Citation Nr: 18145721 Decision Date: 10/30/18 Archive Date: 10/29/18 DOCKET NO. 15-05 816 DATE: October 30, 2018 REMANDED Entitlement to service connection for residuals of a jaw surgery is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1963 to September 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In July 2018, the Veteran and the Veteran’s spouse testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. 1. Entitlement to service connection for residuals of a jaw surgery is remanded. The Veteran asserts that he is entitled to service connection for acquired edentulism because the claimed disability is the result of active service. More specifically, the Veteran alleges that while in service he injured his jaw which required surgery. Following the surgery, the Veteran alleges that his jaw line was not properly aligned which ultimately lead to loss of teeth. An August 1963 medical note in the service medical records indicates that the Veteran was treated for a fractured jaw. The cause of the fracture was noted as a slip and fall. The Veteran underwent jaw surgery and had a tooth removed. In an April 2011 VA dental examination, the Veteran was diagnosed with acquired edentulism. The examiner noted there was no history of trauma to teeth, but there was a history of difficulty chewing. Other significant history included loss of most of the dentition. The examiner noted that there was no tooth loss due to mandible. It was opined that the Veteran’s dentition could have been caused by multiple factors. No malunion was noted on the hospital discharge record following surgery in-service. The examiner stated that “…acquired absence of teeth with alveolar atrophy, or a malocclusion related to the reduction could be factors, but cannot be proven from the records available.” Ultimately, the examiner could not provide an opinion without speculation as to whether or not the Veteran’s tooth loss was the result of the surgical reduction in service. The examiner then noted that “occlusal changes can be the result of alveolar atrophy secondary to tooth loss after leaving service…” At the July 2018 hearing before the Board, the Veteran testified that he broke his jaw during a fight in active service. During the fight, the Veteran stated that he fell between sinks and was hit several times which resulted in a broken jaw. He then reported to the dentist that he had a slip and fall. The Veteran stated that following the surgery his jaws were not aligned which ultimately led to tooth loss. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The April 2011 VA examination is insufficient for adjudication. The examiner could not provide an opinion without resorting to speculation. The examiner did not take into consideration the Veteran’s reported continuity of symptomatology or statements regarding the onset of tooth loss. Therefore, a new examination is necessary. 2. Entitlement to service connection for a low back disability is remanded. The Veteran contends that he is entitled to service connection for a low back disability, as the alleged disability is the result of a fall in service. An April 1965 service medical record notes that the Veteran was treated for an acute thoracolumbar muscle strain and spasm following a fall in-service. At the July 2018 hearing, the Veteran testified that he did not experience any back problems prior to service and likely did not seek continuous treatment in service due to being “too macho.” The Veteran stated that he had been receiving continuous treatment for low back pain since separation from service in 1966. In an April 2011 VA spine examination, the examiner stated that to provide an opinion as to whether or not the Veteran’s claimed back condition was related to service would require resort to mere speculation. No opinion was provided on the etiology of the Veteran’s low back disability. The examiner stated that service medical records were silent for back symptoms, treatment, or diagnosis, and the Veteran had a normal spine examination at separation from service. The basis of “lack of evidence during active service,” alone, is not sufficient. In addition, a service medical record does not treatment for back symptoms. Therefore, a new examination is necessary to determine the etiology of the Veteran’s low back disability. 3. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran contends that bilateral hearing loss is the result of his military occupational specialty in service, and should be service connected. The Veteran’s service separation form shows that his military occupational specialty was aircraft mechanic. Highly probable acoustic trauma has previously been conceded. High frequency hearing loss was noted on the Veteran’s August 1964 entrance examination. However, the Veteran was noted as “normal” on the September 1966 separation examination. In an April 2011 VA audiology examination, the examiner opined that the Veteran’s bilateral hearing loss was less likely as not caused by or a result of in-service noise exposure. The rationale provided was that there was no evidence of any permanent hearing loss in-service or at separation. In the alternative, the examiner stated that hearing loss was more likely due to “aging, hypertension, usage of potentially ototoxic medication, and occupational and recreational noise exposure.” At the July 2018 hearing, the Veteran testified that while in service as an aircraft mechanic, he was constantly exposed to loud noised with infrequent non-required hearing protection. The Veteran also stated that he had a mastoidectomy when he was a one-year old child. The Veteran’s spouse testified that hearing loss was present when they first started dating about thirteen years ago and had been noticeable since. When VA obtains an examination or opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The basis of “no evidence of any permanent hearing loss in service,” alone, is not sufficient to determine that a disability is not related to service or could not have manifested thereafter as a result of service. As a result, the Board finds that examination to be of less probative value and a new examination is necessary. Clinical documentation dated after October 2011 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Associate with the record any VA medical records not already of record of treatment of the Veteran, including records dated from October 2011 to present. 2. Schedule the Veteran for a VA dental examination to determination the etiology of any jaw surgery residuals, to include edentulism. The examiner must review the claims file and should note that review in the report. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should provide a rationale for all opinions provided. The VA examiner should opine as to whether it is at least as likely as not a (50 percent or greater probability) that residuals of jaw surgery had onset in, or are otherwise related to, the Veteran’s active service to include in-service jaw surgery with tooth removal. The examiner must also opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a dental disorder (to include a missing tooth/teeth) that began during service or as the result of some incident of active duty, to include trauma and the subsequent jaw surgery. The examiner should discuss the Veteran’s lay statements regarding the history and continuity of symptomatology. If the examiner determines that the Veteran’s jaw surgery residuals are not the result of active service, but should be attributed to some other cause, other than what is listed above, the examiner should so state, taking into account the Veteran’s full post-service work and medical history. 3. Schedule the Veteran for a VA audiology examination to determine the etiology of bilateral hearing loss with an examiner who has not previously examined him in conjunction with this claim. The examiner must review the claims file and should note that review in the report. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should provide a rationale for all opinions provided. (a.) The examiner should opine as to whether it is as likely as not (50 percent or greater probability) that any identified hearing loss had its onset during active service, is related to the Veteran’s conceded in-service noise exposure; or is otherwise related to service. (b.) If the examiner determines that hearing loss clearly and unmistakably preexisted entrance to service, then the examiner should opine if it is clear and unmistakable that hearing loss was not aggravated during service. (c.) The examiner should discuss the Veteran’s lay statements regarding the history and continuity of symptomatology. If the examiner determines that the Veteran’s bilateral hearing loss is not the result of active service, but should more likely be attributed to some other cause, the examiner should so state, taking into account the Veteran’s full post-service work and medical history. The examiner should specifically address any in-service threshold shifts. The basis of the opinion cannot be that hearing was normal at separation. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any low back disability. The examiner must review the claims file and note that review in the report. All indicated tests and studies should be accomplished and the findings reported in detail. The examiner should discuss the Veteran’s lay statements regarding the history and continuity of symptomatology. The examiner should provide a complete rationale for any opinions offered. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any low back disability is related to active service, or complaints and treatment during service, to include in April 1965 related to a fall. If the examiner determines that the low back disability is not the result of active service, and another etiology can be determined, the examiner should provide an opinion as to what more likely caused the low back disability, taking into account the Veteran’s full post-service work and medical history. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. D. Cross, Associate Counsel