Citation Nr: 18148727
Decision Date: 11/08/18	Archive Date: 11/07/18

DOCKET NO. 15-31 239A
DATE:	November 8, 2018
ORDER
Service connection for a dental disorder for compensation purposes is denied.
Entitlement to receipt of VA outpatient dental treatment is granted; the Veteran is authorized to receive any needed dental treatment.
Entitlement to an effective date prior to September 6, 2011, for the award of service connection for anxiety and posttraumatic stress disorder (PTSD) is denied.
REMANDED
Entitlement to service connection for a skin disorder, claimed as melanoma, is remanded.
Entitlement to a disability rating in excess of 50 percent for anxiety and PTSD is remanded.
FINDINGS OF FACT
1. The competent medical evidence does not reflect the Veteran has a current dental disorder, other than his service-connected residuals of mandible fracture, for which compensation may be paid.
2. The Veteran’s dental disorder aggravates his service-connected anxiety disorder; thus, the Veteran is entitled to Class III outpatient dental treatment.
3. On September 6, 2011, the Veteran filed claims for service connection for an acquired psychiatric disorder; there is no prior, unadjudicated claim seeking service connection for this disability.
CONCLUSIONS OF LAW
1. The criteria for service connection for a dental disorder for compensation purposes are not met. 38 U.S.C. §§ 1712, 5107; 38 C.F.R. §§ 3.306, 3.381, 4.150, 17.161.
2. The criteria for entitlement for receipt of VA dental treatment are met. 38 U.S.C. §§ 1712; 38 C.F.R. § 17.161.
3. The criteria for an effective date prior to September 6, 2011, for the award of service connection for anxiety and PTSD are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.157, 3.400.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
1. Missing Teeth
The Veteran has asserted entitlement to service connection for a dental condition, loss of teeth, due to facial trauma sustained in service. Specifically, the Veteran reports that he sustained facial trauma during a fight in service. In an April 2016 decision, the RO granted service connection for residuals of left mandible fracture.
Service connection may be awarded for missing teeth due to dental trauma or bone loss in service. The law and regulations also provide that treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are considered non-disabling conditions and may be considered service-connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161; see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995).
However, service connection for compensation purposes is only warranted for certain dental conditions. Specifically, dental disabilities that may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and 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. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916.
To establish entitlement to service connection for loss of a tooth, the Veteran must have sustained a combat wound or other in-service trauma. 38 U.S.C. § 1712; 38 C.F.R. § 3.381 (b). The significance of finding that a dental condition is due to in- service trauma is that a veteran will be eligible for VA outpatient dental treatment, without being subject to the usual restrictions of a timely application and one-time treatment. 38 C.F.R. § 17.161 (c).
The Veteran asserted the treatment for his service-connected mandible fracture may have damaged his teeth as treatment included wiring his jaw closed which limited his ability to perform adequate hygiene and left his teeth with cracks and chips. 
An October 2011 VA examination notes the Veteran was diagnosed with a compound fracture of the left mandible after a fight during service. The examiner noted that records indicate the Veteran lost no teeth due to this fracture because the fracture in an edentulous space. Upon entry into service, the Veteran was missing teeth #1, 2, 14, 16, 18, 19, 20, and 30. The fracture was in the body of the mandible in the #19 area. The Veteran stated he did not have dental care for 6 to 8 years after leaving service because he did not have a need. The care that followed has been considerable. A current panoramic film shows the wire use to stabilize the fracture. His jaw is being augmented to better accommodate a prosthesis. X-rays from service show a healing fracture and no loss of mandible due to the fracture. The examiner noted the Veteran did not lose any teeth from the fracture of the mandible in 1966 and did not lose any mandible or have sequalae from the event. 
Even though the Veteran does have missing teeth and there is credible evidence of facial trauma in service, the competent evidence of record does not link the Veteran's in-service trauma to his currently diagnosed missing teeth. The Board must find that service connection for compensation purposes must be denied as the diagnosed condition is not a dental disorder for which VA compensation may be paid. For these reasons, the claim of service connection for a dental disorder for compensation purposes must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application in the instant case. 
2. Dental Treatment
The Veteran asserts that service connection for dental treatment purposes is also warranted. 
As found above, service-connection for a dental disorder for compensation purposes has not been granted. However, the Board finds that the criteria for entitlement to receipt of VA outpatient dental treatment have been met. Outpatient dental treatment may be authorized by the Chief, Dental Service, for beneficiaries defined in 38 U.S.C. § 1712 (b) and 38 C.F.R. § 17.93 if the veteran meets criteria under one of six criteria under one of six different treatment classes. In particular, under Class III, those having a dental condition professionally determined to be aggravating disability from an associated service-connected condition or disability may be authorized dental treatment for only those dental conditions which, in sound professional judgment, are having a direct and material detrimental effect upon the associated basic condition or disability. 38 C.F.R. § 17.161. In an October 2011 VA examination report, the examiner indicated the Veteran is anxious and worries about his health, including intrusive thoughts concerning the problems with his jaw and dentition. The Veteran submitted a letter from his treating dentist dated in June 2016 which indicates the Veteran has extreme anxiety of dental work, and severe depression and anxiety due to the conditions of his teeth and mouth. The Veteran is currently service-connected for anxiety and PTSD. As the Veteran has provided a professional opinion stating his dental condition aggravates a service-connected disability, the Board finds the Veteran is entitled to receive any Class III dental treatment.
3. Earlier Effective Date
Unless specifically provided otherwise, the effective date for an award based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application thereof. 38 U.S.C. § 5110(a). This statutory provision is implemented by regulation, which provides that the effective date of an award of disability compensation based on an original claim will be the date of receipt of the claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400; see also 38 C.F.R. § 3.4 (b)(1) (defining disability compensation as basic entitlement for a veteran who is disabled as a result of a disease or injury incurred in or aggravated in the line of duty in active service).
The effective date for an award of direct service connection will be the day following separation from service or the date entitlement arose if the claim is received within one year after service separation; otherwise the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400.
The information of record does not contain any communication from the Veteran indicating his intent to file a formal or informal claim for service connection for an acquired psychiatric disorder dated prior to September 6, 2011.
The Veteran submitted his claim for PTSD on September 6, 2011. In a May 2012 rating decision, the RO granted service connection for anxiety, and assigned a 50 percent rating, effective September 6, 2011. Later, in an August 2015 rating decision, the RO granted service connection for PTSD and combined the evaluation with the Veteran’s service-connected anxiety. 
Although the evidence of record does not reveal the exact date upon which entitlement arose, the Board notes that such information is not required in order to conclude that the September 6, 2011 date assigned is the earliest date possible for which service connected may be effectuated. The reason for this is that, if entitlement arose prior to September 6, 2011, then the date of the claim would be the later of the two events, and hence the correct effective date as provided by 38 C.F.R. § 3.400(b)(2). Any evidence showing that entitlement arose after the selected effective date (September 6, 2011) would not entitle the Veteran to an even earlier effective date.
Put another way, the effective date of an award of compensation based on an original claim (received beyond one year after discharge), will be the date of VA receipt of the claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a), (b)(1); 38 C.F.R. § 3.400(b)(2). The Board notes that, even if the Veteran's claim was received after the medical evidence demonstrated that the Veteran was experiencing an acquired psychiatric disorder due to service, the effective date remains the date of the claim for which service connection was raised (September 6, 2011), which is the later date.
In reaching this conclusion, the Board emphasizes that an effective date of an award of service connection is not based on the earliest medical evidence, but rather on the date that the application upon which service connection was eventually awarded was filed with VA, i.e., the formal application for compensation of September 6, 2011, which demonstrated the Veteran's intent to file a claim for VA compensation benefits based on this disability. As previously indicated, the information of record reflects that the Veteran did not file a formal or informal application for service connection for an acquired psychiatric disorder prior to September 6, 2011, and that there is no evidence of any communication prior to September 6, 2011.
Accordingly, the Board finds that an effective date earlier than September 6, 2011 for the grant of service connection for an acquired psychiatric disorder is not warranted.
REASONS FOR REMAND
1. Skin
The Veteran initially filed his claim for service connection for melanoma and underwent a VA examination in December 2011. The examiner reported a diagnosis of actinic keratoses but did not give an opinion as to the etiology of the Veteran’s actinic keratoses. As the Veteran asserts his skin disorder is due to sun exposure in service, the Board finds an additional VA skin examination and etiology opinion is necessary.   
2. PTSD
VA treatment records dated in February 2016 indicate that the Veteran’s service-connected psychiatric disabilities have increased in severity since the Veteran was last examined by VA. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his anxiety and PTSD.
The matters are REMANDED for the following action:
1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s actinic keratoses is at least as likely as not related to sun exposure in service.
2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected anxiety and PTSD.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.  The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms.  To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his anxiety and PTSD alone.

 
M. TENNER
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Diane M. Donahue Boushehri, Counsel