Citation Nr: 1714799 Decision Date: 05/04/17 Archive Date: 05/11/17 DOCKET NO. 05-40 052 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for temporomandibular joint (TMJ) dislocation with tooth injury, to include as secondary to service-connected depression. 2. Entitlement to service connection for sleep apnea, to include as secondary to service-connected depression and/or service-connected sinusitis and chronic rhinitis with chronic headaches. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from April 1983 to July 1983, and from December 1984 to December 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2008 and May 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In December 2012, the Board, in pertinent part, remanded the service connection appeals for a TMJ disability and sleep apnea for any outstanding records pertinent to the appeals, supplemental VA medical opinions addressing the etiology of the TMJ disability and sleep apnea, and subsequent readjudication of the appeal. Pursuant to the Board's remand directives, the Agency of Original Jurisdiction (AOJ) asked the Veteran, in a January 2013 letter, to provide any additional information regarding outstanding records pertinent to the appeals, to include medical treatment received from private medical providers or VA medical providers. In February 2013, a supplemental VA medical opinion was obtained addressing the likely etiology of sleep apnea to include consideration of whether sleep apnea was caused or aggravated by depression. In August 2013, a VA examination was provided with a medical opinion addressing whether the TMJ disability was causally related to the in-service tooth extraction. In January 2015, the Board remanded the issue of service connection for a TMJ disability for a supplemental VA medical opinion to address the question of whether the TMJ disability was either caused or aggravated by the service-connected depression, and to request an October 2013 medical opinion from a private dentist. The Board also remanded the issue of service connection for sleep apnea to obtain the February 2013 VA examination report and associate it with the record, and to provide further VA examination with a medical opinion addressing whether sleep apnea was caused or permanently worsened by then-recently service-connected sinusitis or chronic rhinitis. In an attempt to comply with the Board's remand directives, August 2015 and November 2015 supplemental VA medical opinions were obtained. In consideration of the foregoing, the Board finds that there has been substantial compliance with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). In September 2016, the Board referred the case to the Veterans Health Administration (VHA) for a medical expert opinion to address certain medical questions pertaining to the issue of service connection for the TMJ disability on appeal. In December 2016, a medical opinion from a VA oral surgeon was obtained, and a copy of the medical opinion was provided to the Veteran and the representative. 38 C.F.R. § 20.901 (2016) (the Board has the authority to obtain a VHA medical expert opinion when, in its judgment, such medical expertise is needed for an equitable disposition of an appeal). The Board acknowledges that the issues of entitlement to service connection for alopecia and erectile dysfunction have been perfected, but not yet certified to the Board. Review of the record reveals that the Agency of Original Jurisdiction (AOJ) is still taking action on these issues. As such, the Board will not accept jurisdiction over them at this time, but they will be the subject of a subsequent Board decision, if otherwise in order. FINDINGS OF FACT 1. The Veteran sustained a facial and tooth injury during service and underwent a tooth extraction during service. 2. The Veteran did not have symptoms of a TMJ disability during service. 3. The TMJ disability was first manifested many years after service separation and is not causally or etiologically related to service. 4. The TMJ disability was neither caused nor aggravated by the service-connected depression. 5. No respiratory injury or disease other than sinusitis and rhinitis was manifested during service. 6. The Veteran did not have sleep apnea or symptoms of sleep apnea during service. 7. Sleep apnea was first manifested many years after service separation and is not causally or etiologically related to service. 8. Sleep apnea was neither caused nor worsened in severity by the service-connected depression or the service-connected sinusitis and rhinitis with headaches. CONCLUSIONS OF LAW 1. The criteria for service connection for TMJ dislocation with tooth injury, to include as secondary to service-connected depression, are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). 2. The criteria for service connection for sleep apnea, to include as secondary to service-connected depression and/or service-connected sinusitis and chronic rhinitis with chronic headaches, are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice should be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which 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 the April 2008 and February 2010 notice letters sent prior to the initial denial of the claims, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits, and described the types of information and evidence that the Veteran needed to submit to substantiate the claims. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claims. The RO further informed the Veteran how VA determines the disability rating and effective date once service connection is established. In consideration of the foregoing, the Board finds that the VCAA notice requirements were fully satisfied prior to the initial denial of the claims, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's duty to assist in claims development, the record contains all available evidence pertinent to the appeal. VA has requested records identified throughout the claims process. The Veteran was given appropriate notice of the responsibility to provide VA with any treatment records pertinent to the appeal, and the record contains sufficient evidence to make a decision on the appeal. The complete service treatment records are included in the record, and post-service treatment records identified as relevant to the appeal have been obtained or otherwise submitted. The RO provided the Veteran with VA examinations with medical opinions in October 2008, February 2010, and August 2013. Supplemental VA medical opinions were obtained in April 2009, February 2013, August 2015, and November 2015. In December 2016, a VHA advisory medical opinion was obtained in connection with the service connection appeal for the TMJ disability. The collective examination reports and VHA advisory medical opinion include all relevant findings and medical opinions needed to adjudicate fairly the appeals. The VA examiners considered an accurate history of the claimed disabilities as provided through interview of the Veteran and review of the record, as well as consideration the Veteran's subjective complaints as it related to the current symptomatology and its effects on daily life, and performed thorough examinations. The August 2015 and December 2016 VA reviewers reviewed the record, including prior VA examination reports, treatment records, and written statements included in the record. Thus, the VA examiners and VA reviewers had adequate facts and data regarding the history and condition of the claimed disabilities when providing the medical opinions. The VA medical opinions are supported by adequate rationale. For these reasons, the Board finds that the collective VA examination reports are adequate, and there is no need for further examination or medical opinion. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed, and no further development is required. Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran is currently diagnosed with TMJ dysfunction and obstructive sleep apnea. Neither diagnosis is a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the Board finds that the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are not applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for disability which is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). Service Connection Analysis for TMJ Dysfunction The Veteran contends that the current TMJ dysfunction was caused by a facial injury or tooth extraction during service. He contends that he was hit in the mouth with the butt of a rifle and underwent a tooth extraction during service, and believes that the in-service facial injury and/or in-service tooth extraction caused him to develop TMJ dysfunction. He further asserts that he has experienced TMJ symptoms since service. See April 2008 VA Form 21-4138. After review of all the lay and medical evidence of record, the Board finds that there was a facial and tooth injury and tooth extraction during service. When asked whether he had ever had serious injuries of the head, face, or jaws on the November 1987 service dental health patient questionnaire, the Veteran reported that he had been hit in the mouth during training, which loosened and chipped an upper front tooth. See October 2008 VA examination report (noting a slight incisal chip of Tooth 26 consistent with being hit in the mouth during service). In October 1987 (i.e., during service), the Veteran underwent extraction of Tooth 32 (i.e., a wisdom tooth). The weight of the evidence is against finding that the current TMJ disability is causally or etiologically related to service or was otherwise caused or worsened in severity (aggravated) by the service-connected depression. Although there was a facial and tooth injury and tooth extraction during service, there was no report, complaint, diagnosis, or treatment for any jaw problems or TMJ dysfunction during service. At the September 1987 service separation examination, the face and head were clinically evaluated as normal, and the Veteran denied that he then had or had ever had swollen or painful joints, severe tooth or gum trouble, or any bone, joint, or other deformity. The earliest evidence of a TMJ disability is shown in April 2008, approximately 21 years after service. See April 2008 private dental treatment note. The Board notes that private dental treatment notes dated prior to April 2008 (i.e., from February 2006 to April 2008) are of record and show complaints of several dental problems with no report of any problems with the jaw joint or indicative of a TMJ disability. See also July 2001 VA primary care note (noting that the Veteran had good dental repair). Considered together with the evidence showing no TMJ disability or TMJ dysfunction symptoms during service or at service separation, the absence of symptoms or diagnosis of TMJ dysfunction for more than two decades after service is a factor that weighs against a finding of service incurrence. See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and complaint of a claimed disability is one factor to consider as evidence against a claim of service connection). After review of the record, the December 2016 VA reviewer opined that the current TMJ disability was not at least as likely as not caused by the facial injury or tooth extraction during service or that the in-service facial injury contributed to bruxism. The December 2016 VA reviewer explained that the in-service injury was to the right upper front tooth, was not treated, involved the maxilla, and was mild. The December 2016 VA reviewer noted that, given the nature of the injury and the degree of mildness, the in-service injury could not have contributed to the TMJ symptoms or bruxism because it did not involve the mandible or the joints in any fashion and was of a very mild nature. The December 2016 VA reviewer commented that any injury of such a nature suffered by the Veteran during service should not have impacted the TMJ or contributed to bruxism in any way. The December 2016 VA reviewer added that the small chip noted on Tooth 26 was not related to the in-service injury to the upper front tooth because it was a mandibular tooth and the Veteran claimed injury to the maxillary tooth. The December 2016 VA reviewer also noted that the Veteran's assertion that extraction of Tooth #32 during service either caused or contributed to the current TMJ symptoms had no basis. The December 2016 VA reviewer wrote that the Veteran's claim that the treating dentist extracted the tooth by standing on his chest was ridiculous because there was no physically possible way to extract a tooth by standing on a patient's chest. The December 2016 VA reviewer also wrote that the progress notes for the in-service tooth extraction clearly stated that the tooth was sectioned and removed as was typical for a procedure of that nature. The December 2016 VA reviewer noted that the in-service extraction of the tooth could not have contributed to TMJ symptoms because the Veteran did not have any TMJ symptoms after the extraction. The December 2016 VA reviewer further noted that, even assuming the veracity of the Veteran's account of the in-service tooth extraction, the Veteran would have experienced TMJ dislocation immediately and would have had discomfort immediately following the surgery. The December 2016 VA reviewer also provided a negative medical opinion on the question of whether TMJ was caused or aggravated by the service-connected depression. The December 2016 VA reviewer opined that, although some patients with depression could have TMJ symptoms, depression did not cause TMJ problems. The December 2016 VA reviewer wrote that it was more likely that patients with chronic severe TMJ issues can have depression from the same just like any other chronic and difficult to treat conditions, rather than the reverse (i.e., vice versa). The December 2016 VA reviewer noted that many young and health patients can have TMJ clicking, popping, and discomfort without any relation to depression, and the Veteran's TMJ issues were not caused by the service-connected depression. The December 2016 VA reviewer further opined that the current TMJ could not be related to the bruxism caused by stress alone. Citing the November 2015 VA medical opinion, the December 2016 VA reviewer noted that he agreed that many patients can have bruxism as a habit and can have occasional TMJ discomfort, popping, and clicking without any history of active military duty or wisdom tooth extraction or injury to the face or any stress at all. The December 2016 VA reviewer added that, if that was the case, all veterans with depression and posttraumatic stress disorder would have bruxism and TMJ discomfort. The December 2016 VA reviewer noted that the claim that missing tooth #32 could contribute to bruxism was baseless because impacted wisdom teeth had no relation to occlusion and were not in occlusion. Because the December 2016 VA reviewer is trained as an oral surgeon and provided sound rationale based on accurate facts and data, the December 2016 VHA advisory medical opinion is of significant probative value. The December 2016 VHA advisory medical opinion is the only adequate medical opinion of record. In October 2013, a private dentist who has treated the Veteran since 2006 purported to opine that the in-service facial injury and tooth extraction could very likely have caused or, at a minimum, contributed to, the TMJ condition; however, the private medical statement is of no probative value because it lacked any rationale and was expressed in speculative terms. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight); see also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical evidence merely indicating that a claimed disorder "may or may not" be related to service is too speculative to establish any such relationship); 38 C.F.R. § 3.102 (reasonable doubt does not include resort to speculation or remote possibility). The Board notes the Veteran's more recent report of jaw problems during and since service; however, the account is inconsistent with, and outweighed by, other more contemporaneous and more credible evidence, such as the service treatment records, showing no report, complaint, diagnosis, or treatment for jaw problems during service, findings of the head and face within normal limits at service separation, the Veteran's handwritten notation that he was in "good health" at service separation, and the Veteran's denial of severe tooth or gum trouble and bone, joint or other deformity at service separation; the post-service lay and medical evidence showing the absence of any complaint of jaw problems during the course of medical and dental treatment for many years after service separation; the Veteran's report at the August 2013 VA examination that he first experienced TMJ problems after service, which contradicts the assertion of jaw problems during and since service; and the negative December 2016 VHA advisory medical opinion. Because the Veteran's competent lay account of having TMJ symptoms during service and since service is inconsistent with, and outweighed by, other, more credible and probative lay and medical evidence of record, it is not credible so is of no probative value. Although the Veteran has asserted that the current TMJ dysfunction was caused by the facial and tooth injury or the tooth extraction during service, he is a lay person and, under the specific facts of this case, does not have the requisite medical expertise to render a competent medical opinion as to the etiology of TMJ dysfunction. The facts of this case (established by the weight of the evidence) include negative TMJ symptoms or findings in service and at service separation and that TMJ symptoms first began many years after service separation. The etiology of TMJ dysfunction is a medical etiological question dealing with the origin and progression of conditions of the jaw joint and muscles of the head and neck. The Veteran is competent to report any jaw symptoms that he experienced at any time; however, under the facts of this case, which include no credible evidence of onset of TMJ dysfunction until many years after service, the Veteran is not competent to opine on whether there is a link between the TMJ disability that started many years after service and active service or the service-connected depression. Such nexus opinion requires specific medical knowledge and training in TMJ disorders. In consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against service connection for TMJ dislocation with tooth injury, to include as secondary to service-connected depression, the appeal must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection Analysis for Sleep Apnea The Veteran contends that the current obstructive sleep apnea was caused or aggravated by the service-connected depression or service-connected sinusitis and rhinitis. In the alternative, he contends that that sleep apnea is related to service. He seeks service connection on these bases. After review of all the lay and medical evidence of record, the Board finds that no respiratory injury or disease other than sinusitis and rhinitis was manifested during service and no sleep apnea symptoms were manifested during service. The service treatment records are absent of any report, complaint, diagnosis, or treatment for sleep apnea or symptoms of sleep apnea. At the September 1987 service separation examination, the lungs and chest were clinically evaluated as normal. On the September 1987 service separation report of medical history, the Veteran checked "No" when asked if he then had or had ever had frequent trouble sleeping. Because the service treatment records are complete, show treatment for another respiratory illnesses such as sinusitis and rhinitis during service without any notation of sleep apnea or sleep apnea symptoms, the lungs and chest were clinically evaluated at the September 1987 service separation examination and determined to be normal, and the Veteran was specifically asked if he had experienced frequent trouble sleeping on the September 1987 service separation report of medical history and then denied having any such symptoms, the Board finds that a respiratory injury, a respiratory disease, and sleep apnea are conditions that would have ordinarily been recorded during service had they occurred or been present; therefore, the lay and medical evidence generated contemporaneous to service, which shows no respiratory injury or disease other than sinusitis and rhinitis, and no sleep apnea or sleep apnea symptoms during service, is likely to reflect accurately the Veteran's physical condition, so is of significant probative value and provides evidence against a finding of respiratory injury or disease other than sinusitis or rhinitis, or sleep apnea or sleep apnea symptoms during service. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (stating that VA may use silence in the service treatment records as evidence contradictory to a veteran's assertions if the service treatment records appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred) (Lance, J., concurring); see also Fed. R. Evid. 803(7) (indicating that the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded). The weight of the evidence is against finding that sleep apnea is otherwise causally or etiologically related to service. Sleep apnea was diagnosed by polysomnography in November 2009, 22 years after service separation. Considered together with the evidence showing no sleep apnea or sleep apnea symptoms during service or at service separation, the absence of symptoms or diagnosis of sleep apnea for more than two decades after service is a factor that weighs against a finding of service incurrence. See Buchanan, 451 F.3d at 1336; see also Maxson, 230 F.3d at 1333. In the February 2013 supplemental VA medical opinion, the February 2010 VA examiner opined that sleep apnea was less likely than not incurred in or caused by service. In support of the medical opinion, the February 2010 VA examiner explained that service treatment records showed no diagnosis or treatment for sleep apnea during service, and the Veteran denied having sleep problems at service separation. Because the February 2013 VA medical opinion is based on an accurate history of no sleep apnea symptoms during service or at service separation and is supported by adequate rationale, it is of significant probative value. There is no medical opinion to the contrary of record. The weight of the evidence is against finding that sleep apnea was caused or permanently worsened beyond the natural progression by the service-connected depression or the service-connected sinusitis and rhinitis. After review of the record and interview and examination of the Veteran, the February 2010 VA examiner opined that it was less likely than not (i.e., less than 50 percent probability) that a sleep apnea condition was caused by or aggravated by the service-connected depression. In support of the medical opinion, the February 2010 VA examiner explained that sleep apnea was caused by structural problems that caused mechanical interference with the movement of air through the nasopharyngeal and oropharyngeal airways during sleep. The February 2010 VA examiner wrote that the most common cause of sleep apnea was obesity with a body habitus consisting of a short, thick neck, increased fat deposition in the face and neck structures, and a low-lying soft palate with a large uvula and/or large tonsils. The February 2010 examiner noted that the Veteran had the typical body habitus for the disorder. In the February 2013 supplemental VA medical opinion, the February 2010 VA examiner considered additional evidence received since the February 2010 VA examination and again opined that sleep apnea was less likely than not caused by or chronically worsened by the service-connected depression. The February 2010 VA examiner reiterated that obstructive sleep apnea was primarily caused by structural problems that caused mechanical interference with the movement of air through the nasopharyngeal and oropharyngeal airways during sleep, and the most common cause of sleep apnea was obesity. The February 2010 VA examiner explained that the Veteran had the classic body habitus for sleep apnea, including a short, thick neck, increased fat deposition in the face and neck structures and a low-lying soft palate with a large uvula and large tonsils. The February 2010 VA examiner noted that the Veteran's private physician did not document issues of depression in the discussion of the Veteran's reported sleep problems that led to the November 2009 sleep study, and wrote that depression would not cause mechanical obstruction of the oropharyngeal airway during sleep. The February 2010 VA examiner commented that there was no evidence in the available records to indicate that depression directly caused any chronic worsening of sleep apnea. The February 2010 VA examiner added that, based on the available evidence, the most likely cause of the sleep apnea was the Veteran's obesity, and the most likely cause of the chronic persistence and/or worsening of sleep apnea would be chronic obesity combined with issues pertaining to CPAP (continuous positive airway pressure) compliance. After reviewing the record, the August 2015 VA reviewer opined that it would be speculation to state that the service-connected sinusitis and rhinitis was a causative or aggravating factor for the Veteran's sleep apnea. The August 2015 VA reviewer reasoned that, while sleep apnea can be aggravated by nasal congestion, the Veteran had a thick neck and large tongue relative to size of his mouth, both of which can be contributing factors for sleep apnea. The August 2015 VA reviewer noted that he believed that other factors played a more important part in contributing to the sleep apnea than nasal congestion. The August 2015 VA reviewer reiterated that, although nasal congestion may aggravate sleep apnea, it would be speculation to state that the Veteran's nasal congestion was a contributing or causative factor for sleep apnea. When rendering the February 2013 and August 2015 VA medical opinions, the February 2010 VA examiner and August 2015 VA reviewer had adequate facts and data and provided sound rationale for the medical opinion; therefore, the February 2013 and August 2015 supplemental VA medical opinions are of significant probative value. There is no competent medical opinion to the contrary of record. Although the Veteran has asserted that sleep apnea was either caused or aggravated by depression or sinusitis/rhinitis is otherwise causally related to service, he is a lay person and does not have the requisite medical training or credentials to be able to render a competent medical opinion regarding the cause of his sleep apnea. The etiology of the Veteran's sleep apnea is a complex medical etiological question dealing with the origin and progression of the respiratory system, and sleep apnea is a disorder diagnosed primarily on clinical findings and physiological testing, to include a polysomnography. Thus, while the Veteran is competent to relate respiratory symptoms that he experienced or observed at any given time, he is not competent to opine on whether there is a link between sleep apnea, symptoms of which were manifested many years after service, and active service or service-connected depression or service-connected sinusitis and rhinitis on a causation or aggravation basis, because such a medical opinion requires specific medical knowledge and training. For these reasons, the Veteran's unsupported lay opinion is of no probative value. Thus, the weight of the evidence is against a finding that sleep apnea was incurred in or was otherwise caused by active service, or was caused or aggravated by service-connected depression or the service-connected sinusitis and chronic rhinitis with chronic headaches. In consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the appeal of service connection for sleep apnea, including as secondary to service-connected depression and/or sinusitis/rhinitis; consequently, the appeal must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for temporomandibular joint (TMJ) dislocation with tooth injury, to include as secondary to service-connected depression, is denied. Service connection for sleep apnea, to include as secondary to service-connected depression and/or service-connected sinusitis and chronic rhinitis with chronic headaches, is denied. ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs