Citation Nr: 18160262 Decision Date: 12/26/18 Archive Date: 12/26/18 DOCKET NO. 16-54 894 DATE: December 26, 2018 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a dental disability is remanded. Entitlement to an initial compensable rating for service-connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1967 to June 1969. This matter comes to the Board of Veterans’ Appeals (Board) from a July 2014 rating decision which granted service connection for PTSD, evaluated as noncompensable, and denied service connection for bilateral hearing loss, tinnitus, and a dental disability. Incomplete service treatment records The Veteran’s service treatment records appear to be incomplete. There is no entrance examination associated with the claims file and while the Veteran served on active duty from October 1967 to June 1969, his treatment records do not begin until March 1969, when he sustained injuries in Vietnam. The AOJ should obtain the Veteran’s complete service treatment records, to include his entrance examination. The AOJ should make a formal finding of unavailability if the Veteran’s records cannot be located. Incomplete VA treatment records The record reflects that the Veteran received treatment from the VA in 1970, 1977, and 1988, and hospital summaries are associated with the claims file. However, it is not clear whether the Veteran received outpatient treatment during this time, nor does it appear that the AOJ requested any associated outpatient treatment records. VA treatment records dated in 2014 reflect that the Veteran received a referral to the VA dental clinic. VA dental records have not been associated with the claims file. The Veteran’s complete VA outpatient treatment records should be obtained. 1. Entitlement to service connection for bilateral hearing loss and tinnitus is remanded. The Veteran was afforded a VA audiologic examination in June 2014. While the examiner opined that the Veteran’s bilateral hearing loss and tinnitus were less than likely as not caused by or a result of the Veteran’s military service, the examiner’s opinion was based upon a finding of normal hearing at separation from service. The etiology of a Veteran’s hearing loss cannot be based solely on a Veteran’s “normal” hearing at entrance to and separation from service. A remand is warranted to obtain a new VA examination that addresses the nature and etiology of the Veteran’s bilateral hearing loss and tinnitus. 2. Entitlement to service connection for a dental disability is remanded. The Veteran contends that service connection is warranted for a dental disability. Specifically, he states that he lost several of his front teeth during basic training when a BB ricocheted back into his mouth. In a July 1969 application for outpatient treatment, the Veteran reported that in August 1968, he had his teeth capped and filled while at Ft. Knox. In a December 1969 statement, the Veteran’s father reported that the Veteran lost his two front teeth because of an accident at the firing range. An April 1970 VA dental examination reflects that teeth #7, 8, and 9 had been crowned. The Board finds the December 1969 statement from the Veteran’s father credible and that the Veteran suffered an injury to his front teeth while in service. The Veteran should be afforded a VA dental examination to assess the current severity of the loss of his front teeth. 3. Entitlement to an initial compensable rating for service-connected posttraumatic stress disorder (PTSD) is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to an intial compensable rating for PTSD at this time. An April 2014 PTSD Disability Benefits Questionnaire (DBQ) reflects that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity and that he was incapable of managing his financial affairs. A June 2014 VA PTSD examination reflects that while the Veteran had PTSD, his symptoms were not severe enough to either interfere with occupational and social functioning or to require continuous medication. The Board notes that the Veteran was prescribed Zoloft as early as 2009 and thus finds the June 2014 VA examiner’s opinion was based on an inaccurate or incomplete premise. Due to the differences of findings of severity of the Veteran’s PTSD, the Board finds that a new VA examination should be obtained to ascertain the severity and manifestations of the Veteran’s service-connected PTSD. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s complete service treatment records, to include his entrance examination. 2. Obtain the Veteran’s complete VA treatment records, to include treatment from 1969 to present. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s bilateral hearing loss and tinnitus. The examiner must opine whether the Veteran’s hearing loss and/or tinnitus at least as likely as not (1) began during active service, to include related to an in-service injury, event, or disease, including the Veteran’s in-service hazardous noise exposure, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any dental disability, to include loss of the front teeth. The examiner should identify all manifestations of the Veteran’s traumatic loss of teeth, to include any condition that resulted from the traumatic loss of teeth and any additional treatment. The examiner must opine whether the Veteran had loss of teeth due to bone loss of the body of the maxilla or the mandible due to trauma or disease such as osteomyelitis. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected posttraumatic stress disorder (PTSD). The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his PTSD alone. (Continued on the next page)   6. After completing the above, and any other development as may be indicated, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Owen, Associate Counsel