Citation Nr: 1337680 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 10-11 183 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for service-connected temporomandibular joint dysfunction (TMJD) with bone resorption prior to August 25, 2008, and in excess of 50 percent thereafter. 2. Entitlement to a disability rating in excess of 20 percent for service-connected cervical strain. 3. Entitlement to a disability rating in excess of 20 percent for service-connected lumbosacral strain. 4. Entitlement to service connection for a left shoulder disorder. 5. Entitlement to an initial disability rating in excess of 30 percent for service-connected hypertensive cardiovascular disease with cardiac arrhythmias. 6. Entitlement to an effective date prior to September 28, 2007, for the grant of service connection for TMJD with bone resorption. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had active military service from September 1959 to October 1963. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in June 2008 and September 2011 by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. The Board notes that the procedural history of the Veteran's appeal and the procedural posture is quite long and complicated. Consequently, the Board has moved such discussion to the reasons and bases section of this decision rather than putting it here in this introduction section. The Veteran appeared and testified at a Board video conference hearing before the undersigned Veterans Law Judge in April 2013. A copy of the transcript of this hearing has been associated with the claims file. A review of the transcript demonstrates that the Veterans Law Judge complied with the requirements set forth in Bryant v. Shinseki, 23 Vet. App. 488, 491-93 (2010). The issue of entitlement to service connection for headaches and earaches as secondary to service-connected TMJD with bone resorption has been raised by the medical evidence of record (see December 2010 VA examination reports). In addition, although the Veteran's VA Form 9 filed in July 2012 as to the denial of service connection for an eye disorder as secondary to service-connected TMJD with bone resorption was found to be untimely (as discussed in more detail in the Procedural Background section below), the Board finds that it can be construed as an informal claim to reopen the previous final denial of that claim. Consequently, the Board finds that the above issues have been raised by the record but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of an increased disability rating for service-connected hypertensive cardiovascular disease with cardiac arrhythmias, an earlier effective date for the grant of service connection for TMJD with bone resorption, and service connection for a left shoulder disorder 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. Resolving reasonable doubt in the Veteran's favor, the Veteran's TMJD was productive of bone resorption of the left lower mandibular area at the time he filed his claim for service connection on September 28, 2007. 2. The Veteran's TMJD with bone resorption has not been productive of complete loss of the mandible between angles. 3. The Veteran's other claimed symptoms of blurred vision and left shoulder pain are not productive of marked interference with employment or frequent hospitalizations. Furthermore, VA has already provided compensation based on recognition that the Veteran's TMJD with bone resorption and the problems associated therewith have caused interference with employment as a TDIU was awarded effective August 25, 2008. 4. The Veteran's cervical strain is not productive of limitation of forward flexion to 15 degrees or less or ankylosis of the cervical spine; nor is it productive of an exceptional disability picture. 5. The Veteran's lumbosacral strain is not productive of forward flexion limited to 30 degrees or less, or ankylosis of the thoracolumbar spine; nor is it productive of an exceptional disability picture. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 50 percent, but no higher, for service-connected TMJD with bone resorption are met effective September 28, 2007. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7 and 4.150, Diagnostic Code 9905-9902 (2013). 2. The criteria for a disability rating in excess of 20 percent for service-connected cervical strain are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5237 (2013). 3. The criteria for a disability rating in excess of 20 percent for service-connected lumbosacral strain are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5237 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Background The Veteran served on active duty from September 1959 to October 1963. Service records show the Veteran was seen for repeated back complaints, shown as back strain and myositis, although no back complaints were seen after September 1961. He was initially denied service connection for a back condition in the July 1964 rating decision; however, his claim was revisited in a March 1965 rating decision and service connection was established for a lumbosacral strain evaluated as noncompensable effective October 23, 1963. In a May 1965 rating decision, service connection was also granted for cervical strain evaluated as noncompensable effective October 23, 1963. In a March 1998 rating decision, the RO granted increased disability ratings for the Veteran's lumbosacral and cervical strains to 20 percent each effective July 9, 1997. In June 1998, the RO denied a claim for service connection for TMJD as not well grounded because the Veteran failed to respond to a duty to assist letter asking him to submit medical evidence pertaining to treatment he received. Consequently, there was no evidence showing any relationship between his TMJD and any disease or injury during military service. In September 2007, the Veteran filed a new claim seeking service connection for TMJD. He also claimed that his TMJD due to the loss of 11 teeth in service led to his back condition not properly healing and him experiencing constant pain not only in his back but also his neck, jaw and shoulders. The RO took this statement as claims for increased disability ratings for his already service-connected lumbosacral and cervical strains, as well as a claim for service connection for a "shoulder condition." In the June 2008 rating decision on appeal, the RO granted service connection for TJMD and evaluated it as 30 percent disabling effective September 28, 2007. In addition, the RO denied service connection for a shoulder condition and increased disability ratings for service-connected lumbosacral strain and cervical strain in excess of 20 percent. In a July 2008 statement, the Veteran expressed disagreement with the effective date assigned for the grant of service connection for TMJD. In an October 2010 statement, the Veteran further disagreed with the initial disability rating assigned for his now service-connected TMJD claiming his bone loss was not considered, as well as the denials of increased disability ratings for his service-connected lumbosacral and cervical strains and service connection for a shoulder condition. In the November 2009 Statement of the Case, the RO granted a 50 percent disability rating for TMJD with bone resorption effective August 25, 2008, thereby creating a staged rating for this disability. The issue on the Title page has been characterized to show this staging of the Veteran's rating. In addition, with regard to his claim of bone loss, in a November 2009 rating decision, the RO granted separate service connection for bone resorption on maxillary arch, which was initially evaluated as noncompensable, effective August 25, 2008. In an April 2010 rating decision, however, the RO granted a 30 percent disability rating for bone resorption on maxillary arch effective August 25, 2008. The Board notes that the Veteran did not appeal either of those rating decision and, therefore, they are final. Consequently, there is no appeal as to that issue presently before the Board. As to the Veteran's appeal for an earlier effective date for the grant of service connection for TMJD set forth in the July 2008 statement, in an April 2010 rating decision, the RO denied an effective date earlier than September 28, 2007, for the grant of service connection for TMJD. The Board finds, however, since this issue was raised on appeal from an original grant of service connection for TMJD, a Statement of the Case should have been issued but was not. Thus, this issue has been added as on appeal and will be handled in the Remand section of this decision. In addition, in a rating decision issued in February 2013, service connection was granted for right shoulder osteoarthritis as secondary to lumbar and cervical spine disabilities. Although the RO stated in the rating decision that this was a full grant of this issue on appeal, the Board disagrees for the reasons set forth in more detail in the Remand section of this decision. The Board finds that service connection for left shoulder disorder is still on appeal and, consequently, this issue has been added on the Title page to reflect this. Furthermore, during the pendency of the Veteran's appeal on the above issue, the Board notes that he filed additional multiple claims for service connection for conditions he claimed as secondary to his now service-connected TMJD. In a July 2008 statement, the Veteran claimed secondary service connection for numbness, pain and cramps in both his legs and feet as due to his service-connected TMJD and back disabilities. This claim (characterized by the RO as one for peripheral neuropathy of the bilateral lower extremities) was initially denied in an October 2008 rating decision and again in a May 2010 rating decision. In September 2010, the Veteran filed a Notice of Disagreement. In a July 2011 rating decision, however, the RO granted service connection for chronic lumbar radiculopathy of the bilateral lower extremities (claimed as numbness, pain and cramps and previously characterized as peripheral neuropathy), effective July 10, 2008, and evaluated each lower extremity as 10 percent disabling. The Veteran filed a Notice of Disagreement as to the effective date assigned. In December 2011, the RO issued a Statement of the Case; however, the Veteran did not file a timely substantive appeal. Therefore the RO's decision as to the effective date is final. Consequently, there is no appeal as to that issue presently before the Board. In addition, in a July 2008 statement, the Veteran raised the issue of having vision problems related to his TMJD. Service connection for his vision problems was denied in an April 2010 rating decision. The Veteran disagreed with this decision in a September 2010 Notice of Disagreement. In July 2011, the RO issued a Statement of the Case on this issue. In October 2011, the Veteran submitted a statement regarding his disagreement with the continued denial of service connection for vision problems as secondary to his service-connected TMJD. In addition, in July 2012, the Veteran submitted a VA Form 9 continuing disagreement with the denial of service connection for his vision problems. In a letter sent in February 2013, the Veteran was notified that his substantive appeal was untimely as he had 60 days from the date the Statement of the Case was issued, which was on July 12, 2011, to complete his appeal. The Board notes that neither the October 2011 statement that could be considered a substantive appeal nor the VA Form 9 filed in July 2012 were timely to perfect his appeal. Consequently, the Board finds that this issue is not on appeal. The Board further notes that, in May 2010, the Veteran filed a claim for entitlement to a total disability rating due to individual unemployability due to service-connected disabilities (TDIU), which also raised a claim for higher disability ratings for service-connected disabilities not already on appeal. In an August 2010 rating decision, the RO initially denied the Veteran's claim for a TDIU; however, in a February 2011 rating decision, it granted entitlement to a TDIU effective May 25, 2010. In a July 2011, the RO granted an earlier effective date of February 2, 2010 for the grant of TDIU. In September 2011, the Veteran filed a Notice of Disagreement as to the effective date arguing that it should be taken back to August 25, 2008. In a December 2011 rating decision, the RO granted an effective date of August 25, 2008, for the award of a TDIU thereby providing the full benefit sought by the Veteran. Consequently, the Board finds that this issue is no longer on appeal. In April 2009, the Veteran claimed service connection for obstructive sleep apnea as secondary to his service-connected TMJD. In the April 2010 rating decision, the RO granted service connection for obstructive sleep apnea effective April 2, 2009, and evaluated it as 30 percent disabling. The Veteran did not appeal that decision. Based on the Veteran's claim for a TDIU filed in May 2010, the RO adjudicated a claim for an increased disability rating for the Veteran's obstructive sleep apnea in a February 2011 rating decision and granted a 50 percent disability rating effective May 25, 2010. Again the Veteran did not disagree with this decision. Consequently, the Board finds that there is no issue relating to the Veteran's service-connected obstructive sleep apnea on appeal. In March 2011, the Veteran filed a claim for service connection for cardiovascular disability secondary to his service-connected obstructive sleep apnea. By rating decision issued in July 2011, service connection was awarded for hypertensive cardiovascular disease with cardiac arrhythmias, effective April 18, 2011, and evaluated as 30 percent disabling. In an October 2011 statement, the Veteran disagreed with both the 30 percent disability rating assigned and the effective date assigned. The RO issued a Statement of the Case in December 2011 as to the appeal for an earlier effective date for the grant of service connection for hypertensive cardiovascular disease with cardiac arrhythmias. The Veteran, however, failed to file a timely substantive appeal. Consequently, the Board finds that this issue is no longer on appeal to the Board. However, the RO failed to issue a Statement of the Case as to the appeal of the assignment of a 30 percent disability rating. Consequently, the Board finds that this issue is on appeal and has been added to the issues on the title page and will be discussed in more detail in the Remand portion of this decision. In September 2012, the Veteran filed a claim for special monthly compensation based upon the need for aid and attendance. In September 2012, the RO denied special monthly compensation based upon the need for aid and attendance, being permanently bed ridden or being housebound (to include the fact that the Veteran did not have a single 100 percent rated disability with additional disabilities combined to 60 percent). The Veteran did not disagree with this decision. Consequently, the Board finds that this issue is not on appeal. Finally, although the Veteran was in receipt of a TDIU starting August 25, 2008, the Board notes that, because of the above noted grants of service connection, the Veteran's combined rating reached a schedular 100 percent effective May 7, 2010. Consequently, the Veteran has been rated as totally disabled since August 25, 2008 whether due to entitlement to a TDIU or because of having a schedular 100 percent disability rating. II. Notice and Assistance Requirements VA's duties to notify and assist claimants in substantiating a claim for VA benefits are described in 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and notify the claimant and his or her representative, if any, of what information and evidence not already provided, if any, is necessary to substantiate, or will assist in substantiating, each of the five elements of the claim including notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Sufficient notice must inform the claimant (1) of any information and evidence not of record that is necessary to substantiate the claim; (2) of the information and evidence that VA will seek to provide; and (3) of the information and evidence that the claimant is expected to provide. Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). For a claim seeking increased compensation for an already service-connected disability, 38 U.S.C.A. § 5103(a) requires, at a minimum, that VA notify the claimant that he/she must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment in order to substantiate the claim. Vazquez-Flores, 22 Vet. App. 37 (2008). VA must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation. Id. It is noted that, on September 4, 2009, the Federal Circuit vacated and remanded Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), and Schultz v. Peake, No. 03-1235, 2008 WL 2129773, at 5 (Vet. App. Mar. 7, 2008). Specifically, the Federal Circuit concluded that "the notice described in 38 U.S.C. § 5103(a) need not be veteran specific." In addition, the Federal Circuit determined that "while a veteran's 'daily life' evidence might in some cases lead to evidence of impairment in earning capacity, the statutory scheme does not require such evidence for proper claim adjudication." Thus, the Federal Circuit held, "insofar as the notice described by the Veterans Court in Vazquez-Flores requires the VA to notify a veteran of alternative diagnostic codes or potential 'daily life' evidence, we vacate the judgments." In this case, notice was sent to the Veteran in October 2007, prior to the initial adjudication of his claims, that informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. He was also advised that should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life, and on what evidence and/or information is necessary to establish entitlement to an effective date should benefits be granted. Id., see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board acknowledges that the notice letter sent to the Veteran in October 2007 does not fully meet the requirements set forth in Vazquez-Flores and is not sufficient as to content and timing. However, content-compliant notice was provided to the Veteran in March 2009, and his claims were subsequently adjudicated in November 2009. Thus, the Board finds that any deficiency as to timing has been cured. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (defects in timing of notice may be cured by affording the Veteran appropriate notice and subsequent adjudication). The Board may therefore proceed to adjudicate the Veteran's claim without prejudice to him. Furthermore, with regard to the claim for an increased disability rating for service-connected TMJD with bone resorption, the Board notes that the Veteran's claim was originally one for service connection for this disability, which was granted in the June 2008 rating decision and evaluated initially as 30 percent disabling effective September 28, 2007 (the date the Veteran's claim for service connection was filed). Thereafter, the Veteran disagreed with the 30 percent evaluation of this now service-connected disability. Consequently, since the Veteran's claim was initially one for service connection, which has been granted, the Board finds that VA's obligation to notify him was met as the claim for service connection was obviously substantiated. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Therefore, any deficiency in either the timing or content of the March 2009 notice relating to the Veteran's appeal for an increased rating for his service-connected TMJD with bone resorption is not prejudicial to him. With respect to VA's duty to assist, VA is only required to make reasonable efforts to obtain relevant records that the Veteran has adequately identified to VA. 38 U.S.C.A. § 5103A(b)(1). All efforts have been made to obtain relevant, identified and available evidence. The duty to assist includes providing the Veteran a thorough and contemporaneous examination. Green v. Derwinski, 1 Vet. App. 121 (1991). The Veteran was afforded VA examinations in October 2007, June 2008, September 2009, and December 2010. In addition, an independent medical opinion relating to the Veteran's TMJD and bone loss was obtained in March 2010. Significantly, the Board observes that he does not report that the conditions have worsened since he was last examined, and thus a remand is not required solely due to the passage of time. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Furthermore, despite the Veteran's complaints about the VA examinations conducted relating to his service-connected TMJD with born absorption, the Board notes that the examination reports reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate physical examinations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran. Additional efforts to assist or notify him would serve no useful purpose. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. III. Analysis Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2. It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor, 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board acknowledges that the United States Court of Appeals for Veterans Claims (Court) has held that lay testimony is competent regarding features or symptoms of injury or disease when the features or symptoms are within the personal knowledge and observations of the witness. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Furthermore, lay evidence is considered competent and sufficient to establish a diagnosis of a condition when 1) a lay person is competent to identify the medical condition; 2) the lay person is reporting a contemporaneous medical diagnosis; or 3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). TMJD with Bone Resorption On September 28, 2007, the Veteran filed a claim for service connection for his "teeth condition/misaligned teeth or temporomandibular joint dysfunction (TMJ)." Since the Veteran was previously denied service connection for TMJ in a final June 1998 rating decision, the RO appropriately treated the Veteran's claim as a claim to reopen. In a June 2008 rating decision, the RO reopened the Veteran's claim and granted service connection for TMJD effective the date the Veteran's claim was received. It evaluated this now service-connected disability as 30 percent disabling under Diagnostic Code 9905, which evaluates temporomandibular articulation, limited motion of the inter-incisal range. This rating was based upon the findings on VA examination in June 2008 that the Veteran's had limitation of the inter-incisal range to 15mm. In an October 2008 Notice of Disagreement, the Veteran expressed disagreement with the assignment of 30 percent as the initial disability rating for his TMJD stating that, by the VA's own dentist's examination on August 25, 2008, there is considerable bone loss. In the Statement of the Case issued in November 2008, the RO granted a 50 percent disability rating for TJMD with bone resorption under Diagnostic Code 9902 for loss of approximately one-half of the mandible involving temporomandibular articulation effective August 25, 2008, the date of the Veteran's treating physician's records showing he had bone resorption of the lower jaw. The Veteran has continued to disagree with the evaluation of his TMJD with bone resorption. It appears that he essentially claims that his TMJD should be evaluated as 100 percent disabling because it has affected multiple bodily systems, which should all be considered as a whole. The rating criteria under Diagnostic Code 9905, for limited motion of the temporomandibular articulation, provides that inter-incisal range limited from 31 to 40 mm warrants a 10 percent rating; from 21 to 30 mm warrants a 20 percent rating; from 11 to 20 mm warrants a 30 percent rating; and from 0 to 10 mm warrants a 40 percent rating. 38 C.F.R. § 4.150. Range of lateral excursion limited to 0 to 4 mm is assigned a 10 percent rating. Id, Diagnostic Code 9905. Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. Id., Note to Diagnostic Code 9905. Under Diagnostic Code 9902, loss of approximately one-half of the mandible involving temporomandibular articulation is rated as 50 percent disabling. It is rated as 30 percent disabling if it does not involve the temporomandibular articulation. 38 C.F.R. § 4.150. Further, under Diagnostic Code 9901, complete loss of the mandible, between angles, warrants a 100 percent disability rating. Diagnostic Code 9900 applies when there is osteomyelitis or osteoradionecrosis of either the maxilla or mandible and directs the rater to rate as osteomyelitis, chronic, under Diagnostic Code 5000. In the present case, the Board notes that, on VA examination in June 2008 and December 2010, the examiner noted that there was no bone loss of the mandible, although, in the December 2010 VA examination report, the examiner also noted X-rays and other studies that show severe or advanced bone loss/resorption of the lower mandibular left quadrant, as well as stating that there is tooth loss due to loss of substance of the mandible. This evidence is directly against the statements and treatment records of the Veteran's private TMJD specialist. Consequently, the Board finds the more probative and persuasive evidence as to whether the Veteran has bone loss/resorption of the mandible and its severity is the records from the Veteran's treating private TMJD specialist. However, as to the extent of the limitation of the inter-incisal range, the Board notes that the treating private dentist's records do not relate any range of motion measurements but the VA examination reports do; thus, the VA examinations are the more probative and persuasive evidence as to the limitation of the temporomandibular articulation. In support of his claim, the Veteran submitted a statement from one of his private treating physicians dated in January 2008 in which she sets forth a detailed account of the Veteran's history, which will not be reiterated here as it is extensive. Significantly, however, she indicates the Veteran was diagnosed to have TMJD in December 1994 and was referred to a specialist who provided the Veteran with a mandibular orthopedic repositioning appliance (MORA) or plastic Gelb splint (hereafter "splint") in order to elevate the Veteran's bite to the proper vertical height. Upon wearing the splint, the Veteran reported immediate relief to his whole body. She also indicated that she was performing reconstruction of the Veteran's bridges and crowns to correct and maintain his vertical jaw dimension. Treatment records dated August 25, 2008, from the Veteran's TMJD specialist (to whom he was sent by VA on a fee basis) shows a diagnosis of advanced bone resorption of the upper arch/maxilla and lower left jaw bone. Upper full denture is Loose, thick and heavy due to numerous relines and adjustments for the past years. Lower left partial denture is 3 mm lower than the 10 units bridge work due to bone loss. She also diagnosed him to have lower periodontal disease on the anterior and posterior 10 units bridge work, with the gums easily bleeding and flabby and a periodontal pocket of 5 to 7 mm. In July 2009, the Veteran's treating TMJD specialist submitted a statement entitled "Case History." Significantly in this statement she sets forth the results of multiple X-rays and studies involving the Veteran's jaw. According to her statement, a panoramic X-ray showed advanced bone loss on the lower mandibular left quadrant and severe bone loss underneath 10 units bridge work with infection; a cephlometric X-ray showed jaw imbalance and retruded mandible causing obstruction of the airway; a transcranial X-ray showed right and left condyle head of the TMJ is superiorly displaced; and a study case showed advanced upper right maxillary arch and lower left mandibular arch bone resorption. The Board notes that the dates of these studies are not noted but, as they are consistent with the findings shown in the August 25, 2008 treatment notes, they must have been conducted prior to that date. In considering this evidence, the Board considers that the evidence shows the Veteran's bone loss/resorption is either severe or advanced and that the studies showing these findings were likely conducted prior to the August 25, 2008 treatment record, which is the basis of the effective date of the current 50 percent disability rating. Given the long history of dental and TMJD problems the Veteran has as set forth in the January 2008 private dentist's statement, the severity of his bone loss/resorption as shown by the diagnostic studies and the August 2008 treatment note and the fact that this evidence is less than one year after the Veteran submitted his claim for service connection, the Board finds that it is most likely that the Veteran's bone loss of the mandible was present at the time he filed his claim on September 28, 2007. Although the exact severity cannot be determined, the Board resolves reasonable doubt in the Veteran's favor that the severity of the bone loss to the mandible was not significantly less than what is shown in the August 2008 records. Thus, in resolving reasonable doubt in the Veteran's favor, the Board finds that a 50 percent disability rating under Diagnostic Code 9902 for loss of approximately half of the mandible involving temporomandibular articulation is warranted back to September 28, 2007, the date service connection was effective. To that extent, the Veteran's appeal for a higher disability rating is granted. The Board finds, however, that the preponderance of the evidence is against a disability rating higher than 50 percent because the evidence fails to demonstrate that there is complete loss of the mandible between angles. The evidence clearly demonstrates it is only the left side of the mandible that is affected by the bone resorption rather than the whole mandible. Consequently, a higher disability rating is not warranted under Diagnostic Code 9901. Moreover, although there is bone resorption resulting in bone loss of the mandible and there is evidence of infection of the gums (i.e., periodontal disease), there is no evidence of an infection of the bone such as osteomyelitis or osteoradionecrosis. Thus, evaluation under Diagnostic Code 9900 is not warranted as well. Finally, the Board must consider referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321(b). It is generally provided that the rating schedule will represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from a service-connected disability. 38 C.F.R. § 3.321(a). In the exceptional case, however, to accord justice, where the schedular evaluations are found to be inadequate, the Secretary is authorized to approve, on the basis of the criteria set forth in 38 C.F.R. § 3.321(b)(1), an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b). The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. The Veteran's entire history is reviewed when making disability evaluations. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate. In other words, whether the disability picture presented in the record is adequately contemplated by the rating schedule. In doing so, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. It is appropriate to consider extraschedular referral on a "disability-by-disability" basis. Johnson v. Shinseki, 26 Vet. App. 237, 244-45 (2013). In the present case, the Veteran has essentially argued that his TMJD and all complications related thereto should be evaluated as a whole and that he should receive a 100 percent disability rating for it. Such complications he has asserted includes numbness and tingling in his lower extremities, bilateral shoulder pain, vision problems, neck and back pain, and a sleep disorder. As set forth in the background section above, the Veteran has essentially been awarded service connection for most of his complaints except for vision problems and a left shoulder disorder. The Board acknowledges that the rating criteria under which the Veteran's TMJD with bone resorption is evaluated does not appear to take into consideration complications caused by such a disorder such as pain in other areas of the body, vision problems, sleep problems, headaches, ear problems, etc. However, as set forth above, most of those problems are able to be separately service-connected and rated as secondary to the Veteran's TMJD with bone resorption. For those problems that have not been, the Board finds that they are not shown to cause any significant additional disability, marked interference with employment or frequent hospitalizations. As for the Veteran's complained of vision problems, the Board notes that his private treating specialist has submitted statements to the effect that TMJD can cause nerve problems that affect a patient's vision. See July 2009 statement. The Veteran was afforded a VA eye examination in August 2009. In the report, the examiner noted that the Veteran had been diagnosed 19 years ago with TMJD. The Veteran also reported that his vision got blurred and the grade of his spectacles became higher. He related that his vision problems became slowly progressive along with his TJM problems. After examination of the Veteran's eyes, the examiner diagnosed him to have bilateral immature cataracts, myopia, astigmatism and presbyopia. The examiner further noted that the fluctuations in vision described by the Veteran were probably secondary to transient blood flow abnormalities related to his TMJD. The Board points out that the private TMJD specialist's statements fail to separate out the Veteran's cataracts and refractive errors of the eyes that are not caused by his TMJD from the problems that are caused by it. Thus, based upon the VA examination findings, the Board finds that the Veteran's TMJD affects his vision in that it causes transient blurring of vision due to blood flow abnormalities. Despite this, the Board finds that the evidence fails to demonstrate that this causes any disability beyond that caused by the Veteran's nonservice-connected cataracts and refractive errors. Furthermore, there is no evidence that the Veteran's visual problems cause marked interference with employment or frequent hospitalizations. Rather the Veteran merely complained of his vision getting worse as his TMJD worsened. The Veteran, however, clearly has cataracts and refractive errors that could account for those complaints and the evidence fails to demonstrate the his TMJD would account for either the onset of those problems or the worsening thereof. Further evidence to support such a conclusion is the opinions of the VA examiners who conducted the December 2010 VA dental and general medical examinations. Neither of these examiners expressed the opinion that the Veteran's blurred vision, whether transient or not, was related to the Veteran's TMJD or resulted in any impact on his employability. Since the Veteran has not been employed at any time during the appeal period, there is no evidence of actual interference with employment. Thus, the Board can only rely on the evidence showing the effect on employability. As for the Veteran's complained of left shoulder pain, VA examination conducted in September 2011 showed objective findings of pain and slight limitation of motion along with the Veteran's complaints thereof. The examiner, however, failed to diagnose any disorder causing such limitations (unlike the right shoulder, which the examiner diagnosed to have osteoarthritis as seen on X-ray). The Board acknowledges that the Veteran's private treating specialist has related the Veteran's complaints of shoulder pain to his TMJD. Nevertheless, the Board finds that the evidence fails to demonstrate that the Veteran's left shoulder symptoms cause marked interference with employment or frequent hospitalizations. There is no evidence that the Veteran has received regular treatment for his left shoulder pain although there was a comment in the January 2008 private dentist's note that he underwent therapy for his TMJD problems. As the Veteran has not worked for many years, there is no evidence to show that his left shoulder disorder caused any specific interference with his employment. The opinions of the VA examiners who conducted the December 2010 VA dental and general medical examinations failed to express that the Veteran's left shoulder pain resulted in any impact on his employability. The Board acknowledges that the September 2011 VA examiner makes a statement as to the affect on employability, but finds that this only relates to the Veteran's right shoulder as the examiner only diagnosed him to have a disability relating to right shoulder and not the left. More important, the Board notes that VA has already acknowledged that the Veteran's TMJD and his associated problems have caused interference with his employability as he was awarded a TDIU effective August 25, 2008. This award was based on the findings by the VA examiners who conducted the December 2010 VA examinations. The dental examiner opined that the Veteran's TMJD would limit him in securing and maintaining gainful employment because his TMJD with associated complications such as headaches, earaches, neck pain and jaw dysfunction have an effect on the Veteran's quality of life, and such simple tasks as eating, conversation and even sleeping can be painful and can take a heavy toll on one's quality of life. (See December 2010 VA dental and oral examination.) Furthermore, the general medical examiner stated that the Veteran's TMJD rendered him with difficulty in chewing and speech, and resulted in various pains in the head, nape and back thereby affecting his ability to obtain gainful work. Consequently, the Veteran has been rated as totally disabled since that date and, as such, extraschedular consideration of his TMJD with associated complications would be impermissible pyramiding. Consequently, the Board finds that referral for consideration of an extraschedular rating are not warranted. With regards to the Veteran's argument that his TJMD and all the related problems he has a result of it should be evaluated together and rated as 100 percent disabling, the Board notes that the VA rating schedule does not contain specific Diagnostic Code or even an analogous Diagnostic Code for evaluating the Veteran's TMJD and associated as one. However, as set forth in the Procedural Background section above, the Veteran has been granted service connection for all almost all of the problems he has claimed service connection for even if not as directly related to his TMJD. For example, the Veteran sought service connection for numbness, pain and cramping in his legs and feet. The RO initially denied service connection for peripheral neuropathy as secondary to TMJD; however, eventually it granted service connection for bilateral radiculopathy as secondary to his service-connected lumbosacral strain. The rating of 10 percent per lower extremity takes into account all symptoms manifested by this now service-connected disability. Consequently, even though it is not exactly characterized as the Veteran would chose (i.e., as being related to his TMJD), the fact remains that service connection for his lower extremity problems has been granted and appropriately rated. Furthermore, based upon the Veteran's TMJD and associated problems, he was found to be entitled to a TDIU effective August 25, 2008, which essentially means he was found to be totally disabled and was being compensated for that. Furthermore, effective May 7, 2010, the Veteran's service-connected disabilities had reached a combined schedular rating of 100 percent. Consequently, as of that date, the Veteran has been found to be totally disabled due to his service-connected disabilities. Hence, the Board finds that VA has essentially done what the Veteran has asked, in other words, that he be rated at 100 percent for his TMJD disorder and associated problems. For the foregoing reasons, the Board finds that a disability rating of 50 percent is warranted for the Veteran's TMJD with bone resorption as of September 28, 2007, the date service connection was granted. The preponderance of the evidence is, however, against finding that a disability rating higher than 50 percent is warranted or that the Veteran's claim should be referred for extraschedular consideration. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Veteran's claim for a disability rating higher than 50 percent is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Cervical Strain Service connection for cervical strain has been in effect since October 1963 and the current 20 percent disability rating has been in effect since July 1997. While the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that the current 20 percent disability rating was awarded under the old rating criteria in effect prior to September 2003. However, as the Veteran's claim was not filed until September 2007, the current rating criteria is for application alone. Spine disabilities are rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. When rating under the General Rating Formula for Diseases and Injuries of the Spine, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the rating criteria provide a 100 percent rating for unfavorable ankylosis of the entire spine. The criteria for a 40 percent rating are unfavorable ankylosis of the entire cervical spine. For a 30 percent rating, the criteria are forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 10 percent rating is provided for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The rating criteria define normal range of motion for the various spinal segments for VA compensation purposes. Normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexions are zero to 45 degrees, and left and right lateral rotations are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2). The fact that the criteria include symptoms such as pain, stiffness, aching, etc., if present, means that evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurological sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. In the present case, the medical evidence of record includes the reports of two VA examinations conducted in October 2007 and December 2010. There are also a few VA treatment records but no private medical evidence has been submitted or identified. The VA treatment records on file are from January 2004 through July 2008. A primary care note from July 2008 shows the Veteran complained of lightheadedness, photophobia, easy fatigability, joint pain, leg pains with numbness, pain on chewing and diabetes mellitus, type II. Physical examination did not note any abnormalities of the cervical spine; however, the assessment included cervical arthritis. The Veteran initially underwent VA examination in October 2007. At that examination, he was noted to have spasm and tenderness of the cervical spine. He, however, had full range of motion of the cervical spine. The diagnosis was arthritis. A second VA examination was conducted in December 2010. The Veteran reported injury to his back in service in 1962 from lifting a heavy crate. He related that this worsened until at least once a week his back would give out. This occurred until 1995 when he was diagnosed with TMJ misalignment and after a splint was placed, he was slightly relieved of his back and neck pains. On a review of systems, the Veteran reported having fatigue, loss of motion, stiffness, spasm and pain but denied weakness. He reported that the location of distribution of his pain was in the neck all the way down to his low back, and described his pain as a dull ache/soreness to sharp pain. The severity was described as mild with frequency and duration as constant and daily. On physical examination, his posture was noted to be stooped although his head was in normal position. His gait was also normal. His spine was symmetrical. Abnormal spinal curvatures of kyphosis and scoliosis were noted. Examination of the muscles of the cervical spine was negative for spasm, atrophy, guarding, tenderness or weakness, but was positive for pain with motion. The examiner stated that there was no spasm, localized tenderness or guarding severe enough to be responsible for abnormal gait or spinal contour. He also noted that there was no ankylosis of the spine. Range of motion of the cervical spine was forward flexion of 45 degrees, extension of 45 degrees, left lateral flexion of 45 degrees, left lateral rotation of 74 degrees, right lateral flexion of 45 degrees and right lateral rotation of 74 degrees. There was objective evidence of pain on active range of motion and on repetitive motion. The examiner stated, however, that there was no additional limitation after three repetitions of range of motion. The reflexes, sensory and motor examinations were all within normal limits. X-rays of the cervical spine showed unchanged exaggerated cervical lordosis, mild osteoporosis and cervical spondylosis. The assessment was cervical spondylosis. Based upon the available evidence, the Board finds that a disability rating higher than 20 percent is not warranted because the evidence fails to demonstrate that the Veteran has limitation of forward flexion of the cervical spine to 15 degrees or less; or ankylosis of the cervical spine, whether favorable or unfavorable, which would warrant a disability rating of 30 percent or higher under the rating schedule. As for consideration of referral for an extraschedular rating, the Board finds that the evidence does not show that the Veteran's service-connected cervical strain is of such an exceptional disability picture as to render the rating schedule inadequate. The Veteran's main complaint relating to his cervical spine disability is pain. VA examination has shown that the Veteran's range of motion is essentially normal, although the December 2010 VA examination showed some slight limitation of rotation of the cervical spine. Hence, the medical evidence does not demonstrate that there are any extraordinary signs or symptoms relating to the Veteran's cervical spine disability, nor has the Veteran claimed that he has any. Thus, it is clear that the current 20 percent disability rating more than adequately compensates the Veteran for the current severity of his service-connected cervical strain. Consequently, the Board finds that referral for an extraschedular rating is not warranted. After considering all the evidence of record, the Board finds that the preponderance of the evidence is against finding that a disability rating higher than 20 percent is warranted for the Veteran's cervical strain. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Veteran's claim is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Lumbosacral Strain Service connection for lumbosacral strain has been in effect since October 1963 and the current 20 percent disability rating has been in effect since July 1997. While the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that the current 20 percent disability rating was awarded under the old rating criteria in effect prior to September 2003. However, as the Veteran's claim was not filed until September 2007, the current rating criteria is for application alone. Spine disabilities are rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. When rating under the General Rating Formula for Diseases and Injuries of the Spine, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the revised rating criteria provide a 100 percent rating for unfavorable ankylosis of the entire spine; and a 50 percent rating for unfavorable ankylosis of the entire thoracolumbar spine. The criteria for a 40 percent rating require forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 10 percent rating is provided for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The rating criteria define normal range of motion for the various spinal segments for VA compensation purposes. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexions are zero to 30 degrees, and left and right lateral rotations are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2). The fact that the criteria include symptoms such as pain, stiffness, aching, etc., if present, means that evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurological sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). For example, impairment of the sciatic nerve is addressed under Diagnostic Code 8520. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. In the present case, the medical evidence of record includes the reports of two VA examinations conducted in October 2007 and December 2010. There are also a few VA treatment records but no private medical evidence has been submitted or identified. The VA treatment records on file are from January 2004 through July 2008. A nursing note from January 2004 shows the Veteran complained of stiffness and soreness in the back with tingling and numbness of the toes. A pain scale, however, notes the Veteran reported "0." A primary care treatment note from July 2008 shows the Veteran complained of lightheadedness, photophobia, easy fatigability, joint pain, leg pains with numbness, pain on chewing and diabetes mellitus, type II. Physical examination was normal except for lumbar spine tenderness with loss of lordosis. The assessment was lumbosacral spine arthritis. VA examination conducted in October 2007 showed the Veteran had full range of motion of the lumbar spine on physical examination. Furthermore, the examiner noted there was no limitation due to pain on repetition. The diagnosis was intervertebral osteochondrosis and scoliosis. On VA examination conducted in December 2010, the Veteran reported injury to his back in service in 1962 from lifting a heavy crate. He related that this worsened until at least once a week his back would give out. This occurred until 1995 when he was diagnosed with TMJ misalignment and, after a splint was placed, he was slightly relieved of his back and neck pains. On a review of systems, the Veteran reported having fatigue, loss of motion, stiffness, spasm and pain but denied weakness. He reported that the location of distribution of his pain was in the neck all the way down to his low back, and described his pain as a dull ache/soreness to sharp pain. The severity was described as mild with frequency and duration as constant and daily. On physical examination, his posture was noted to be stooped although his head was in normal position. His gait was also normal. His spine was symmetrical. Abnormal spinal curvatures of kyphosis and scoliosis were noted. Examination of the muscles of the lumbar spine was negative for spasm, atrophy, tenderness or weakness, but was positive for guarding and pain with motion. The examiner stated that there was no spasm, localized tenderness or guarding severe enough to be responsible for abnormal gait or spinal contour. He also noted that there was no ankylosis of the spine. Range of motion of the thoracolumbar spine was limited to forward flexion of 83 degrees, extension of 26 degrees, left lateral flexion of 26 degrees, left lateral rotation of 30 degrees, right lateral flexion of 26 degrees and right lateral rotation of 30 degrees. There was objective evidence of pain on active range of motion and on repetitive motion. The examiner also stated that there was additional limitation after three repetitions of range of motion. After three repetitions, the Veteran's range of motion was further limited to forward flexion of 79 degrees, extension of 25 degrees, left lateral flexion of 25 degrees, left lateral rotation of 28 degrees, right lateral flexion of 25 degrees and right lateral rotation of 28 degrees. The reflexes, sensory and motor examinations were all within normal limits. X-rays of the lumbosacral spine showed markedly narrowed to almost completely obliterated L4-L5 disc space with associated posterior osteophytes and some degree of ostopenia. The assessment was lumbar spondylosis. Based upon the available evidence, the Board finds that a disability rating higher than 20 percent is not warranted because the evidence fails to demonstrate that the Veteran has limitation of forward flexion of the thoracolumbar spine to 30 degrees or less; or ankylosis of thoracolumbar spine, whether favorable or unfavorable, which would warrant a disability rating of 40 percent or higher under the rating schedule. In addition, the Board acknowledges that the Veteran was granted service connection for radiculopathy of the bilateral lower extremities in a July 2011 rating decision, effective July 10, 2008, evaluated as 10 percent disabling for each lower extremity. The Board also notes, however, that the Veteran did not disagree with the initial ratings assigned for these disabilities. Although neurologic manifestations of a spine disability are part of the rating of such a disability, in the present case the Board finds no reason to disturb the RO's evaluations of the Veteran's bilateral lower extremities radiculopathy as he has not disagreed with those ratings and the evidence does not support higher ratings. As for consideration of referral for an extraschedular rating, the Board finds that the evidence does not show that the Veteran's service-connected lumbosacral strain is of such an exceptional disability picture as to render the rating schedule inadequate. The Veteran's main complaint relating to his lumbosacral spine disability is pain. VA examination has shown that the Veteran's range of motion was normal at the October 2007. Although the December 2010 VA examination showed some limitation of motion in all spheres of the thoracolumbar spine, the Board notes that such limitation of motion does not even support a rating of 20 percent under the current rating criteria. Hence, the medical evidence does not demonstrate that there are any extraordinary signs or symptoms relating to the Veteran's lumbosacral spine disability, nor has the Veteran claimed that he has any. Thus, it is clear that the current 20 percent disability rating more than adequately compensates the Veteran for the current severity of his service-connected lumbosacral strain. Consequently, the Board finds that the referral for extraschedular rating is not warranted. After considering all the evidence of record, the Board finds that the preponderance of the evidence is against finding that a disability rating higher than 20 percent is warranted for the Veteran's service-connected lumbosacral strain. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Veteran's claim is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER 1. Entitlement to an initial disability rating in excess of 50 percent for service-connected temporomandibular joint dysfunction (TMJD) with bone resorption from September 28, 2007 to August 24, 2008, is granted, subject to controlling regulations governing the payment of monetary benefits. 2. Entitlement to a disability rating in excess of 50 percent for service-connected TMJD with bone resorption is denied. 3. Entitlement to a disability rating in excess of 20 percent for service-connected cervical strain is denied. 4. Entitlement to a disability rating in excess of 20 percent for service-connected lumbosacral strain is denied. REMAND The Board finds that remand of the remaining issues is warranted as discussed below. Service Connection for a Left Shoulder Disorder The Board notes that the Veteran's initial claim was that his TMJD caused pain in his "shoulders." The RO, however, adjudicated his claim as one for service connection for "a shoulder condition," which was initially denied. The Veteran has continued to contend that his TMJD causes pain in his shoulders and has submitted statements by his private treating TMJD specialist to that affect. In a rating decision issued in February 2013, the RO granted service connection for right shoulder osteoarthritis as secondary to the Veteran's service-connected spine arthritis. The RO did not, however, adjudicate whether the Veteran had a disorder involving his left shoulder. Rather, the RO stated: "This is a full grant of this issue on appeal and thus will be removed from your pending appeal." The Board disagrees with that assessment as it is clear from the Veteran's initial statement of claim and subsequent statements from him and his private physician that his initial claim was for the bilateral shoulders, not just the right one. Consequently, although service connection has been granted for right shoulder osteoarthritis, the issue of service connection for a left shoulder disorder remains outstanding. The RO, however, did not adjudicate whether service connection for a left shoulder is warranted in the February 2013 rating decision nor has it issued a Supplemental Statement of the Case as to the continued appeal of the issue of service connection for a left shoulder disorder. Hence, remand is warranted for such action. Increased Rating for Hypertensive Cardiovascular Disease with Cardiac Arrhythmias The Board must consider all documents submitted prior to its decision and review all issues reasonably raised from a liberal reading of these documents. Suttmann v. Brown, 5 Vet. App. 127, 132 (1993) (citations omitted). Where such review reasonably reveals that the claimant is seeking a particular benefit, the Board is required to adjudicate the issue or, if appropriate, remand the issue to the RO for development and adjudication. However, the Board may not ignore an issue so raised. Id. Service connection for hypertensive cardiovascular disease with cardiac arrhythmias was granted in a July 2011 rating decision and was evaluated as 30 percent disabling. In an October 2011 statement, the Veteran disagreed with the 30 percent evaluation of this now service-connected disability. To date, however, a Statement of the Case has not been issued. Consequently, the Board remands this claim for the RO to issue a Statement of the Case. See 38 C.F.R. § 19.9(c). See also, Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); see also Godfrey v. Brown, 7 Vet. App. 398, 408-410 (1995); Archbold v. Brown, 9 Vet. App. 124, 130 (1996); VAOPGCPREC 16-92 (O.G.C. Prec. 16-92). However, this issue will be returned to the Board after issuance of the Statement of the Case only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997); Archbold, 9 Vet. App. at 130. Earlier Effective Date for the Grant of Service Connection for TMJD with Bone Resorption Service connection for TMJD was awarded in the June 2008 rating decision on appeal effective September 28, 2007. In the present decision, the Board further found that the Veteran's bone resorption also was present back to September 28, 2007, and awarded the 50 percent disability rating based upon that finding back to the date of the grant of service connection. In a July 2008 statement, the Veteran disagreed with the assignment of September 28, 2007 as the effective date for the grant of service connection. In response, the RO issued a rating decision in April 2010 denying an earlier effective date for the grant of service connection. The Board finds, however, as the Veteran's disagreement was based upon the initial grant of service connection, it is considered a "downstream" issue from that grant. Thus, rather than a rating decision, the RO should have issued a Statement of the Case as the Veteran's Notice of Disagreement placed that issue on appeal. Consequently, the Board remands this claim for the RO to issue a Statement of the Case. See 38 C.F.R. § 19.9(c). See also, Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); see also Godfrey v. Brown, 7 Vet. App. 398, 408-410 (1995); Archbold v. Brown, 9 Vet. App. 124, 130 (1996); VAOPGCPREC 16-92 (O.G.C. Prec. 16-92). However, this issue will be returned to the Board after issuance of the Statement of the Case only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997); Archbold, 9 Vet. App. at 130. Accordingly, the case is REMANDED for the following action: 1. Conduct any additional development necessary relating to the Veteran's claim for service connection for a left shoulder disorder. Thereafter, readjudicate the claim. If such action does not resolve the claim, a Supplemental Statement of the Case should be issued to the Veteran and his representative, if any. An appropriate period of time should be allowed for response. Thereafter, this claim should be returned to this Board for further appellate review, if in order. 2. Provide the Veteran with a Statement of the Case as to the issues of (1) entitlement to a disability rating in excess of 30 percent for service-connected hypertensive cardiovascular disease with cardiac arrhythmias and (2) entitlement to an effective date earlier than September 28, 2007 for the grant of service connection for TMJD with bone resorption. The Veteran should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of this issue to the Board. See 38 C.F.R. §§ 20.200, 20.202, and 20.302(b). If a timely substantive appeal is not filed, the claims should not be certified to the Board. If a timely substantive appeal is filed, these claims should be returned to the Board for further appellate consideration, as appropriate and subject to the current appellate procedures. 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). _____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs