Citation Nr: 18149913 Decision Date: 11/15/18 Archive Date: 11/14/18 DOCKET NO. 15-14 395A DATE: November 15, 2018 ORDER Service connection for an aneurysm is granted. Service connection for a right eye disability is granted. Service connection for vertigo is granted. Service connection for post-surgical scars of the right neck, right temple, and right thigh is granted. Service connection for bilateral arm tremors is granted. Service connection for a cervical spine disability is denied. Service connection for a bilateral hip disability is denied. Service connection for left ear hearing loss is denied. Service connection for tinnitus is denied. A 10 percent disability rating for traumatic brain injury is granted for the entire initial rating period on appeal. Entitlement to a compensable disability rating for loss of teeth numbered 6, 7, 8, 9, and 10, with trauma to teeth numbered 23 through 26, is denied for the entire initial rating period on appeal. A 10 percent disability rating due to multiple noncompensable service-connected disabilities under the provisions of 38 C.F.R. § 3.324 is denied. REMANDED Entitlement to service connection for right ear hearing loss is remanded. Entitlement to service connection for temporomandibular joint (TMJ) dysfunction is remanded. FINDINGS OF FACT 1. The medical evidence of record is at least in equipoise as to whether the aneurysm that was diagnosed in 1994 is etiologically related to the 1962 in-service car accident. 2. The current right eye disability, vertigo, post-surgical scars of the right neck, right temple, and right thigh, and bilateral arm tremors were caused or aggravated by the service-connected aneurysm. 3. Symptoms of cervical spine and bilateral hip disabilities, left ear hearing loss, and tinnitus were not continuous or recurrent in service or since service separation; arthritis, a left ear hearing loss disability, and tinnitus did not manifest to a compensable degree during or within one year of active service; and there is no medical nexus between the claimed cervical spine and bilateral hip disabilities, left ear hearing loss disability, or tinnitus and active service. 4. Throughout the initial rating period on appeal, the Veteran’s TBI has most closely approximated no more than level 1 impairment for any facet of the rating criteria, with evidence of mild functional impairment resulting from mild impairment of memory, attention, concentration, or executive functions. 5. Throughout the initial rating period on appeal, the Veteran’s service-connected loss of teeth has manifested a masticatory surface that can be restored by suitable prosthesis. 6. Throughout the period on appeal, the Veteran is in receipt of a compensable disability rating. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for the aneurysm have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 2. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for a right eye disability have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 3. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for vertigo have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 4. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for post-surgical scars of the right neck, right temple, and right thigh have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 5. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for bilateral arm tremors have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 6. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 7. The criteria for service connection for a bilateral hip disability have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 8. The criteria for service connection for left ear hearing loss have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 9. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 10. Resolving reasonable doubt in favor of the Veteran, the criteria for a 10 percent disability rating for traumatic brain injury have been met for the entire initial rating period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code (DC) 8045. 11. The criteria for entitlement to a compensable disability rating for loss of teeth numbered 6, 7, 8, 9, and 10, with trauma to teeth numbered 23 through 26, have not been met for any part of the initial rating period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.150, Diagnostic Code (DC) 9913. 12. There is no legal entitlement to a 10 percent disability rating for multiple noncompensable service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.324. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from May 1962 to October 1964. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from May 2014 and May 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent 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). The United States Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis or organic diseases of the nervous system (e.g., sensorineural hearing loss and tinnitus), to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In this case, the medical evidence of record demonstrates current diagnoses of arthritis, sensorineural hearing loss, and tinnitus. Where the veteran asserts entitlement to service connection for a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); 38 C.F.R. § 3.307 (service connection authorized for chronic diseases diagnosed within the presumptive period). However, for the reasons set forth below, the Veteran was not diagnosed with arthritis, sensorineural hearing loss, or tinnitus within one year of separation from service, nor has there been continuity of symptomatology. With specific regard to continuity of symptomatology, for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, such as arthritis, sensorineural hearing loss, or tinnitus noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The remaining conditions at issue are not among the “chronic diseases” listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to those disorders. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, 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 current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). 1. Service connection for an aneurysm is granted. The Veteran contends that her aneurysm, which was diagnosed in 1994, was caused by her in-service car accident in 1962. For the reasons discussed below, the Board finds that the evidence is at least in relative equipoise as to whether the aneurysm was caused by the in-service car accident, has resolved reasonable doubt in favor of the Veteran, and finds that service connection for the aneurysm is warranted. Service treatment records show that in October 1962, the Veteran was involved in a car accident and suffered multiple injuries. A Report of Investigation from that month found that the following diagnoses resulted from the accident and were considered to have been incurred in the line of duty: brain concussion, traumatic hematomas of the zygomatic arch and supra orbital ridge, avulsion of the maxillary and mandibular incisor teeth, laceration of the lip and chin, contusion of the right wrist, contusion of the right thigh region, and extraction of the maxillary and mandibular incisor teeth. The report noted that there was no artery or nerve involvement. Service treatment records are negative for any findings or diagnoses of an aneurysm. Following separation from active service, in September 1994, the Veteran underwent an MRI study of the brain to investigate the cause of right ear hearing loss. An incidental finding was made of an aneurysm of the right internal carotid artery. She underwent an internal carotid artery to middle cerebral artery bypass in April 1995 to address the aneurysm. An April 2014 VA examiner (a neurologist) diagnosed a cerebral aneurysm status post surgery, and opined that the aneurysm was less likely than not incurred in or caused by the in-service car accident. The examiner reasoned that a significant amount of time passed between the motor vehicle accident and the diagnosis of aneurysm (more than 30 years). The examiner stated that while trauma can cause aneurysms, it is not a frequent cause of this condition, and it is usually diagnosed early on. Therefore, it would be less likely that it would not be diagnosed for such a length of time. In September 2016, the Veteran submitted a letter from a private neurologist, Dr. S. The doctor stated that the Veteran is his patient and that he reviewed medical records she provided to him. He opined that her 1962 automobile accident more likely than not contributed to the formation of the aneurysm. He explained that, typically, aneurysms are formed when there is a weakening of one of the arterial walls. Over time, including many years, the constant pressure on the weakened arterial wall causes the arterial wall to expand or bulge out resulting in an aneurysm. He stated that this process can take many years to occur. He opined that the 1962 car accident caused damage to her internal carotid artery and, over time, that arterial damage resulted in the formation of her giant carotid artery aneurysm, which ultimately required surgical intervention. Dr. S. stated that while there is no way to prove this with 100 percent certainty, he believed that the car accident was more likely than not the cause of her aneurysm. Based on the foregoing, the Board finds that the evidence is at least in relative equipoise as to whether the aneurysm was caused by the in-service car accident. While the April 2014 VA opinion is negative, Dr. S., in his September 2016 letter, provided adequate rationale for his favorable nexus opinion. Resolving reasonable doubt in the Veteran’s favor, the Board finds that service connection for the aneurysm is warranted. 2. Service connection for right eye disability, vertigo, scars, and bilateral arm tremors as secondary to the aneurysm is granted. The Veteran contends that her right eye disability, vertigo, surgical scars, and bilateral arm tremors are related to her aneurysm, and that, therefore, service connection is warranted. The Board agrees. At a May 2014 VA eye examination, the examiner diagnosed decreased field in the right eye. The examiner stated that the field contraction was due to the cerebral aneurysm. Post-service treatment records also indicate that the right eye condition is due to the service-connected aneurysm. A September 1994 treatment note indicates that the Veteran reported experiencing haziness in the middle of her right visual field, which the doctor stated could be related to the newly diagnosed aneurysm. May 1995 and March 1996 letters from a neuro-ophthalmologist, Dr. M., explain that the aneurysm was compressing the right optic nerve and right optic tract, and that the Veteran had a very mild scotomatous visual field defect in the right eye which was related to damage to the lateral tract by the aneurysm. With regard to the vertigo, at an April 2014 VA examination, the Veteran reported that “motion sickness” started 4 to 5 years after the 1962 car accident. She described feeling nauseated and experiencing vertigo sensations while at the movies, in cars, and turning over in bed. These sensations lasted for five minutes. The