Citation Nr: 1335307 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-06 846 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a right leg fracture. 2. Entitlement to service connection for disability manifested by a tremor. 3. Entitlement to service connection for pes planus. 4. Entitlement to service connection for a dental disability for compensation purposes. 5. Entitlement to service connection for a dental disability for purposes of eligibility for outpatient dental treatment. 6. Entitlement to service connection for a lumbar spine disability. 7. Entitlement to service connection for a psychiatric disability, claimed as post-traumatic stress disorder (PTSD). 8. Entitlement to service connection for diverticulitis, to include as secondary to a psychiatric disability. 9. Entitlement to service connection for hypertension, to include as secondary to a psychiatric disability. 10. Whether new and material evidence has been submitted to reopen a claim for service connection for peripheral neuropathy of the right lower extremity, to include as secondary to herbicide exposure. 11. Whether new and material evidence has been submitted to reopen a claim for service connection for peripheral neuropathy of the left lower extremity, to include as secondary to herbicide exposure. 12. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to herbicide exposure, on a de novo basis. 13. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to herbicide exposure, on a de novo basis. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from January 1958 to March 1978. His awards and decorations include the Vietnam Service Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2007 rating decision of the Portland, Oregon, regional office (RO) of the Department of Veterans Affairs (VA). The Veteran's claims for service connection for peripheral neuropathy for the right lower extremity and left lower extremity have both been characterized on a de novo basis. As will be seen, service connection for each of these issues was previously denied in a final rating decision. A determination on whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider an underlying claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Therefore, regardless of the RO's action, the Board must initially address the question of whether new and material evidence has been presented to reopen the claim of service connection for peripheral neuropathy of the right and left lower extremities. 38 U.S.C.A. § 5108 (West 1991 & Supp. 2002); 38 C.F.R. § 3.156a (2013). Similarly, the Veteran's claim for service connection for a dental disability has to this point been developed only as a claim for compensation. 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). Accordingly, the Board has rephrased the issues as indicated on the title page. 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 issues of entitlement to service connection for a dental disability for purposes of eligibility for outpatient dental treatment; service connection for a lumbar spine disability; service connection for a psychiatric disability; service connection for diverticulitis; service connection for hypertension; service connection for peripheral neuropathy of the right lower extremity on a de novo basis, and; service connection for peripheral neuropathy of the left lower extremity on a de novo basis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The service treatment records are negative for evidence of a right leg fracture, and there is no current evidence of a disability due to the residuals of a right leg fracture. 2. The preponderance of the evidence is against a finding that the Veteran had tremors in service, and there is no competent medical opinion that relates the Veteran's current tremors to active service. 3. The Veteran's bilateral pes planus was noted upon entry into active service; there is no evidence that it was ever symptomatic or that there was an increase in disability during service. 4. The Veteran sustained a trauma to tooth #9 in January 1969 which resulted in the extraction of this tooth and replacement with a bridge; there is no evidence that the loss of this tooth was the result of loss of substance of the jaw. 5. Entitlement to service connection for peripheral neuropathy was denied in a June 2005 rating decision; the Veteran did not submit a notice of disagreement within one year of notification of this decision, and he did not submit additional evidence during this period. 6. Evidence received since June 2005 includes material not considered by the June 2005 decision makers, and which raises the possibility that the Veteran's peripheral neuropathy is related to exposure to Agent Orange during service. CONCLUSIONS OF LAW 1. A disability due to the residuals of a right leg fracture was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2013). 2. A disability manifested by tremors was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2013). 3. Pes Planus was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1111, 1131, 1151, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.303, 3.304(a), 3.306(a) (2013). 4. 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), 3.381, 4.150, 17.161 (2013). 5. The June 2005 rating decision that denied entitlement to service connection for peripheral neuropathy of the right and left lower extremities is final. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.105(a), 3.156(b) (2013). 6. New and material evidence has been submitted to reopen a claim for service connection for peripheral neuropathy of the right lower extremity, to include as secondary to herbicide exposure. 38 C.F.R. § 3.156(a) (2013). 7. New and material evidence has been submitted to reopen a claim for service connection for peripheral neuropathy of the left lower extremity, to include as secondary to herbicide exposure. 