Citation Nr: 1802540 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 09-37 850 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a bilateral hip disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. 2. Entitlement to service connection for a bilateral knee disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. 3. Entitlement to service connection for a lumbar spine disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. 4. Entitlement to service connection for a cervical spine disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. 5. Entitlement to service connection for a jaw disorder. ORDER Service connection for bilateral hip disorder is denied. Service connection for a bilateral knee disorder is denied. Service connection for a lumbar spine disorder is granted. Service connection for a cervical spine disorder is denied. Service connection for jaw disorder is denied. FINDINGS OF FACT 1. The hip diagnoses are not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; a bilateral hip disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 2. The knee diagnoses are not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; a bilateral knee disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 3. A lumbar spine disorder is related a service-connected disability. 4. Arthritis of the cervical spine did not become manifest to a degree of 10 percent or more within one year of service separation; a cervical spine disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 5. Arthritis of the jaw did not become manifest to a degree of 10 percent or more within one year of service separation; temporomandibular joint dysfunction and myofascial pain dysfunction are not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; a jaw disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. CONCLUSIONS OF LAW 1. A bilateral hip disorder was not incurred in service and is not proximately due to, a result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 2. A bilateral knee disorder was not incurred in service and is not proximately due to, a result of, or aggravated by a service-connected disability; arthritis of the knees is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 3. A lumbar spine disorder is proximately due to or a result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2017). 4. A cervical spine disorder was not incurred in service and is not proximately due to, a result of, or aggravated by a service-connected disability; arthritis of the cervical spine is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 5. A jaw disorder was not incurred in service and is not proximately due to, a result of, or aggravated by a service-connected disability; arthritis of the jaw is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from January 1980 to October 1983. This appeal comes before the Board of Veterans' Appeals (Board) from an April 2008 rating decision of the RO in Waco, Texas. In August 2011, the Veteran testified during a Board videoconference hearing and a transcript of that hearing is of record. The Veterans Law Judge who presided over the hearing is no longer employed at the Board. As such, in August 2015, the Board contacted the Veteran and offered him the opportunity to testify at another hearing before a Veterans Law Judge who would decide the claim on appeal. 38 C.F.R. § 20.707. The Veteran responded in September 2015 that he did not wish to appear for another hearing. In March 2014, March 2014, and May 2017, the Board remanded this appeal for additional evidentiary development. The appeal has since been returned to the Board for further appellate action. The Board also remanded a claim of entitlement to service connection for a left ankle disorder and denied a claim of entitlement to service connection for a dental disorder. The Board's decision with respect to the dental claim is final. See 38 C.F.R. § 20.1100 (2017). The RO subsequently granted service connection for a left ankle disorder on remand. Accordingly, the appeal of that matter is resolved. The Veteran submitted additional medical evidence relevant to the back claim after the most recent adjudication of these claims and did not specify whether he wished to have the appeal remanded to the Agency of Original Jurisdiction (AOJ) for initial consideration. However, the Board is granting service connection for a lumbar spine disorder. The evidence submitted is not relevant to any other claims. VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C.A. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310(a),(b); Wallin v. West, 11 Vet. App. 509, 512 (1998). For specific enumerated diseases designated as "chronic" there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Shinseki, 21 Vet. App. 303, 308-09. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017). A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. Entitlement to service connection for a bilateral hip disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. Entitlement to service connection for a bilateral knee disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. Entitlement to service connection for a lumbar spine disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. Entitlement to service connection for a cervical spine disorder, to include as due to a service-connected fracture right 5th metatarsal, and/or service-connected right ankle disability. Service treatment records reveal no complaints, treatment, or diagnoses pertinent to the hips, knees, lumbar spine, or cervical spine. A report of medical examination performed on February 18, 1983, at service separation, reveals normal findings for the lower extremities, spine, and neck. Physical profile ratings of L-1 and U-1 were assigned. The L stands for lower extremities. This factor concerns the legs and pelvic girdle in regard to strength, range of motion, and general efficiency. The L factor also includes the lower back musculature and lower spine (lower lumbar and sacral) in regard to strength, range of motion, and general efficiency. U stands for upper extremities. However, this factor includes the upper spine (cervical, thoracic, and upper lumbar) in regard to strength, range of motion, and general efficiency. With respect to each physical profile rating, the number 1 indicates that the Veteran possessed a high level of medical fitness and, consequently, was medically fit for any military assignment. See 9-3(c)(1) Army Regulation 40-501, Change 35; Hanson v. Derwinski, 1 Vet. App. 512 (1991); Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). After service, there is no record of treatment for hip, knee, back, or neck complaints for many years. An August 14, 2009, VA Primary Care Note reveals the Veteran denied neck pain (VBMS record 05/23/2017 at 246). A July 26, 2010, VA Primary Care Note reveals complaint of slight pain in the hips and knees after walking. The Veteran did not require any medication (VBMS record 05/23/2017 at 232). A September 23, 2011, VA Primary Care Note reveals complaint of back pain (VBMS record 05/23/2017 at 199). A September 27, 2011, Clinical Note from the Veteran's private chiropractor reveals a diagnosis of enthesopathy of the hip region, internal derangement of the knee, lumbago, lumbosacral spondylosis without myelopathy, and lumbar segmental dysfunction, cervical spondylosis without myelopathy, and cervical segmental dysfunction. The note reflects that initial treatment was on September 22, 2011, and this was specifically for the back. The hip, knee, and neck complaints were noted as new conditions at that time. Onset of hip, knee, and neck symptoms was described as 10+ years. Onset of back symptoms was described as over the prior 20 years. These descriptions are consistent with onset of symptoms after service (VBMS record 10/18/2011). The report of a June 2014 VA Examination reveals the Veteran's complaint of pain in the right hip area, neck and low back since 1984, and pain in both knees on and off since 2010. The Veteran reported that he strained his low back in physical training and marching, and that he was not seen or treated for his neck in service, or since 2007, 2011. The examiner diagnosed right hip pain/strain, bilateral knee strain, and degenerative arthritis of the lumbar and cervical spine. The examiner opined that the Veteran's bilateral hip condition, bilateral knee condition, lumbar spine condition, and cervical spine condition were less likely than not (less than 50% probability) incurred in service. The rationale was that the lack of treatment for hip, knee, low back, or neck complaints in service, and the Veteran's report of post-service onset of pain with respect to the neck, knees, and hips, as well as the lack of specific injuries to the knees, hips, or neck during service. The June 2014 VA examiner also opined that each claimed condition was less likely than not caused or aggravated by the service-connected right 5th toe disability. The rationale was that there is no nexus between these conditions physiologically or anatomically; and, the 5th toe does not participate in significant weight bearing (mostly both great toes and other toes along with metatarsals), either to cause the claimed conditions or to aggravate the claimed conditions. The report of a June 2016 VA Examination reveals the Veteran's complaint of back pain which started in 1980, bilateral hip and knee pain which started in 1990, after service, and neck pain which started in 1992 or 1995, after service. According to the Veteran, he did not go for evaluation for his back pain during service, even though he was treated for his 5th metatarsal fracture, which he associated with the same injury. He reported intermittent pain since then, but not too bad. He also reported that he did not see any doctors for his back pain when he got out of service until he saw a chiropractor in 1999, and was treated for several months. His back pain reportedly got better, though he stated there was constant dull pain. He went back to see the chiropractor in 2011, and got an X-ray and was told his lumbar spine was "messed up." The Veteran also stated he went to see a chiropractor in 1992 for 6 months and also went to see a chiropractor in 1995 for his back pain. The Veteran stated that he did not have knee, hip, or neck pain during service, so he was never evaluated for these conditions during service. He denied any direct trauma to the knees. According to the Veteran, his hips would hurt only when he would run or climb up stairs. He used to do a lot of athletic activities, like running and climbing stairs and it prevented him from doing so, due to pain. The Veteran stated that his chiropractor told him his previous right 5th metatarsal fracture was "attributing" to all his back, neck, hips, knees, and ankle pain. The examiner diagnosed hip and knee strain, date unknown, lumbar degenerative disc disease, and cervical degenerative disc disease. The examiner opined that the hip, knee, back, and neck conditions were less likely than not (less than 50% probability) incurred in or caused by an in- service injury, event or illness. The rationale was the lack of treatment for the hips, knees, back, and neck during service, the normal findings at service separation, and the Veteran's report of hip, knee, and neck pain starting after discharge from service. With respect to the back, the examiner noted that, even though the Veteran stated his back pain started while in service, there is no evidence to support he sought medical attention for his back pain during service. Degenerative changes in his lumbar spine and neck were found to be consistent with the normal aging process and not unusual in a person of his age. The examiner also opined that the hip, knee, back, and neck disorders were less likely than not (less than 50% probability) proximately due to, a result of, or aggravated by, his service-connected toe fracture or right ankle disability. The rationale was that his right 5th metatarsal fracture had healed after casting since 1980. Moreover, the 5th metatarsal does not have a significant relation anatomically or physiological to the hips, knees, back, or neck. Also, the right ankle disability was not severe enough to have a significant relation anatomically or physiologically to cause the claimed conditions. The report of a July 2017 VA Examination reveals the Veteran's complaint that he gradually started having bilateral hip pain over time; that he had onset of knee pain in the 1980s; that he had onset of low back pain in the late 1980s, and that he had gradual onset of neck pain over time. The examiner diagnosed hip strain, patellofemoral pain syndrome, and degenerative disc disease of the lumbar and cervical spine. The July 2017 VA examiner opined that each condition was less likely than not incurred in or caused by military service. The rationale was the lack of complaint or treatment in service. The examiner opined that the claimed conditions were also less likely than not proximately due to, or aggravated by, the Veteran's 5th metatarsal fracture with subsequent non-union or right ankle strain. The rationale was that, though it is possible that the fracture of the right 5th metatarsal and its subsequent non-union, and the right ankle strain, altered his alignment of the lower body, aggravating the hip, knee, back, and neck conditions over a period of time due to altered biomechanics, the chronicity of the bilateral hip condition during and immediately after the Veteran's time in service cannot be established. The Veteran submitted a private opinion from S. Burgest, MD, dated December 21, 2017, which opines that the Veteran's chronic lower back mechanical pain (lumbar strain) is more likely than not (more than 50% secondary service-connected due to abnormal gait, which is secondary to his bilateral ankle and right foot disability. The rationale refers to agreement among his primary care physician, physical therapist and pain management specialist and refers to an article titled "When lower extremity dysfunction contributes to back pain." An Examination of the same date conducted by H. Tran, MD, includes diagnoses of lumbar stenosis, lumbar spondylosis, lumbar radiculopathy, lumbar degenerative disc disease, and retrolisthesis. The examiner found the Veteran's right lower back pain was secondary to lumbar facet arthropathy, and that his right ankle/foot issue had caused an abnormal gait which "can certainly" contribute to right lower back pain. After a review of all of the evidence, the Board finds that current bilateral or unilateral disorders of the hip and knee, and a current neck disorder, are not related to service or to any service-connected disability. However, the evidence in favor of service connection for a lumbar spine disorder has attained relative equipoise with the evidence against the claim. The Board notes that the Veteran has not been entirely consistent in describing the onset of his symptoms. However, with respect to the hips, knees, and neck, he has reported the onset was after service. While the earliest report of onset of hip pain is 1984, one year after service separation, the Veteran has not been diagnosed with arthritis or other presumptive chronic disease of the hips or knees. Strain, sprain, and enthesopathy of the hips, and internal derangement of the knees, are not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered. With respect to the neck, while arthritis is a presumptive disease, there is no manifestation of arthritis to a degree of 10 percent or more within one year of service separation. The Board notes that the regulations pertaining to degenerative arthritis require X-ray evidence of the condition. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. While the Veteran has reported that his private chiropractor provided a medical nexus opinion relating his claimed disorders to his service-connected right 5th toe fracture residuals, the treatment records from that provider include the following opinion dated October 14, 2011: Pes planus or flat feet can affect the knees, hips and spine. In his case, I believe it is likely to have produced abnormal stresses to the knees, hips and lumbar spine causing an accelerated degenerative process which has led to his current spondylosis. The opinion includes a graphic depiction of a lower torso with a flattened arch shown to cause excessive pronation and various lower extremity and spine imbalances. The Board notes that service connection is not in effect for pes planus or flatfoot. The opinion does not address any service-connected foot condition, but notes: I have frequently seen soldiers and retired veterans with foot, knee and spine disorders that are much more severe than in the normal population. This is often due to the amount of running and physical activities required of them while in active duty. [The Veteran's] case is complicated by his profession with has also put repetitive stress on these joints from bending kneeling and lifting of heavy objects. The Board finds that this statement does not link the Veteran's claimed disorders to service or to a service-connected disability. The chiropractor's observation that soldiers and retired veterans frequently have more severe foot, knee and spine disorders than the general population is anecdotal and cannot be read, either alone, or with any other statement, as affirmatively linking the Veteran's hip, knee, or neck disorders to service or a service-connected disability. The chiropractor also stated that the Veteran had sustained a cumulative trauma injury to the lumbar spine, the hip, bilaterally, the knee, bilaterally, and the great toe. To the extent he intends that this occurred during service, it is inconsistent with the service treatment records, which reflect no such injury. The Board also notes that it is not the Veteran's right great (1st) toe that is service-connected, it is the right 5th toe. In sum, the Board finds that, the October 2014 opinion does not conclusively relate a hip, knee, or neck disorder to service or to a service-connected disability. The June 2014, June 2016, and July 2017 VA opinions are all against a nexus to service or service-connected disabilities. Moreover, the latter two opinions also address secondary causation and aggravation. These opinions are consistent with the service treatment records, which reflect no disease or injury of the hips, knees, or neck in service, and with the post-service records, which reflect onset of symptoms for the hips, knees, and neck, after service. They are therefore accorded greater probative weight than the statements of the Veteran's private chiropractor. The Veteran contends that the July 2017 VA opinion is inadequate. The Board acknowledges some awkward wording employed by the July 2017 VA examiner. He appeared in one sentence to allow the possibility that the service-connected foot and ankle disabilities may have altered the alignment of the lower body, "aggravating the claimed conditions over a period of time due to altered biomechanics." However, he subsequently stated definitively that the claimed conditions were not aggravated by his service-connected disabilities. The Board finds that the initial statement is inconclusive, allowing only the possibility of aggravation. The second statement is conclusive, finding that there is no aggravation. Therefore, in the context of the entire opinion, there is no ambiguity. See Lee v. Brown, 10 Vet. App. 336 (1997) (an etiological opinion should be viewed in its full context, and not characterized solely by the medical professional's choice of words). See also McLendon v. Nicholson, 20 Vet. App. 79, 85 (2000); Beausoleil v. Brown, 8 Vet. App. 459 (1996) (general and inconclusive statement about the possibility of a link between current disability and service injury is insufficient); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The Board finds the opinion adequate to decide these claims. The opinion of Dr. Burgest does not purport to relate disorders of the knees, hips, or neck to service or to a service-connected disability, to include the lumbar spine disability. Accordingly, the Board finds that the VA opinions are accorded the greatest probative weight on the question of nexus with respect to those claims. The Board also finds that, as there is no competent evidence of a nexus between the lumbar spine disability and the claimed knee, hip, and neck disorders, no additional development is necessary to obtain a medical opinion on that question. The Veteran has stated his belief that his current hip strains, knee conditions, and neck condition are related to a service-connected disability. The Board finds that relating a current diagnosis of a hip strain, knee derangement, or arthritis of the spine, to a service-connected disability, is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). The Board emphasizes that there was no injury or disease reported in service and the Veteran has reported post-service onset of symptoms with respect to the hips, knees, and neck. Therefore, such an opinion would require specialized medical training and knowledge, and is not a matter capable of lay observation. Moreover, establishment of arthritis of the lumbar or cervical spine requires X-ray evidence. This is also not capable of lay observation. Accordingly, the Board finds that service connection for lumbar strain is warranted. However, service connection for a bilateral hip disorder, bilateral knee disorder, and/or cervical spine disorder, is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Entitlement to service connection for a jaw disorder. The Board notes initially that service connection was denied for a dental disability in the Board's May 2017 decision. While the service treatment records reveal the Veteran sustained a laceration of his skin covering his chin during a fall in August 1980, service connection has already been granted for the resulting scar. Service treatment records otherwise reveal no complaints, treatment, or diagnoses pertinent to the jaw. A report of medical examination performed on February 18, 1983, at service separation, reveals normal findings for the lower extremities, spine, neck, and mouth. A physical profile rating of P-1 was assigned. The P stands for physical capacity or stamina. This factor normally includes dental conditions. The number 1 indicates that the Veteran possessed a high level of medical fitness with respect to dental health and, consequently, is medically fit for any military assignment. See 9-3(c)(1) Army Regulation 40-501, Change 35; Hanson, 1 Vet. App. 512; Odiorne, 3 Vet. App. at 457. After service, there is no record of treatment for jaw complaints for many years. The report of an August 2016 VA Examination reveals the Veteran's complaint of pain in the lower jaw. He denied any diagnosis or treatment for a jaw condition. On examination, there was no limitation in range of motion of the jaw at the articular joint. There was no popping, no clicking, no crepitus. The Veteran pointed to the lower portion of his jaw (masseter muscle) as painful, not the temporomandibular joint. X-rays of the jaw showed no pathology. The examiner found no disorder of the jaw to support a diagnosis. The report of a July 2017 VA Examination reveals a diagnosis of right temporomandibular joint dysfunction. The examiner opined that the condition was not related to service, but was more likely that it was caused by his bruxism habit with myofascial pain dysfunction. The examiner reasoned that, although trauma to the temporomandibular joint can eventually lead to temporomandibular joint dysfunction, the X-ray findings from the prior examination suggest that the temporomandibular joints appeared to be normal in their sockets. Therefore, the cause of the current temporomandibular joint dysfunction may be due to other factors that could have occurred on or after those X-rays were taken, but not the fall that occurred in 1980. The examiner cited a study finding that 40 percent of temporomandibular joint dysfunction diagnoses occurred 6 months after oro- maxillofacial trauma (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052671). Therefore, the examiner concluded that the Veteran's myofascial pain dysfunction due to bruxism was less likely than not incurred in or caused by military service. After a review of all of the evidence, the Board finds that a jaw disorder is not related to service or to a service-connected disability. There is no medical opinion that purports to relate the recently diagnosed temporomandibular joint dysfunction to service. The evidence establishes that this condition has recent onset. The Veteran has argued that the July 2017 VA opinion is inadequate because the study finding that 40 percent of temporomandibular joint dysfunction diagnoses occur within 6 months of injury implies that 60 percent do not occur within 6 months of injury. The Veteran argues that this violates the standard of proof in VA claims. The Board finds that the study itself does not violate the standard of proof for VA claims. It is merely information used by the examiner in formulating an opinion. The examiner's opinion is stated conclusively. In other words, the examiner did not state that he was only 40 percent certain. The statistical significance of the 40 percent figure in the context of the examiner's medical specialty is a medical matter which the Board is not competent to determine. Moreover, the examiner based his opinion on the very recent 2016 X-rays which showed no temporomandibular joint dysfunction at that time, more than 35 years after the injury in service. Regarding bruxism and the associated myofascial pain dysfunction, the Board finds that bruxism is not itself a disability for which service connection can be granted. Bruxism is defined in Dorland's Illustrated Medical Dictionary as "involuntary, nonfunctional, rhythmic or spasmodic gnashing, grinding, and clenching of teeth (not including chewing movements of the mandible), usually during sleep, sometimes leading to occlusal trauma. Causes may be related to repressed aggression, emotional tension, anger, fear, and frustration." See Dorland's Illustrated Medical Dictionary 260 (31st ed. 2007). Indeed, bruxism was characterized by the July 2017 examiner as a "habit," not a disorder. The Board finds that, for bruxism to support a grant of service connection, the act or habit of bruxism must not only result in a disability, the cause of the bruxism must either be a service-connected disability, or the bruxism must have occurred in service and caused injury or disease in service. Here, the definition of bruxism seems to suggest psychiatric or mental cause, at least in some cases. However, service connection is not in effect for any psychiatric or mental disability. With respect to occurrence of bruxism in service and incurrence of injury or disease in service, the Board finds that the normal examination findings at service separation to be highly probative evidence against such incurrence, as are the normal examination and X-ray findings in August 2016. The Board assigns this evidence greater probative weight than what is essentially speculation in favor of the claim. The Veteran submitted excerpts of his research on the causes of temporomandibular joint dysfunction with his VA Form 9. This evidence lists numerous possible causes, including trauma to the jaw. A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, however, the medical text evidence submitted by the Veteran is not accompanied by the medical opinion of a medical professional. Additionally, it fails to demonstrate with any degree of certainty a relationship between the Veteran's temporomandibular joint dysfunction and service, or a service-connected disability. For these reasons, the Board finds that the medical text evidence does not contain the specificity to constitute competent evidence of the claimed medical nexus in this case. The Veteran has stated his belief that his temporomandibular joint dysfunction is directly related to the injury in service. The Board finds that relating a recent diagnosis of temporomandibular joint dysfunction, with clear post-service onset, to a remote injury in service, or to a service-connected disability, is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized medical training and knowledge, and is not a matter capable of lay observation. The Veteran's spouse has provided a written account dated June 24, 2009, which attests that she has been married to the Veteran since 1984 and supports his temporomandibular joint dysfunction claim. However, she did not specifically state the date of onset of temporomandibular joint dysfunction. Moreover, the Board finds that the August 2016 examination, which established by X-ray findings that there was no temporomandibular joint dysfunction at that time, is more probative regarding this question than the statements of the Veteran or his spouse. Accordingly, the Board finds that service connection for a jaw disorder is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD L. Cramp, Counsel Copy mailed to: Disabled American Veterans Department of Veterans Affairs