Citation Nr: 18155222 Decision Date: 12/03/18 Archive Date: 12/03/18 DOCKET NO. 14-38 597 DATE: December 3, 2018 ORDER Prior to August 6, 2018, an initial rating in excess of 30 percent for bipolar disorder is denied. As of August 6, 2018, an initial rating of 100 percent for bipolar disorder is granted, subject to the laws and regulations governing the payment of monetary awards. An initial rating in excess of 40 percent for lumbar spasm and degenerative arthritis is denied. REMANDED Entitlement to service connection for residuals of a fractured mandible is remanded. Entitlement to service connection for headaches, to include as secondary to residuals of a fractured mandible, is remanded. FINDINGS OF FACT 1. For the appeal period prior to August 6, 2018, the Veteran’s bipolar disorder was manifested by symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximated occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. As of August 6, 2018, the Veteran’s bipolar disorder is manifested by total occupational and social impairment. 3. For the entire appeal period, the Veteran’s lumbar spasm and degenerative arthritis did not result in ankylosis of the thoracolumbar or entire spine, intervertebral disc syndrome (IVDS) with incapacitating episodes, or associated objective neurologic abnormalities other than radiculopathy of the left lower extremity. CONCLUSIONS OF LAW 1. Prior to August 6, 2018, the criteria for an initial rating in excess of 30 percent for bipolar disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9432. 2. As of August 6, 2018, the criteria for an initial rating of 100 percent for bipolar disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9432. 3. The criteria for an initial rating in excess of 40 percent for lumbar spasm and degenerative arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2,.4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1969 to March 1972. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in May 2011, March 2012, and November 2013 by a Department of Veterans Affairs (VA) Regional Office. In July 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In a rating decision issued on October 1, 2018, the Agency of Original Jurisdiction (AOJ) granted an increased rating of 70 percent for bipolar disorder, effective August 6, 2018. As this does not represent a full grant of the benefits sought on appeal, the increased rating issue has been characterized accordingly on the title page and remains on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The AOJ also granted a separate rating of 10 percent for left lower extremity radiculopathy associated with the Veteran’s lumbar spasm and degenerative arthritis and entitlement to a total disability rating based on individual unemployability due to service-connected disabilities, effective August 6, 2018. To date, the Veteran has not expressed disagreement with the assigned rating for the left lower extremity radiculopathy or the effective dates. However, the time limit for filing a notice of disagreement does not expire until October 1, 2019, i.e., a year from the issuance of such rating decision. Consequently, the Board finds that it would be premature to assume jurisdiction over such matters at this time. Further, while additional evidence relevant to the Veteran’s claims was associated with the record since the issuance of the respective statements of the case, such was considered by the AOJ in connection with the claims decided herein in the September 2018 rating decision. Moreover, as the remainder of the claims are remanded, the AOJ will have an opportunity to consider such newly received evidence in connection with the readjudication of such issues. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. 1. Entitlement to an initial rating in excess of 30 percent prior to August 6, 2018, and in excess of 70 percent thereafter for bipolar disorder. The Veteran’s service-connected bipolar disorder is evaluated as 30 percent disabling as of December 30, 2010, and 70 percent as of August 6, 2018, under the criteria of Diagnostic Code 9432, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity, due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in most areas.” Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, Diagnostic Code 9432. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126(a). The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug, 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, No. 16-1208 (February 23, 2018). Prior to August 6, 2018, the Veteran’s service-connected bipolar disorder is rated as 30 percent disabling. Therefore, the evidence must demonstrate manifestations that more nearly approximate occupational and social impairment with reduced reliability, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment to warrant a higher rating during this period. With respect to specific symptoms and functional limitations associated with the Veteran’s bipolar disorder, VA treatment records show that, for the period prior to August 6, 2018, he was oriented and dressed appropriately, with unremarkable speech, linear thought processes, and fair to good insight and judgment. He consistently denied suicidal and homicidal ideations. While he reported feeling depressed at times, those reports were often associated with situational depression, to include financial difficulties and physical disabilities. Additionally, a January 2012 VA examination reflects that the Veteran had depressed mood, anxiety, chronic sleep impairment and disturbances of motivation and mood; however, his symptoms did not include suspiciousness, panic attacks, memory loss, flattened affect, altered speech, impaired judgment or abstract thinking, suicidal ideation, obsessional rituals, or delusions. The examiner found the Veteran’s symptomatology resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Furthermore, while the Veteran reported mood swings, isolating behavior, difficulty sleeping, difficulty getting along with others, difficulty with memory and concentration, and paranoia at his July 2018 Board hearing, he also reported good relationships with his girlfriend and children, and socialized with friends on occasion, and indicated that he could not work due to his back disability. Concerning occupational impairment, while the Veteran has reported that he last worked in August 2010, a November 2011 VA treatment record indicated he desired to work and often was frustrated that his physical ailments prevented him from working. A May 2012 VA treatment record indicates the Veteran had worked “the other day”, and a June 2013 VA treatment record shows the Veteran reported an offer of day labor pouring concrete. Further, as noted above, while the Veteran reported difficulty getting along with others at the July 2018 Board hearing, he was unable to work due to his back disability. As to social impairment, an April 2011 VA treatment record shows the Veteran was spending time with his family, and, in August 2011, he had been able to ride his motorcycle for two weeks and was strongly connected to an organization for sobriety. In December 2011, the Veteran spent Christmas with his friends, and VA treatment records dated in February 2012 indicate he spent time with his grandson and wished to help his son with his problems. A September 2012 VA treatment record indicates the Veteran continued to have close relationships with his sober peers, and in February 2013, he reported that he had joined a gym. Further, VA treatment records dated from 2017 and 2018, as well as the Veteran’s July 2018 testimony, reflect that he had a good relationship with his girlfriend of almost 20 years and children. Further, he had plans to visit his parents in Florida, and enjoyed his friends and motorcycle club. Upon review, the Board finds the evidence does not reflect symptomatology that more nearly approximates occupational and social impairment with reduced reliability, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment to warrant a higher rating during this period. The primary symptoms reported by the Veteran during the period were that of depression, anxiety, and chronic sleep impairment, which were mostly related to situational depression and financial difficulties. In addition, the record indicates the Veteran desired to work but that more often than not his physical, rather than his psychiatric, disabilities prevented him from doing so. Further, the Veteran reported close friendships and familial relationships, as well as the ability to travel and spend time outside the home. Finally, the January 2012 VA examiner found the Veteran’s bipolar disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation, which is consistent with the currently assigned 30 percent rating. Here, the Board finds this level of severity to be consistent with the other evidence of record during the appeal period, and as such, a rating in excess of 30 percent prior to August 6, 2018, for bipolar disorder is not warranted. As of August 6, 2018, the Veteran’s service-connected bipolar disorder is rated as 70 percent disabling. Therefore, to warrant a higher rating, the evidence must demonstrate that his psychiatric symptomatology most nearly approximates total occupational and social impairment. Initially, the Board notes the record contains a minimal amount of treatment records dated after August 6, 2018, which primarily pertain to the Veteran’s medication, and as a result, the decision herein relies heavily on the September 2018 VA examination. In this regard, the VA examiner found the Veteran’s mental diagnoses of bipolar disorder and alcohol use disorder caused total occupational and social impairment. Although it was difficult to differentiate what portion of functional impairment was separately attributable to each diagnosis, the VA examiner found the Veteran’s bipolar disorder was the primary diagnosis causing functional impairment in his life. Based on this evidence, and resolving the benefit of the doubt in the Veteran’s favor, the Board finds a rating of 100 percent as of August 6, 2018, for bipolar disorder is warranted. 2. Entitlement to an initial rating in excess of 40 percent for lumbar spasm and degenerative arthritis. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The Veteran’s lumbar spasm and degenerative arthritis is evaluated under Diagnostic Code 5242, which pertains to degenerative arthritis of the spine under the General Rating Formula. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Such provides for a 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1): Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. IVDS may be evaluated under either the General Rating Formula or under the IVDS Rating Formula, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The IVDS Rating Formula provides that a 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. The Veteran’s back disability is currently rated as 40 percent disabling throughout the appeal period. To warrant a higher rating, the evidence must show unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine, or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Here, the Board finds such are not demonstrated at any time during the appeal period. On VA examination in March 2011, the VA examiner found there was no thoracolumbar spine ankylosis. Flexion was to 30 degrees, extension to 10 degrees, right and left lateral rotation were to 30 degrees, left lateral flexion was to 10 degrees, and right lateral flexion was to 15 degrees. In August 2018, such measurements were 70 degrees, 20 degrees, 30 degrees, 30 degrees, and 30 degrees, respectively, and the VA examiner found that there was no evidence of ankylosis of the spine. Further, while the Veteran reported pain, fatigue, stiffness, and flare-ups, there is still no evidence that his back disability resulted in ankylosis in contemplation of such factors. Moreover, at the July 2018 hearing, the Veteran reported limited range of motion, but he did not assert that he could no longer move his back. Therefore, as neither the medical evidence of record nor the Veteran’s lay statements indicate the presence of ankylosis in either the thoracolumbar spine or entire spine, the Board finds a rating in excess of 40 percent for the Veteran’s back disability under the General Rating Formula is not warranted at any time during the appeal period. Concerning a higher rating under the IVDS Rating Formula, the March 2011 VA examiner found the Veteran did not experience incapacitating episodes of spine disease. In August 2018, the VA examiner stated the Veteran did not have IVDS of the thoracolumbar spine. The Board notes the Veteran testified that he had “spent a couple of days in bed here and there” and stated that he had flare-ups once or twice a month for which physicians had told him to use ice and lie in bed. Upon review, however, the Board finds evidence, to include the Veteran’s lay statements, do not reflect symptomatology that rises to the level of IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months, which would warrant a rating in excess of 40 percent. With respect to associated objective neurologic abnormalities, the Veteran is already separately service-connected for radiculopathy of the left lower extremity, rated as 10 percent disabling, as of August 6, 2018. As noted in the Introduction, the Board has found that consideration of the propriety of the assigned rating or effective date for such disability would be premature at the current time. Furthermore, the Veteran does not contend, nor does the evidence show, that he experiences radiculopathy of the right lower extremity, or bladder or bowel impairment, associated with his back disability. While he does contend that he experiences erectile dysfunction, the medical evidence of record does not show, or suggest, that such is related to his back disability. Neither VA examiner found the Veteran experienced erectile dysfunction associated with his back disability. Furthermore, his VA treatment records reflect treatment for such disorder in connection with his nonservice-connected benign prostatic hyperplasia and lower urinary tract symptoms. Consequently, the Board finds the Veteran’s lumbar spasm and degenerative arthritis does not result in associated objective neurologic abnormalities other than radiculopathy of the left lower extremity. Therefore, additional separate ratings are not warranted. Other Rating Considerations In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence when evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran’s testimony concerning the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluations of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. The Board has also considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such disabilities is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record with regard to his initial rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). In conclusion, the Board has considered the applicability of the benefit of the doubt doctrine, which resulted in the award of an initial rating of 100 percent for bipolar disorder as of August 6, 2018. However, the preponderance of the evidence is against the Veteran’s claims of entitlement to an initial rating in excess of 30 percent prior to August 6, 2018, for bipolar disorder and an initial rating in excess of 40 percent for lumbar spasm and degenerative arthritis and, consequently, the benefit of the doubt doctrine is inapplicable and such must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 3. Entitlement to service connection for residuals of a fractured mandible. 4. Entitlement to service connection for headaches, to include as secondary to residuals of a fractured mandible. The Veteran contends that he has residuals of a fractured mandible and headaches as a result of an in-service assault that occurred in December 1971. Specifically, his service treatment records reflect that, at such time, he was hit in the face by another individual, which resulted in a fracture of his jaw. The Veteran further reports that he had dentures upon his entry to service, but after the assault and subsequent treatment, his jaw did not properly close. In this regard, his November 1969 entrance examination showed that he had a top plate. As determined by the AOJ in a March 2011 administrative decision, such assault, and resulting injury, occurred in the line of duty. Therefore, the Veteran claims that service connection for residuals of a fractured mandible, to include headaches, is warranted. In May 2011, the Veteran underwent a VA dental examination, at which time he reported occasional discomfort on the left side of his lower jaw and clicking that forced him to move his jaw around until he could reposition it. The Veteran reported a headache to the left temporal area on those occasions, which occurred a couple of times a month. The VA examiner reviewed the record and noted documentation of the Veteran’s in-service jaw fracture, but opined that it was not likely that the Veteran’s old jaw fracture was causing the clicking or headaches. Rather, he found that the occlusion on his dentures could be off or he could be over closed; however, this could not be evaluated because the Veteran did not bring his lower denture with him. In January 2012, the Veteran underwent a separate VA examination for his claimed headaches; however, at such time, the examiner found that he did not have a diagnosis of a headache disorder, and opined that such were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of such opinion, the examiner again noted that the Veteran did not have headaches per se, but rather may be reporting temporomandibular joint dysfunction, which began approximately 10 years previously, despite his jaw fracture occurring in the 1970’s. Consequently, he found such unlikely to be related. In August 2018, the Veteran was again afforded a VA examination so as to determine the nature and etiology of his headaches. At such time, the examiner diagnosed headaches with an onset in 2016. However, he opined that it was less likely than not that such were incurred in or caused by the claimed in-service injury, event, or illness. In support of such opinion, he stated that the Veteran did not seek medical attention for any ongoing headaches while on active duty. Further, the Veteran stated during the examination that his headaches began a few years previously, and had not had any imaging or seen any medical providers for such disorder. Consequently, the examiner stated that no medical nexus can be established at such time. Upon review, the Board finds that the opinions are inadequate to decide the instant claims. With respect to the Veteran’s claimed residuals of a fractured jaw, the May 2011 VA examiner offered a negative opinion, and found that the Veteran’s symptoms, to include clicking and associated headaches, could be related to his dentures. However, such could not be evaluated because the Veteran did not bring his lower denture with him. Consequently, the examiner’s opinion is not supported by an adequate rationale. Moreover, he did not consider the Veteran’s contention that, while he had full upper dentures upon his entry to service, his jaw did not properly close after the assault and subsequent treatment. Additionally, while the January 2012 VA examiner found that the Veteran’s reported jaw symptoms were unrelated to his in-service facture as such began 10 years previously, he did not appear to consider the Veteran’s report that he has experienced jaw symptoms, to include clicking, since his in-service jaw fracture. Further, with respect to the Veteran’s claimed headaches, while the January 2012 VA examiner did not find a diagnosis of such disorder, the August 2018 VA examiner did, in fact, find such a diagnosis, but offered a negative opinion. In this regard, such was based on the Veteran’s report that his headaches began a few years previously. However, such is not borne out by the record as evidenced by the fact that he filed a claim for service connection for headaches as early as December 2010, originally identified as residuals of his fractured mandible, which he indicated included headaches in January 2012. Furthermore, at his Board hearing, he testified that he had experienced headaches since his in-service jaw fracture. Therefore, the Board finds that a remand is necessary in order to afford the Veteran a new VA examination so as to determine the nature and etiology of his residuals of a fractured mandible and headaches. The matters are REMANDED for the following actions: Afford the Veteran an appropriate VA examination to determine the nature and etiology of his claimed residuals of a fractured mandible and headaches. The record, to include a complete copy of this remand, must be made available to the examiner, and all indicated tests and studies should be accomplished. (A) Identify all current disorders of the Veteran’s jaw and headaches. (B) For each currently diagnosed jaw disorder and/or headaches, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is related to the Veteran’s military service, to include the December 1971 assault where his jaw was fractured. In offering such opinion, the examiner should specifically address the Veteran’s contention that, while he had full upper dentures upon his entry to service, his jaw did not properly close after the assault and subsequent treatment. Additionally, he or she should consider the Veteran’s reports of a continuity of jaw and headache symptomatology since his in-service assault despite the lack of medical treatment. (C) For headaches, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is caused or aggravated by the Veteran’s jaw disorder. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. M. Celli, Counsel