38 C.F.R. § 3.156(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA 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). The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must inform a claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. In this case, the Veteran was provided with a letter in September 2006 that contained all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini. This also included the notification required in requests to reopen claims on the basis of new and material evidence. Kent v. Nicholson, 20 Vet. App. 1, (2006). This letter was provided to the Veteran prior to the initial adjudication of his claims. 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 Veteran's service treatment records have been obtained. Private medical records and VA treatment records have been obtained. He was afforded a VA dental examination. The Veteran has not been afforded VA examinations of his claims for service connection for pes planus, a leg fracture, or trauma. The Board finds that an examination of these disabilities is not required. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. In this case, there is no evidence of a current disability due to a leg fracture, and the Veteran now denies having sustained such a fracture during service. Also, there is no competent medical evidence of a tremor during service or a link between the current tremor and active service. Therefore, both of these claims fail to meet even the low threshold for an examination. As for the claim for pes planus, it is based on the Veteran's contentions that his pre-existing pes planus was aggravated during service, and a current examination would be of no assistance in evaluating that claim. There is no indication that there is any relevant evidence outstanding in these claims. The Veteran has not identified any additional medical records to be obtained. The Board will proceed with consideration of the Veteran's appeal. Service Connection The Veteran contends that he currently has several disabilities as a result of active service. 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, 1131; 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. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic disabilities noted in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's claimed leg fracture, tremors, dental disability and pes planus are not included in 38 C.F.R. § 3.309. With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). But, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999), and a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as tinnitus, hand pain, and shortness of breath, the Veteran is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). 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). Right Leg Fracture In the Veteran's October 2006 claim, he contends that his right leg was in a cast for a fracture from October 1966 to December 1966. The service treatment records are completely negative for any evidence of a right leg fracture. The only broken bone shown to have been incurred in service was a fractured mandible, for which service connection has been established. A December 1966 physical examination conducted for the purpose of discharge and immediate reenlistment did not report a leg cast or note recent treatment for a leg fracture. The remaining records from 1966 are negative for a right leg fracture or case. However, the records do show that the injury that led to the development of the Veteran's service connected right disability was incurred in October 1967. This injury did not include a fracture of the knee. The Veteran did answer "yes" to a history of a broken bone on a September 1974 Report of Medical History. However, the only orthopedic history cited in the physician's summary was a meniscectomy of the right knee. The March 1978 retirement examination found that the lower extremities were normal. The post service medical records are completely negative for evidence of a fracture of the right leg. The Board finds that entitlement to service connection for the residuals of a fracture of the right leg is not warranted. The Veteran would be considered competent to report that he sustained a right leg fracture, as this is an injury that is observable and can be diagnosed by a layman. However, there is no evidence to confirm that the Veteran sustained a right leg fracture during service, and no evidence of a current disability that is the result of a right leg fracture. The only bone fracture treated in service was of the Veteran's left mandible. The service treatment records do not contain evidence of a right leg injury in October 1966 or on a December 1966 reenlistment examination. The evidence does show that the Veteran sustained an injury to the right knee in October 1967 for which service connection has been established, and it is possible that the Veteran is confusing the date and the nature of this injury. In fact, the Veteran denied having had a fracture in his February 2009 substantive appeal. Even if the Veteran were to submit evidence of a right leg fracture during service, there must still be evidence of a current disability before service connection can be established. The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131 (West 1991); see Degmetich v. Brown, 104 F.3d 1328 (1997); (Rabideau v Derwinski, 2 Vet. App. 141, 143 (1992). However, there is no such evidence in either the post service VA or private medical records. In view of the complete absence of evidence of a right leg fracture either during service or after service, entitlement to service connection for this disability is not established. Tremor The Veteran contends that he developed a tremor in his hands towards the end of his 20 years of active service. He states that he did not report this to the medical staff as he was afraid it would affect his retirement. The Veteran says that the tremor is uncontrollable. The service treatment records are negative for complaints or treatment pertaining to a tremor. Reports of Medical Examinations from the end of the Veteran's career dated July 1974 and April 1977 show that the neurologic examination was normal. The March 1978 retirement examination was also normal. A Report of Medical History dated at the time of retirement is not of record. The first post service medical evidence is an October 2004 Agent Orange Registry examination. The neurological examination states that a tremor was present. Private medical records dated May 2005 note a history of essential tremors. The initial medical evidence of tremors is found in VA treatment records dated January 2006. The record states that the Veteran has had tremors since approximately 1978. The diagnosis was benign tremors. A March 2007 VA treatment record states that the Veteran has had a tremor for 40 years. He said he had been to multiple neurologists over the years. The assessment was chronic tremor. In a June 2007 letter from G. H., he states that he has known the Veteran since 1965 when they were stationed at the same location. He reports that he did not see the Veteran after 1968 until his ship pulled into Hong Kong sometime between 1972 and 1976. At that time he noticed that the Veteran had developed health issues since their last meeting. These included "severe trembling". March 2011 VA treatment records state that the Veteran continued to have tremors which were treated with medication. The Board finds that the evidence does not support entitlement to service connection for tremors. The Veteran's contentions and the June 2007 statement from G.H. have been considered. The Veteran is competent to report that he had tremors, and G.H. is competent to observe what he describes as "severe trembling". Unfortunately, their credibility as to when this condition began is questionable. The Veteran states that he did not report this condition on his medical examinations for fear of being forced out of the service early and missing out on retirement. However, the Reports of Medical Examinations completed in July 1974, April 1977, and March 1978 were completed by the doctor and not the Veteran. The Board observes that if the Veteran suffered from uncontrollable "severe trembling" that was visible to a layman at that time, then these tremors would have surely been noticed by a medical professional during the course of a physical examination. Moreover, the March 1978 examination was performed at the time of the Veteran's retirement, at which time there would no longer be any purpose in concealing this affliction. The Board must find that the preponderance of the evidence is against a finding that the Veteran had tremors during active service. The initial post service evidence of tremors is the October 2004 examination, which was conducted 26 years after the Veteran's retirement from service. Although the March 2007 VA treatment record gives a 40 year history of tremors, this is not consistent with the medical record for the reasons that have just been noted. There is no competent medical opinion that relates the Veteran's current tremors to active service. In the absence of a finding of tremors in service or a relationship between the current tremors and service, entitlement to service connection is not warranted. Pes Planus The Veteran contends that his pes planus was aggravated during service. The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). In this case, the January 1958 entrance examination noted that the Veteran had bilateral third degree pes planus. This disability was asymptomatic and not considered disqualifying. As bilateral pes planus was noted upon entry into active service, the Veteran is not entitled to the presumption of soundness for this disability. The Veteran's other service treatment records include a December 1966 Report of Medical Examination. This report states that the Veteran had mild bilateral pes planus, which was asymptomatic. A September 1972 Report of Medical Examination also notes the Veteran's pes planus, and says it is not considered disqualifying. Bilateral pes planus was also noted on a July 1974 Report of Medical Examination. The Veteran answered "yes" to a history of foot trouble on Reports of Medical History obtained in 1968 and September 1974. There was no further elaboration on either history. The Veteran's remaining service treatment records show that he was seen for many illnesses and injuries during his 20 years of service. They do not show that he was ever seen even once for complaints pertaining to pes planus. The Veteran's pes planus was not recorded on the report of the March 1978 discharge examination. The Board finds that entitlement to service connection for pes planus due to aggravation is not warranted. The pertinent laws and regulations state that a preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.306(a). In this case, there is no evidence whatsoever that there was an increase in disability of the Veteran's pes planus. It was not shown to have been symptomatic even once during 20 years of service, and it was never described as other than mild or asymptomatic on examination reports. The preponderance of the evidence is against a finding that there was any increase in disability during service. As no increase in disability during service has been demonstrated, then pes planus may not be presumed to have been aggravated, and service connection is not established. Compensation for Dental Disability The Veteran contends that he sustained a dental disability due to a trauma in service. He states that the trauma occurred in a jeep accident in Vietnam in 1968. 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. Thus, 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. "Periodontal" is defined as "around a tooth." Stedman's Medical Dictionary 1330 (26th Ed.). "Gingivitis" is defined as inflammation of the gingiva, which is the tissue surrounding the teeth. Stedman's at 717. Gingivitis is, therefore, a periodontal disease. In accordance with 38 C.F.R. § 3.381, as a matter of law periodontal disease is not a disability for which service connection can be granted for the purpose of VA disability. 