Citation Nr: 18143642 Decision Date: 10/23/18 Archive Date: 10/19/18 DOCKET NO. 15-34 942 DATE: October 23, 2018 ORDER Entitlement to a right shoulder disability is denied. REMANDED Entitlement to service connection for a missing tooth is remanded. FINDING OF FACT The Veteran’s current right shoulder disorder is not shown to have manifested in service or within the first year following separation from service; and, the more probative evidence of record indicates the disorder is not related to any event during service or caused or aggravated by the service-connected left shoulder disability. CONCLUSION OF LAW The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1970 to October 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. 1. Right shoulder Service treatment are absent any evidence of complaints, treatment, or diagnosis of a right shoulder disorder. There is likewise no evidence that arthritis of the right shoulder developed within a year of service, that the Veteran has had right shoulder symptomatology since service, or that his present right shoulder disability in directly related to service. The Veteran does not argue the contrary. Service connection under 38 C.F.R. §§ 3.303(a), (b), and (d) and 3.307 and 3.309 is not warranted. The Veteran contends that his right shoulder disability is related to his service-connected left shoulder disability. Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310 (a). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998). The record shows that the Veteran has been diagnosed with right shoulder tendonitis of the rotator cuff, long head biceps of the shoulder, and osteoarthritis of the acromioclavicular joint and the glenohumeral joint. See August 2013 VA examination. Additionally, a September 2013 rating decision granted service connection for a left shoulder disability. The first and second elements for secondary service are thereby established. Regarding whether the Veteran’s right shoulder disability was caused or aggravated by the service-connected left shoulder disability, a review of the record indicates that service connection on a secondary basis is not warranted. In so finding, the Board gives significant probative value to the August 2013 VA examination report and September 2013 nexus opinion of record. The VA examiner reviewed the Veteran’s claims file, statements of symptomatology, and medical literature, and conducted physical examination of the Veteran. Based on this thorough examination, the examiner opined that it was less likely than not that the Veteran’s current right shoulder disability was proximately due to or the result of Veteran’s service connected condition. The Board is aware that the examiner did not complete the portion of the Disability Benefits Questionnaire (DBQ) that pertained to aggravation. However, as will be discussed below, the examiner did discuss the question of aggravation in other parts of the report. The examiner noted that the Veteran has bilateral shoulder conditions, but they are caused by distinctly different etiologies. The examiner indicated that the Veteran’s left shoulder has a history of chronic dislocations as well as acromioclavicular arthritis and glenohumeral arthopathy. The examiner reported that the Veteran’s right shoulder has a history of diffuse rotator cuff tendinopathy involving multiple tendons, with some possible ill-defined tearing of the anterior infraspinatus tendon, degenerative labral changes; long head biceps tendinopathy with mild medial subluxation; and severe acomioclavicular arthroses. The examiner noted that the Veteran’s right shoulder signs/symptoms did not appear until 2012 long after his 1978 left shoulder surgery, and 18 years after his last prior left shoulder dislocation. The examiner noted that the Veteran’s left shoulder was most prominently affected in the 1970’s, but his right shoulder problems did not materialize until 2012, so the very remote development of right shoulder symptoms argues against a nexus to the left shoulder condition. As to the question of aggravation, he observed that there was not a gradual development of right shoulder problems as one might expect if he were favoring the left shoulder over decades. On an April 2013 VA treatment record, the Veteran was seen for his right shoulder. The orthopedic surgeon noted that the Veteran inquired about the possible root causes of his right shoulder pain, specifically, whether his long-term compensation for chronic left shoulder pain was a contributing factor. The orthopedic surgeon indicated that as the Veteran could not recall a specific injury to his right shoulder, he stated that was possible but that there in no way for him to definitively know. The term possible also implies that it “may not be possible” and it is too speculative to establish a nexus. Obert v. Brown, 5 Vet. App. 30, 33 (1993). In that regard, the orthopedic surgeon reported that the Veteran’s rotator cuff tendinopathy, acromioclavicular joint arthropathy and biceps tendinopathy are likely caused by a combination of possible contributing factors- age, genetics, repetitive mild trauma, and moderate/major trauma. The August 2013 examination and September 2013 opinion are the only competent medical opinions of record to address the medical relationship, if any, between the Veteran’s right shoulder disability and service, to include secondary to service connected disabilities. The medical opinions provide thorough, clear rationales based on accurate and thorough discussion of the evidence of record. Prejean v. West, 13 Vet. App. 444 (2000). The basis for the negative opinions is consistent with the evidence of record. Neither the Veteran nor his representative has presented or identified any contrary medical opinion that would, in fact, support the claim for service connection for a right shoulder disability. The April 2013 treatment record is essentially non-probative. The only other evidence of record supporting the Veteran’s claim is his own lay statements. In that regard, the Veteran is a layperson, and there is no evidence of record to show that he has the specialized medical education, training, and experience necessary to provide a competent medical opinion as to the nature and etiology of the medical condition he asserts warrants service connection. Diagnosing the right shoulder disability and providing an etiological opinion is medically complex in nature and not subject to be diagnosed or identified by a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran’s statements regarding diagnosis and etiology are not competent. Even if they were competent, they are outweighed by the medical opinion obtained from the August 2013 VA examiner, who found that the claimed right shoulder disability was not caused or aggravated by service connected left shoulder disability. The VA examiners considered the Veteran’s statements, as well as reviewed the claims file, in reaching these conclusions. The Board thus concludes that the preponderance of the evidence shows that the Veteran’s right shoulder was not caused or aggravated by his service connected left shoulder disability. The claim must be denied. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a missing tooth is remanded. Under current VA regulations, compensation is only available for certain types of dental and oral conditions, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. 38 C.F.R. § 4.150. Compensation is available for loss of teeth if such is due to loss of substance of body of maxilla or mandible, only if such bone loss is due to trauma or a disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, as such loss is not considered disabling. Id. at Note. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities and will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. Service treatment records show that the Veteran was treated for laceration on his chin and sutures in June 1976. A July 1976 service treatment record shows that the Veteran’s sutures on his chin were removed and there were no reported complications. A May 2014 rating decision granted service connection for a scar. The Veteran contends that he has a missing tooth due to the same in-service injury that left a tender scar on his chin. The Board is unable to determine whether the Veteran currently has a compensation-eligible dental disability such as loss of teeth due to the loss of substance of the body of the maxilla or mandible (where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease). The Board is not able to adequately resolve these questions on the basis of the evidence currently of record without the benefit of a competent dental examiner’s review of the pertinent dental records and examination of the Veteran. Accordingly, the Board finds that a remand for a VA dental examination is warranted in this case to determine whether any current dental conditions are related to the Veteran’s chin injury in June 1976, particularly in light of the low threshold standard endorsed by the Court in McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159 (c)(4). The matter is REMANDED for the following action: 1. Provide the Veteran with a VA compensation examination to determine the etiology of his dental condition. Any necessary tests or studies must be conducted and all clinical findings should be reported in detail and correlated to a specific diagnosis. The examiner is asked to provide an opinion as to whether the Veteran’s dental condition is related to the Veteran’s in-service laceration and scar on his chin. The examiner must address the following: a) List all current dental disorders. b) For each missing tooth, comment on whether the missing tooth is considered a replaceable missing tooth. c) For each non-replaceable missing tooth, comment on whether it resulted from loss of the substance of the body of the maxilla or mandible due to trauma or disease during service. Specifically note the trauma or disease resulting in tooth loss. d) For any periodontal disease, comment on whether it is acute or chronic. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Grzeczkowicz, Associate Counsel