examiner noted that with simple neck motion while sitting, the Veteran experienced vertigo; therefore, a Dix Hallpike test (Nylen-Barany test) for vertigo was not clinically indicated. The examiner attributed the vertigo to the now service-connected aneurysm. She was also afforded a VA scars examination in April 2014. The examiner identified post-surgical scars on her right neck, right temple, and right thigh due to the aneurysm surgery in 1995. Pictures were attached to the examination report. The April 2014 VA neurological examiner assessed a tremor of the bilateral arms due to the now service-connected aneurysm. The Veteran reported that these tremors began after her aneurysm surgery in 1995, and were not present beforehand. The examiner explained that aneurysm can cause such tremors. Resolving reasonable doubt in favor of the Veteran, the Board finds that the claimed right eye disability, vertigo, surgical scars, and bilateral arm tremor are etiologically related to the now service-connected aneurysm, and that service connection is warranted for these disabilities. 3. Service connection for cervical spine and bilateral hip disabilities, left ear hearing loss, and tinnitus is denied. Next, the Veteran contends that her current cervical spine and bilateral hip disabilities, left ear hearing loss, and tinnitus are related to active service. She has stated that her cervical spine and bilateral hip disabilities are related to the 1962 in-service car accident. With regard to the claimed hearing loss and tinnitus, she testified at the August 2016 Board hearing that she was part of a rifle team for six months in 1963, during which time she trained with weapons eight hours per day, sometimes without hearing protection, and that she began experiencing ringing in her ears during active service. At the outset, for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The threshold for normal hearing is between 0 and 20 decibels, and higher threshold shows some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Turning to the most relevant evidence of record, service treatment records show that the Veteran scored a 15 out of 15 on a whispered voice test at her April 1962 enlistment examination. The treatment records pertaining to the October 1962 car accident do not mention any cervical spine or hip injuries, including the Report of Investigation discussed above. The September 1964 discharge examination report shows that clinical evaluations of the neck, lower extremities, and spine were marked as normal. An audiogram revealed puretone thresholds of 20, 5, 5, and 10 in the left ear at the test frequencies of 500, 1000, 2000, and 4000 Hz, respectively (Note: Prior to November 1, 1967, service department audiometric test results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). In order to facilitate data comparison in this decision, for service department audiometric test results through October 31, 1967, the ASA standards have been converted to ISO-ANSI standards.) The Veteran checked “no” next to swollen or painful joints, ear trouble, and arthritis, bone, joint or other deformity on her Report of Medical History. She also wrote that her health was “excellent.” Following separation from service, in July 1991, an audiogram revealed puretone thresholds of 10, 20, 20, 5, and 10 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. The Veteran also reported tinnitus with history of head injury. The doctor assessed essentially normal hearing in the left ear. A January 2010 private treatment note indicates that the Veteran reported experiencing hearing loss since the late 1980s. She reported that since her 1995 bypass surgery, she had experienced a very slow, progressive hearing loss, and she brought in audiograms to confirm that. Her current audiogram, the results of which are not included in the treatment note, revealed a mild sensorineural hearing loss in the left ear. In April 2014, the Veteran was afforded a VA examination for her hips. She reported that she initially developed bilateral hip pain after the 1962 car accident, and that she had experienced recurrent bilateral hip pain since then. Currently, she stated she had hip pain once per week that lasted for two days and was treated with over-the-counter medication. She had not sought treatment for the hip pain. The examiner diagnosed degenerative joint disease of the hips with decreased motion, and opined that the hip disability is less likely than not related to active service, including the in-service car accident. The examiner reasoned that although she was noted to have a contusion on her right thigh following the 1962 car accident, she did not have a documented history of treatment for bilateral hip pain at the time or since then. Thus, this combined information was not supportive for the minimal degenerative changes in both hips (as seen on current X-ray reports) to be related to the car accident more than 50 years after the accident. At an April 2014 VA cervical spine examination, the Veteran reported that she started experiencing neck pain in her mid-20s without inciting event. She stated that it came upon her slowly over time. She reported that, currently, it was more of a nuisance and hurt her intermittently. X-rays showed mild osteopenia and mild degenerative change of the cervical spine. The examiner diagnosed cervical degenerative disc disease and degenerative joint disease, and opined that the condition was not related to active service, including the 1962 car accident. The examiner reasoned that the Veteran reported neck pain that started slowly in her mid-20s. Given the timeline from this report and her car accident reported at age 18, this did not correlate in the time frame for the neck condition to be caused directly by the accident. The Veteran was also afforded a VA audiological examination in April 2014. An audiogram revealed puretone thresholds of 30, 35, 30, 30, and 30 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. Speech discrimination was 96 percent in the left ear. In a May 2014 addendum report, the April 2014 VA audiological examiner opined that although the Veteran was exposed to hazardous noise levels while in service, her electronic hearing testing conducted at discharge showed that she did not have a significant threshold shift beyond normal variability while in service. Thus, the examiner opined that her hearing loss and tinnitus are less likely as not caused by or a result of noise exposure while in service. The examiner cited to a number of medical literature sources in support of his opinion. In April 2015, a VA neurologist opined that the Veteran’s hearing loss and tinnitus were less likely than not incurred in or caused by the in-service car accident, noting that she reported at the time of his examination “hearing loss in her right ear since the1970s.” She also reported tinnitus since that time. Given the time elapsed from the accident to the time frame of the reported hearing loss and tinnitus, the examiner stated that the hearing loss and tinnitus were less likely than not due to the TBI/car accident while in service. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the competent evidence demonstrates there is no relationship between the Veteran’s current cervical spine and bilateral hip disabilities, left ear hearing loss, or tinnitus and her military service, including no credible evidence of continuous or recurrent symptoms of the claimed disabilities during active service, continuous or recurrent symptomatology of the claimed disabilities following service separation, or competent medical evidence establishing a link between the current disabilities and active service. Therefore, the Board finds that a preponderance of the evidence that is of record weighs against the claim for service connection for the cervical spine and bilateral hip disabilities, left ear hearing loss, and tinnitus, and outweighs the Veteran’s more recent contentions regarding in-service continuous or recurrent symptoms and continuous or recurrent post-service symptoms. First, as discussed above, service treatment records are entirely negative for any signs, symptoms, reports, treatment, or diagnoses of a cervical spine or bilateral hip disability, left ear hearing loss, or tinnitus, including the negative service separation examination. Thus, the evidence weighs against a finding of chronic symptoms of the claimed disabilities during active service. Next, the preponderance of the evidence demonstrates that arthritis, hearing loss, and tinnitus did not manifest to a compensable degree within one year of service separation. The preponderance of the evidence demonstrates no arthritis, hearing loss, or tinnitus symptoms during the one-year period after service, and no diagnosis or findings of arthritis, hearing loss, or tinnitus of any severity during the one-year post-service presumptive period. Indeed, the evidence does not demonstrate a diagnosis of cervical spine or hip arthritis until 2014. Further, tinnitus was not reported until 1991, and hearing loss in the left ear was not demonstrated until 2010. For these reasons, the Board finds that arthritis, left ear hearing loss, and tinnitus did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for arthritis and organic diseases of the nervous system are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309. The Board next finds that the preponderance of the evidence demonstrates that symptoms of a cervical spine or bilateral hip disability, left ear hearing loss, and tinnitus were not continuous or recurrent since separation from active service in October 1964. The first post-service documentation of a cervical spine or bilateral hip problem was in 2013, when the Veteran filed her claim for service connection. The first documentation of reported tinnitus was in 1991, and a left ear hearing loss disability was not shown by the evidence until 2010, as outlined above. The absence of post-service complaints, findings, diagnosis, or treatment for tinnitus, left ear hearing loss, and cervical spine and bilateral hip disabilities for 27, 46, and 50 years, respectively, after service separation is one factor that tends to weigh against a finding of continuous or recurrent symptoms of the claimed disabilities after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence demonstrating that symptoms of the claimed disabilities were not continuous or recurrent since service separation includes the July 1991 audiogram demonstrating normal hearing in the left ear. With regard to the Veteran’s more recent assertions made in the context of the current disability claim of continuous or recurrent cervical spine and bilateral hip disability, left ear hearing loss, and tinnitus symptoms since service, the Board finds that, while the Veteran is competent to report the onset of symptoms of the claimed disabilities, these more recent assertions are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran’s assertions of continuous or recurrent symptoms of the claimed disabilities after service are not accurate because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records, which are entirely negative for any signs, symptoms, reports, findings, treatment, or diagnoses of a cervical spine or bilateral hip disability, left ear hearing loss, or tinnitus; the 1991 audiogram showing normal hearing in the left ear; and the lack of any medical documentation of reports or treatment for tinnitus until 1991, left ear hearing loss until 2010, and a cervical spine and bilateral hip disability until 2014, all decades after service separation. As such, the Board does not find that the evidence sufficiently supports continuous or recurrent symptomatology of the claimed disabilities since service so as to warrant a grant of service connection. Finally, the Board finds that the weight of the competent medical evidence weighs against a finding of a medical nexus between the current cervical spine and bilateral hip disabilities, left ear hearing loss, and tinnitus and active service. In this regard, the Board finds that the 2014 VA nexus opinions, discussed above, are the most probative evidence of record. The VA opinions are competent and probative medical evidence because they are factually accurate and are supported by adequate rationale. The VA examiners interviewed and examined the Veteran, were informed of the pertinent evidence, reviewed the Veteran’s claims file, and fully articulated the opinions in the reports. There are no contrary competent medical opinions of record. At the August 2016 Board hearing, the record was held open to give the Veteran the opportunity to submit favorable nexus opinions, but no such opinions have been received. The Board acknowledges the Veteran’s belief that her cervical spine and bilateral hip disabilities, left ear hearing loss, and tinnitus are related to her active service. However, her statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, she is not shown to be competent to render medical opinions on questions of etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a layperson, she is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Initial Disability Ratings Disability evaluations (ratings) are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). 4. A 10 percent disability rating for traumatic brain injury is granted for the entire initial rating period. Service connection for a TBI was granted in the May 2014 rating decision on appeal. An initial noncompensable disability rating was assigned. The Veteran contends that she is entitled to a compensable disability rating because she believes that many of the disabilities discussed above were incurred in the same car accident that caused the TBI. For the reasons discussed below, the Board finds that a 10 percent disability rating is warranted for her service-connected TBI for the entire initial rating period on appeal. The Veteran’s TBI has been evaluated under DC 8045, found under 38 C.F.R. § 4.124. The current version of DC 8045 states that there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. See 38 C.F.R. § 4.124, DC 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. VA is to evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified.” Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, should be evaluated under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified.” However, VA is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” table. VA is to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified.” VA is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed in 38 C.F.R. § 4.124a, DC 8045, that are reported on an examination, VA is to evaluate under the most appropriate diagnostic code. Each condition is to be evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Diagnostic Code 8045 instructs that VA should consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. The table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” contains ten important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a fifth level, the highest level of impairment, labeled “total.” However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than “total,” since any level of impaired consciousness would be totally disabling. A 100 percent evaluation is assigned if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” the overall percentage evaluation is assigned based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, a 70 percent evaluation is assigned if 3 is the highest level of evaluation for any facet. The current version of DC 8045 contains the following notes: Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from “activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms “mild,” “moderate,” and “severe” traumatic brain injury, which may appear in medical records, refer to a classification of a traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. First, with respect to physical complaints, the Veteran has been granted service connection for loss of teeth, discussed below, as associated with the in-service car accident and service-connected TBI. The rating assigned for her loss of teeth is also discussed below. Moreover, the other physical disabilities which she claims are related to her in-service car accident have been discussed above. Further, her migraine headaches have been determined not to be related to her TBI (see April 2014 TBI examination report). Therefore, any further discussion of her physical complaints need not be addressed in the context of evaluating whether a higher disability rating for the TBI is warranted. With respect to the Veteran’s emotional/behavioral dysfunction, she was afforded a VA mental disorders examination in March 2014. Although she reported some cognitive difficulties, she did not describe any psychological difficulties, such as depression or irritability, developing in the aftermath of the in-service car accident or otherwise. The examiner determined that she did not meet the criteria for a diagnosis of a mental disorder. There is no other medical evidence suggesting that she has been diagnosed with a mental disorder. The Board will therefore evaluate symptoms of cognitive impairment, subjective symptoms, and emotional/behavioral impairment related to her TBI under the criteria of DC 8045. Turning to the evidence of record, at the March 2014 VA psychological examination, the examiner noted that the Veteran appeared to understand the evaluator during the evaluation without any significant difficulty, and that her speech was fluent and easily elicited. She did not exhibit any psychomotor abnormalities. She stated that the primary cognitive difficulty she had was feeling cognitively slowed. She described mild word finding problems and mild memory inefficiencies. She reported that she did not have problems with losing or misplacing items, but often forgot things that people told her. She was easily distracted when she was trying to focus, such as when she was working on her accounting. However, she did focus well when she was watching television. She described a delay in her recognition of visual stimuli. For example, it took her a moment to differentiate between a bird and an airplane in the sky. Very occasionally, she experienced thinking that something was in her peripheral vision that was not there. She had mild depth perception problems; however, she had not had accidents related to her visual issues. Evaluating the TBI criteria, the examiner noted no complaints of impairment of memory, attention, concentration, or executive functions; judgment was normal; social interaction is routinely appropriate; she was always oriented to person, time, place, and situation; she had normal visual spatial orientation; and she had no neurobehavioral effects. Overall, the results of the brief cognitive testing reveal intact attention, language, visual-spatial, learning and memory abilities. The Veteran did exhibit subtle verbal fluency inefficiencies on both the SLUMS and the RBANS tests. However, even her verbal fluency scores were not impaired and they were generally within the expected range given estimates of her pre-morbid functioning. The examiner concluded that the Veteran sustained a concussion with loss of consciousness secondary to the car accident in1962, and that she described a full recovery and did not notice any cognitive symptoms developing in the aftermath of the injury. A VA neurologist conducted a TBI examination in April 2014 and noted that motor activity was normal, there were no subjective symptoms, and that the Veteran was able to communicate by spoken and written language. Consciousness was normal. Moreover, the Veteran did not have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere’s disease). Based on the lay and medical evidence of record, the Board has resolved reasonable doubt in the Veteran’s favor and finds that the evidence is at least in equipoise as to whether a 10 percent disability rating is warranted for the Veteran’s TBI. In essence, the Board has determined that one of the facets of cognitive impairment and other residuals of TBI not otherwise classified warrants an evaluation of level 1 impairment, but no higher, on the table found under DC 8045. Specifically, although the VA examiner indicated that there were no complaints of impairment of memory, attention, concentration, or executive functions, the Veteran reported difficulty with word finding and concentration, although there was no objective evidence of this on testing. This, according to the criteria under DC 8045, warrants the assignment of a level 1 impairment under the memory, attention, concentration, and executive functions category. None of the other facets of cognitive impairment and other residuals of TBI not otherwise classified warrant an evaluation higher than level 0. For example, judgment was normal to above average, warranting the assignment of a level 0 impairment. Social interaction, orientation, motor activity, and visual spatial orientation were normal, and thus a 0 is assigned for each of these facets. The VA examiner found no subjective symptoms related to the TBI; thus, a level 0 impairment is assigned for that facet. Further, there were no neurobehavioral effects, communication was normal, and the Veteran was conscious; thus, a level 0 impairment is assigned for those facets as well. To the extent that the rating criteria for the TBI contemplates some of the symptoms and disabilities for which service connection has been granted herein as secondary to the now service-connected aneurysm (e.g., bilateral arm tremors, vertigo, etc.), the Board clarifies that the assignment of a 10 percent rating for the service-connected TBI is based solely on the Veteran’s subjective reports of cognitive and executive function impairment. Thus, for the reasons discussed above, the Board has resolved reasonable doubt in the Veteran’s favor and finds that she is entitled to a 10 percent disability rating under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified,” because one of the facets is classified at an impairment level of “1,” but no higher, throughout the initial rating period on appeal. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 5. An initial compensable disability rating for loss of teeth numbered 6, 7, 8, 9, and 10, with trauma to teeth numbered 23 through 26, is denied. Service connection was granted for loss of teeth, as outlined above, associated with the in-service car accident in the May 2014 rating decision on appeal. An initial noncompensable disability rating was assigned under the provisions of 38 C.F.R. § 4.150, DC 9913. DC 9913, found in the Schedule of Ratings for Dental and Oral Conditions, contemplates the loss of teeth due to loss of substance of the body of the maxilla or mandible without loss of continuity, and provides for a noncompensable (0 percent) rating where loss of the masticatory surface can be restored by suitable prosthesis. A rating of 10 percent is assigned when all upper and lower teeth on one side are missing; when all lower anterior teeth are missing; or, when all upper anterior teeth are missing. A rating of 20 percent is assigned when all upper and lower anterior teeth are missing, or when all upper and lower posterior teeth are missing. A rating of 30 percent is assigned with loss of all upper teeth, or with loss of all lower teeth. A rating of 40 percent is assigned for loss of all teeth. Ratings of 10 percent or higher are assigned where the lost masticatory surface cannot be restored by suitable prosthesis. A note to DC 9913 states that these ratings apply only to bone loss through trauma or disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease since such loss is not considered disabling. 38 C.F.R. § 4.150. Turning to the most relevant evidence of record, the Veteran was afforded a VA dental examination in April 2014. The examiner assessed the loss of teeth numbered 6, 7, 8, 9, and 10, and trauma to teeth numbered 23 through 26 due to a blow to the face from the car accident in October 1962. The Veteran reported the loss of teeth numbered 6 through 10, and stated that she subsequently required frequent root canals on teeth numbered 11, 12, 23, 26, and 34 (only 23 and 26 were affected by the in-service car accident). Her military dentist made her a partial that she wore until approximately 2004. She had a new partial made by a civilian dentist with which she was currently satisfied. However, she stated that she feared that her lower teeth were becoming fragile and would require crowns in the future. She stated they had chipped over the years and required composite restorations. She was not currently in any pain. She expressed interest in implant replacement of her upper missing teeth. The VA examiner observed that a root canal and crown were required on tooth number 26 during active service. Several other root canals (teeth numbered 23, 24, 11, and 12) were completed after the service by civilian dentists. The examiner noted that she did not have loss of mandible or loss of maxilla (as documented by x-ray studies), and the loss of her teeth was not due to loss of substance of the body of maxilla or mandible. The examiner stated that the masticatory surfaces can be restored by suitable prosthesis. The Veteran was functioning well with her current prosthesis. However, her lower anterior teeth appeared fragile; there were several craze lines and chipping present in teeth numbered 23 through 25. There was clear documentation of the injury to the anterior teeth and loss of teeth 6 through 10, and a root canal/crown on number 26. The examiner noted that it is common dental knowledge that teeth may require root canal therapy several years after a trauma (as with teeth numbered 23 and 24). In a September 2014 letter, a private dentist, Dr. H., wrote that the October 1962 car accident left teeth imprints in the dash of the car and caused injury to the lower anterior teeth. He noted that she had a maxillary partial to replace her anterior teeth that were lost due to the accident, and that the partial had created some soft tissue problems as well as some problems associated with the breakage of the teeth on the partial due to space limitation. A May 2015 VA dental treatment note indicates that the Veteran’s missing teeth included numbers 1, 2, 6, 7, 8, 9, 10, 16, 19, and 30. Additionally, root canals had been performed on teeth numbered 11, 12, 24, and 26. Teeth numbered 23 and 24 had been restored, and a crown had been placed on tooth number 26. An August 2015 VA dental treatment note indicates the Veteran’s maxillary partial was getting old but that it still fit. In January 2016, root canal treatment was performed on tooth number 23. In March 2016, it was noted that teeth numbered 23 through 26 were fractured and broken, and the dentist recommended that they be restored with crowns. In addition, it was noted that the maxillary partial was ill-fitting, and the dentist recommended they fit the Veteran with a new partial. In a September 2016 letter, Dr. H. explained that any time you lose teeth, the replacement of said teeth with a removal partial, more likely than not, will cause other teeth in the mouth to have dental problems. The Veteran’s partial was anchored to teeth on both sides of the maxillary (molars, cuspids, and bicuspids), and those will need more work to maintain a good base for the partial. He stated that her bite has been affected by the partial due to space limitations in her mouth. When the lower teeth need fillings or crowns, they must have more adjustments in order to make sure that her bite does not cause pain to the rest of her teeth. Since the partial replaced the teeth, she has had several crowns due to her bite in addition to root canals needed due to the trauma to her teeth in the accident. She will likely need more root canals due to the space limitations of her bite. Her partial has also created some soft tissue problems. In a December 2017 letter, Dr. H. stated that the October 1962 car accident resulted in the Veteran losing her maxillary incisors and trauma to the mandibular incisors. Examination revealed that she is missing teeth six through ten and has popping of both right and left TMJ joints. Using a leaf gauge showed that there is no anterior contact with the existing partial in place, which had been in place for many years. He recommended replacing her partial with either implants or a fixed bridge to gain acceptable disclusion of her posterior teeth. After a review of the evidence, lay and medical, the Board finds that the weight of the evidence is against the assignment of a compensable disability rating for the Veteran’s loss of teeth for any part of the initial rating period on appeal. Namely, the evidence does not demonstrate that the masticatory surface cannot be restored by a suitable prosthesis. Although the Veteran has had difficulty with her maxillary partial, both her VA and private dentists have recommended replacement of the partial with either a new partial, implants, or a fixed bridge – all of which are evidently deemed suitable prosthesis by the treating dentists. The criteria for a compensable disability rating for loss of teeth have not been met. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The Board has considered whether any other diagnostic code would allow for a higher disability rating. However, the medical evidence does not demonstrate impairment of the ramus, condyloid process, coronoid process, hard palate, or that the Veteran suffers from chronic osteomyelitis or osteoradionecrosis; therefore, the Board concludes that the remaining diagnostic codes under 38 C.F.R. § 4.150 do not apply. The issue of entitlement to service connection for temporomandibular joint dysfunction is being remanded for the reasons discussed below. 6. A 10 percent disability rating due to multiple noncompensable service-connected disabilities under the provisions of 38 C.F.R. § 3.324 is denied. Whenever a veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the Rating Schedule, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. See 38 C.F.R. § 3.324. The provisions of 38 C.F.R. § 3.324 are predicated on the existence only of noncompensable service-connected disabilities. Once a compensable rating for any service-connected disability has been awarded, the applicability of the provisions under 38 C.F.R. § 3.324 is rendered moot. See Butts v. Brown, 5 Vet. App. 532, 541 (1993). Since the Board has assigned a 10 percent rating for the entire period on appeal for the Veteran’s TBI, the application of provisions of 38 C.F.R. § 3.324 is rendered moot. Accordingly, the claim must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive the Board should deny the claim on the ground of the lack of legal merit or the lack of entitlement under the law). REASONS FOR REMAND 1. Entitlement to service connection for right ear hearing loss is remanded. The medical evidence of record suggests that the right ear hearing loss may be etiologically related to the now service-connected aneurysm. Post-service treatment records show right ear hearing loss complaints beginning in the early 1990s. In a September 1994 letter, a neurologist, Dr. S., indicated that the Veteran complained of hearing loss in the right ear of three years’ duration, which the doctor said could be related to the aneurysm. In addition, in a January 2010 private treatment note, another doctor reviewed the Veteran’s right ear hearing loss history and diagnosed mixed hearing loss in the right ear, which may represent otosclerosis, but could also be in part due to the 1995 bypass procedure. While the April 2014 VA examiner address the relationship of the claimed hearing loss to acoustic trauma in active service, and a VA neurologist addressed the relationship of the claimed hearing loss to the 1962 car accident in an April 2015 report, neither examiner addressed the possibility of an etiological relationship between the right ear hearing loss and the aneurysm. Therefore, in light of the medical evidence discussed above and the grant of service connection for the aneurysm herein, the Board finds that a remand is necessary to obtain a VA opinion regarding whether or not the right ear hearing loss was caused or aggravated by the aneurysm. 2. Entitlement to service connection for TMJ dysfunction is remanded. In a May 2017 rating decision, service connection for TMJ dysfunction was denied. In January 2018, the Veteran submitted a timely notice of disagreement (NOD) with the May 2017 rating decision. In a February 2018 letter, the RO acknowledged receipt of the NOD, but a statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matter is REMANDED for the following action: 1. Obtain a VA opinion (or examination, if deemed necessary) from an appropriate specialist addressing the nature and etiology of the claimed right ear hearing loss disability. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran’s right ear hearing loss disability was caused or aggravated by her service-connected aneurysm? Note: The term “at least as likely as not” does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term “aggravated” in the above context refers to a permanent worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Send the Veteran and her representative a statement of the case that addresses the issue of entitlement to service connection for temporomandibular joint dysfunction. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Sherrard, Counsel