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). The Veteran's service treatment and dental records show that the Veteran was hit in the face with a club while on liberty in November 1959, which resulted in a fracture of the mandible. The mandibular incisors were mobile. It was decided to leave the teeth in question in the mouth, with periodic follow-up to determine their eventual prognosis. Dental records show that the Veteran was seen approximately one month later in December 1959. These records do not show any treatment for trauma, but do show that the Veteran had fillings placed in teeth #5, 10, 2, 13, 14, and 31. There is no indication of any further dental treatment that might be related to the November 1959 injury. At this point the Board notes that service connection for fracture of the left mandible with loss of left temporomandibular condyle has already been established. These records also show that the Veteran was seen in January 1969 following a traumatic blow to the tooth #9, which resulted in a vertical right fracture. The fracture prevented crowning, so the tooth was extracted. He was fitted with a ceramic bridge over #8 and #10 in April 1969. The bridge was apparently recemented in November 1970. The remainder of the Veteran's service treatment records show only routine dental treatment subsequent to the January 1968 trauma. Post service medical records include a December 2006 VA dental examination of the Veteran. His service treatment records were reviewed by the examiner. The Veteran reported being hit in the face by a board in 1959, which resulted in a fracture of the lower jaw in two places. He was hit in the face by the butt of a rifle by accident in January 1969, which knocked out tooth #9. On examination, he was missing teeth #3, 9, 14, 18, and 30. The bridge at #8 to 10 was noted, and the spaces were closed where he was missing his other teeth. The remaining teeth were in good repair, and the Veteran's oral hygiene was good. The Veteran had mild horizontal bone loss consistent with mild periodontal disease, which was common for his age. An X-ray study showed complete loss of the head of the left condyle, and the joint was articulating on the neck of the condyle. The diagnoses included loss of tooth #9 from trauma while in service, which was replaced with a fixed bridge that was functioning well. The Board finds that service connection for a dental disability is not warranted. The record clearly establishes that the Veteran lost #9 due to a trauma, which was confirmed at the October 2006 VA dental examination. However, this in and of itself is not considered to be a disability for the purposes of compensation. As noted, service connection for compensation purposes is available only due to the loss of teeth due to loss of substance of the upper or lower jaw. 38 C.F.R. § 4.150. In this case, there is no evidence that the trauma led to loss of substance that caused the loss of #9. Instead, the evidence shows that the tooth was removed because it was fractured in the initial trauma. There is no evidence of osteomyelitis or osteoradionecrosis, or loss, malunion, or limited motion of the maxilla, ramus, condyloid process, or hard palate at the time the tooth was extracted. Service connection has already been established for the injury to the mandible. As there is no evidence that the loss of tooth #9 or any other tooth was the result of loss of substance of the upper or lower jaw, service connection for compensation purposes is not warranted. 38 C.F.R. § 4.150. New and Material Evidence for Peripheral Neuropathy The Veteran contends that he has developed peripheral neuropathy due to either herbicide exposure during service or secondary to his service connected right knee disability. He believes that he has submitted new and material evidence to reopen a previously denied claim for this disability. The record shows that the Veteran served in Vietnam. A veteran who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307. If a veteran was exposed to an herbicide agent during active military, naval, or air service, there are certain diseases that shall be service-connected even though there is no record of such disease during service. Until very recently these diseases included acute and subacute peripheral neuropathy. 38 C.F.R. § 3.309(e) (2013). This regulation has now been changed to read "early-onset peripheral neuropathy". A requirement that the neuropathy become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent remains unchanged. Disease Associated With Exposure to Certain Herbicide Agents: Peripheral Neuropathy, 78 Fed. Reg. 54763, 54766 (September 6, 2013) (to be at 38 C.F.R. § 3.309(e)). Notwithstanding the foregoing presumption provisions, the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). Entitlement to service connection for peripheral neuropathy was denied in a June 2005 rating decision. The Veteran was notified of this decision and provided with his appellate rights in a letter dated June 23, 2005. Although the Veteran submitted a notice of disagreement signed on June 23, 2006, it was not received by either his representative or the RO until June 30, 2006. As he did not submit a notice of disagreement within one year of receipt of the letter, and as no additional evidence was received during this time period, the June 2005 decision is final, and is not subject to revision on the same factual basis. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.105(a), 3.156(b). A veteran may reopen a finally adjudicated claim by submitting new and material evidence. New evidence is defined as existing evidence not previously submitted to the VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The June 2005 rating decision considered the Veteran's service treatment records, as well as the findings of an October 2004 VA Agent Orange Registry Exam. This decision found that service connection could not be established since the neuropathy did not first become manifest to a compensable degree within one year after last exposure to herbicides. The evidence received since June 2005 includes private medical records from the Harvard Medical Group dated May 2005. These records note that the Veteran carries a diagnosis of peripheral neuropathy, "presumably related to Agent Orange exposure". Following the examination, the assessment noted regarding the peripheral neuropathy, "Whether this "represents exposure to Agent Orange or not is unclear". The Board finds that the June 2005 private medical records represent evidence that is both new and material. It is new in that it contains information that was not previously before the June 2005 decision maker. It is material in that a competent medical professional raises the possibility that the Veteran's peripheral neuropathy is related to herbicide exposure. Although there is still no evidence that the peripheral neuropathy began within one year of the Veteran's final exposure to herbicides, this evidence still raises the reasonable possibility of proof of direct causation under Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran's claims for service connection for peripheral neuropathy for his right and left lower extremities are reopened. These issues will be addressed on a de novo basis in the remand section at the end of this decision. ORDER Entitlement to service connection for the residuals of a right leg fracture is denied. Entitlement to service connection for tremors is denied. Entitlement to service connection for pes planus is denied. Entitlement to service connection for a dental disability for compensation purposes is denied. New and material evidence has been submitted to reopen a claim for service connection for peripheral neuropathy of the right lower extremity, to include as secondary to herbicide exposure; to this extent only the claim is allowed. New and material evidence has been submitted to reopen a claim for service connection for peripheral neuropathy of the left lower extremity, to include as secondary to herbicide exposure; to this extent only the claim is allowed. REMAND The Veteran contends that he has developed a low back disability due to active service. He argues that his current back disability is related to episodes for which he was treated during active service. The evidence includes a March 2007 VA treatment record that contains an assessment of low back pain. The examiner adds that this is caused by right knee pain. There is no indication if this statement is a medical opinion or a record of a contention of the Veteran. If it is a medical opinion, there is no discussion in the examination of a relationship between the back and knee, or any reasons and bases to support the opinion. Entitlement to service connection for a right knee disability has previously been established. Therefore, the March 2007 VA treatment record raises the issue of entitlement to service connection for a low back disability as secondary to the service connected right knee disability. As the Veteran has not been afforded a VA examination of the back that fully addresses this theory of entitlement, he must be scheduled for such an examination. The Veteran's claims for service connection for peripheral neuropathy of the right lower extremity and left lower extremity have now been reopened. Further development is required in these matters for several reasons. First, an April 2009 VA treatment record contains a diagnosis of degenerative disc disease. This raises the possibility that the Veteran's peripheral neuropathy is related to his low back disability. The VA has a duty to address all issues raised during the course of an appeal. Martin v. Derwinski, 1 Vet. App. 411, 413 (1991). In addition, issues which are inextricably intertwined must be considered together. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The Veteran's claim for service connection for a low back disability has not been resolved, and as there is a possibility that the peripheral neuropathy related to the back disability, these claims must be held in abeyance until the claim for service connection for the back disability has been resolved. Similarly, an April 2009 VA treatment record includes an assessment of right mechanical piriformis syndrome that is most likely caused by or the result of gait compensation for the Veteran's service connected right knee degenerative joint disease. The Board observes that piriformis syndrome is a neuromuscular disorder that occurs when the sciatic nerve is compressed or otherwise irritated by the piriformis muscle causing pain, tingling and numbness in the buttocks and along the path of the sciatic nerve descending down the lower thigh and into the leg. This raises the possibility that the Veteran's peripheral neuropathy of the right lower extremity is secondary to the service connected right knee disability. The June 2012 VA examination did not note the piriformis syndrome or otherwise discuss a possible relationship between it and peripheral neuropathy. This must be further addressed. Finally, the Veteran's May 2005 private medical examination notes that the Veteran carries a diagnosis of peripheral neuropathy, "presumably related to Agent Orange exposure". Following the examination, the assessment noted regarding the peripheral neuropathy, "Whether this "represents exposure to Agent Orange or not is unclear". As these statements are equivocal, they do not provide a basis for a favorable determination. However, they at least raise the possibility of service connection for peripheral neuropathy due to Agent Orange on a direct basis. The June 2012 VA examination did not provide an opinion as to such a possibility. Furthermore, the RO has not had an opportunity to consider the recent changes to service connection for peripheral neuropathy on a presumptive basis. See Disease Associated With Exposure to Certain Herbicide Agents: Peripheral Neuropathy, 78 Fed. Reg. 54763, 54766 (September 6, 2013) (to be at 38 C.F.R. § 3.309(e)). As for the Veteran's claim for service connection for a psychiatric disability, an April 2009 VA examination contains an opinion that the Veteran's current psychiatric disability is depression, and further opined that this depression is due to peripheral neuropathy. The claim for service connection for depression is therefore inextricably intertwined with service connection for peripheral neuropathy, and as the claim for service connection for peripheral neuropathy has not been resolved, the claim for service connection for a psychiatric disability should be held in abeyance. Similarly, the Veteran contends that both his hypertension and diverticulitis were caused by his psychiatric disability. The Board notes that even if the Veteran's psychiatric disability was not the initial cause of these disorders; secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). These matters are also inextricably intertwined and should be held in abeyance until the claim for service connection for a psychiatric disability is resolved. As noted in the introduction, the Veteran's claim for service connection for a dental disability for compensation is also considered to be a claim for service connection for a dental disability for purposes of eligibility for outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306 (1993). This issue has not yet been considered by the RO, and must first be addressed by them in order to protect the Veteran's rights. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination of his low back disability. The claims folder must be made available to the examiner for use in the study of this case, and the examination report must reflect that it has been reviewed. All indicated tests and studies should be completed. At the completion of the examination and record review, the examiner should attempt to express the following opinions: A) Does the Veteran have a diagnosis or diagnoses of a low back disability? If so, what are these diagnoses? If not, please address the March 2007 VA treatment record of low back pain and the April 2009 VA X-ray report of degenerative disc disease and explain why these findings did not represent a chronic disability. B) For all current diagnoses regarding the low back, the examiner should attempt address: i) Is it as likely as not that the low back disability was incurred due to instances during active service? ii) Is it as likely as not that the low back disability was incurred or aggravated (increased in severity beyond natural progression) by the Veteran's service connected right knee disability? The reasons and bases for all requested opinions must be provided. If the examiner is unable to provide any of the requested opinions without resort to speculation, the reasons and bases for this opinion should be noted, and any evidence that might enable the examiner to provide the requested opinion should be identified. 2. Schedule the Veteran for an additional VA examination of his peripheral neuropathy. The claims folder must be made available to the examiner for use in the study of this case, and the examination report must reflect that it has been reviewed. All indicated tests and studies should be completed. At the completion of the examination and record review, the examiner should attempt to express the following opinions: A) Is it as likely as not that the Veteran's peripheral neuropathy of the lower extremities was incurred due to herbicide exposure during active service? B) Is it as likely as not that the Veteran's peripheral neuropathy of the lower extremities was incurred due to his low back disability? C) Is it as likely as not that the Veteran's peripheral neuropathy of the right lower extremity was incurred due to piriformis syndrome? If so, is it as likely as not that the piriformis syndrome was incurred due to the Veteran's service connected right knee disability? The reasons and bases for all requested opinions must be provided. If the examiner is unable to provide any of the requested opinions without resort to speculation, the reasons and bases for this opinion should be noted, and any evidence that might enable the examiner to provide the requested opinion should be identified. 3. After the completion of the development requested above, the claims for service connection for a low back disability and peripheral neuropathy should be readjudicated. 4. After the claims for service connection for a low back disability and peripheral neuropathy have been fully developed and readjudicated, then, and only then, should the claims for service connection for a psychiatric disability, hypertension and diverticulitis should be readjudicated. Any further development suggested as a result of the additional evidence that is obtained should be conducted, to include if necessary additional VA examinations for one or more of these disabilities. 5. Adjudicate the claim for service connection for a dental disability for purposes of eligibility for outpatient dental treatment. The Veteran should be provided notice of any unfavorable outcome, which should include his appellate rights. This matter should be returned to the Board if, and only if, there is a timely notice of disagreement followed by a timely substantive appeal. 6. After the development requested above has been completed to the extent possible, review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the Veteran and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THOMAS H. O'SHAY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs