Citation Nr: 18145693 Decision Date: 10/29/18 Archive Date: 10/29/18 DOCKET NO. 16-34 292 DATE: October 29, 2018 ORDER 1. Entitlement to service connection for concussion residuals is denied. 2. Entitlement to service connection for headaches is denied. 3. Entitlement to service connection for maladjusted jaw is denied. 4. Entitlement to service connection for loss of teeth is denied. FINDINGS OF FACT 1. A current chronic disability manifested by concussion residuals is not shown by the probative evidence of record and did not have its onset during active service. 2. A current chronic headache disability is not shown by the probative evidence of record and did not have its onset during active service. 3. A current chronic disability manifested by maladjusted jaw is not shown by the probative evidence of record and did not have its onset during active service. 4. A current chronic dental disability manifested by loss of teeth did not have its onset during active service and is not otherwise due to trauma or injury incurred during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for concussion residuals have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for headaches have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for service connection for maladjusted jaw have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for loss of teeth have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 4.150 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1980 to August 1993. In the July 2016 VA Form 9, Appeal to the Board, the Veteran, through his representative, asserted that his claimed disabilities were incurred in service and alleged that VA never scheduled him for relevant examinations in conjunction with his claims. In this regard, and as discussed further below, the Board finds that the Veteran’s assertions regarding his claimed in-service injury lack credibility, and for three of these issues (concussion residuals, headaches, and maladjusted jaw), there is a lack of evidence of a current disability. Thus, the claims do not meet the criteria for entitlement to a VA examination, since there is a lack of competent evidence of a current disability or persistent or recurrent symptoms of a disability for three of the issues, and a lack of credible evidence establishing that an event, injury, or disease occurred in service for all four of these issues. Therefore, VA examinations are not warranted. Additionally, in a June 2015 submission from the Veteran’s representative, he asserted that the Veteran’s claimed headache disability may be associated with a service-connected disability. This does not change the determination that an examination is not warranted, as the Board finds that the claim for service connection for headaches does not meet the criteria for entitlement to a VA examination. Again, as will be laid out in more detail below, the Board finds as fact that there is no competent and credible evidence of a current headache disability. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. In order to warrant compensation for a dental disability, the evidence must show that a trauma has caused a loss of substance of the body of the maxilla or mandible resulting in a loss of teeth, or that disease (such as osteomyelitis, but not periodontal disease) has caused a loss of substance of the body of the maxilla or mandible resulting in a loss of teeth. 1. Entitlement to service connection for concussion residuals. 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for maladjusted jaw. 4. Entitlement to service connection for loss of teeth. The Veteran claims entitlement to service connection for concussion residuals, headaches, maladjusted jaw, and loss of teeth as a result of his active service. Specifically, in the September 2010 claim, the Veteran reported that he suffered an in-service injury that resulted in a concussion, loss of teeth, maladjusted jaw, and headaches and which required him to be hospitalized at Fort Benning and treated at the Fort Polk dental clinic. Regarding the first element of a service connection claim, the requirement of a current disability, the Board notes that post-service VA treatment records from February 2003 document the Veteran’s report that he broke teeth #s 25, 26, and 27 during active service. The VA provider noted that the Veteran had received excellent private dental care, with a dental bridge replacing teeth #s 25, 26, and 27. The Board finds this sufficient evidence to satisfy the requirement of a current dental disability regarding the Veteran’s claim pertaining to loss of teeth. However, the post-service evidence of record does not document current disabilities regarding the Veteran’s other claimed disabilities of concussion residuals, headaches, or maladjusted jaw. Notably, there are no post-service treatment records for any of these claimed conditions. For example, in the same February 2003 document that addressed the Veteran’s teeth, the examiner listed three other medical “problems,” which did not include concussion residuals, headaches, or maladjusted jaw. Examination of the head was normal. The Veteran was seen regularly by VA after that in February 2004, February 2005, February 2006, January 2007, March 2008, July 2010, March 2011, October 2013, April 2014, September 2016, and December 2017. The medical “problem list” changed over the years, where new “problems” were added, but concussion residuals, headaches, or maladjusted jaw were not part of the Veteran’s medical “problem list.” These VA records cover a period of 13 years. In October 2013, the examiner documented that the Veteran specifically denied headaches. If the Veteran had been experiencing chronic headaches since an in-service injury, it would have likely been documented in the October 2013 medical record. The private medical records are silent for these disabilities as well. For example, a July 2009 treatment record from Tallahassee Orthopedic Clinic shows that the when the examiner addressed the Veteran’s past medical history, it did not include concussion residuals, headaches, or maladjusted jaw. When a seven-page July 2010 independent medical expert opinion was submitted by the Veteran, the physician addressed multiple disabilities, which the physician attributed to service, but which did not discuss concussion residuals, headaches, or maladjusted jaw. This further supports the Board’s finding that there is a lack of competent and credible evidence that the Veteran has disabilities associated with concussion residuals, headaches, or maladjusted jaw. While the Veteran’s statements as a layperson are competent as to observable symptoms such as headaches and maladjusted jaw, the objective evidence of record does not document symptoms or complaints of headaches or maladjusted jaw during the appeal period, despite the Veteran’s ongoing treatment for multiple, unrelated medical conditions that span a period of more than 20 years. As such, his reports regarding a current headache disability and a maladjusted jaw lack credibility. Additionally, to the extent the Veteran asserts a current disability that is the result of an in-service concussion, the Board finds this to be a complex and internal condition beyond the competence of a layperson to identify and diagnose; therefore, the Veteran’s statements in this regard are of no probative value. Regarding the second element of a service connection claim, an in-service disease or injury, the Board finds that service treatment records do not document complaints, treatment, or diagnoses of chronic disabilities, including a concussion or related residuals, headaches, maladjusted jaw, or loss of teeth. At the March 1993 separation examination, clinical evaluations of the head, face, neck, and scalp and the mouth and throat were normal. In response to remarks and additional dental defects and diseases, the examiner wrote, “acceptable.” In the Report of Medical History that the Veteran completed at that time, he specifically denied a history of frequent or severe headache, severe tooth or gum trouble, head injury, and periods of unconsciousness. He was asked if he had been a patient in any type of hospital, and he checked yes and wrote down he was treated at a hospital in Florida in 1975. He was asked if he had any illness or injury other than those already noted, and he checked no. The Board finds the Veteran’s allegation of an in-service injury that caused a concussion and hospitalization lacks credibility. If the Veteran had sustained an in-service injury resulting in concussion, loss of teeth, maladjusted jaw, and headaches, the Board finds as fact that he would have sought treatment, as he sought treatment for multiple other medical conditions throughout his years in service. Additionally, the Board finds as fact that had he sustained this injury and residuals from the injury, he would have reported it during his separation physical and/or documented it in the Report of Medical History; however, he did not do so. Rather, the Veteran specifically denied headaches, a head injury, severe tooth trouble, and a period of unconsciousness, and when he reported a hospitalization, it was one that occurred prior to service, which is consistent with what he documented in the Report of Medical History he completed at enlistment in August 1980. Had the Veteran been hospitalized for this in-service injury, he would have listed that in the March 1993 Report of Medical History, as he took the time to check yes and then write down when he was hospitalized. The Veteran checked yes to multiple symptoms on this form, which means he read each question and answered yes to those symptoms he had experienced and no to those he had not experienced. He signed the Report of Medical History and certified that the facts he reported were true and complete to the best of his knowledge. The Board has no reason to question the accuracy of the facts the Veteran wrote in that document, since he completed it contemporaneously with service. This is further evidence that supports the conclusion that the Veteran did not suffer an injury resulting in a concussion or related residuals, headaches, maladjusted jaw, or loss of teeth during active service. Further supporting the finding that the Veteran’s allegations of an in-service injury are not credible are the service dental treatment records, which do not document any trauma or related treatment regarding teeth #s 25, 26, and 27 during active service, but document other dental treatment he received during service. In a January 2016 buddy statement from D.R., he wrote that the Veteran was injured in 1981 while riding in the rear compartment of a personnel carrier after a radio became dislodged and fell on his face, which resulted in the Veteran being knocked unconscious and transported to a hospital for treatment; the following week he noticed that the Veteran had lost a few teeth and had bruises on his face where the radio fell on him. The Board finds that this statement also lacks credibility, as it is inconsistent with contemporaneous report by the Veteran at service discharge, where he denied headaches, a head injury, severe tooth trouble, and a period of unconsciousness, and did not document an in-service hospitalization while documenting a hospitalization that had occurred almost 20 years before his service discharge. The Board accords more probative value to the contemporaneous records than a story recalled after more than 30 years. The Board has considered July 1990 service treatment records, which document that the Veteran fell on the bleachers at the gym and suffered a laceration to his right cheek, which was treated with sutures. He also reported hitting his right temple when he fell, but denied any loss of consciousness, dizziness, or blurred vision. There was no mention of concussion symptoms, loss of teeth, maladjusted jaw, or headaches in relation to the injury. In fact, subsequent treatment records document that the Veteran’s right cheek laceration was healing well with no other complaints regarding additional symptoms he was experiencing after this injury. The Veteran was seen regularly throughout his service for multiple medical complaints, and if he had been experiencing concussion residuals, headaches, maladjusted jaw, and loss of teeth, the Board finds it reasonable to conclude that he would have sought treatment for these symptoms and would have documented them in the March 1993 Report of Medical History that he completed at separation. Instead, he denied these symptoms in that Report of Medical History. For all the reasons laid out above, the Board finds that the preponderance of the evidence weighs against the fact that the Veteran’s claimed disabilities had their onset during active service. Without a current disability and an in-service disease or injury, service connection for the Veteran’s claimed concussion residuals, headaches, maladjusted jaw, and loss of teeth is not warranted. As the preponderance of evidence weighs against the Veteran’s claims, there is no reasonable doubt to be resolved, and the claims must be denied. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Chad Johnson, Counsel