Citation Nr: 1330339	
Decision Date: 09/20/13    Archive Date: 09/25/13

DOCKET NO.  07-38 126A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Oakland, California


THE ISSUES

1.  Entitlement to service connection for a dental disability for compensation purposes. 

2.  Entitlement to service connection for a dental disability for purposes of eligibility for outpatient dental treatment under other than Class II.

3.  Entitlement to a compensable initial evaluation for old healed fracture of the fifth metacarpal bone of the left hand. 

4.  Entitlement to an effective date prior to August 6, 2008, for the award of service connection for left hand ulnar neuropathy. 


ATTORNEY FOR THE BOARD

J. L. Prichard, Counsel


INTRODUCTION

The Veteran served on active duty from December 2000 to June 2005. 

This matter has come before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision of the Philadelphia, Pennsylvania, Department of Veterans Affairs (VA) Regional Office (RO) and an August 2008 rating decision of the Oakland, California, RO.  The February 2006 rating decision denied service connection for a dental condition and granted service connection for old healed fracture of the fifth metacarpal bone of the left hand, evaluated as noncompensable (0 percent) disabling, effective June 24, 2005.  The August 2008 rating decision granted service connection for left hand ulnar neuropathy and assigned 10 percent evaluation, effective August 6, 2008. 

The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case.  It does not contain any evidence not already in the claims folder or considered by the RO.  

The Board notes that, in general, a claim for service-connected disability compensation for a dental disorder may also be treated as a claim for VA outpatient dental treatment.  Mays v. Brown, 5 Vet. App. 302, 306 (1993).  Cf. 38 C.F.R. § 4.150 (setting forth dental and oral conditions for which compensation may be paid); 38 C.F.R. § 17.161 (setting forth criteria for authorization of outpatient dental treatment).  The record shows that entitlement to Class II treatment has already been established.  Accordingly, the Board has rephrased the issues on the title page.

This matter was previously before the Board in August 2011, when the Board remanded the appeal in order to schedule the Veteran for a hearing.  The Veteran withdrew his request for a hearing in August 2013.  The Board will proceed with the adjudication of the Veteran's claim. 




FINDINGS OF FACT

1.  The Veteran sustained an infection of tooth #29 shortly before discharge from active service, which was treated with a root canal at a VA facility within a year of discharge; the record shows that entitlement to Class II treatment has already been established.  

2.  The Veteran does not claim and the evidence does not show that he has a disability due to trauma to the teeth; osteomyelitis or osteoradionecrosis; loss, malunion, or limited motion of the mandible, maxilla, ramus, condyloid process or hard palate; or loss of teeth due to loss of substance of the upper or lower jaw.  

3.  The Veteran does not have a compensable service-connected dental condition; he does not have a service-connected dental condition resulting from a combat wound or other service trauma; he does not have a dental condition aggravating his service connected disabilities; he does not have a rating of 100 percent; he is not homeless; he was not a Prisoner of War; he is not participating in a rehabilitation program under 38 U.S.C.A., Chapter 31; and fixing his dental problems was not medically necessary for a medical condition currently under treatment by VA.

4.  The Veteran retains full range of motion of his fifth finger of the left hand, without additional loss of function with repetitive motion; he is also in receipt of the highest evaluation available under the applicable rating criteria.  

5.  Although the Veteran submitted a claim of service connection for the residuals of a left hand injury within a year of his June 2005 discharge, the existence of ulnar neuropathy was first established on August 6, 2008; it follows that this is the date entitlement arose.  






CONCLUSIONS OF LAW

1.  The criteria for an award of service-connected compensation for a dental disability have not been met.  38 U.S.C.A. §§ 1110, 5107(b), 1712 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303(a), 4.150, 3.381, 17.161 (2013). 

2.  The criteria for entitlement to service connection for a dental condition for purposes of eligibility for VA outpatient dental treatment under other than Class II have not been met.  38 U.S.C.A. §§ 1712, 5107 (West 2002); 38 C.F.R. § 17.161 (2013).

3.  The criteria for an initial compensable evaluation for an old healed fracture of the fifth metacarpal bone of the left hand have not been met.  38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Codes 5227, 5230 (2013). 

4.  The criteria for an effective date prior to August 6, 2008 for service connection for left hand ulnar neuropathy have not been met.  38 C.F.R. § 3.400(b)(2)(i) (2013). 


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance.  38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013).  

Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide.  38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2013).  Pelegrini v. Principi, 18 Vet. App. 112 (2004).

In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. 

The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim.  Those five elements include:  1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability.  Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  

In this case, the Veteran was provided with letters in October 2005 and August 2009 that contained all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini.  The Veteran did not receive notification as to the assignment of disability evaluations and effective dates until after the initial adjudication of his claims.  The claim of service connection for a dental disability has not been readjudicated since the receipt of this notification, as the most recent supplemental statement of the case is dated the same day as the notification.  However, the Veteran does not allege that this results in any harm to his claim, and as this claim will be denied, neither a disability rating nor an effective date will be assigned.  The Board may proceed with adjudication of this claim without fear of harm to the Veteran.  Bernard v. Brown, 4 Vet. App. 384, 394 (1993).  

With respect to the Veteran's appeal for an increased evaluation and an earlier effective date, these arise from disagreement with the initial evaluation and effective date assigned following the grant of service connection.  The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial.  Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007).  The Board concludes that the duty to notify has been met. 

The Board further concludes that the duty to assist has also been met.  The service treatment records have been obtained.  VA treatment records have been obtained.  He was afforded appropriate VA examinations, and relevant opinions and information have been obtained from the examiners after a review of the claims folder.  The Veteran withdrew his request for a hearing before a Veterans Law Judge.  He has not indentified any private medical records to be obtained.  There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal.

Service Connection

The Veteran contends that he is entitled to service connection for a dental disability.  He notes that he was treated for an infected tooth during service that eventually required a root canal, and he states that there is still a lump in the gums in the vicinity of his infection.  

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a).  

Establishing service connection generally requires (1) medical evidence of a current 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 claimed in-service disease or injury and the present disability.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. 

Service connection for compensation purposes is available only for dental disabilities that are the result of osteomyelitis or osteoradionecrosis, or due to the loss, malunion, or limited motion of the mandible, maxilla, ramus, condyloid process, or hard palate, or due to the loss of teeth due to loss of substance of the upper or lower jaw.  38 C.F.R. § 4.150.  

A note to 38 C.F.R. § 4.150, Code 9913, which is the rating code for loss of teeth due to loss of substance of the body of the maxilla or mandible without loss of continuity states that these criteria apply only to bone loss due to trauma or disease such as osteomyelitis.  This note further adds that loss of the alveolar process as a result of periodontal disease is not included. 

The Board observes that in order to establish service connection for compensation purposes, it is not enough to show that the teeth were lost due to trauma.  The evidence must demonstrate that the trauma resulted in loss of substance of the maxilla or mandible, which then resulted in the loss of the teeth. 

Service connection for treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment in accordance with 38 C.F.R. § 17.161.  38 C.F.R. § 3.381.

The Board notes that in a precedent opinion VA's General Counsel held that dental treatment of teeth, even extractions, during service did not constitute dental trauma.  See VAOPGCPREC 5-97, 62 Fed. Reg. 15,566 (1997).

Legal authority provides for various categories of eligibility for VA outpatient dental treatment, such as veterans having a compensable service-connected dental condition (Class I eligibility); veterans having a noncompensable service-connected dental condition, provided that they apply for treatment within a year after service (Class II eligibility); and those having a noncompensable service-connected dental condition adjudicated as resulting from a combat wound or other service trauma (Class II(a) eligibility).  There are categories of treatment for certain homeless veterans (Class II(b) eligibility), for prisoners of war (Class II(c) eligibility), and for certain categories of missing teeth if application is made before April 5, 1983 (Class IIR).  Other categories include treatment for veteran's having a dental condition determined to be aggravating disability from an associated service-connected disability (Class III eligibility); veteran's whose service connected disabilities are evaluated as 100 percent, or who receive a total rating for individual unemployability (Class IV eligibility); and certain treatment for those who are enrolled in a rehabilitation program under chapter 31 (Class V eligibility).  Finally, any veteran scheduled for admission or otherwise receiving care and services under chapter 17 of 38 U.S.C. may receive outpatient dental care which is medically necessary, i.e., is for dental condition clinically determined to be complicating a medical condition currently under treatment (Class VI eligibility).  38 U.S.C.A. § 1712; 38 C.F.R. § 17.161.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant.  38 U.S.C.A. § 5107(b).  

The Board finds that entitlement to service connection for a dental disability for compensation purposes is not supported by the evidence.  First, the Veteran does not contend, and the record does not show, that he sustained a disability as a result of a trauma.  As noted above, service connection for compensation purposes is available only for dental disabilities that are the result of osteomyelitis or osteoradionecrosis; loss, malunion, or limited motion of the mandible, maxilla, ramus, condyloid process or hard palate; or, loss of teeth due to loss of substance of the upper or lower jaw.  38 C.F.R. § 4.150.  

There is no evidence that the Veteran has any of the above-noted disabilities.  Instead, service treatment records from May 2005 show that he was seen by the dentist for reports of an occasional throbbing pain in the lower right side between his teeth.  It was determined that he had an infection of tooth #29, that the tooth might have a communication with the pulp, and that the Veteran might need a root canal.  The December 2005 VA examination shows that the Veteran had a draining fistula at #29, and diagnosed an active infection around the tooth.  The Veteran apparently underwent a root canal in December 2005 following his VA examination, and he was scheduled to receive additional treatment in February 2006.  Both the service treatment records and post service VA records are negative for any other dental disability.  

As there is no evidence that the Veteran has a dental disability listed in 38 C.F.R. § 4.150, the preponderance of the evidence is against the claim, and there is no basis for service connection for compensation purposes.  

With regard to whether service connection may be available for treatment purposes only, the Veteran submitted his claim in September 2005, which was within a year of his June 2005 discharge.  His December 2005 VA dental examination states that the Veteran is entitled to Class II treatment, and that his treatment status was active.  He apparently underwent a root canal at the time of the December 2005 VA examination, and was scheduled for follow-up treatment in February 2006.  As entitlement to Class II treatment is already established, there is no case or controversy in that regard.  However, the Board will examine whether or not he is entitled to any other category of dental treatment.  

The evidence shows that the Veteran is not service-connected, compensable or otherwise, for any dental disorder.  Similarly, the Veteran does not allege, and the evidence does not show, that his service connected left hand neuropathy or old healed fracture of the fifth metacarpal bone of the left hand are aggravated by a dental disorder.  He has not previously applied for dental treatment.  Also, he does not have a rating of 100 percent.  Moreover, service records do not indicate, and the Veteran does not contend, that he was a POW.  He is not homeless and was discharged many years after April 5, 1983.  The Veteran was also not participating in a rehabilitation program under 38 U.S.C.A., Chapter 31, and fixing his dental problems was not medically necessary for a medical condition currently under treatment by VA.  Finally, the record does not show that the Veteran incurred any wounds in combat.  Rather, the evidence shows he developed an infection at tooth #29.  

For these reasons, the Board finds that the Veteran does not qualify for Class I, II(a), (b), (c), IIR, III, IV, V, or VI eligibility, because he does not satisfy the criteria for any eligibility class under 38 C.F.R. § 17.161.  Accordingly, he is not entitled to dental treatment under any category other than Class II for the residuals of the infection at tooth #29.  38 C.F.R. § 17.161

Increased Evaluation

The Veteran contends that the noncompensable evaluation currently assigned for his service connected fracture of the fifth metacarpal bone of the left hand is inadequate to reflect the impairment that is caused by this disability.  He argues that his job requires typing, and that his disability causes his hand to become fatigued.  He further argues that he has a weakened grip, which makes it difficult to carry the books and other materials he is required to use in his job as a lawyer.  

The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria.  38 U.S.C.A. § 1155.  Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  In addition, the entire history of the veteran's disability is also considered.  Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life.  38 C.F.R. § 4.10.  

If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating is assigned.  38 C.F.R. § 4.7.

In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified.  Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances.  38 C.F.R. § 4.21.  

The Board notes that this issue involves the Veteran's dissatisfaction with the initial rating for his disability assigned following the grant of service connection.  The Court has found that there is a distinction between a Veteran's disagreement with the initial rating assigned following a grant of service connection, and the claim for an increased rating for a disability in which entitlement to service connection has previously been established.  In instances in which the Veteran disagrees with the initial rating, the entire evidentiary record from the time of the Veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability, and staged ratings are to be considered in order to reflect the changing level of severity of a disability during this period.  Fenderson v. West, 12 Vet. App. 119 (1999).  

The record indicates that entitlement to service connection for an old healed fracture of the fifth metacarpal bone of the left hand was established in the February 2006 rating decision on appeal.  This decision assigned a noncompensable evaluation under the rating code for ankylosis of the ring or little finger.  

The rating code for ankylosis of the ring or little finger states that a noncompensable evaluation is warranted for either favorable or unfavorable ankylosis of both the major and minor hand.  This is the maximum evaluation available under this rating code.  38 C.F.R. § 4.71a, Code 5227.  The rating code for limitation of motion of these digits also states that a noncompensable rating is the maximum evaluation available for limitation of motion of either of these fingers.  38 C.F.R. § 4.71a, Code 5230.

The Board recognizes that the disability of the musculoskeletal system is primarily the inability due to damage or an infection in parts of the system to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance.  Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled.  Factors to be considered include pain on movement, weakened movement, excess fatigability, and incoordination.  38 C.F.R. §§ 4.40, 4.45.  Functional impairment due to pain must be considered.  38 C.F.R. § 4.59.  

The Veteran was afforded a VA examination in January 2006.  The claims folder was not available for review by the examiner.  An examination of the left hand showed no deformity.  There was no palpable tenderness, no edema, and no crepitus.  The Veteran had a small two centimeter cyst on the proximal interphalangeal joint of the fourth finger of the left hand which was of no clinical significance.  Otherwise, there were no abnormalities noted.  He was able to approximate the tip of his thumb to the tip of all the other fingers, and the tip of all the other fingers could be approximated to the palmar crease.  The diagnosis was an old healed fracture of the fifth metacarpal bone of the left hand.  

The Veteran underwent a second VA examination in August 2008.  The claims folder was available for review by the examiner.  The Veteran reported that since the injury he had intermittent pain in the hand.  He reported numbness of the small finger and ring finger, which affected activities such as typing for longer than ten minutes.  He had to take a break from typing after ten minutes.  He was not taking any medication or receiving treatment for the disability and he had not lost any work time.  The Veteran worked as a lawyer, and he was not able to carry court files because of his hand issue.  He reported that his problem would flare when he used his hand for longer periods of time.  

On examination, there was mild tenderness to deep palpation to the fourth and fifth metacarpals of the left hand.  Handgrip was slightly reduced on the left side when compared to the right.  Small finger abduction was somewhat decreased, and muscle strength on the left when compared to the right was slightly reduced.  Both motions were approximately four out of five strength.  Range of motion of the left hand metacarpal phalangeal joint was normal.  The Veteran could flex the joint to 120 degrees on both sides.  He could touch the distal palmar crease with the fingertip of the left hand small finger and fully extend the metacarpal phalangeal joint to zero degrees.  All the joints of the fingers had normal range of motion.  The assessments included status post left hand fifth finger metacarpal fracture.  The examiner reported there was no change in the range of motion after repetitive movement, and added that pain was a major functional impact.  

The Board finds that entitlement to an increased evaluation for the Veteran's old healed fracture of the fifth metacarpal bone of the left hand is not warranted.  The maximum scheduler evaluation is in effect under the applicable rating code.  This includes consideration of additional limitation due to pain, weakness, incoordination or fatigability, as any increased compensation based on these factors must be derived from the rating criteria.  As the maximum schedular evaluation is in effect, no additional discussion is necessary.  Johnston v. Brown, 10 Vet. App. 80, 85 (1995).  

In reaching this decision, the Board has considered whether or not an evaluation as amputation is warranted.  However, there is no partial or full amputation of the fifth metacarpal bone of the left hand.  As the Veteran retains full range of motion of his finger, and as he experiences only periodic pain with extended use of the finger, there is no indication that evaluation as an amputation would be appropriate.  Although the Veteran reports some pain in his fourth finger, it retains full range of motion, so there is no basis for an additional evaluation based on limitation of motion of a second finger.  He is already in receipt of a separate evaluation for ulnar neuropathy of the left hand, which contemplates impairment in the overall function of this hand.  See 38 C.F.R. § 4.71a, Code 5227.  

Consideration has also been given regarding whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities."  38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record).  In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability.  See Thun v. Peake, 22 Vet. App. 111, 115 (2008).  If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization.  Thun, 22 Vet. App. at 115-16.  When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating.  Otherwise, the schedular evaluation is adequate, and referral is not required.  38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. 

The schedular evaluation in this case is not inadequate.  Indeed, the rating criteria adequately describe the Veteran's symptoms for his old healed fracture of the fifth metacarpal bone of the left hand.  These symptoms include limitation of motion of the finger and pain, all of which are provided for in the rating criteria.  Accordingly, referral for consideration of an extra-schedular rating is not warranted. 

Finally, the Board notes that the Veteran does not contend, and the record does not indicate, that his disability prevents him from holding gainful employment.  Entitlement for a total rating for compensation based upon individual unemployability due to service-connected disabilities is not for consideration.  See Rice v. Shinseki, 22 Vet. App. 447 (2009).

Earlier Effective Date

The Veteran contends that he is entitled to an effective date prior to August 6, 2008 for the award of service connection for left hand ulnar neuropathy.  He notes that this disability is the result of his service-connected old healed fracture of the fifth metacarpal bone of the left hand.  He asserts that as he has experienced his symptoms since discharge and as he submitted his claim for service connection within one year of discharge from active service, service connection should be effective from that date.  

The record shows that the Veteran submitted his original claim for service connection for a "broken left hand" in September 2005.  This was within one year of his June 23, 2005 date of discharge.  This claim was the basis for the grant of service connection for the old healed fracture of the fifth metacarpal bone of the left hand and the June 24, 2005, effective date for that disability.  

Entitlement to service connection for left hand ulnar neuropathy was established in an August 2008 rating decision.  The effective date for this disability was August 6, 2008, which was the date of the VA examination that first noted neurological symptoms and diagnosed the Veteran as having left hand ulnar neuropathy.  

In general, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later.  38 C.F.R. § 3.400.  

The effective date for direct service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, it will be the date of receipt of claim, or date entitlement arose, whichever is the later.  38 C.F.R. § 3.400(b)(2)(i).  

In this case, a claim for residuals of a broken left hand was received within one year of the Veteran's service separation.  However, on the face of that claim, there is no mention of a neurologic disability.  Also, and as will be discussed in detail below, despite his expressed belief that his neuropathy has existed since the bone fracture, there is no suggestion in the record of actual neurologic symptomatology at the time that his original claim (for the broken left hand) was submitted.  Accordingly, it cannot be found that a claim of service connection for ulnar neuropathy, even by inference, was filed within a year of discharge.  Therefore, the appropriate effective date in this case will be the date of receipt of claim, or date entitlement arose, whichever is the later.  38 C.F.R. § 3.400(b)(2)(i).  

The Veteran's service treatment records show that he was treated for an injury to his left hand in December 2002, but there was no initial evidence of ulnar neuropathy.  He complained of pain on the ulnar side of the left hand, which was his dominant hand.  There was a noticeable deformity to the fifth metacarpal bone.  On examination, sensation was 10/10 to light touch.  An X-ray study showed that the Veteran had a left Boxer's fracture, and this was also the final diagnosis.  He was treated with an ulnar splint for four to six weeks.  A second December 2006 record one week following the injury continues to find that the sensory examination was intact.  Follow up treatment records dated February 2003 state that the sensory examination was 10/10.  

The Veteran was seen again for pain in the left fifth metacarpal bone in September 2003, which occurred after the site of the previous injury was crushed by a moving box.  An X-ray study was negative.  

The remainder of the Veteran's service treatment records is negative for any additional treatment of the injury to his left fifth metacarpal bone, and the entirety of his service treatment records are negative for any neurologic findings relating to the left hand.  

The January 2006 VA examination states that the Veteran complained of occasional pain, which was not severe enough for medications.  He also reported some mild decrease in grip strength.  On examination, he was able to make a fist without significant decrease in strength.  The Veteran did not have any motor or sensory loss.  A neurological examination was entirely benign.  

The next medical evaluation of the Veteran's left hand of record is the August 6, 2008 examination.  The claims folder was reviewed by the examiner.  Testing showed that sensation was decreased to monofilament testing in the small finger and ring finger of the left hand as well as the ulnar aspect of the palm.  Handgrip was slightly reduced.  Tinel sign of the tunnel of guyon produced some symptoms in the hand consistent with mild ulnar neuropathy.  The assessment included left hand mild ulnar neuropathy. 

The Board finds that the currently assigned effective date of August 6, 2008 is the earliest possible effective date for the Veteran's left hand ulnar neuropathy.  There is no objective medical evidence to establish the existence of this disability prior to this date.  The service treatment records show that the Veteran retained full sensation in his left hand.  He reported a reduced hand grip in January 2006, but the examiner stated there was no significant decrease, and all neurological findings were normal on the January 2006 VA examination.  As the existence of ulnar neuropathy was first established on August 6, 2008, then this is the date entitlement arose, and it is the earliest possible effective date for this disability.  38 C.F.R. § 3.400(b)(2)(i).  

In reaching this decision, the Board has considered the Veteran's July 2010 statements expressing his belief that his left hand ulnar neuropathy existed since the bone fracture and should have been apparent during the January 2006 VA examination.  He would be competent to report the existence of neurological symptoms that result from ulnar neuropathy.  However, the record prior to July 2010 is devoid of any neurological findings or complaints.  There is no indication in the service treatment records or the January 2006 VA examination that the Veteran reported any neurologic symptoms, and all objective testing at that time was normal.  The Veteran submitted a December 2007 statement in which he describes the symptoms of his old healed fracture of the fifth metacarpal bone of the left hand, but these do not include any neurologic symptoms such as the loss of sensation that was first identified in August 2008.  Instead, he talks about pain with use of his hand, such as with writing.  As previously discussed, these symptoms are contemplated by the rating criteria for old healed fracture of the fifth metacarpal bone of the left hand.  See 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Codes 5227, 5230 (2012).  

A careful reading of the Veteran's July 2010 substantive appeal shows that he does not claim to have experienced neurologic symptoms at the time of his original injury, only that he believes the left hand ulnar neuropathy existed since the original injury.  While the Veteran would be competent to describe the presence of neurologic symptoms prior to August 2008, there is no record that he has done so.  He is not competent to attribute the pain or weakness he experienced then to ulnar neuropathy, or otherwise make a diagnosis of this disability, as this is a complex medical question addressed through medical testing.  See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007).  Finally, while the Veteran believes that ulnar neuropathy should have been apparent at the January 2006 VA examination, a neurologic examination was conducted and found to be normal.  Ulnar neuropathy was first demonstrated August 6, 2008, and this is the proper effective date.  

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ORDER

Entitlement to service connection for a dental disability for compensation purposes is denied. 

Entitlement to service connection for a dental condition for purposes of eligibility for outpatient dental treatment under other than Class II is denied. 

Entitlement to a compensable initial evaluation for old healed fracture of the fifth metacarpal bone of the left hand is denied. 

Entitlement to an effective date prior to August 6, 2008, for service connection for left hand ulnar neuropathy is denied. 




____________________________________________
ERIC S. LEBOFF
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs