with tooth # 9. X-rays showed an open fracture of the left angle that was non-displaced. On July 3, 1972, the Veteran had closed reduction surgery with eight IV loops and 4 intermaxillary wires and tooth # 17 was in the line of the fracture. On July 5, 1971, he was observed as comfortable with stable occlusion. On July 7, 1972, he was doing well. On July 10, 1972, he was doing well with stable occlusion. On July 18, 1972, he had stable occlusion and positive fixation. On July 31, 1972, all wires were removed. The Veteran's mandible was healed clinically with a range of motion that was within normal limits. He masticated a normal diet. On August 3, 1972, it was noted that the Veteran's mandible range of motion was within normal limits. The post-service evidence shows that, in a November 2001, D.F.W, M.D., stated that the Veteran had been involved in a motor vehicle accident in December 2000 "in which his car was rear-ended." The Veteran reported that "he hit his head on the speaker in his van" at the time of this accident but did not lose consciousness. Following this accident, the Veteran had experienced "headaches off and on." The diagnoses included cervical syndrome and headaches which was a "common consequence[] of this type of neck injury." In a handwritten postscript to this letter, Dr. D.W. stated that the Veteran was "developing some depression because of his ongoing symptoms." On VA bones examination in March 2002, the Veteran reported that he had fractured his jaw during active service when he was "sucker-punched." He also reported that this in-service injury was treated "with wiring of the jaw." After examination, the impressions included no deformity of the bony architecture of the jaw. On VA dental examination in March 2002, the Veteran complained, " My jaw has been tired since my [motor vehicle accident]" in December 2000. He also complained of pain "in the same region that was fractured in 1972." The Veteran reported that he had teeth extracted "due to inability to be restored." He had been asymptomatic between 1972 and 2000. Physical examination showed the following missing teeth: #2-5, 12, 15, 17, 19, 30, and 31, a normal range of motion in the jaw, "bone loss consistent with tooth extraction of long duration," positive palpation of the medial muscle, negative palpation of the other muscles of mastication, normal mandibular movements, and no deviation of the mandible during opening. The Veteran ate a normal diet. X-rays showed no radiographic residuals of mandible fracture. The VA examiner stated that he was "unable to verify presence of pain from clinical exam." The impressions included no clinical residuals of mandible fracture. Following VA outpatient treatment in July 2002, the assessment included headaches with no evidence of a radiculopathy on examination or on electromyograph (EMG)/nerve conduction velocity (NCV) studies. On VA joints examination in August 2003, the Veteran's complaints included left knee pain. It was noted that the Veteran had worked as a general contractor until he had been forced to stop working in 2000 following a motor vehicle accident when he was diagnosed as having "nerve root damage." He described his left knee as "where it is very hard to load on his left side." He reported left knee pain and stiffness, especially in the mornings, instability, and occasional locking. His left knee had been "much worse" since his motor vehicle accident. Physical examination detailed findings associated with the left knee. Clinical findings for the right knee were not recorded. The diagnoses included chronic left-sided knee pain with mild degenerative joint disease of the left knee. An August 2003 VA Form 119, "Report of Contact," included in the Veteran's claims file indicates that personnel at the VA Medical Center in Portland, Oregon, notified RO personnel that there were no VA dental treatment records available for the Veteran at this facility dated between April 2001 and August 2003. A review of the SSA's September 2003 decision on the Veteran's application for SSA benefits shows that he was awarded SSA disability benefits effective September 28, 2002, for degenerative disc disease, tinnitus with vertigo, and hepatitis C. On VA dental examination in September 2003, the Veteran complained of increased jaw pain in the left mandible area since a motor vehicle accident in 2000. He had been asymptomatic between 1972 and 2000. He also complained of pain when eating hard foods since his last tooth extraction. A "multiple history of fractures" was noted in the Veteran's medical records. The Veteran ate a soft diet "due to lack of teeth. Physical examination showed the following missing teeth: #2-5, 12, 13, 15, 17, 19, 30, and 31 with "prosthesis possible," a normal range of motion in the jaw, moderate bone loss with "prosthesis possible," inflamed tissue, and tenderness to palpation on the right masseter. X-rays showed no radiological residuals of mandible fracture. The impressions included no radiographic residuals of mandible fracture at the left angle of the mandible and a normal range of motion. On VA outpatient treatment on December 12, 2003, the Veteran's complaints included sleeping 1-2 hours a night and being "awakened repeatedly by his physical pain." He had "very little social support. He said that he has no face-to-face social interactions and spends almost all of his time alone. He does not belong to any clubs or organizations and does not participate in organized religion." He had been married once but had been divorced for eight years. He was homeless and lived in his van. He had three adult sons. He enjoyed fishing and read the newspaper daily but "did not identify any other enjoyable hobbies or activities that he did on a regular basis." After mental status examination, the VA clinician concluded that the Veteran "suffers from a number of symptoms related to depression." On VA outpatient treatment on December 18, 2003, the Veteran's complaints included headaches "which he describes as 'in space' and throbs in his forehead, left greater than right, and also his left eye." The Veteran rated his pain as between 8/10 and 10/10 on a pain scale. "He sleeps one to two hours total. He is unable to fall asleep. He finds his mind racing and like a pinball, bouncing...from one thought to another." A physical examination was conducted. The assessment included muscle tension headaches and depression. A Depression Screen conducted on VA outpatient treatment in January 2006 was negative. On VA dental examination in August 2006, the Veteran's complaints included occasional difficulty in chewing some foods. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's in-service jaw fracture and closed reduction surgery was noted. There was no history of trauma to the teeth, difficulty in talking, fever, swelling, pain, drainage, or difficulty in opening the mouth. Physical examination showed less than 25% loss of bone of the maxilla which was replaceable by prosthesis, no malunion or non-union of the maxilla, a loss of bone of the mandible which was replaceable by prosthesis, no malunion or non-union of the mandible, no limitation of motion at the TMJ articulation, no loss of bone of the hard palate, no evidence of osteoradionecrosis or osteomyelitis, no tooth loss due to loss of substance or body of the maxilla or mandible, and no speech difficulty. X-rays showed generalized bone loss consistent with periodontal disease. The VA examiner stated that the Veteran's loss of teeth was not related to his in-service mandible fracture but was secondary to periodontal disease and decay. The diagnoses included no current residuals of mandible fracture and periodontitis which was consistent with poor oral hygiene and was not related to the mandible fracture or active service. On private outpatient treatment later in August 2006, the Veteran's complaints included right knee pain. The assessment included right knee pain. On VA outpatient treatment in April 2008, the Veteran complained of right knee pain which had lasted for six months. There was no known right knee injury. His right knee pain had worsened in the previous three weeks and was located "through the medial joint line and top of the knee cap." His pain was 8/10 on a pain scale when walking. "He still walks several city blocks. He is using a brace and takes Vicodin." After physical examination, the assessment was degenerative joint disease of the right knee with a possible loose body. The Veteran was referred for a magnetic resonance imaging (MRI) scan of the right knee. VA MRI scan of the Veteran's right knee taken later in April 2008 showed an extensive tear of the mid-body and posterior horn of the medial meniscus, loose body between the posterior cruciate ligament and posterior joint capsule, advance osteoarthritis of the medial joint space, and severe degeneration of the patellar articular cartilage. It was noted that the Veteran's MRI was reviewed with him and he agreed to undergo right knee arthroscopy, medial meniscectomy, and possible removal of the loose body. The Veteran had right knee arthroscopy and medial meniscectomy surgery at a VA Medical Center in July 2008. The pre-operative diagnoses were right knee medial meniscus tear and loose body. The post-operative diagnoses were right knee medial meniscus tear but no visible loose body. On VA dental examination in October 2008, the Veteran complained of "episodes where his 'jaw catches' when he eats certain foods." He also complained of "episodes of his 'jaw locking'" which he reduced on his own. The VA examiner reviewed certain of the Veteran's service treatment records. The Veteran reported a history of moderate left jaw pain that occurred monthly but less than weekly. He also reported a history of difficulty in talking. He denied any history of trauma to the teeth, neoplasm, swelling, difficulty in opening his mouth, or drainage. Physical examination showed no loss of bone of the maxilla, no malunion or non-union of the maxilla, bilateral bone loss of the mandible that was replaceable by prosthesis, no non-union or malunion of the mandible, no limitation of motion at the TMJ articulation, no bone loss of the hard palate, no evidence of osteoradionecrosis or osteomyelitis, no tooth loss due to loss of substance of body of maxilla or mandible (other than loss due to periodontal disease), reported difficulty with phonetics "due to loss of teeth," negative palpation of the muscles of mastication, no posterior occlusion, and gross caries. The VA examiner stated that the Veteran's tooth loss was not related to his mandible fracture but was secondary to periodontal disease and decay. This examiner opined that the Veteran's muscle discomfort and jaw locking was due to the loss of posterior occlusion from gradual loss of posterior teeth and was not due to mandible fracture that occurred during service. The rationale was that the mandible fracture had healed and was without residuals. The diagnosis was muscle tenderness secondary to loss of posterior teeth. In a February 2009 statement, D.P. stated that he had witnessed another soldier "sucker punch" the Veteran when they served together during active service. D.P. also stated that the Veteran's jaw had been wired shut for several weeks after this incident. On VA dental examination in November 2009, the Veteran's complaints included a history of occasional difficulty in chewing for all food, a history of moderate to severe pain at the left masseter/joint that occurred at least weekly but less than daily. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's in-service treatment for a jaw fracture was noted. The Veteran reported that "his front maxillary incisors have a grove that developed due to contact on his lower incisors." He lost tooth #9 two years earlier and the upper right posterior teeth "possibly three years ago." The pain in his left masseter had begun after his in-service mandible fracture. He experienced pain "that does not last" in the left masseter/joint region during chewing one to two times per week and rated it as 7-8/10 on a pain scale. Physical examination in November 2009 showed no loss of bone of the maxilla, no malunion or non-union of the maxilla, no loss of bone of the mandible, no non-union or malunion of the mandible, no limitation of motion at the TMJ articulation, no loss of bone of the hard palate, no evidence of osteoradionecrosis or osteomyelitis, no tooth loss due to loss of substance of the body of the maxilla or mandible (other than loss due to periodontal disease), no speech difficulty, root tip teeth # 9, 31, no joint sounds, and palpation pain 4/10 on the left occipital, 3/10 on the bilateral temporalis, 3/10 on the left masseter, 5/10 on the left medial pterygoid, and 3-4/10 on the left TMJ. The VA examiner opined that the Veteran's pain in the masseter region was at least as likely as not due to the loss of his posterior teeth as it was due to residuals from a healed mandible fracture. The rationale was that the Veteran experienced this pain "during function and [it] is consistent with pain that develops from poor ability to masticate due to loss of teeth." The Veteran also had a normal range of motion in the jaw. The diagnosis was pain in the left masseter/joint region secondary to loss of posterior occlusion. On VA outpatient treatment on September 1, 2010, the Veteran complained of "many months of slow decline, anhedonia, low motivation, [and] lack of energy." He reported a history of suicidal ideation "most recently about three weeks ago." He denied any current suicidal or homicidal ideation "but declines to lock up his guns." The assessment included gradually worsening depression. On VA mental disorders examination on September 4, 2010, the Veteran's complaints included anxiety. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. A history of alcohol abuse was noted. It also was noted that the Veteran "has worked only a short time since a motor vehicle accident in 2000." He reported being homeless. He did not socialize "because he doesn't like being around people." He denied "any enjoyable leisure activities at all." He walked outside "every day or almost every day, about one or two miles." The Veteran's motor vehicle accident in 2000 was noted. He had experienced anxiety since service. He had "an uncomfortable feeling" most of the time which "comes from not being able to concentrate or be focused on things." He had a panic attack in February 2010. He did not like crowds and did not make new friends. The Veteran reported that his physical pain averaged 9-10/10 on a pain scale. The examiner noted, "[o]n the other hand, he reports that pain treatments provide 40% relief. If this is the case, it is not logical that his pain is never reported at less than an intensity of 9." After mental status examination, the VA examiner opined that the Veteran's depression was not caused by or related to his left mandible fracture. She also opined that the Veteran's depression was at least as likely as not "partly exacerbated by the effects of" his left mandible fracture. The diagnoses included chronic major depressive disorder and anxiety disorder, not otherwise specified. On VA outpatient treatment in September 2010, the provisional diagnoses included possible major depressive disorder versus dysthymia. In September 2012, the Veteran complained of "feeling blah, negativity." He reported that he was experiencing anxiety "which he attributes to pain (worst in his foot and back). He report ongoing anger and irritability." His appetite and concentration were normal and his energy level "is variable." He had motivation and energy "to engage in activities - he lives on three acres with his son, he spends most of his time clearing the property - trimming trees, working on his car." He denied any feelings of suicidal or homicidal ideation, manic symptoms or auditory or visual hallucinations, obsessive-compulsive disorder, hopelessness, or PTSD symptoms. A history of possible major depressive disorder versus dysthymia was noted. He was in "a good living situation" living with his son and daughter-in-law. He had worked as a crane operator. He spent time by himself "in the woods, fishing." A mental status examination was conducted. The assessment was irritability "related to perceived slights against him and long-standing anger towards the government related to his service-connected benefits and pain management." The VA clinician noted that the Veteran "has irritability and psychomotor changes, thought [he] does not endorse other [symptoms] of depression or anxiety." There was no medical etiology found for his irritability. "He appears functionally impaired by his irritability/anger, which may be related to dysthymia or an underlying personality disorder." The diagnoses included rule-out dysthymia. On VA dental examination in January 2013, the Veteran's complaints included episodes of open jaw locking that occurred while eating "multiple times per week" and were rated as 8/10 on a pain scale and reciprocal bilateral joint sounds. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's in-service mandible fracture and jaw surgery were noted. He denied any flare-ups which impacted his TMJ function. Physical examination showed a range of motion for lateral excursion greater than 4 millimeters (mm) with painful motion greater than 4 mm, a range of motion for opening the mouth greater than 40 mm with no objective evidence of painful motion, no additional limitation of motion in range of motion of either TMJ following repetitive-use testing, no functional loss or functional impairment of either TMJ, weakened movement, excess fatigability, incoordination, and pain on movement in the left TNJ, and crepitation on the left TMJ. The Veteran was missing multiple posterior teeth. The VA examiner opined that the Veteran's current symptoms were less likely than not caused by or residuals of his in-service mandible fracture. The rationale was that the Veteran had a normal range of motion in his jaw, reported pain in the masseter region on palpation, and had poor posterior occlusion. This examiner also noted in his rationale that the Veteran's pain occurred during function and was consistent with pain that developed from a poor ability to masticate (or chew) due to the loss of teeth. The diagnosis was no TMJ condition. On VA mental disorders Disability Benefits Questionnaire (DBQ) in February 2013, the Veteran's complaints included depression, anxiety, chronic sleep impairment, and difficulty focusing and concentrating since active service. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's in-service jaw fracture following a fight with another soldier was noted. The Veteran reported that he was divorced from his wife and "has had positive relationships with women but is 'afraid to get involved again.'" He also reported having several good male friends "who he feels a sense of mutual support." After examination, the VA examiner opined that, based on the Veteran's "description of the onset of depression during active duty," it was at least as likely as not that his current chronic depression was related to active service and had its onset during service. The rationale was that the Veteran's "documented in-service assault must be presumed to be at least an aggravating factor" in his major depression. The diagnoses included chronic recurrent moderate major depression without psychotic features. On VA knee and lower leg conditions DBQ in February 2013, the Veteran's complaints included bilateral knee pain since active service. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. This examiner noted that the Veteran previously had reported to his VA treating providers that his right knee pain began in 2003. The Veteran's motor vehicle accident in 2000 and right knee meniscectomy in 2008 were noted. The Veteran denied that flare-ups of right knee pain impacted his knee and/or lower leg function. The Veteran's physical examination findings were recorded. Thereafter, the VA examiner opined that it was less likely than not that the Veteran's right knee disability was related to or had its onset in service or was caused or aggravated by a service-connected disability. The rationale for this opinion was that there was no "basis in medical fact" to support an etiological relationship between the Veteran's right knee disability and active service, to include as due to a service-connected disability. The VA examiner stated that she had reviewed the Veteran's relevant statements and x-rays. The diagnosis was right knee degenerative joint disease and internal derangement first diagnosed in 2003. On VA headaches DBQ in February 2013, the Veteran complained of worsening headaches since being "punched in the jaw" during active service. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran denied experiencing any head trauma. He experienced several daily headaches which lasted from a few seconds to a few minutes and were bilateral. He did not take any medication for his headaches. His pain was on both sides of his head. He denied any characteristic prostrating attacks of migraine headache and non-migraine headache pain. He also denied any frequent prostrating and prolonged attacks of migraine headache and non-migraine headache pain. The VA examiner opined that it was less likely than not that the Veteran's headaches were related to or had their onset in service or were caused or aggravated by a service-connected disability. The rationale was that a review of the medical records indicated that the Veteran's headaches were associated with his motor vehicle accident in 2000. The rationale also was that the Veteran's headache history was inconsistent with the medical records and his description of his headaches as headaches was atypical. The VA examiner stated that she had reviewed the Veteran's relevant statements and x-rays. The diagnosis was unspecified headache diagnosed in 1972. In a March 2013 statement, the Veteran contended that his August 2003 VA examination showed that his current right knee disability was related to "gait abnormalities caused by his service-connected left foot fracture." He also contended that having his jaw wired shut for 30 days while on active service caused or contributed to his current dental disability. Analysis Right Knee The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a right knee disability, to include arthritis, including as due to a service-connected left foot fracture. The Veteran has contended that he incurred a right knee disability during active service or, alternatively, his service-connected left foot fracture caused or contributed to his current right knee disability. The record evidence does not support his assertions, however. It shows instead that, although the Veteran currently experiences a right knee disability, it is not related to active service or any incident of service, to include his service-connected left foot fracture. The Veteran's service treatment records document his in-service treatment for a left foot fracture but show no complaints of or treatment for a right knee disability during active service, although the Board acknowledges that the lack of in-service complaints of and treatment for a right knee disability does not preclude a grant of service connection for this disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). It appears that, following his service separation in May 1974, the Veteran first complained of and was treated for a right knee disability approximately 34 years later when he complained of a three-week history of right knee pain on VA outpatient treatment in April 2008. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Mense v. Derwinski, 1 Vet. App. 354 (1991). Following an MRI scan of the right knee later in April 2008, the Veteran had right knee surgery to repair a medial meniscus tear in July 2008. The Veteran has contended that his August 2003 VA examination contained evidence supporting a finding of an etiological link between his right knee disability and active service. He specifically contended that this VA examination showed that his right knee disability was caused by gait abnormalities which he experienced as a result of his service-connected left foot fracture. See March 2013 statement. A detailed review of the August 2003 VA examination does not support the Veteran's assertions, however. This examination focused on the Veteran's complaints of left knee disability and low back pain. The Veteran did not contend, and the August 2003 VA examiner did not report, that he experienced right knee disability at that time. Although the August 2003 VA examiner noted that the Veteran was "in some mild discomfort" when he walked, this examiner did not indicate, nor did the Veteran report, that any alleged gait abnormalities caused or contributed to a right knee disability. Thus, the Board finds that the Veteran's argument concerning the August 2003 VA examination is without merit. The record evidence demonstrates that, although the Veteran currently experiences a right knee disability, it is not related to active service or any incident of service, to include as due to a service-connected left foot fracture. The February 2013 VA examiner specifically opined that it was less likely than not that the Veteran's right knee disability was related to or had its onset in service or was caused or aggravated by a service-connected disability. The rationale for this opinion was that there was no "basis in medical fact" to support an etiological relationship between the Veteran's right knee disability and active service, to include as due to a service-connected disability. This examiner stated that she had reviewed the Veteran's relevant statements and x-rays. The Veteran also has not identified or submitted any evidence, to include a medical nexus, demonstrating an etiological relationship between his right knee disability and active service, to include as due to a service-connected left foot fracture. In summary, the Board finds that service connection for a right knee disability, to include as due to a service-connected left foot fracture, is not warranted. The Board also finds that service connection for right knee arthritis not warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. The Board acknowledges that, because arthritis is considered a "chronic" disability, the theory of continuity of symptomatology remains valid in adjudicating the Veteran's claim of service connection for right knee arthritis. See Walker, 708 F.3d at 1331. The record evidence does not support a finding of continuity of symptomatology for right knee arthritis, however. The evidence does not show, nor does the Veteran contend, that he experienced right knee arthritis during active service or within the first post-service year (i.e., by May 1975). It appears instead that the Veteran first complained and was treated for right knee arthritis in approximately April 2008, several decades after his service separation. See also Maxson, 230 F.3d at 1333. Thus, the Board finds that service connection for right knee arthritis is not warranted on a presumptive basis as a chronic disease. Id. Dental Disorder The Board next finds that the preponderance of the evidence is against the Veteran's claim of service connection for a dental disability, including as due to service-connected residuals of a left mandible fracture, for purposes of outpatient treatment only. Although the Veteran contends that his in-service broken jaw constituted dental trauma, and although the Board does not doubt that this in-service injury was a traumatic experience for the Veteran, his service dental records do not indicate that he had any missing teeth or experienced any dental trauma during active service. See 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 17.161. The treatment which the Veteran received for his broken jaw (wiring his jaw shut for 30 days) while on active service constitutes mere dental treatment and is not considered a dental disability due to in-service trauma for VA compensation purposes. See 38 C.F.R. § 3.306(b)(1); VAOGCPREC 5-97. The record evidence also does not show that the Veteran experiences any of the dental disabilities listed in 38 C.F.R. § 4.150 for which service connection is available for purposes of VA outpatient treatment only. See 38 C.F.R. § 4.150, DC's 9900-9916. The Veteran's VA dental examinations in March 2002 and in September 2003 indicate that he did not experience either a dental disability at either of these examinations which could be attributable to active service. Nor did March 2002 and September 2003 VA examiners diagnose the Veteran as having any residuals of his acknowledged in-service mandible (or jaw) fracture at either of these examinations. The Board acknowledges that, following VA dental examinations in October 2008 and in November 2009, the Veteran was diagnosed as having tenderness or pain in his jaw, respectively. The Board notes in hits regard, however, that the presence of a mere symptom (such as tenderness or pain) alone, absent evidence of a diagnosed medical pathology or other identifiable underlying malady or condition that causes the symptom, does not qualify as disability for which service connection is available. See generally Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). More importantly, the October 2008 VA examiner attributed the Veteran's muscle tenderness to the loss of teeth secondary to periodontal disease and decay (both of which are considered non-disabling conditions and are not compensable disabilities for VA purposes). The October 2008 VA examiner also specifically found that the Veteran's muscle discomfort and reported jaw locking were due to the loss of posterior occlusion from the gradual loss of his posterior teeth and were not related to active service because his in-service mandible fracture had healed and was without residuals. The November 2009 VA examiner similarly opined that the Veteran's pain in the masseter region was at least as likely due to the loss of posterior teeth because his pain occurred during jaw function and was consistent with pain that developed from a poor ability to masticate (or chew) due to the loss of teeth. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. It appears that the Veteran does not experience any current dental disability (other than jaw pain and locking) which could be attributed to active service. The Board notes again that complaints of pain without an underlying diagnosis are not considered a disability for which service connection is available. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). A review of the January 2013 VA dental examination shows that no dental diagnosis was rendered although the Veteran reported experiencing jaw pain and locking at that examination. The January 2013 VA examiner opined that the Veteran's current symptoms were less likely than not caused by his service-connected residuals of a mandible fracture. This examiner also provided a sufficient rationale for his negative nexus opinion. In summary, the Board finds that service connection for a dental disability, to include as due to service-connected residuals of a left mandible fracture, is not warranted. An acquired psychiatric disorder, diagnosed as depression The Board next finds that the evidence supports granting the Veteran's claim of service connection for an acquired psychiatric disability other than PTSD, diagnosed as depression. The Veteran contends that his service-connected residuals of a left mandible fracture caused or contributed to his current depression. The record evidence supports his assertions concerning the contended etiological link between depression and his service-connected residuals of a left mandible fracture. The Veteran's service treatment records show that he fractured his jaw after being involved in a fight with his roommate in July 1972 during active service. These records show no complaints of or treatment for depression, although, as noted above, this does not preclude granting service connection for a claimed disability. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. It appears that, following his service separation, the Veteran's depression was noted following VA outpatient treatment in December 2003 when a VA clinician stated that, although psychological testing was incomplete, the Veteran suffered from "a number of symptoms related to depression." He was diagnosed as having depression later in December 2003. The Board notes that, following VA examination in September 2010, the VA examiner opined that, although the Veteran's depression was not caused by or related to his service-connected residuals of a left mandible fracture, it was at least as likely as not "partly exacerbated by the effects of" his left mandible fracture. This opinion appears to be contradictory as to the etiological origin of the Veteran's current depression and its contended causal relationship to his service-connected residuals of a left mandible fracture. The September 2010 VA examiner did not explain the apparent contradiction in finding that the Veteran's depression was not caused by or related to his service-connected residuals of a left mandible fracture, although it was "partly exacerbated by the effects of" this disability. It also appears that this examiner was not asked to provide, and did not provide, an opinion concerning the contended causal relationship between the Veteran's depression and active service on a direct service connection basis. See generally 38 C.F.R. §§ 3.303, 3.304. Given the deficiencies in the September 2010 VA examination report, the Board finds that it is less than probative on the issue of whether the Veteran's acquired psychiatric disability other than PTSD, to include depression, is related to active service, including as due to service-connected residuals of a left mandible fracture. By contrast, following VA mental disorders DBQ in February 2013, which noted the Veteran's reported medical history and included a comprehensive mental status examination, the VA examiner concluded that the Veteran's in-service jaw fracture in a fight with his roommate (which the examiner characterized as an in-service assault) had resulted in a "permanent and disturbing memory" for him. This examiner also concluded that, based on the Veteran's description that his depression began in active service after his roommate broke his jaw during a fight, it was at least as likely as not that the Veteran's depression was related to service. This examiner noted that the Veteran's in-service assault resulting in a broken jaw "must be presumed to be at least an aggravating factor" in causing his current chronic depression. The evidence indicates that the Veteran currently experiences an acquired psychiatric disability other than PTSD, diagnosed as chronic recurrent moderate major depression without psychotic features, which is related to service and service-connected disability. The lay evidence is consistent as to the facts and circumstances of the Veteran's in-service jaw fracture as he contends that he was "sucker punched" by another soldier. The medical evidence suggests that the Veteran found this incident to be traumatic and led him to experience depression continuously since his service separation. In summary, the Board finds that service connection for an acquired psychiatric disability other than PTSD, to include depression is warranted. Headaches The Board finally finds that the preponderance of the evidence is against the Veteran's claim of service connection for headaches, including as due to service-connected residuals of a left mandible fracture. The Veteran has contended that his in-service jaw fracture led him to experience headaches continuously since service. The record evidence does not support his assertions regarding in-service incurrence of headaches or continuity of symptomatology for headaches since service separation, although the Board recognizes that continuity of symptomatology is no longer a valid theory of service connection in adjudicating this claim because headaches are not considered a chronic disability for VA purposes. See Walker, 708 F.3d at 1331. The evidence shows instead that, although the Veteran currently experiences unspecified headaches, they are not related to active service or any incident of service, including as due to service-connected residuals of a left mandible fracture. The Veteran's service treatment records show no complaints of or treatment for headaches at any time during service, including at the time of his in-service jaw fracture in July 1972, although the absence of in-service complaints or treatment does not prevent granting service connection for a claimed disability. See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303. The post-service evidence also shows that, although the Veteran currently experiences headaches, they are not related to active service, including as due to service-connected residuals of a left mandible fracture. As outlined above, the record evidence shows that the Veteran does not experience any current residuals of a left mandible fracture (including his claimed headaches). Following his service separation in May 1974, the Veteran first sought treatment for headaches in November 2001, more than 27 years later and almost one year after a December 2000 motor vehicle accident. See Maxson 230 F.3d at 1333. In November 2001, Dr. D.W. diagnosed the Veteran as having headaches which were a "common consequence[] of this type of neck injury" experienced as a result of his motor vehicle accident in December 2000. The VA examiner provided a similar opinion about the etiology of the Veteran's headaches following VA headaches DBQ in February 2013. At that examination, the Veteran denied any characteristic prostrating attacks and any frequent prostrating and prolonged attacks of migraine headache and non-migraine headache pain. The VA examiner opined that it was less likely than not that the Veteran's headaches were related to or had their onset in service or were caused or aggravated by a service-connected disability. The rationale was that a review of the medical records indicated that the Veteran's headaches were associated with his motor vehicle accident in 2000. The rationale also was that the Veteran's headache history was inconsistent with the medical records and his description of his headaches as headaches was atypical. Pursuant to the Board's November 2012 remand directives, the February 2013 VA examiner stated that she had reviewed the Veteran's relevant statements and x-rays in rendering her nexus opinion. The Veteran also has not identified or submitted any competent evidence, to include a medical nexus, which relates his headaches to active service or any incident of service, including as due to service-connected residuals of a left mandible fracture. In summary, the Board finds that service connection for headaches, including as due to service-connected residuals of a left mandible fracture, is not warranted. Other considerations In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). 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 issues in this case, a right knee disability, a dental disability, and headaches fall 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). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, 21 Vet. App. at 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claim, in recent statements and sworn testimony, the Veteran has asserted that his symptoms of a right knee disability, a dental disability, and headaches have been continuous since service. He asserts that he continued to experience symptoms relating to the right knee (pain and swelling, difficulty walking, and problems climbing stairs), a dental disability (jaw pain and swelling), and headaches after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of any of these disabilities after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of right knee disability, a dental disability, and headaches since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that these disorders began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied all relevant history or complaints of symptoms. Specifically, the service separation examination report reflects that the Veteran was examined and he was found to be normal clinically. He also reported that he was in good health at his separation physical examination. The Veteran's in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). The post-service medical evidence does not reflect complaints or treatment related to a right knee disability, a dental disability, or for headaches for several decades following active service. The Board emphasizes the multi-year gap between discharge from active service (1974) and initial reported symptoms related to the right knee in approximately August 2006 (a 32-year gap), a dental disability in approximately March 2002 (an 28-year gap), and headaches in approximately November 2001 (a 27-year gap. See Maxson, 230 F.3d at 1333; 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). The Board finds it especially significant that, when he initially complained of jaw pain on VA examination in March 2002, the Veteran related it to his December 2000 motor vehicle accident. The Board also finds it especially significant that, when he initially complained of headaches in November 2001, these complaints also were related to his December 2000 motor vehicle accident. The Board notes that the Veteran sought treatment for a myriad of medical complaints since discharge from service, including a left knee disability. Significantly, and as noted elsewhere, when he specifically complained of a left knee disability on VA examination in August 2003, he did not report any complaints related to the right knee. Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). When the Veteran sought to establish medical care with VA for a right knee disability after service in April 2008, he did not report the onset of right knee symptomatology during or soon after service or even indicate that the symptoms were of longstanding duration. He complained instead of right knee pain which had lasted for six months (or since approximately November 2007). He also reported that his right knee pain had worsened only in the previous three weeks. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Id. The Veteran filed multiple VA disability compensation claims for service connection for tinnitus, hearing loss, vertigo, ear infections, and for residuals of a fracture of the left little toe in October 2000 but did not claim service connection for a right knee disability, an acquired psychiatric disability, or for headaches or make any mention of any relevant symptomatology. He did not claim that symptoms of these disabilities began in (or soon after) service until he filed his current VA disability compensation claims. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories and his previous statements made for treatment purposes. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). During the recent VA compensation claims, the Veteran reported the onset of symptoms to different times. Specifically, when he filed his service connection claims in July 2007, he contended that all of his claimed disabilities began during active service. As noted above, however, he previously reported on outpatient treatment in November 2001 with Dr. D.W. that his headaches had begun only after an motor vehicle accident in December 2000. As also noted above, on VA outpatient treatment in April 2008, the Veteran reported a history of right knee pain only going back approximately six months or to November 2007. These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, and his previous statements made for treatment purposes. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER Entitlement to service connection for a right knee disability, to include arthritis, including as due to a service-connected left foot fracture, is denied. Entitlement to service connection for a dental disability, including as due to service-connected residuals of a left mandible fracture, for purposes of outpatient treatment only, is denied. (CONTINUED ON NEXT PAGE) Entitlement to service connection for an acquired psychiatric disability, diagnosed as depression, including as due to service-connected residuals of a left mandible fracture, is granted. Entitlement to service connection for headaches, including as due to service-connected residuals of a left mandible fracture, is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs