Citation Nr: 18143623 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 16-13 453 DATE: October 19, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to a higher initial rating for service-connected mild degenerative changes at the right acromioclavicular (AC) joint, rated as 10 percent disabling prior to April 18, 2017 and as 20 percent disabling from that date, is denied. REMANDED Entitlement to service connection for degenerative arthritis of the back is remanded. Entitlement to service connection for degenerative arthritis of the bilateral hands is remanded. Entitlement to service connection for hepatitis is remanded. Entitlement to service connection for a dental disability of a front tooth (to include tooth number 8), for compensation and treatment purposes, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current right ear hearing loss disability; the Veteran’s left ear hearing loss did not manifest to a compensable degree within the applicable presumptive period, continuity of symptomatology is not established, and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 2. The Veteran is right-hand dominant. 3. Prior to April 18, 2017, the service-connected right shoulder disability did not limit the right arm motion to shoulder level. 4. After April 18, 2017, the service-connected right shoulder disability did not limit the right arm motion to midway between the side and shoulder level. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral hearing loss disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a), 3.385. 2. During the period prior to April 18, 2017, the criteria for a higher rating in excess of 10 percent for mild degenerative changes of the right AC joint, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5201. 3. During the period from April 18, 2017, the criteria for a disability rating in excess of 20 percent for the service-connected right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1975 to August 1978. This case comes to the Board of Veterans’ Appeals (Board) on appeal from decisions of the Agency of Original Jurisdiction (AOJ) dated in February 2014 and February 2015. The Veteran testified before a Decision Review Officer (DRO) of the Regional Office (RO) at a September 2017 hearing; a transcript of the hearing is of record. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303 (b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303 (b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The nexus element may be fulfilled by (1) a nexus opinion or (2) competent and credible evidence showing that the veteran has experienced frequent and persistent symptoms of the disease since service. 38 U.S.C. § 1154 (a); 38 C.F.R. §§ 3.303 (a), (d); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may only be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); but see McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, the tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and sensorineural hearing loss becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such diseases during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. Service connection for bilateral hearing loss The Veteran contends that he has a current bilateral hearing loss disability due to noise exposure in service. He testified that his duties in supply during service included delivering items to the flight line, where he was exposed to the noise from airplane engines, and to the field, where he was exposed to noise from artillery. See September 2017 hearing transcript. The question for the Board is whether the Veteran has a current bilateral hearing loss disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. For the purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies 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; see also McKinney v. McDonald, 28 Vet. App. 15 (2016) (holding that a minimum degree of hearing loss is a prerequisite for entitlement to service connection, and that a change in hearing as a result of service is a disability if it exceeds the levels specified in 38 C.F.R. § 3.385). Service connection for hearing loss may be granted where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting regulatory requirements for hearing loss disability for VA compensation purposes (i.e., under 38 C.F.R. § 3.385), and a medically sound basis upon which to attribute the post-service findings to the injury in service, as opposed to intercurrent causes. Hensley v. Brown, 5 Vet. App. 155 (1993). To establish entitlement to service connection, it is not required that a hearing loss disability by these standards of 38 C.F.R. § 3.385 be demonstrated during service, including at time of separation, although a hearing loss disability by these standards must be currently present, and service connection is possible if this current hearing loss disability can be adequately linked to service. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993) (citing Current Medical Diagnosis & Treatment, Stephen A. Schroeder, et. al. eds., at 110-11 (1988)). Right Ear A review of the evidence shows that a hearing loss disability of the right ear was not shown under 38 C.F.R. § 3.385 on VA examinations in January 2015 and November 2017. On VA examination in January 2015, audiometric testing revealed right ear decibel thresholds of 15, 15, 25, 30, and 30 and left ear decibel thresholds of 20, 20, 25, 30, and 35, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. Speech recognition scores using the Maryland CNC Test were 96 percent in the right ear and 92 percent in the left ear. The January 2015 VA examiner opined that the current bilateral hearing loss is not related to service. On VA examination in November 2017, audiometric testing revealed right ear decibel thresholds of 25, 25, 25, 30, and 30, and left ear decibel thresholds of 25, 25, 25, 25, and 45, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. Speech recognition scores using the Maryland CNC Test were 100 percent in the right ear and 96 percent in the left ear. The November 2017 VA examiner opined that the current bilateral hearing loss is not related to service. There is no probative evidence of record showing that the Veteran has a current hearing loss disability of the right ear under governing regulation. The Board concludes that the Veteran does not have a current hearing loss disability of the right ear under 38 C.F.R. § 3.385, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. §§ 3.303 (a), (d), 3.385. Although the Veteran has been diagnosed with bilateral sensorineural hearing loss, the results of the Veteran’s January 2015 and November 2017 VA audiological examinations confirm that he does not have sufficient hearing loss in the right ear to be considered a disability according to the requirements of 38 C.F.R. § 3.385. Thus, service connection for right ear hearing loss is not warranted as a current hearing loss disability is not shown, and the claim is denied. Left Ear With regard to the claim of service connection for left ear hearing loss, the Board finds that the results of the Veteran’s January 2015 and November 2017 VA audiological examinations show that he has sufficient hearing loss in the left ear to be considered a disability according to the requirements of 38 C.F.R. § 3.385. After a review of the evidence of record, including the Veteran’s service personnel records, and his statements and testimony, the Board finds that his military service is consistent with noise exposure. The January 2015 VA examiner opined that the current bilateral hearing loss is not related to service. The examiner noted that the Veteran had excellent hearing in both ears at the time of separation examination in 1978, with no decrease when compared with the enlistment examination in 1975. The examiner opined that there was no permanent positive threshold shift in auditory thresholds greater than normal measurement variability at any frequency between 500 and 6000 hertz. The November 2017 VA examiner opined that the Veteran's hearing loss is not at least as likely as not caused by or a result of an event in military service. the examiner stated that his hearing thresholds at the time of entrance and separation were within normal limits. The examiner stated that according ot the American College of Occupational Medicine Noise and hearing Conservation Committee, a noise-induced hearing loss will not progress once it is stopped. The examiner opined that therefore his current hearing loss was less likely than not related to military noise exposure/acoustic trauma. The Board finds that the January 2015 and November 2017 VA examinations constitute highly probative evidence against the Veteran’s claim of service connection for a left hearing loss disability, and outweighs the Veteran’s lay opinion. It is based on current examination results, the Veteran’s reported history, and a review of the medical records, including examinations during and after service. This fact is particularly important, in the Board’s judgment, as the references make for a more convincing rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The VA examiner opined that the Veteran’s hearing loss was not incurred in service. This opinion reflects a clear and unequivocal conclusion regarding the relationship between the Veteran’s left ear hearing loss and his active duty. The weight of the evidence does not show that the Veteran’s left ear hearing loss became manifest to a compensable degree within the first year after discharge from service, continuity of symptomatology is not established, and there is no probative medical opinion of record showing that the Veteran’s current left ear hearing loss disability is etiologically related to service. In sum, the Board finds the Veteran is not shown to have left ear hearing loss that was incurred in or aggravated by service. Accordingly, the claim must be denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, supra. 2. Entitlement to a higher rating for a right shoulder disability The Veteran contends that his service-connected right shoulder disability is more disabling than currently evaluated. He asserts that he has difficulty lifting his arm over his head. See RO hearing transcript at page 10. The RO has rated the service-connected mild degenerative changes at the AC joint of the right shoulder as 10 percent disabling prior to April 18, 2017, under Diagnostic Codes 5003 (pertaining to arthritis) and Diagnostic Code 5201 (pertaining to limitation of motion of the arm), and as 20 percent disabling from that date, under Diagnostic Code 5201. 38 C.F.R. § 4.71a. Normal ranges of upper extremity motion are defined by VA regulation as follows: forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71, Plate I. The record reflects that the Veteran is right-hand dominant, so his right shoulder disability is rated for impairment of the major upper extremity. Under Diagnostic Code 5201, a 20 percent rating is assigned for limitation of motion of either arm to shoulder level (90 degrees), a 30 percent rating is assigned for limitation of motion of the major arm to midway between the side and shoulder level (45 degrees), and a 40 percent rating is assigned for limitation of motion of the major arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. A 20 percent rating is the minimum rating under Diagnostic Code 5201. Prior to April 18, 2017, a 10 percent rating was assigned based on degenerative arthritis with painful motion of the shoulder. Under Diagnostic Code 5003, degenerative or traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. However, in the absence of limitation of motion, the disability is to be rated as 10 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups; and as 20 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Upon review of the record, the Board finds that a rating in excess of 10 percent prior to April 18, 2017, and a rating in excess of 20 percent from that date, is not warranted. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. Governing law provides that the evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14. In Esteban, the United States Court of Appeals for Veterans Claims (Court) found that when a Veteran has separate and distinct manifestations from the same injury he should be compensated under different Diagnostic Codes. When it is not possible to separate the effects of the service-connected disability from a non-service-connected disability, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Court previously indicated that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). However, the Court recently suggested that the plain language of 38 C.F.R. § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joint or periarticular pathology that are painful, whether or not evaluated under a diagnostic code predicated on range of motion measurements. See Correia v. McDonald, 28 Vet. App. 158 (2016); Southall-Norman v McDonald, 28 Vet. App. 346 (2016). The Board further notes that in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court explained that "the VA Clinician's Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from a veteran, including during flare-ups.” When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). In general, the degree of impairment resulting from a disability is a factual determination and the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any initial rating/increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed and considered the Veteran’s assertions in support of his claim, including his reports of pain with a popping sensation, and difficulty lifting things (as reported in April 2017). However, the objective medical evidence of record is of greater probative value as to the Veteran’s level of impairment than his assertions. During the period prior to April 18, 2017, even considering his subjective complaints of pain and other symptoms described in DeLuca, limitation of motion of the right (major) arm to shoulder level has not been shown such that a higher rating would be warranted. See Thompson, 815 F.3d at 786. Range of motion testing performed during a February 2014 VA examination revealed right shoulder flexion to 180 degrees, with pain beginning at 180 degrees; right shoulder abduction to 180 degrees, with pain beginning at 180 degrees; left shoulder flexion to 180 degrees, with no objective evidence of painful motion; and left shoulder abduction to 180 degrees, no objective evidence of painful motion. There was no additional limitation upon repetition. The Veteran denied flare-ups that impacted the function of the shoulder and/or arm. The examiner indicated that there was pain on movement of the right shoulder. There was no guarding or ankylosis, and muscle strength was full. Range of motion on VA orthopedic examination in January 2017 was 0 to 160 degrees of flexion, and 0 to 170 degrees of abduction. He had nearly full range of motion during this period. Accordingly, a rating in excess of 10 percent is not warranted for the right shoulder during the period prior to April 18, 2017. During the period from April 18, 2017, even considering his subjective complaints of pain and other symptoms described in DeLuca, limitation of motion of the major arm to midway between the side and shoulder level has not been shown such that a higher rating would be warranted. See Thompson, 815 F.3d at 786. Range of motion testing performed during an April 18, 2017 VA examination revealed right shoulder flexion to 135 degrees; right shoulder abduction to 120 degrees; left shoulder flexion to 135 degrees; and left shoulder abduction to 120 degrees. There was no additional functional loss or limitation of motion upon repetition. Pain was noted on examination but did not result in or cause functional loss. There was pain with flexion, abduction, external rotation and internal rotation. There was pain with weightbearing in the right shoulder only. The Veteran denied flare-ups that impacted the function of the shoulder and/or arm. There was no crepitus or ankylosis, and muscle strength was full. There was pain with passive range of motion, but it did not result in or cause functional loss. Accordingly, a rating in excess of 20 percent is not warranted for the right shoulder during the period after April 18, 2017. In reaching the above conclusions with respect to all issues decided, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND 1. Service connection for disabilities of the back and hands are remanded. The Board cannot make a fully-informed decision on the issues of service connection for arthritis of the back and hands because no VA examiner has opined whether these claimed conditions were aggravated by a service-connected disability. These issues are remanded for a supplemental medical opinion. Updated medical records should also be obtained. 38 U.S.C. § 5103A (c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). 2. Service connection for hepatitis The Veteran contends that he has current hepatitis C due to events in service. He testified that he did not use drugs intravenously in service, and that he always used protection during a sexual relationship he had in service. He asserted that he contracted hepatitis due to dirty instruments used during dental root canal surgery in service, or possibly when sharing cigarettes with other soldiers. See RO hearing transcript at pages 17-18. He also asserted that he was diagnosed with hepatitis C during service and was given a “shot to clear it.” He said he learned his hepatitis had returned after service, when he was told he could no longer donate plasma. Service treatment records are negative for hepatitis. A May 1978 treatment note reflects that the Veteran was treated for gonorrhea, and was treated with injections of penicillin. A February 1998 post-service treatment note from the Substance Abuse Residential Rehabilitation Treatment Program (SATP) reflects that the Veteran reported a history of alcohol and cannabis use for 20 years, and smoking cocaine for five years. He reported a history of prostitute engagement. He denied intravenous drug abuse. VA medical records reflect a diagnosis of hepatitis B. In light of the above, the Board will expand the claim to include service connection for hepatitis B. A July 2014 VA outpatient treatment record reflects that the Veteran had a positive hepatitis B antigen, and substance use disorder. He had a history of alcohol abuse, cannabis abuse, and cocaine dependence. He denied intravenous use of illicit substances. An August 2014 VA infectious disease note reflects that the Veteran reported that he had an episode of scleral icterus during military service and was told he had “hepatitis.” He donated plasma until over 20 years ago when he was told he had hepatitis. The physician noted that he currently used cocaine. The diagnostic impression was likely hepatitis B surface antigen carrier state. Subsequent VA outpatient treatment records reflect that the Veteran has been diagnosed with chronic hepatitis B. See, e.g., May 2016 VA rheumatology note. The Board cannot make a fully-informed decision on the issue of service connection for hepatitis because no VA examiner has opined whether current hepatitis B is related to service. Remand is required for a VA medical opinion. 3. Service connection for a front tooth disability for compensation and treatment The Veteran contends that he underwent a root canal of a front tooth in service that was inadequately performed, and he has current residuals, including pain and sensitivity. See RO hearing transcript at page 3. Service dental records show that he underwent a root canal of tooth number 8 in mid-September 1975, within one month of entry into service. An April 2017 VA dentistry note shows that the Veteran had generalized alveolar bone loss, and a dental restoration of tooth 8. The Board notes that disability compensation may be provided for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. Compensation is available for loss of teeth only if such is due to loss of substance of body of maxilla or mandible. See Simmington v. West, 11 Vet. App. 41 (1998). For loss of teeth, bone loss through trauma or disease, such as due to osteomyelitis, must be shown for purposes of compensability. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See Note to Diagnostic Code 9913, 38 C.F.R. § 4.150. It is unclear from the medical evidence of record whether the Veteran has a dental disorder for which service-connection may be awarded. A VA dental examination has not yet been performed with regard to this claim, and this claim is remanded for an examination and medical opinion. The matters are REMANDED for the following action: 1. Obtain updated VA medical records of treatment or evaluation of disabilities of the back and hands, hepatitis, and a dental condition. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s disabilities of the back and/or hands are at least as likely as not aggravated beyond their natural progression by service-connected disability. The examiner must discuss the underlying rationale for all opinions expressed, if necessary citing to specific evidence in the file. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and explain why this is so. 3. Send the claims file to a VA examiner in the appropriate specialty such as infectious diseases or liver disease to obtain an opinion on the Veteran’s claim for service connection for hepatitis. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. The examiner should consider the August 2014 VA infectious disease note. After review of the claims file, the specialist should respond to the following: (a.) Does the Veteran have a diagnosis of hepatitis C? (b.) What is the likelihood (more likely, at least as likely as not, or less likely) that the Veteran’s diagnosed hepatitis B (and C, if diagnosed) is causally related to in-service sexual activity, in light of the documented treatment for gonorrhea in service? (c.) What is the likelihood (more likely, at least as likely as not, or less likely) that the Veteran’s current hepatitis is causally related to an in-service root canal in September 1975? (d.) Is it at least as likely as not that current hepatitis is otherwise related to service? A rationale for all opinions expressed should be provided. The term, “as likely as not,” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the examiner’s conclusion as it is to find against it. 4. Schedule the Veteran for a VA dental examination to determine the nature of the claimed dental disability of the front teeth (numbers 8 and 9). The record must be made available to and reviewed by the examiner, and any indicated tests, including an X-ray study, should be performed. The examiner should provide an opinion as to the following questions: (a.) Is it at least as likely as not (50 percent or greater probability) that any current dental impairment of the front teeth (to include teeth 8 and 9) was incurred in or is due to the Veteran’s military service, to include dental trauma or any documented in-service dental treatment. (b.) Is it at least as likely as not (50 percent or greater probability) that any current dental impairment of the front teeth, including teeth 8 or 9, including any bone/tooth loss, is due to a periodontal condition. The examiner must discuss the underlying rationale for all opinions expressed, if necessary citing to specific evidence in the file. (Continued on the next page)   If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and explain why this is so. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. L. Wasser, Counsel