Citation Nr: 1340003 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 07-29 950 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for a low back disorder with spasms, claimed as degenerative arthritis of the lumbar spine (hereinafter referred to as a "lumbar spine disorder"). 2. Entitlement to service connection for a cervical spine disorder. 3. Entitlement to an increased rating for service-connected temporomandibular dysfunction, residuals of fractured mandible, evaluated as noncompensable prior to of April 21, 2003, as 10 percent disabling prior to December 21, 2012, and as 20 percent disabling thereafter. 4. Entitlement to a compensable rating for paralysis of the right side of the face. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from June 1981 to June 1984, and from March 1990 to July 1993, with service in the U.S. Army Reserve and Ohio Army National Guard from August 1980 until his retirement from the Reserve in July 1993; presumably this includes periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. Subsequently, the claims file was transferred to the jurisdiction of the RO in Atlanta, Georgia. In February 2011, the Board remanded the claims for additional development. In September 2010, the Veteran was afforded a videoconference hearing before Jonathan B. Kramer, who is the Veterans Law Judge rendering the determination in this claim and was designated by the Chairman of the Board to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 2002). The issue of entitlement to service connection for a lumbar spine disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In an unappealed decision, dated in March 1995, the RO denied claims for service connection for back pain, and back spasms. 2. The evidence received since the RO's March 1995 decision, which denied claims of entitlement to service connection for back pain, and back spasms, which was not previously of record, and which is not cumulative of other evidence of record, raises a reasonable possibility of substantiating the claim. 3. The evidence of record does not show that the Veteran has a cervical spine disorder that is related to active duty service, or to a service-connected disability. 4. Prior to of April 21, 2003, the Veteran's temporomandibular dysfunction, residuals of fractured mandible, is not shown to have been manifested by a nonunion of the mandible, a malunion of the mandible, or an inter-incisal range of 31 to 40 millimeters, or a range of lateral excursion of zero to 4 millimeters. 5. Between April 21, 2003, and December 20, 2012, the Veteran's temporomandibular dysfunction, residuals of fractured mandible, is shown to have been productive of complaints of pain, with popping of the temporamandibular joint, but not a limitation of motion between 21 and 30 millimeters, a malunion or nonunion of the maxilla with severe displacement, a severe nonunion of the mandible, or a malunion of the mandible with severe displacement. 6. As of December 21, 2012, the Veteran's temporomandibular dysfunction, residuals of fractured mandible, are shown to have been productive of complaints of pain, with popping of the temporamandibular joint, an opening of 23 millimeters, weakness, and fatigue, but not a limitation of motion between 0 and 10 millimeters. 7. The Veteran's service-connected paralysis of the right side of the face is not shown to have been productive of moderate incomplete paralysis. CONCLUSIONS OF LAW 1. New and material evidence has been received since the RO's March 1995 decision which denied claims for service connection for back pain, and back spasms; the claim for service connection for lumbar spine disorder is reopened. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2012); 38 C.F.R. § 3.156 (2013). 2. A cervical spine disorder was not incurred in, and is not otherwise due to, the Veteran's active duty service, nor was it caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). 3. Prior to April 21, 2003, the criteria for a compensable rating for temporomandibular dysfunction, residuals of fractured mandible, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107, 5110 (g) (West 2002); § 5103 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.59, Diagnostic Codes 9903, 9904, 9905 (2013). 4. Between April 21, 2003, and December 20, 2012, the criteria for a rating in excess of 10 percent for temporomandibular dysfunction, residuals of fractured mandible, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107, 5110 (g) (West 2002); § 5103 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.59, Diagnostic Codes 9903, 9904, 9905 (2013). 5. As of December 21, 2012, the criteria for a rating of 30 percent, and no more, for temporomandibular dysfunction, residuals of fractured mandible, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107, 5110 (g) (West 2002); § 5103 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, Diagnostic Code 9905 (2013). 6. The criteria for a compensable evaluation for service-connected paralysis of the right side of the face have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.31, 4.124a, Diagnostic Code 8205 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. New and Material The appellant asserts that new and material evidence has been presented to reopen the claim for service connection for lumbar spine disorder. He has argued that service connection is warranted because he was treated for back symptoms in 1983, and in 1989. See Veteran's claim (VA Form 21-526) and attachment, received in August 1993. During the Veteran's hearing, held in September 2010, it was argued that a back disorder was sustained as the result of an August 1992 gunshot wound to the face. In March 1995, the RO denied the Veteran's claims for service connection for back pain, and back spasms. The RO essentially held that these symptoms were not shown upon separation from service. The Veteran did not appeal that decision, nor did he submit any new and material evidence within a year of the March 1995 rating decision. 38 C.F.R. § 3.156(b). As such, the March 1995 rating decision is the last final denial of the claim. See 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. § 20.1103 (2012). In April 2003, the Veteran filed to reopen the claim. In February 2006, the RO determined that new and material evidence had not been presented to reopen the claim. The Veteran has appealed. In the most recent supplemental statement of the case, dated in January 2013, the Appeals Management Center (AMC) denied the claim, apparently on the merits, although this was not specifically stated. Regardless of the RO's actions, the Board must still determine whether new and material evidence has been received. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) (reopening after a prior Board denial); Wakeford v. Brown, 8 Vet. App. 237 (1995) (VA failed to comply with its own regulations by ignoring issue of whether any new and material evidence had been submitted to reopen the veteran's previously and finally denied claims). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Barnett. Further analysis, beyond consideration of whether the evidence received is new and material, is neither required nor permitted. Id. at 1384; see also Butler v. Brown, 9 Vet. App. 167, 171 (1996). Unappealed rating decisions by the RO are final with the exception that a claim may be reopened by submission of new and material evidence. 38 U.S.C.A. §§ 5108, 7105(c) (West 2002). When a veteran seeks to reopen a claim based on new evidence, VA must first determine whether the additional evidence is "new" and "material." Smith v. West, 12 Vet. App. 312 (1999). Second, if VA determines that new and material evidence has been added to the record, the claim is reopened and VA must evaluate the merits of a veteran's claim in light of all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140 (1991); Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996). When making determinations as to whether new and material evidence has been presented, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). VA regulation defines "new" as not previously submitted and "material" as related to an unestablished fact necessary to substantiate the claim. If the evidence is new and material, the next question is whether the evidence raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Shade v. Shinseki, 24 Vet. App. 110 (2010). Specifically, in Shade, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d) (2013). Service connection may also be granted for arthritis, when manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a); and that continuity of symptomatology only relates the specified chronic diseases). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the medical nexus. Id. The most recent and final denial of this claim was in March 1995. Therefore, the Board must determine if new and material evidence has been submitted since that time. See 38 U.S.C.A. § 5108. When determining whether the evidence is new and material, the specified basis for the last final disallowance must be considered. See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The evidence of record at the time of the RO's March 1995 rating decision included the Veteran's service treatment records from his first period of active duty, which showed that in October 1983, the Veteran was treated for complaints of back and stomach pain. The diagnosis is somewhat difficult to read, but appears to note viral syndrome. A July 1984 separation examination report showed that his spine was clinically evaluated as normal. In the associated "report of medical history," the Veteran denied a history of recurrent back pain, and stated that he was in good health. As for the medical evidence dated between the Veteran's first and second periods of active duty, a May 1988 examination report associated with Army National Guard duty, showed that his spine was clinically evaluated as normal. In the associated "report of medical history," the Veteran denied a history of recurrent back pain, and stated that he was in good health. A March 31, 1989 statement from a physician at the New York Hospital showed that the physician stated that the Veteran had been treated for back spasms that day. Service treatment records from the Veteran's second period of active duty include a June 1992 examination report, which showed that his spine was clinically evaluated as normal. In the associated "report of medical history," the Veteran denied a history of recurrent back pain, and stated that he was in good health. In August 1992, the Veteran was shot in the face in the state of Maryland. Service treatment records indicated that the bullet appears to have fragmented, fracturing facial, maxillary and mandible bones, and causing defects in the hard and soft palate, as well as trauma to the right optic nerve resulting in no light perception right eye blindness. The Veteran's separation examination report, dated in February 1993, showed that his spine was clinically evaluated as normal. In the associated "report of medical history," the Veteran indicated that he had a history of recurrent back pain, and there was a notation of complaints of pain an edema of the left upper back post-GSW (gunshot wound) in August 1992. At the time of the RO's March 1995 decision, the only relevant post-active duty medical evidence was a November 1994 VA examination report, which showed that the Veteran complained of back pain and spasms. On examination, the spine had a full range of motion, with no spasms. A neurological examination was negative. There was no relevant diagnosis. At the time of the RO's March 1995 rating decision, the Veteran's service treatment reports did not show evidence of lumbar spine pathology, or a diagnosis of a lumbar spine disorder. There was no post-service evidence of a diagnosed lumbar spine disorder, and no medical opinion indicating that a lumbar spine disorder was related to the Veteran's service. The evidence received since the RO's March 1995 rating decision consists of VA and non-VA reports, dated between 1992 and 2013, to include some private treatment reports that are dated during the Veteran's active duty. Private hospital records, dated in August 1992, note that the bullet entered the floor of the mouth on the right side, and exited at the base of the left neck. A July 2000 VA progress note shows treatment for complaints that included a four-day history of back pain. The assessment was musculoskeletal pain/spasm. A private treatment report, dated in October 2004, shows treatment for low back pain, and contains a diagnosis of acute low back sprain. VA progress notes, dated between November 2004 and June of 2005, show treatment for complaints of low back pain. The assessments included low back pain. A private MRI (magnetic resonance imaging) study, dated in May 2005, shows that there was a posterior disc protrusion at L5-S1, and a loss of signal at this level which was compatible with disc degeneration. A January 2006 VA progress note shows complaints of low back pain, and includes an assessment of chronic lower back pain. Several 2009 VA progress notes containing "active problem" lists that include notations of chronic low back pain. The Board notes that in April 1997, the RO determined that the Veteran's gunshot wound was sustained in the line of duty. This evidence, which was not of record at the time of the March 1995 decision, is not cumulative, and is "new" within the meaning of 38 C.F.R. § 3.156. The evidence is also material. This evidence shows that the Veteran has been treated for increased low back symptoms following service, that there is MRI evidence of lumbar spine pathology, and that he has been diagnosed with chronic low back pain. The Board therefore finds that the submitted evidence is both new and material, and that it raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156; see also Shade v. Shinseki, 24 Vet. App. 110 (2010) (38 C.F.R. § 3.159(c)(4) "does not require new and material evidence as to each previously unproven element of a claim."). The claim is therefore reopened. The appeal is granted to this extent only. II. Service Connection The Veteran asserts that he has a cervical spine disorder due to his service, to include caused or aggravated by a service-connected disability. In addition to the law discussed in Part I, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Additionally, when aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation; specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the appellant's claim was pending when the new provisions were promulgated, the Board will consider this appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects). The Veteran's service treatment records from his first period of active duty do not show any treatment for, or diagnoses of, a cervical spine disorder. A July 1984 separation examination report showed that his neck, and spine, were clinically evaluated as normal. In the associated "report of medical history," the Veteran was not noted to have any relevant symptoms. He stated that he was in good health. As for the medical evidence dated between the Veteran's first and second periods of active duty, a May 1988 examination report associated with Army National Guard duty, showed that his neck, and spine, were clinically evaluated as normal. In the associated "report of medical history," the Veteran denied a history of recurrent back pain, and stated that he was in good health. A March 31, 1989 statement from a physician at the New York Hospital showed that the physician stated that the Veteran had been treated for back spasms that day. Service treatment records from the Veteran's second period of active duty include a June 1992 examination report, which showed that his neck, and spine, were clinically evaluated as normal. In the associated "report of medical history," the Veteran was not noted to have any relevant symptoms. He stated that he was in good health. In August 1992, the Veteran was shot in the face in the state of Maryland. Service treatment records indicated that the bullet appears to have fragmented, fracturing facial, maxillary and mandible bones, and causing defects in the hard and soft palate, as well as trauma to the right optic nerve resulting in no light perception right eye blindness. There was no indication of damage to cervical spine. Private hospital records and treatment records from Walter Reed Army Medical Center show that the Veteran was treated for a gunshot wound to the face in August 1992. Several August 1992 Prince George's Hospital Center records refer to the Veteran having been shot in the mouth, the face, or the neck. Part of the bullet exited at the left neck. There was "swelling and expansion in the left neck." The September 1992 Walter Reed Army Medical Center discharge summary noted that small bullet fragments had exited the back of the left side of the neck. The Veteran's separation examination report, dated in February 1993, as well as the associated "report of medical history," does not indicate that the Veteran had a cervical spine or neck disorder. The post-service medical evidence consists of VA and non-VA reports, dated between 1994 and 2013. This evidence includes VA examination reports, dated in November 1994 and September 2003, which do not indicate that the Veteran was found to have a cervical spine or neck disorder. VA progress notes, dated in April 2003, show complaints of neck pain and grinding when turning his neck. On examination, there was a severe restriction of motion on left rotation, and a moderate restriction on bilateral side-bending of the cervical spine. The assessment noted chronic neck pain related to old trauma from GSW. A VA examination report, dated in December 2005, shows that the Veteran complained of a neck disorder due to his gunshot wound. He reported having neck pain, as well as a decreased range of motion. The relevant assessment was cervical spine degenerative disease per X-ray. In an addendum, the examiner stated that the Veteran's claims file had been reviewed, and that it was her opinion that the Veteran's current neck condition is not secondary to his gunshot wound. She explained that there is no evidence that the Veteran had any involvement of his neck as a result of his gunshot wound, and that he had primary pathology in the cervical spine that is the cause of his current complaints. A March 2007 VA neurology note contains impressions that included rule out DJD (degenerative joint disease) cervical spine. A November 2008 VA X-ray report for the cervical spine contains an impression noting chronic disc degeneration of the lower cervical spine with disc space narrowing and marginal endplate spurring at C5-6 and C6-7, with no fractures or vertebral body compression, and straightening of the cervical spine with well-preserved alignment of the cervical vertebral segments. A VA examination report, dated in February 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The examiner summarized the Veteran's relevant medical history. An examination was performed. The Veteran was noted to have sustained a gunshot wound going from the right side of the mouth that exited at the nape of the neck on the left side, posteriorly. X-rays, dated in 2008, were noted to show cervical spine degenerative joint disease at C5-6 and C6-7. The diagnosis was cervical spine degenerative joint disease, C5-6-7 levels, with minimal disability. The examiner stated: It is less likely than not that this commonly-occurring form of degenerative joint disease is related to any of the Veteran's service-connected gunshot wound injur[ies] sustained in 1992 or is otherwise related to any event or incidence in service. There are no suggestions of any acute trauma that occurred to the spine relative to that injury. The examiner further stated, "This is typical degenerative joint disease and not unexpected in a person at age 49. There is no evidence to suggest this is associated with trauma such as would occur with a gunshot injury." The Board finds that the claim must be denied. Despite some notations in private treatment reports, dated in August 1992, which indicate involvement of the neck, the treatment reports detailing the Veteran's actual injuries do not indicate that his August 1992 gunshot wound involved his neck or cervical spine. There is no other evidence to show that the Veteran was treated for neck/cervical spine symptoms during service, or that he had a disorder of the neck or cervical spine during service. The Veteran's February 1993 separation examination report shows that his neck and spine were clinically evaluated as normal, and the associated "report of medical history" does not show that he reported having any relevant symptoms. Given the foregoing, the Veteran is not shown to have had a chronic disease during service. See 38 C.F.R. § 3.303(b). Rather, the earliest medical evidence of a cervical spine disorder is dated no earlier than April 2003, which is almost 10 years after separation from the second period of active duty service. There is no evidence to show that arthritis of the cervical spine was manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307, 3.309. Furthermore, there is no competent evidence of record to show that the Veteran has a cervical spine disorder due to his service, to include his August 1992 gunshot wound, or that it was caused or aggravated by a service-connected disability. The only competent opinions are found in the December 2005 and February 2011 VA examination reports, and these opinions weigh against the claim. In particular, the February 2011 opinion is considered to be highly probative evidence against the claim, as it is shown to have been based on a review of the Veteran's medical records, and it is accompanied by a sufficient rationale. Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board has considered the notation in the April 2003 VA progress note relating chronic neck pain to his inservice gunshot wound, however, it is afforded little probative weight, as it is not shown to have been based on a review of the Veteran's claims files, or any other detailed and reliable medical history, it is not accompanied by an explanation, and it is clearly by history only. Id. Accordingly, the Board finds that the preponderance of the evidence shows that the Veteran does not have a cervical spine disability due to his service, or that was caused or aggravated by a service-connected disability, and that it is against the claim, and that the claim must be denied. With regard to the Veteran's own contentions, a layperson is generally not capable of opining on matters requiring complex medical knowledge. Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). The issue on appeal is based on the contention that a cervical spine disorder was caused by service, to include as due to a gunshot wound incurred in August 1992. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, these fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The medical records have been discussed. The Board has determined that the Veteran's cervical spine disorder is not related to his service, or to a service-connected disability. Given the foregoing, the Board finds that the medical evidence outweighs the Veteran's contentions to the effect that a cervical spine disorder was caused by service, or that it was caused or aggravated by a service-connected disability. The Board therefore finds that the preponderance of the evidence is against the claim for service connection, and that the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Increased Ratings The Veteran asserts that he is entitled to an increased rating for temporomandibular dysfunction, residuals of fractured mandible, evaluated as 10 percent disabling prior to December 21, 2012, and as 20 percent disabling thereafter, and a compensable rating for mild paralysis of the right side of the face. With regard to the history of the disabilities in issue, it has been discussed in Part I. Briefly stated, in August 1992, the Veteran sustained a gunshot wound to the face. The bullet appears to have fragmented, fracturing facial, maxillary, and (left) mandible bones, and causing defects in the hard and soft palate, as well as trauma to the right optic nerve resulting in no light perception right eye blindness. See 38 C.F.R. § 4.1 (2013). Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board notes that a decision of the Social Security Administration (SSA), dated in August 2005, shows that the SSA determined that the Veteran was disabled as of October 2004, with a primary diagnosis of affective disorders. A. Temporomandibular Dysfunction, Residuals of Fractured Mandible During his September 2010 Board hearing, the Veteran testified that his temporomandibular dysfunction affected his eating and chewing to some degree, while the mild paralysis on the right side of his face sometimes caused slurring of speech, and that he felt numb on that side of his face. In April 1997, the RO granted service connection for a fractured mandible, evaluated as noncompensable (0 percent disabling). In March 2003, the RO denied a claim for a compensable rating. In each case, there was no appeal, and the RO's decisions became final. See 38 U.S.C.A. § 7105(c). In April 2003, the Veteran filed a claim for a compensable rating. In February 2006, the RO recharacterized the Veteran's disability as "temporomandibular dysfunction, residuals of fractured mandible," and granted the claim, to the extent that it assigned a 10 percent rating, with an effective date of April 21, 2003. The Veteran appealed the issue of entitlement to an increased rating. In January 2013, the AMC granted the claim, to the extent that it assigned a 20 percent rating, with an effective date of December 21, 2012. Since this increase did not constitute a full grant of the benefit sought, the increased rating issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The RO and the AMC have evaluated the Veteran's temporomandibular dysfunction, residuals of fractured mandible under 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 9904-9905. However, the U.S. Court of Appeals for Veterans Claims held that hyphenated codes are only appropriate for diseases, and that they are inappropriate for injuries. Tropf v. Nicholson, 20 Vet. App. 317 (2006). Under the circumstances in this case, the use of the hyphenated code did not result in any prejudice to the Veteran. Here, DC 9904 represents a malunion of the mandible, and DC 9905 represents limited motion of temporomandibular articulation, and the Board has analyzed the claim under the appropriate diagnostic codes, as noted below. The Veteran's claim was received April 21, 2003, therefore, the time period in issue is from a year prior to the date of receipt of the claim, i.e., April 21, 2002, to the present. See 38 C.F.R. § 3.400(o)(2) (2013); see also Hazan v. Gober, 10 Vet. App. 511 (1997); Servello v. Derwinski, 3 Vet. App. 196 (1992). 1. Prior to April 21, 2003 Under 38 C.F.R. § 4.71a, DC 9903, Mandible, nonunion of: moderate, warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, DC 9904, Mandible, malunion of: Moderate displacement, warrants a 10 percent rating. A note following this subsection reflects that the rating assigned depends on the degree of motion and relative loss of masticatory function. Under 38 C.F.R. § 4.71a, Diagnostic Code 9905, a 10 percent rating is warranted for an inter-incisal range of 31 to 40 millimeters. In addition, a range of lateral excursion of zero to 4 millimeters also warrants a 10 percent rating. A note states that ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. The Board finds that a compensable rating is not warranted under DC's 9903, 9904, or 9905. Specifically, the only medical evidence of record is in the form of VA progress notes. None of this evidence contains any findings to show that the Veteran's temporomandibular dysfunction, residuals of fractured mandible, was manifested by a nonunion of the mandible, a malunion of the mandible, or an inter-incisal range of 31 to 40 millimeters, or a range of lateral excursion of zero to 4 millimeters. Accordingly the criteria for a 10 percent rating are not shown. DC's 9903, 9904, and 9905. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. The Board has also considered the functional impairment which can be attributed to pain and weakness. In this case, there are no findings showing ranges of inter-incisal motion or lateral excursion, and no evidence showing functional loss, to include no findings of such symptoms as neurologic deficits, loss muscle strength, or muscle atrophy. The Board therefore finds that there is insufficient evidence of objective pain on motion, or any other functional loss, to warrant a compensable rating. See DeLuca v. Brown, 8 Vet. App. 202 (1995). 2. April 21, 2003 to December 20, 2012 Under 38 C.F.R. § 4.71a, DC 9903, a 30 percent rating is warranted for: Mandible, nonunion of: Severe. Under 38 C.F.R. § 4.71a, DC 9904, a 20 percent rating is warranted for Mandible, malunion of: Severe displacement. Under 38 C.F.R. § 4.71a, DC 9905, a 20 percent rating is warranted for an inter-incisal range of 21 to 30-mm. A VA progress note, dated on April 21, 2003, shows that the Veteran reported having jaw pain. He denied swelling, lumps, oral lesions, bleeding, numbness, and burning. On examination, there were no masses or lumps of the neck, lips, tongue, mucosa, palate, or oropharnyx. The assessment notes TMD (presumably, temporomandibular joint disorder) symptoms (pain and discomfort on closing) "which seems to be related to the past fracture of the mandible in 1992." A QTC examination report, dated in December 2009, shows that the Veteran reported that his jaws cracked when open, that he had mouth numbness, and mouth pain. He stated that he was not receiving any treatment for his symptoms. On examination, the maxilla was within normal limits. The mandible was abnormal, with metal on the lower left, and bone loss. Examination of the ramus and palates revealed no abnormal findings. Examination of temporomandibular joint showed that the range of motion was "+10" bilaterally, and that repetitive motion was possible ("+10"), and that there was additional ("+10") millimeters of limitation, bilaterally. There was pain and fatigue after repetitive lateral excursion, bilaterally, but no weakness, lack of endurance, or incoordination. Fatigue had the major functional impact, bilaterally. Inter-incisal measurements showed that the ROM (range of motion) was "+10," that repetitive range of motion was possible ("+10"), and that there was additional ("+10") millimeters of limitation of motion. After repetitive inter-incisal motion, the Veteran had incoordination, which was the major impact, with no pain, fatigue, weakness, or lack of endurance. X-rays were noted to show bone loss. The Veteran was noted to have a loss of teeth due to periodontal disease. The diagnosis was temporomandibular articulation, with an active condition, and subjective reports of pain upon opening the mouth, numbness on the left side of the tongue and lips, right side of the cheeks and lips. Objective factors were "circle and popping at opening." An opinion from a VA specialist, dated in July 2012, noted that the December 2009 QTC examination report did not contain findings of inter-incisal measurement that were explanatory, as the report did not contain ranges of motion in accordance with DC 9905. The Board finds that a rating in excess of 10 percent is not warranted under DC's 9903, 9904, or 9905. Specifically, there is no medical evidence of record which contains any findings to show that the Veteran's temporomandibular dysfunction, residuals of fractured mandible, was manifested by a severe nonunion of the mandible, a severe malunion of the mandible, or an inter-incisal range of 21 to 30 millimeters. As noted in the July 2012 VA specialist's opinion, the December 2009 QTC examination report does not contain findings sufficient to evaluate the Veteran's disability under DC 9905. Accordingly, the Board finds that the criteria for a rating in excess of 10 percent rating are not shown, DC's 9903, 9904, and 9905, that the preponderance of the evidence is against the claim, and that the claim must be denied. The Board has also considered the functional impairment which can be attributed to pain and weakness. In this case, there is evidence of pain, fatigue, and incoordination, however, as previously noted, there are insufficient findings of ranges of inter-incisal motion or lateral excursion upon which to base an increased rating. The Board therefore finds that there is insufficient evidence of objective pain on motion, or any other functional loss, to warrant a rating in excess of 10 percent. DeLuca. 3. As of December 21, 2012 Under 38 C.F.R. § 4.71a, DC 9903, a 30 percent rating is warranted for: Mandible, nonunion of: Severe. Under 38 C.F.R. § 4.71a, DC 9905, a 30 percent rating is warranted for an inter-incisal range of 11 to 20-mm. A VA dental examination report, dated December 21, 2012, shows that the examiner stated that the Veteran's claims file had been reviewed. The Veteran complained of an inability to open his mouth comfortably, and that when he opens his mouth, he hears cracking and popping. He stated that it sometimes felt like he had a locked jaw when his mouth was in the closed position, where he could not get his mouth back open. He reported fatigue while chewing and that he had to take frequent breaks while eating. He said that he felt self-conscious in public due to the noise from his jaw, and stated that he could not eat certain foods he liked, such as steak and Twizzlers. He said that he felt his condition was getting progressively worse, and that he had worsening pain. He stated that he did not have jaw pain at rest, but that he had jaw pain while eating, characterized as "8/10." On examination, there was no oral pain until opening of the jaw, and on palpation of the temporomandibular joint. An extra-oral examination resulted in no significant findings. An intra-oral examination showed Class I occlusion with an anterior crossbite at tooth #26. There was no first molar occlusion on the right. Both right and left canines were in Class I occlusion. There was a 4 millimeter (mm.) overjet and a 2 mm. overbite. There was a maximal incisal opening of 29 mm. At first opening, the Veteran could only achieve an opening of 23 mm. comfortably, but he could force himself to open to 29 mm. with moderate pain. There was functional impairment due to loss of motion in that he could not fully open his jaw without discomfort, and he cannot open wide enough to bite into certain foods without pain, and is unable to chew his food (repetitive motion) without discomfort and fatigue. The examiner stated that this would indicate some level of masticatory function loss given the pain and fatigue he experiences. Lateral excursions were 0 (zero) mm., bilaterally. There was no evidence of any bone loss of the mandible, maxilla, or hard palate, although there was some evidence of loss of alveolar crest consistent with periodontal disease and tooth loss. The diagnosis noted that there was no evidence of loss of teeth due to loss of substance of the body of the maxilla or mandible. The examiner stated that the Veteran's limitations in maximum opening, pain and discomfort, and fatigue upon chewing are impacting his range of motion and masticatory function. His pain, limitation of opening, and difficulty with chewing are at least as likely as not caused by or a result of his temporomandibular joint disorder. In this case, there is no medical evidence of record which contains any findings to show that the Veteran's temporomandibular dysfunction, residuals of fractured mandible, has been manifested by a severe nonunion of the mandible. With regard to the inter-incisal range of motion, even using the Veteran's first attempted opening of 23 mm., this is in excess of that required for a rating in excess of 20 percent. DC 9905. However, the examiner noted that the Veteran had discomfort when opening his jaw, and he cannot open wide enough to bite into certain foods without pain, and is unable to chew his food (repetitive motion) without discomfort and fatigue. The examiner stated that "this would indicate some level of masticatory function loss given the pain and fatigue he experiences." The Veteran's first demonstrated range of motion was 23 mm., which is just 3 mm. short of the criteria for a 30 percent rating. Accordingly, affording the Veteran the benefit of all doubt, the Board finds that the evidence is at least in equipoise, and that a 30 percent rating is warranted as of December 21, 2012. DeLuca. A rating in excess of 30 percent is not warranted, as there is no evidence of an inter-incisal range of motion of 10 mm. or less. In addition, when the ranges of motion in the jaw are considered together with the evidence showing functional loss -- to include the findings pertaining to neurologic deficits, muscle strength, and the lack of evidence of muscle atrophy -- the Board finds that there is insufficient evidence of objective pain on motion, or any other functional loss, to warrant a rating in excess of 30 percent. DeLuca. B. Paralysis, Right Side of the Face During his September 2010 Board hearing, the Veteran testified that he had paralysis on the right side of his face sometimes caused slurring of speech, and that he felt numb on that side of his face. In April 1997, the RO granted service connection for "mild paralysis of right side of face secondary to gunshot wound," evaluated as noncompensable. In March 2003, the RO denied a claim for a compensable rating. In each case, there was no appeal, and the RO's decisions became final. See 38 U.S.C.A. § 7105(c). In April 2003, the Veteran filed his claim for a compensable rating. In February 2006, the RO denied the claim. The Veteran has appealed. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). A note in the Rating Schedule pertaining to "Diseases of the Peripheral Nerves" provides that the term "incomplete paralysis" indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, DC's 8510 through 8540 (2013). The criteria for evaluating the severity or impairment of the fifth (trigeminal) cranial nerve are set forth under Diagnostic Code 8205. Under DC 8205, a 10 percent rating requires moderate incomplete paralysis. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2013). The medical evidence includes a September 2003 VA examination report, which shows that the Veteran reported having numbness on the right side of his face, especially over the right cheek, that was somewhat fluctuating in its intensity. There was also numbness on the right side of the mouth. There was no significant pain in the face. A CT (computerized tomography) scan was noted to show a bullet at the right maxillary sinus, just inferior to the right orbit with a particle projection on the base of the right optic nerve. There was no intracerebral lesion or bullet fragment. On examination, there was no evidence for cognitive dysfunction. Upon examination of the fifth cranial nerve, there was sensory deficit in the right cheek with tingling and mild numbness to light touch over the V2 distribution, most likely secondary to the right infraorbital nerve being affected. Pinprick was appreciated. There was intact V1 and V3 distribution. As for the other cranial nerves, examination showed intact eye closure symmetrically, with mild asymmetry of the facial mimic, with a hint of delay on the right. The palate was symmetric to movement, the uvula was midline. The tongue was midline, fully mobile in all directions, with no tongue atrophy. A CT of the head was noted to contain an impression of a somewhat smaller lateral and third ventricle which could be a normal variation, with no evidence of cerebrovascular disease. The examination report diagnosis noted status post gunshot injury in 1992 with residual bullet in the right maxillary sinus, and right trigeminal nerve sensory deficit, most likely affecting the right infraorbital nerve (branch of V2) and possibly other sensory branches (such as to the right inside cheek). An October 2003 VA neurological outpatient note shows that the Veteran was noted to have fluent speech, with good comprehension and naming and repetition intact. There was trigeminal hypesthesia on the right side of the face with no facial asymmetry. A motor examination revealed good bulk and tone with no focal weakness. A VA examination report, dated in December 2005, shows that on examination, the cranial nerves 2-12 were grossly intact, with the exception of cranial nerve #7 on the right. There was slight right facial droop, and right paresthesia. There were no focal motor deficits. The relevant aspect of the assessment was status post gunshot wound to the right face with right-sided paralysis, affecting cranial nerve #7. A June 2006 VA progress note shows that the Veteran was found to have a slight paralysis of the facial nerve on the right side, with lateral deviation of the right eye, and slight fasciculation of the tongue. An August 2006 VA neurological outpatient note shows that the Veteran was noted to have a normal brain CT. Examination of the cranial nerves revealed normal facial sensation, facial motor functioning, palate, sternocleidomastoid function, and tongue protrusion. A sensory examination was normal. A VA progress note, dated in March 2009, notes a CT scan of the head revealed a metallic foreign body within the superior aspect of the right maxillary sinus, and unremarkable osseous structures. On examination, cranial nerves 2-12 were intact except for a loss of vision in the right eye. Sensation was intact to light touch. Speech was fluent and appropriate. The Veteran reported that he worked as a chef on a railroad. A QTC examination report, dated in December 2009, shows that the Veteran reported that his jaws cracked and that his cheeks fluttered, and that his symptoms had worsened over time. He reported constant bilateral jaw pain. He stated that he could function with medication, and that he was not receiving treatment for his symptoms. He denied having overall functional impairment due to his condition. On examination, cranial nerves 1-12 were normal. Coordination was within normal limits. The Veteran was noted to speak normally. The diagnosis was paralysis of the fifth trigeminal nerve, with resolution of paralysis on the right side, and no finding of smell or taste problems. There was no effect on his usual occupation or daily activities. A VA examination report, dated in February 2011, shows that the Veteran reported that he had worked as a cook on a railroad beginning in 2005, until he quit about a year and a half ago due to migraine headaches and low back pain. The Board finds that the Veteran's condition is not shown to have been manifested by moderate incomplete paralysis of the fifth cranial nerve, such that a compensable rating is warranted for the Veteran's paralysis of the right side of the face under DC 8205. In September 2003, the Veteran was noted to have sensory deficit in the right cheek with tingling and "mild" numbness to light touch over the V2 distribution, and "mild" asymmetry of the facial mimic, with a hint of delay on the right. In December 2005 and June 2006, there was evidence of "slight" right facial droop, and right paresthesia. As of August 2006, the Veteran has been shown to have normal examinations of the cranial nerves, and normal sensory examinations. The December 2009 QTC examination report shows that the diagnosis noted a resolution of paralysis on the right side, and that the examiner concluded that there were no effect on his usual occupation or daily activities. At all times, the Veteran's speech has been noted to be fluent, with no evidence of defect. There is no evidence of impairment of smell or taste. In summary, overall, the medical evidence does not contain objective evidence of such findings as muscle atrophy, weakness, or sensory impairment to the required degree. Based on the foregoing, the Board finds that the evidence does not show that the Veteran's paralysis of the right side of the face is shown to have been manifested by symptomatology that more nearly approximates the criteria for a compensable evaluation under DC 8205, and that the preponderance of the evidence is against a compensable rating. C. Conclusion In deciding the Veteran's increased rating claims, the Board has considered the Court's decision in Hart v Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. The evidence of record supports the conclusion that the Veteran's disabilities have consistently not approximated the criteria for higher ratings that those assigned throughout the appeal period, and that separate rating periods are not in order, except as noted. Consideration has also been given to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2013); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2013); Thun, 22 Vet. App. at 116. The schedular evaluations in this case are not inadequate. When comparing the Veteran's disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that manifestations of the service-connected disabilities are congruent with the disability picture represented by the disability ratings assigned herein. The criteria for the ratings currently assigned more than reasonably describe the Veteran's disability level and symptomatology. The Veteran is shown to have some increased limitation of jaw motion, with pain, and to have had some slight-to-mild facial nerve symptoms that appear to have resolved, with no post-service history of surgery. The rating schedule contemplates functional loss, which may be manifested by, for example, by decreased motion, strength, speed, coordination, or endurance, as well as symptoms of nerve impairment. 38 C.F.R. §§ 4.40, 4.124a; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). The schedular criteria considered contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for the Veteran's disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is primarily manifested by some impairment of jaw motion and a facial nerve. In short, there is nothing exceptional or unusual about the Veteran's disabilities because the rating criteria reasonably describe his disability levels and symptomatology. Thun, 22 Vet. App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that his disabilities have caused him to miss work, or have resulted in any hospitalizations. The evidence indicates that the Veteran has reported he stopped work due to symptoms that are not in issue, and that the SSA determined that he was disabled as of 2004, due to a psychiatric disability. The Board finds, therefore, that the Veteran's service-connected disabilities in issue do not result in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. In reaching these decisions, the Board has considered the oral and written testimony of the Veteran. The Board points out that, although a lay person is competent to testify only as to observable symptoms, see Falzone v. Brown, 8 Vet. App. 398, 403 (1995), a layperson is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability, unless such a relationship is one to which a lay person's observation is competent. See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). In this case, the Board has determined that the medical evidence is more probative of the issues, and that it outweighs the lay statements. Accordingly, the Veteran's claims must be denied. Finally, although the Veteran has submitted evidence of medical disability, and made claims for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable due to the service-connected disabilities in issue. In this regard, a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is in effect from May 21, 2010. Prior to that, the Veteran has reported working full-time employment as a cook from 2005 to about 2009, and that he stopped working due to headaches and a low back disorder. See Report of VA examination February 2011. The SSA has determined that he is disabled as of October 2004, due to psychiatric symptoms. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability (prior to May 2010) has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). IV. Duties to Notify and Assist The Board finds that the duties to notify have been fulfilled by information provided to the Veteran in letters from the RO dated in January 2006, December 2009, March 2011, and August 2012. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, and identified the Veteran's duties in obtaining information and evidence to substantiate his claims. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson, 20 Vet. App. 537 (2006). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service medical reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's service treatment records, VA and non-VA medical records, and SSA records. The Veteran has been afforded examinations, and with regard to the claim for service connection, an etiological opinion has been obtained. In February 2011, the Board remanded these claims. The Board directed that the Veteran be provided with appropriate notice, pursuant to the VCAA under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), that includes the requirements for establishing secondary service connection pursuant to 38 C.F.R. § 3.310. In March 2011, and August 2012, the Veteran was sent duty-to-assist letters that were in compliance with the Board's remand instructions. The Board further directed that the Social Security Administration (SSA) be contacted that that copies of the Veteran's records regarding his application for SSA benefits be obtained. This has been done. The Board directed that the Veteran be contacted and that he be request to furnish the names, addresses and approximate dates of treatment for all medical care providers, VA and non-VA, who have treated his for relevant symptoms, and whose records are not found within the claims file, to include records from the Atlanta VAMC dated beginning in December 2009. In March 2011, the Veteran reported that he received all of his treatment through VA. VA records, dated through January 2013, were subsequently obtained, to include records from the Atlanta VAMC, dated between December 2009 and 2011. Finally, the Board directed that the Veteran be afforded a VA examination to determine whether degenerative joint disease of the cervical spine is related to service. In February 2011, this was done. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). In September 2010, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the September 2010 hearing, the undersigned identified the issues on appeal. Also, with regard to the claim for service connection, information was solicited regarding the claimed etiology of his disability. The testimony did not reflect that there were any outstanding medical records available that would support any of his claims. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. The Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination). In view of the above, the Board finds that the notice requirements pertinent to the issues on appeal have been met. In summary, the Board finds that the available medical evidence is sufficient for an adequate determination of the claims on appeal. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims does not cause any prejudice to the Veteran. ORDER New and material evidence having been submitted, the claim of entitlement to service connection for a lumbar spine disorder is reopened. To this extent only, the appeal is granted. Service connection for a cervical spine disorder is denied. Prior to April 21, 2003, a compensable rating for temporomandibular dysfunction, residuals of fractured mandible, is denied. For the period from April 21, 2003 to December 20, 2012, a rating in excess of 10 percent for temporomandibular dysfunction, residuals of fractured mandible, is denied. As of December 21, 2012, a rating of 30 percent, and no more, for temporomandibular dysfunction, residuals of fractured mandible, is granted, subject to the laws and regulations governing the award of monetary benefits. A compensable evaluation for service-connected paralysis of the right side of the face is denied. REMAND With regard to the claim for service connection for a lumbar spine disorder, VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection 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); 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 threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. The appellant's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. Id. The evidence in this case shows that the Veteran was treated for back symptoms during service, although he was not noted to have a lumbar spine disorder at that time. The evidence further shows that following service, the Veteran has been treated for low back symptoms, and he has been shown to have irregularities of his lumbar spine in an MRI. The Veteran has asserted that he has a lumbar spine disorder due to his service, and his current claim also includes the theory of secondary service connection under 38 C.F.R. § 3.310. The Veteran has not yet been afforded an examination, and an etiological opinion has not been obtained. Under the circumstances, the Board finds that the Veteran should be afforded an examination, and an etiological opinion should be obtained. McLendon. The appellant must be advised of the importance of reporting to any scheduled VA examination and of the possible adverse consequences, to include the denial of her claim, of failing to so report. See 38 C.F.R. § 3.655 (2013). Accordingly, the case is REMANDED for the following action: 1. Update the claims folder with any new relevant medical records that may have come into existence since the Agency of Original Jurisdiction (AOJ) last had custody of the claims folder. 2. The Veteran should be afforded an examination of his lumbar spine. The claims folder and a copy of this REMAND should be reviewed by the examiner, and the examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. The examiner must be provided with a list of the Veteran's service-connected disabilities. a) Following the claims file review, physical examination, and interview of the Veteran, the examiner should provide an opinion as to whether it is at least likely as not (a 50 percent probability or greater) that the Veteran has a lumbar spine disorder that had its onset in service, or whether lumbar spine arthritis was manifested to a compensable degree within one year of service discharge, or is otherwise etiologically related to his active service. b) If, and only if, the examiner determines that the Veteran does not have a lumbar spine disorder that is related to his service on any basis, the examiner should state whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran has a lumbar spine disorder that has been caused by, or aggravated, by any of his service-connected disabilities. c) If the examiner cannot express any part of the requested opinions, the examiner should explain the reasons therefor. d) The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. e) "Aggravation" is defined as a permanent worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Afterwards, review the claims files to ensure that the aforementioned development and remand instructions have been fully and properly executed. Any noncompliance found should be rectified with the appropriate development. 4. Thereafter, readjudicate the issue on appeal. If the determination remains unfavorable to the appellant, he should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claim for benefits. The appellant should be given an opportunity to respond to the SSOC. The appellant 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). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs