Citation Nr: 1553563 Decision Date: 12/23/15 Archive Date: 12/30/15 DOCKET NO. 14-06 914A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan THE ISSUES 1. Whether new and material evidence has been received to reopen the Veteran's claim of entitlement to service connection for a neck disorder and, if so, whether service connection is warranted. 2. Whether new and material evidence has been received to reopen the Veteran's claim of entitlement to service connection for a back disorder and, if so, whether service connection is warranted. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). 4. Entitlement to service connection for a right shoulder disorder to include injury residuals and arthritis. 5. Entitlement to service connection for a right elbow disorder to arthritis. 6. Entitlement to service connection for a right hand disorder to include carpal tunnel syndrome (CTS). 7. Entitlement to service connection for a left hand disorder to include CTS. 8. Entitlement to service connection for breast cancer residuals claimed as the result of exposure to contaminated drinking water at Camp Lejeune, North Carolina. 9. Entitlement to service connection for a dental disorder to include trauma residuals and upper gum tear residuals. 10. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) for the period prior to March 19, 2014. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran is the appellant in the instant appeal. He had certified active service from January 1979 to February 1982. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of the Detroit, Michigan, Regional Office (RO) which, in pertinent part, determined that new and material evidence had not been received to reopen the Veteran's claims of entitlement to service connection for both a neck disorder and a back disorder and denied service connection for depression, PTSD, right shoulder arthritis, right elbow arthritis, a hand disorder, and torn top gums. In October 2012, the RO denied service connection for breast cancer residuals. In September 2013, the Veteran was afforded a hearing before a VA Decision Review Officer (DRO). A hearing transcript was prepared and incorporated into the record. In November 2013, the RO granted service connection for depression and anxiety; assigned a 50 percent evaluation for that disability; and effectuated the award as of March 23, 2011. In February 2014, the RO tacitly determined that new and material evidence had been received to reopen the Veteran's claims of entitlement to service connection for both a neck disorder and a back disorder and denied the claims on the merits. In June 2015, VA, in pertinent part, recharacterized the Veteran's service-connected psychiatric disability as unspecified depressive and anxiety disorders; increased the schedular evaluation for that disability from 50 to 100 percent; effectuated the award as of March 19, 2014; and denied a TDIU. In September 2015, the Veteran was afforded a videoconference hearing before the undersigned Acting Veterans Law Judge. A hearing transcript was prepared and incorporated into the record. As to the issues of whether new and material evidence has been received to reopen the Veteran's claims of entitlement to service connection for both a neck disorder and a back disorder, the Board is required to consider the question of whether new and material evidence has been received to reopen the Veteran's claims without regard to the RO's determination in order to establish the Board's jurisdiction to address the underlying claim and to adjudicate the claim on a de novo basis. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). The Board has reframed the issues on appeal in accordance with the United States Court of Appeals for Veterans Claims' (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). The Court has directed that when entitlement to a TDIU is raised during the adjudicatory process of evaluating the underlying disability or disabilities, it is part of the claim for benefits for the underlying disability or disabilities. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Therefore, the issue of the Veteran's entitlement to a TDIU for the period prior to March 19, 2014, is on appeal and will be addressed in the Remand portion of the decision below, In his March 2011 informal claim for service connection, the Veteran advanced contentions which may be reasonably construed as informal claims for service connection for diabetes mellitus, congestive heart failure, hypertension, and lymphedema. The issues of the Veteran's entitlement to service connection for diabetes mellitus, a heart disorder to include congestive heart failure, hypertension, and a lymphatic disorder to include lymphedema have not been adjudicated and are REFERRED to the Agency of Original Jurisdiction (AOJ) for appropriate action. The issues of service connection for a recurrent cervical spine disorder to include injury residuals, degenerative disc disease, spondylosis, stenosis, and arthritis; a recurrent lumbar spine disorder to include injury residuals, degenerative disc disease, and arthritis; a right shoulder disorder to include injury residuals and arthritis, a right elbow disorder to include arthritis, a right hand disorder to include CTS, a left hand disorder to include CTS, a dental disorder to include trauma residuals and upper gum tear residuals, and breast cancer residuals and a TDIU for the period prior to March 19, 2014, are REMANDED to the AOJ. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. In June 2009, VA denied service connection for a neck disorder. The Veteran was informed in writing of the adverse determination and his appellate rights in June 2009. The Veteran did not subsequently submit a notice of disagreement (NOD) with the decision. 2. The June 2009 rating decision denying service connection for a neck disorder is final. 3. The additional documentation submitted since the June 2009 rating decision is new and material and raises a reasonable possibility of substantiating the Veteran's claim. 4. In June 2009, VA denied service connection for a back disorder. The Veteran was informed in writing of the adverse determination and his appellate rights in June 2009. The Veteran did not subsequently submit an NOD with the decision. 5. The June 2009 rating decision denying service connection for a back disorder is final. 6. The additional documentation submitted since the June 2009 rating decision is new and material and raises a reasonable possibility of substantiating the Veteran's claim. 7. PTSD has been shown to have originated during active service. CONCLUSIONS OF LAW 1. The June 2009 VA rating decision denying service connection for a neck disorder is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2015). 2. New and material evidence sufficient to reopen the Veteran's claim of entitlement to service connection for a neck disorder has been presented. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108 (West 2014); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2015). 3. The June 2009 VA rating decision denying service connection for a back disorder is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2015). 4. New and material evidence sufficient to reopen the Veteran's claim of entitlement to service connection for a back disorder has been presented. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108 (West 2014); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2015). 5. The criteria for service connection for PTSD have been met. 38 U.S.C.A. §§ 1131, 1154, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.326(a) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this decision, the Board reopens and remands the issues of service connection for both a neck disorder and a back disorder and grants service connection for PTSD. Therefore, no further discussion of VA's duties to notify and to assist is necessary as to those issues. II. Application to Reopen Service Connection for a Neck Disorder and a Back Disorder Generally, absent the filing of an NOD within one year of the date of mailing of the notification of the initial review and determination of a veteran's claim and the subsequent filing of a timely substantive appeal, a rating determination is final and is not subject to revision upon the same factual basis except upon a finding of clear and unmistakable error (CUE). 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. §§ 20.200, 20.300, 20.1103 (2015). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The provisions of 38 C.F.R. § 3.156(a) create a low threshold, with the phrase "raises a reasonable possibility of substantiating the claim" enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010); Evans v. Brown, 9 Vet. App 273, 283 (1996). See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Where documents are within VA's control and could reasonably be expected to be a part of the record, such documents are, in contemplation of law, before VA and should be included in the record. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). A. Neck Disorder In June 2009, VA denied service connection for a neck disorder as there was no evidence showing "a link between your current neck symptoms and your military service." The Veteran was informed in writing of the adverse decision and his appellate rights in June 2009. He did not submit an NOD with the decision. The evidence upon which the June 2009 rating decision denying service connection was formulated may be briefly summarized. Service clinical documentation dated in July 1979 states that the Veteran complained of "body trauma/[low back pain], neck, legs." He reported that he had been thrown from a horse. An assessment of "multiple contusions" was advanced. A September 1981 naval treatment record notes that the Veteran complained of "chronic neck pain from muscle tension." An assessment of "situational reaction manifested by anxiety" was advanced. The report of the Veteran's February 1982 physical examination for service separation noted that the Veteran's spine was found to be normal and the Veteran had "no significant medical problems." The Veteran's July 2008 Veteran's Application for Compensation or Pension (VA Form 21-526) conveys that the Veteran had "injured my neck and back during a storm at sea" when he "fell down a ladder to lower deck" aboard the U.S.S. Duluth. A November 2000 written statement from R. Palmitier, M.D., conveys that he had treated the Veteran for cervical stenosis and cervical spondylosis "for several years." New and material evidence pertaining to the issue of service connection for a neck disorder was not received by VA or constructively in its possession within one year of written notice to the Veteran of the June 2009 rating decision. Therefore, that decision became final. 38 C.F.R. § 3.156(b). The additional documentation received since the June 2009 rating decision includes VA examination and clinical documentation, private clinical documentation, Social Security Administration (SSA) documentation, Internet articles, the transcripts of the September 2013 DRO hearing and the September 2015 Board hearing, and written statements from the Veteran and his associates. A December 1995 treatment record from Dr. Palmitier conveys that the Veteran was diagnosed with cervical spine degenerative disc disease and central canal and foraminal stenosis. The Veteran's November 2010 informal application to reopen his claim of entitlement to service connection for a neck disorder conveys that he had been thrown from a horse in 1981 and "hit the ground on my right shoulder and base of my neck." A January 2011 VA treatment record states that the Veteran presented a history of "a series of injuries in his 20's including a fall off of a horse and a fall aboard a ship during a hurricane which resulted in the falling with injury to the neck." An assessment of a "30 year history of lumbar, thoracic, and cervical pain which occurred after a series of injuries that occurred when he was in his 20s and the pain has become more severe in the past few years" was advanced The Veteran's March 2011 informal application to reopen his claim of entitlement to service connection advances that he had reinjured his neck while working as a prison guard and subduing a prisoner; underwent a cervical spine X-ray study following the incident; and was told by his treating physician that the X-ray study revealed that he "had received in the past a serious neck injury." The Veteran's written statements, the January 1995 private treatment record, and the January 2011 VA treatment record are of such significance that they raise a reasonable possibility of substantiating the Veteran's claim for service connection when considered with the previous evidence of record. As new and material evidence has been received, the Veteran's claim of entitlement to service connection for a neck disorder is reopened. B. Back Disorder In June 2009, VA denied service connection for a back disorder as "without evidence of a back condition related to your military service, service connection cannot be established." The Veteran was informed in writing of the adverse decision and his appellate rights in June 2009. He did not submit an NOD with the decision. The evidence upon which the June 2009 rating decision denying service connection was formulated may be briefly summarized. The July 1979 naval treatment record states that the Veteran complained of "body trauma/[low back pain], neck, legs." He reported that he had been thrown from a horse. The Veteran was observed to have sustained a back abrasion. An assessment of "multiple contusions" was advanced. The report of the Veteran's February 1982 physical examination for service separation noted that the Veteran's spine was found to be normal and the Veteran had "no significant medical problems." The Veteran's July 2008 Veteran's Application for Compensation or Pension (VA Form 21-526) conveys that he had "injured my neck and back during a storm at sea" when he "fell down a ladder to lower deck" aboard the U.S.S. Duluth. New and material evidence pertaining to the issue of service connection for a back disorder was not received by VA or constructively in its possession within one year of written notice to the Veteran of the June 2009 rating decision. Therefore, that decision became final. 38 C.F.R. § 3.156(b). The additional documentation received since the June 2009 rating decision includes VA examination and clinical documentation, private clinical documentation, SSA documentation; Internet articles, the transcripts of the September 2013 DRO hearing and the September 2015 Board hearing, and written statements from the Veteran and his associates. The Veteran's November 2010 informal application to reopen his claim of entitlement to service connection for a back disorder conveys that he had been thrown from a horse in 1981 and "hit the ground on my right shoulder and base of my neck." The January 2011 VA treatment record states that the Veteran presented a history of "a series of injuries in his 20's including a fall off of a horse and a fall aboard a ship during a hurricane which resulted in the falling with injury to the neck." An assessment of a "30 year history of lumbar, thoracic, and cervical pain which occurred after a series of injuries that occurred when he was in his 20s and the pain has become more severe in the past few years" was advanced. The February 2011 VA treatment record states "X-ray studies show arthritis changes with degenerative disc disease in the spine from cervical down to the lumbar spine." The Veteran's written statements and the cited VA clinical documentation are of such significance that they raise a reasonable possibility of substantiating the Veteran's claim for service connection when considered with the previous evidence of record. As new and material evidence has been received, the Veteran's claim of entitlement to service connection for a back disorder is reopened. III. Service Connection for PTSD The Veteran asserts that service connection for PTSD is warranted as he experienced several stressful events during active service including having been injured aboard a naval vessel during a storm at sea and a rapid succession of deaths of close family members. Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to establish the service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed aggravation of a disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (2015); a link, established by medical evidence, between current symptoms and an inservice stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Initially, the Board observes that service connection for unspecified depressive and anxiety disorders evaluated as 100 percent disabling is currently in effect. A December 2014 VA psychiatric treatment record states that the Veteran was diagnosed with PTSD and major depression. At a June 2015 VA psychiatric examination, the Veteran was diagnosed with an unspecified depressive disorder; an unspecified anxiety disorder; and PTSD secondary "to a number of family members dying within a short period of time while in the Navy, as well as fear experienced while his ship was in a hurricane without communications or radar, which Veteran was reportedly called upon to fix during the storm." The examiner commented that "[t]here is significant overlap among all of Veteran's diagnoses, reducing differentiation of symptoms, as well as social and occupational impairment, to mere speculation." Given the June 2015 VA psychiatric examination findings and upon resolution of all reasonable doubt in the Veteran's favor, the Board concludes that service connection for PTSD is now warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER The Veteran's application to reopen his claim of entitlement to service connection for a neck disorder is granted. The Veteran's application to reopen his claim of entitlement to service connection for a back disorder is granted. Service connection for PTSD is granted. REMAND All Issues The Veteran testified at the September 2015 Board hearing that he had served in the Marine Corps. He testified at the September 2013 he had been stationed at Camp Upshur near Camp Lejeune, North Carolina, in 1974. The Veteran's period of active service with the Marine Corps and his presence at Camp Upshur have not been verified. VA should obtain all relevant service, VA, and private documentation which could potentially be helpful in resolving the Veteran's claims. See Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Cervical Spine and Lumbar Spine Disorders In light of their reopening above, the Veteran's claims for service connection for a recurrent cervical spine disorder to include injury residuals, degenerative disc disease, spondylosis, and stenosis and a recurrent lumbar spine disorder to include injury residuals, degenerative disc disease, and arthritis are to be adjudicated on the merits following a de novo review of the entire record. The Veteran asserts that he sustained recurrent cervical spine/neck and lumbar spine/back injury residuals after being thrown from a horse and/or falling down a ship's ladder aboard the U.S.S. Duluth during a storm. The Veteran's service treatment records reflect that the Veteran sustained neck and low back trauma. A July 1979 states that the Veteran complained of "body trauma/[low back pain], neck, legs." He reported that he had been thrown from a horse. Treating medical personnel observed that the Veteran exhibited a back abrasion. An assessment of "multiple contusions" was advanced. A September 1981 treatment record notes that the Veteran complained of "chronic neck pain from muscle tension." An assessment of "situational reaction manifested by anxiety" was advanced. A March 2005 physical evaluation from Dr. Palmitier states that the Veteran was treated "in the early 1990's due to a work-related altercation at the prison where he was a security guard" and was diagnosed with a cervical spine herniated disc with stenosis and radiculopathy. The January 2011 VA treatment record states that the Veteran presented a history of "a series of injuries in his 20's including a fall off of a horse and a fall aboard a ship during a hurricane which resulted in the falling with injury to the neck." An assessment of a "30 year history of lumbar, thoracic, and cervical pain which occurred after a series of injuries that occurred when he was in his 20s and the pain has become more severe in the past few years" was advanced. The February 2011 VA treatment record notes "X-ray studies show arthritis changes with degenerative disc disease in the spine from cervical down to the lumbar spine." The report of an April 2012 VA spine examination states that the Veteran was diagnosed with cervical spine spondylosis and lumbar spine degenerative disease. The examiner commented that there was "no documentation of neck ... injury in SMR's;" "[t]hough the Veteran reports a fall from a horse and a fail aboard ship during a storm, there is no documentation to indicate an injury to his neck during military service;" and "[t]here was no documented injury severe enough to have led to the mild degenerative changes currently noted in his lumbar spine." The VA nurse practitioner concluded that: [t]he current degenerative change to the cervical spine may be due to the worker's comp. injury as well as a part of the normal aging process;" "[t]here is no evidence indicating that the cervical neck condition is a residual of military service;" and "[t]hus the neck condition is less as likely as not a residual of military service." She found further that: "[t]he current degenerative changes [of the lumbar spine] are a normal part of the aging process for a 58 year old person;" "[t]he degenerative changes have not exceeded what would be considered the normal progression for a person of 58 years of age;" and [t]hus his claimed low back condition is less as likely as not a residual of military service." The VA nurse practitioner failed to address the Veteran's documented in-service neck/cervical spine trauma and symptoms. Further, she noted, but did not address, the January 2011 VA treatment record reflecting the continuity of the Veteran's spinal symptomatology following his documented in-service trauma. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the examiner's erroneous findings as to the absence of in-service documentation of neck trauma and the other cited deficiencies in the April 2012 VA examination report, the Board determines that further VA spinal evaluation is required to resolve the issues raised by the instant appeal. Clinical documentation dated after April 2015 is not of record. Right Shoulder The Veteran asserts that service connection for recurrent right shoulder injury residuals including arthritis is warranted as he sustained the claimed disability as the result of his documented in-service fall from a horse. The Veteran's service treatment records make no reference to a right shoulder disorder or injury. In his November 2010 informal claim for service connection, the Veteran conveyed that after he was thrown from the horse, "I hit the ground on my right shoulder and base of my neck and rolled and ... I bounced." A February 2011 VA treatment record states that contemporaneous X-ray studies of the right shoulder revealed acromioclavicular joint arthritis and an irregular area on the humerus. The report of an April 2012 VA shoulder examination conveys that the Veteran was diagnosed with a torn right biceps tendon. Contemporaneous X-ray studies of the right shoulder were reported to reveal acromioclavicular joint degenerative changes. The examiner commented that: "[t]here is no documentation of a shoulder injury/condition while in military service;" "[t]here is however documentation of right biceps tear in 2010;" "[t]here is no evidence that any shoulder issue is related to military service;" and "[s]houlder conditions(s) are less as likely as not a residual of military service." The VA nurse practitioner made no findings as the etiology of the Veteran's diagnosed right acromioclavicular joint arthritis and its relationship, if any, to active service. As the April 2012 VA shoulder examination report fails to address the etiology of the Veteran's diagnosed right shoulder acromioclavicular joint arthritis and its relationship, if any, to his documented in-service trauma, the Board finds that further VA shoulder evaluation is required. Right Hand and Left Hand Disorders The Veteran asserts that service connection for a right hand disorder and a left hand disorder is warranted as he developed CTS as the result of his in-service military duties and/or secondary to his recurrent cervical spine disorder. The Veteran's service treatment records do not refer to either a right hand disorder or a left hand disorder. In his March 2011 informal claim for service connection, the Veteran advanced that he "had problems with my hands since working with the needle guns and deck crawlers on the U.S.S. Duluth LPD6 during the shipyard refit at Todd Shipyard in Long Beach, CA." He stated that he had been diagnosed with CTS in 1986 and underwent corrective surgery in 1989. Clinical documentation from Dr. Palmitier dated in 1995 and 1996 indicates that the Veteran was diagnosed with right CTS and left CTS and underwent bilateral surgical CTS release. An October 1995 treatment record states that the Veteran exhibited "bilat[eral] CTS on electrodiagnostic testing done in January of 1992." A January 1996 treatment record states that the Veteran exhibited the "signs of significant cervical stenosis as well as bilat[eral] CTS." The doctor concluded that "[i]t is likely that he has CTS symptoms from a double crush from the cervical stenosis." The Veteran has not been afforded a VA examination which addresses his right hand and left hand disorders and their relationship, if any, to active service. Further, given the nature of the Veteran's upper extremity symptoms, the Board finds that the issues of service connection for a right hand disorder and a left hand disorder are inextricably intertwined with the issue of service connection for a recurrent cervical spine disorder. Harris v. Derwinski, 1 Vet. App. 180 (1991) (noting that two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Dental Disorder The Veteran asserts that service connection for traumatic upper gum tear residuals is warranted as he sustained the claimed disability when he fell down a ship's ladder during a storm while aboard the U.S.S, Duluth. In his November 2010 informal claim for service connection, the Veteran indicated that: "[a}s I fell or slide down the ladder, the ship suddenly came up to meet me like a bat meets a baseball;" "I hurt all over and I think I had torn my upper front gums, because I. remember needing to put rolls of gauze that sickbay provided to soak up the blood;" and "[t]hat injury I still have, and the dentist says I may lose my front teeth." The Veteran's service dental documentation of record makes no reference to torn upper gums or other oral cavity trauma. The dental clinical documentation of record is in apparent conflict as to the nature and etiology of the Veteran's current dental disability. A May 2012 written statement from E. Rupprecht, D.D.S, indicates that: the Veteran "was first seen by me in 1988;" "[e]vidence of upper anterior trauma was noted then;" and "[t]he damage was consistent with the patient history indicating added trauma in mid-July." The report of a June 2013 VA dental examination states that the Veteran was diagnosed with periodontal disease and caries. The examiner commented that the diagnosed disorders "are similar to what one would find in a person in the general population with untreated dental caries and periodontitis." Given the conflicting dental findings as to whether the Veteran exhibits any recurrent oral cavity trauma residuals, the Board concludes that further VA dental evaluation is required. TDIU As entitlement to a TDIU for the period prior to March 19, 2014, is based upon an accurate assessment of all of the Veteran's service-connected disorders, the Board finds that that issue is inextricably intertwined with the remaining issues on appeal. Accordingly, the case is REMANDED for the following action: 1. Contact the National Personnel Records Center (NPRC) and/or the appropriate service entity and request that (1) it verify the Veteran's complete periods of active service, active duty, active duty for training, and inactive duty for training with the Marine Corps and (2) forward all available service personnel and service treatment records associated with such service for incorporation into the record. If no Marine Corps service is verified, a written statement to that effect should be prepared and incorporated into the record. 2. Contact the Veteran and request that he provide information as to all treatment of his cervical spine, lumbar spine, right shoulder, right elbow, right hand, left hand, and dental disorders and his breast cancer residuals after April 2015 including the names and addresses of all health care providers whose records have not already been provided to VA. Upon receipt of the requested information and the appropriate releases, the RO should contact all identified health care providers and request that they forward copies of all available clinical documentation pertaining to treatment of the Veteran, not already of record, for incorporation into the record. If any identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e) (2015). 3. Associate with the record any VA clinical documentation not already of record pertaining to treatment of the Veteran, including that provided after April 2015. 4. Schedule the Veteran for a VA spine examination in order to assist in determining the nature and etiology of his recurrent cervical spine and lumbar spine disabilities. The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified spine disorder had its onset during active service; is related to the Veteran's documented in-service fall from a horse; or otherwise originated during active service. All relevant medical records should be made available to the examiner for review of pertinent documents therein. A rationale for all opinions should be provided. 5. Schedule the Veteran for a VA shoulder examination in order to assist in determining the nature and etiology of his recurrent right shoulder disabilities. The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified right shoulder disorder had its onset during active service; is related to the Veteran's documented in-service fall from a horse; or otherwise originated during active service. All relevant medical records should be made available to the examiner for review of pertinent documents therein. A rationale for all opinions should be provided. 6. Schedule the Veteran for a VA hand examination in order to assist in determining the nature and etiology of his claimed recurrent right hand and left hand disabilities. The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified hand disorder had its onset during active service; is related to the Veteran's documented in-service fall from a horse; or otherwise originated during active service. All relevant medical records should be made available to the examiner for review of pertinent documents therein. A rationale for all opinions should be provided. 7. Schedule the Veteran for a VA dental examination in order to assist in determining the nature and etiology of his claimed recurrent dental trauma residuals. If no recurrent dental trauma residuals are identified, the examiner should expressly state that fact. The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified dental disorder had its onset during active service; is related to the Veteran's claimed in-service oral cavity trauma; or otherwise originated during active service. All relevant medical records should be made available to the examiner for review of pertinent documents therein. A rationale for all opinions should be provided. 8. Then adjudicate the issues of service connection for a recurrent cervical spine disorder to include injury residuals, degenerative disc disease, spondylosis, stenosis, and arthritis and a recurrent lumbar spine disorder to include injury residuals, degenerative disc disease, and arthritis on a de novo basis and readjudicate the remaining issues. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ R. FEINBERG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs