Citation Nr: 18142893 Decision Date: 10/18/18 Archive Date: 10/17/18 DOCKET NO. 15-14 874 DATE: October 18, 2018 ORDER Entitlement to service connection for a dental disability for compensation purposes (claimed damaged left mandible with deformity of the left side of the face) is denied. An initial rating of 20 percent for facial nerve inflammation and pain is granted. FINDINGS OF FACT 1. The Veteran did not have a current dental disability for which VA compensation benefits can be awarded. 2. The service-connected facial nerve inflammation and pain most nearly approximates severe incomplete paralysis of the seventh (facial) cranial nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a dental disability for compensation purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2002); 38 C.F.R. §§ 3.303, 3.381, 4.150 (2017). 2. The criteria for the assignment of a 20 percent rating for facial nerve inflammation and pain have been met. 38 U.S.C. §§ 1155, 5107 (2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8207 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1961 to October 1964. He died in early 2018, with his perfected claim pending on appeal. The appellant claims as the surviving spouse. For claimants who died on or after October 10, 2008, as in the instant case, the Veterans’ Benefits Improvement Act of 2008, Pub. L. No. 110-389, § 212, 122 Stat. 4145, 4151 (2008) created a new 38 U.S.C. § 5121A, which permits an eligible person to file a request to be substituted as the appellant for purposes of processing a claim to completion. The RO granted the Appellant’s request for substitution pursuant to 38 U.S.C. § 5121A. Accordingly, the Board will address the merits of these claims with the Appellant as the substituted party. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2013 rating decision issued by RO. In July 2018, the appellant testified at a video-conference hearing before the undersigned. A transcript of the hearing is included in the electronic case file. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. 1. Entitlement to service connection for a dental disability for compensation purposes (claimed damaged left mandible with deformity of the left side of the face) Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The appellant asserts that the Veteran underwent a dental procedure in service that resulted in a current dental disability. The Veteran’s service treatment records reflect that at enlistment the Veteran had a class III malocclusion. He had teeth extracted in November 1961. A May 1962 service treatment record documents his complaint of progressive swelling of the left side of his face and jaw for the past several months. He had occasional pain when eating. Physical examination showed asymmetrical swelling of the left jaw. Subsequent May 1962 service treatment record reflects that the Veteran was evaluated in the dental clinic for a mandible disorder. However, X-ray findings then showed no significant findings. A September 1962 service sialogram of the left submaxillary gland showed chronic sialadenitis. A November 1962 service treatment record reflects that the Veteran’s persistent swelling along the left side of his jaw had not decreased since August. X-ray findings showed possible chronic sialadenitis. December 1962 x-ray findings of the mandible and temporomandibular joint (TMJ) showed no definite abnormality of the mandible to suggest acromegaly or TMJ pathology. February 1963 letter from the Army dental detachment reflects that no organic disease or metabolic disturbance was elicited on medical examination. An August 1963 service treatment record reflects that the Veteran underwent evaluation of the left mandible. The examiner noted that the Veteran had teeth extracted during basic training. The Veteran reported that he first noted a relationship between “cross-bite” of his teeth and apparent swelling over the left body mandible in May 1962. He received treatment on several occasions for submaxillary gland infection. Oral examination revealed a marked cross-bite relationship with left mandible area. The impression was hypertrophy of left mandible of an undetermined etiology but existed prior to service (EPTS). Dated approximately 49 years after service, a June 2012 Report of VA examination documents the Veteran’s complaint of left submandibular jaw pain and that he had experienced some clicks and pops of the TMJ. He reported that his left submandibular gland area could be painful at any time. There was no discernable swelling associated with his left jaw or TMJ on examination. Objective examination showed that the Veteran was edentulous and wore complete maxillary and mandibular dentures. Crepitus was not noted on lateral excursion of the jaw and TMJ areas were not pressure sensitive bilaterally. No lateral deviation was noted even though the Veteran could not move his jaw to the left for lateral excursion. No clicks or pops were noted on examination. X-ray findings were within normal limits; however, it was possible that the left mandible was more prominent or asymmetrical when compared to the right side. There was no intra-oral loss of tissue or loss of bony tissue from any traumatic event. There was no history of jaw fracture with non-union or malunion. There was no tooth loss due to loss of substance of body of maxilla or mandible. There was no loss of bone in maxilla or mandible. There was no history of malunion or nonunion of the maxilla. There was no loss of bone of the mandible. There was no nonunion or malunion of the mandible. There was no loss of bone of hard palate. There was no evidence of osteoradionecrosis of maxilla, mandible or both. There was no evidence of osteomyelitis of maxilla, mandible or both. There was no speech difficulty. The examiner commented that no loss of teeth occurred due to trauma. Further, there was no loss of bone in maxilla or mandible due to any traumatic event. The Veteran did have a noted history of extractions during his period of service. However, the examiner explained that the Veteran’s claimed mandibular jaw deformity or malocclusion was not related to his extractions given that the skeletal malocclusion (Class III occlusion) was noted on initial dental examination prior to any dental extractions. Thus, the examiner concluded that the extractions in service could not have caused any left side jaw deformity since it was already present. The evidence reflects that the Veteran was missing all his teeth. However, the Veteran had dentures which indicated that his missing teeth were replaceable. Replaceable missing teeth are not compensable disabilities. 38 C.F.R. § 3.381(b). Thus, service connection for the missing teeth for purposes of compensation is not warranted. The Board notes that even if the Veteran’s missing teeth were not replaceable, service connection still would not be warranted. Missing teeth are not considered a disability by VA unless the tooth loss is due to loss of substance of the body of the maxilla or mandible caused by trauma or disease such as osteomyelitis. 38 C.F.R. § 4.150, Diagnostic Code 9913. Loss of the alveolar process because of periodontal disease is not considered disabling. Id. In this case there is no medical or lay evidence reflecting loss of substance of the body of the maxilla or mandible, or that tooth loss occurred because of injury or disease such as osteomyelitis. In fact, in the June 2012 Report of examination, the examiner specifically noted that there was no anatomical loss or bony injury of the mandible or maxilla and no teeth lost due to trauma. The Board notes that VA’s Office of General Counsel has held that dental treatment of teeth during service, to include extractions, does not constitute dental trauma. See VAOPGCPREC 5-97 (1997), 62 Fed. Reg. 15, 566 (1997). As such, there was also no aggravation of any preexisting malocclusion due to dental trauma in service. In short, the Veteran did not have a current dental disability for purposes of VA compensation, and there is no legal entitlement to service connection for a left mandible disorder. The Veteran’s left sided facial pain and deformity symptoms are contemplated by his service-connected facial nerve inflammation and pain disability and the severity of such is discussed below. The appellant is not competent to link the Veteran’s claimed dental disability (damaged left mandible with deformity of the left side of the face) to service. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when 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); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran’s death). The appellant is a lay person and is not competent to establish that the Veteran had a current dental disability that onset due to dental trauma sustained during a period of service. The appellant is not competent to offer an opinion as to etiology of any current dental disability. The question regarding the etiology of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, her allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim of entitlement to service connection for a dental disability must be denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to an initial rating more than 10 percent for facial nerve inflammation and pain Disability ratings with respect to neurological conditions ordinarily are assigned in proportion to the impairment of motor, sensory, or mental function. 38 C.F.R. § 4.12. In evaluating peripheral nerve injuries, attention therefore is given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory. Id. Special consideration is given to complete or partial loss of use of one or more extremities and disturbances of gait. 38 C.F.R. § 4.124a. The Veteran was assigned a 10 percent evaluation for the facial nerve inflammation and pain under Diagnostic Code 8207. Diagnostic Code 8207 pertains to paralysis of the seventh (facial) cranial nerve, and provides that a 10 percent rating is warranted for moderate incomplete paralysis. A 20 percent rating is warranted for severe incomplete paralysis. The maximum rating of 30 percent is reserved for complete paralysis. See 38 C.F.R. § 4.124a, Diagnostic Code 8207. Words such as ‘severe,’ ‘moderate,’ and ‘mild’ are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2016). Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104 (2012); 38 C.F.R. §§ 4.2, 4.6 (2017). A July 2011 VA neurology note reflects that the Veteran had a six-month history of Bell’s palsy. Initially, the Veteran noticed that his watery left eye progressed to ipsilateral facial droop with associated severe eye pain and inability to shut his left eye. He had jaw pain with difficulty coordinating movements and his left nostril would close if he were lying down. After four days of symptoms he sought treatment in the emergency room. He was given a prednisone taper and told to lubricate his eye and wear a patch at night for eye protection. He reported that they prednisone did not alleviate his symptoms and he returned a month later seeking additional treatment. He was given an additional prednisone taper and he tried a variety of treatment options. He stated that his pain had subsided and he had overall improvement; however, he still noticed a slight facial droop that caused self-consciousness. He also had an inability to completely close his left eye independently of his right eye. Objectively, he was unable to blink his left eye though he could almost completely shut his left eye in conjunction with his right eye. When he smiled, the left side of his face had a fairly noticeable facial droop. Chronic Bell’s palsy was diagnosed and the Veteran was encouraged to seek physical therapy for facial movement. The June 2012 Report of VA examination documents the Veteran’s complaint of a painful submandibular gland area and a watering left eye when he ate or chewed. He stated that he was advised that his watering eye was possibly due to previous nerve trauma /past injury. On examination, the examiner noted that the submandibular gland area pain and watering left eye made activities of daily living more difficult. The examiner opined that the Veteran’s submandibular pain and discomfort was as least as likely as not associated with the dental extractions performed during his period of service. In the December 2012 VA examination addendum, the examiner reiterated that the in-service tooth extractions could have traumatized the Veteran’s nerves near the extraction, causing the intermittent, sharp submandibular pain. Further, the examiner explained that the watering of the left eye was called Bogorad’s Syndrome (Crocodile Tear syndrome) and an uncommon consequence of facial nerve inflammation/trauma and nerve regeneration. The regenerated facial nerve caused a person to shed tears while salivating when chewing food, corroborating the possibility of facial nerve inflammation/trauma due to the extraction. An August 2014 VA treatment record documents that the Veteran was having more excessive eye watering when he chewed due to his cranial nerve damage. Here, the Veteran’s symptoms and manifestations were consistent and noted to have caused difficulties with his activities of daily living. Considering the diagnosed Bell’s palsy, when viewed in a light most favorable to the appellant, the evidence supports the assignment of a 20 percent rating for the facial nerve inflammation and pain. The appellant has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Jackson, Counsel