Citation Nr: 19115079 Decision Date: 03/01/19 Archive Date: 02/28/19 DOCKET NO. 17-26 029 DATE: March 1, 2019 ORDER Entitlement to service connection for fibromyalgia, manifested by pain in the feet, knees, hands, back and neck is granted. Entitlement to service connection for irritable bowel syndrome (IBS) is granted. Entitlement to service connection for an acquired psychiatric disorder, including adjustment disorder with anxiety (also claimed as nervousness w/ sleeping difficulties) is granted. Entitlement to service connection for chipped/broken teeth is granted. REMANDED Entitlement to service connection for allergies is remanded. Entitlement to a gastrointestinal disorder, other than IBS, to include gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for chronic headaches is remanded. Entitlement to an initial compensable rating for mandibular malunion, s/p fracture (claimed as jaw pain & jaw clicking) is remanded. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia theater of operations during the Persian Gulf War. 2. The Veteran a current diagnosis of fibromyalgia, manifested by joint pain in the feet, knees, hands, back and neck, which is treated with medication. 3. The Veteran has a current diagnosis of irritable bowel syndrome (IBS), with frequent episodes of bowel disturbance with abdominal distress. 4. The Veteran's adjustment disorder with anxiety was proximately caused by the pain and disability from his service-connected fibromyalgia. 5. It is at least as likely as not that the Veteran’s current dental problems are related to in-service dental trauma. CONCLUSIONS OF LAW 1. The criteria for service connection for fibromyalgia, manifested by joint pain in the feet, knees, hands, back and neck, have been met. 38 U.S.C. §§ 1110, 1117, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for service connection for irritable bowel syndrome (IBS) have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for service connection for adjustment disorder with anxiety, secondary to service-connected disability, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for chipped/broken teeth have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.150. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2001 to July 2007. This matter comes before the Board of Veterans’ Appeals (hereinafter Board) on appeal from a January 2015 rating decision, which granted service connection for mandibular malunion, status post fracture, and assigned a 0 percent rating; that rating denied service connection for chronic headaches, arthritis pain in the feet, knees, hands, back and neck; service connection for allergies, service connection for GERD, service connection for IBS, service connection for chipped/broken teeth, and service connection for anxiety disorder. The Veteran perfected a timely appeal of that decision. The Court has held that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this regard, the Board notes that, while there is no rating decision specifying service connection for fibromyalgia, the Veteran is essentially seeking pain encompassing most areas of his body and he has been diagnosed with fibromyalgia. Therefore, under the facts of this case, the Board construes the Veteran's claim as encompassing entitlement to service connection for fibromyalgia. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a) (2018). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018). The record indicates that the Veteran served aboard the USS Shreveport. A post-deployment assessment, dated in June 2004, listed location of operation as Europe and Southwest Asia. The record further notes that the Veteran participated in Operation Enduring Freedom during the period from February 2004 to September 2004. His DD Form 214 also indicates that he was awarded the Global War on Terrorism Expeditionary Medal. Therefore, he had active military service in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Service connection may also be established for a chronic disability resulting from an undiagnosed illness which became manifests either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Certain medically unexplained chronic multisymptom illnesses (irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia), also may be presumed service connected based on Persian Gulf service. 38 C.F.R. § 3.317 (a)(2). Otherwise, conditions that have been attributed to a clinical diagnosis may not be presumed service-connected pursuant to See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. 38 C.F.R. § 3.317 (a)((1)(ii). Service connection may be established for disability that is proximately due to or the result of, or aggravated by a service- connected disease or injury. 38 C.F.R. § 3.310. The Veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person 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 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id., see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for fibromyalgia, manifested by joint pain in the feet, knees, hands, back and neck The Veteran is seeking service connection for pain in his feet, knees, hands, back and neck, to include as due to an undiagnosed illness. As noted above, the Board finds that the Veteran is a Persian Gulf Veteran within the definition of 38 C.F.R. § 3.317 as a result of his documented participation in Operation Enduring Freedom during the period from February 2004 to September 2004 and being awarded the Global War on Terrorism Expeditionary Medal. See 38 C.F.R. § 3.2 (i). As such, the Board finds that the Veteran has qualifying service in Southwest Asia for the purposes of the presumption in favor of Persian Gulf War Veterans. Id. Submitted in support of the Veteran’s claims are VA progress notes dated from August 2013 through March 2018, which show that the Veteran has received clinical evaluation and treatment for his claimed disabilities. These records reflect a diagnosis of fibromyalgia. During a clinical visit in July 2014, it was noted that the Veteran endorsed early satiety, hand, knee, and lower back joint pains. At that time, he reported having had joint pain in his hands, knees and back for about 9 years, which he attributed to working in the Navy. A nursing nose, dated in January 2015, indicates that the Veteran reported pain in the back, knees and hands. The treatment records also show that the Veteran has been diagnosed with and has received ongoing clinical attention and treatment for his fibromyalgia. During a DBQ examination for his hands and fingers in December 2014, it was noted that the Veteran had been receiving treatment for generalized pain for the past 10 years and he was diagnosed with soft tissue rheumatism, likely fibromyalgia. He was currently being treated with Gabapentin and Tramadol. During a clinical visit in December 2014, it was noted that the Veteran was being followed by rheumatology and diagnosed with fibromyalgia. A clinic note, dated in June 2015, reflects a diagnosis of soft tissue rheumatism, likely fibromyalgia. During a clinical visit in March 2016, it was noted that the Veteran was seen in the rheumatology clinic in September 2014 for generalized musculoskeletal pain and positive ANA; he was appreciated to have soft tissue rheumatism and possible fibromyalgia. It was noted that he continued to complain of generalized pain and he was taking cyclobenzaprine. The assessment was soft tissue rheumatism, likely fibromyalgia. Based on this evidence, the Board finds that the Veteran has met the current disability requirement with regard to his claim for service connection for fibromyalgia, manifested by joint pain. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim). Moreover, the disability has manifested to a compensable degree. Under 38 C.F.R. § 4.71 (a), Diagnostic Code 5025, a compensable rating is warranted for fibromyalgia that requires continuous medication for control. In this regard, the VA treatment records indicate that the Veteran has received continuous medication, such as Gabapentin and Tramadol, to help control symptoms of his fibromyalgia which has included chronic joint pain. Therefore, service connection for fibromyalgia is warranted based on the presumption in favor of Persian Gulf War veterans. 38 C.F.R. §§ 3.102, 3.317; Gilbert, 1 Vet. App. at 56. 2. Entitlement to service connection for irritable bowel syndrome (IBS) The Veteran is seeking service connection for a gastrointestinal disorder, namely IBS, to include as due to an undiagnosed illness. In this regard, the Board notes that the medical evidence reflects that the Veteran has received ongoing clinical evaluation and treatment for complaints of stomach pain and nausea. A GI consult note, dated in July 2014, indicated that the Veteran was seen for evaluation of abdominal pain and diarrhea, querying the possibility of IBD and PUD given his long-standing NSAID use. He underwent both an EGD and colonoscopy yesterday which besides some changes at the ileocecal valve, were fairly unrevealing. Biopsies were obtained at the ileocecal valve, the stomach and the duodenum are pending. An infectious workup for his diarrhea and abdominal pain was also negative. On further discussion with the patient he did describe his abdominal pain as being epigastric with early satiety that worsened with stress. His diarrhea also worsened with stress and I suspect functional dyspepsia and diarrhea-predominant IBS may be contributing to his symptomatology. The Veteran's STRs are negative for complaints, findings, diagnosis, or treatment for a gastrointestinal disorder. However, in his notice of disagreement, dated in June 2015, the Veteran indicated that he experienced severe indigestion and stomach during service. Having carefully reviewed the record, the Board concludes that service connection for IBS is warranted. As noted above, a July 2014 treatment note reflects a diagnosis of IBS. A GI consultation note, dated in July 2014, indicated that the Veteran was seen for increased abdominal pain and diarrhea; at that time, the examiner stated that IBS may be contributing to the Veteran’s symptomatology. The records indicate that he was started on a different medication in August 2016; and, in September 2016, it was again noted that his GI symptoms may related to IBS vs. the medication he was taking. IBS is considered a functional gastrointestinal disorder, subject to presumptive service connection. There is no evidence of record which controverts this finding. Functional gastrointestinal disorders are medically unexplained chronic multisymptom illnesses pursuant to 38 C.F.R. § 3.317 (a)(2)(i)(B). In sum, the record supports a finding that the Veteran has IBS which manifested after his time in the Persian Gulf. There is no evidence in the claims file suggesting that this disorder can be attributed to any known clinical diagnosis. Accordingly, the service connection for IBS is warranted. 3. Entitlement to service connection for an acquired psychiatric disorder, including adjustment disorder with anxiety (also claimed as nervousness w/ sleeping difficulties) The Veteran is seeking to establish service connection for a nervous disorder, claimed as secondary to his service-connected disorders. The Veteran maintains that he has suffered from chronic pain and eventually led to developing anxiety. In the present case, there is no dispute that the Veteran suffers from chronic pain, caused by fibromyalgia, for which service connected has been granted in this decision. There is also no dispute as to the existence of a current nervous disorder. Indeed, submitted in support of the Veteran's claim were VA progress notes, dated from April 2017 to March 2018, which show that the Veteran has been diagnosed with adjustment disorder with anxiety, which has been attributed to chronic pain. In assessing the Veteran's secondary service connection claim, the sole question remaining for consideration is whether the medical evidence demonstrates a causal relationship between the service-connected joint pain and the adjustment disorder with anxiety. After a careful review of the evidence of record, the Board finds that service connection for adjustment disorder with anxiety is warranted. In this regard, the Board notes that VA treatment records dated from April 2017 to March 2018 show that the Veteran has been diagnosed with adjustment disorder with anxiety, which has been attributed to chronic pain. Significantly, during a clinical visit in July 2017, it was recommended that the Veteran see a mental health provider for chronic pain and possible depression and anxiety that comes with it. The pertinent diagnoses were adjustment disorder with anxiety and chronic pain. As discussed above, the Veteran is now service-connected for pain, diagnosed as fibromyalgia. And, the VA treatment records suggest that the Veteran suffers from an adjustment disorder with anxiety caused by chronic pain stemming from a condition for which he is now service-connected. As such, service connection for the Veteran's anxiety disorder is warranted as being secondary to a service-connected disability. Accordingly, service connection for an acquired psychiatric disorder, diagnosed as adjustment disorder with anxiety is granted. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for adjustment disorder with anxiety is warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for chipped/broken teeth The Veteran claims that he sustained broken teeth as a result of a fall in service. The Veteran maintains that tooth number 3 was extracted due to a fractured root as a result of the fractured jaw in service; he also notes that teeth number 27, 4, 12 and 20 were repaired during his treatment for the fractured jaw and he has since experienced a further breakdown of those teeth and other surrounding teeth. Under current legal authority, compensation is only available for certain types of dental and oral conditions, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. See 38 C.F.R. § 4.150 (2018). Compensation is available for loss of teeth if such is due to loss of substance of body of maxilla or mandible, but only if such bone loss is due to trauma or osteomyelitis, and not due to the loss of the alveolar process as a result of periodontal disease, as such loss is not considered disabling. Id. at Note. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purposes of establishing eligibility for outpatient dental treatment and cannot be considered for compensation purposes. See 38 U.S.C. § 1712 (2012); 38 C.F.R. §§ 3.381, 4.150 (2018). 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. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The service treatment records (STRs) indicate that the Veteran was referred to the dental clinic on May 13, 2005 for evaluation after suffering a mandibular fracture of the right condyle. It was noted that he had multiple fractured teeth and laceration of the left chin. Examination revealed that tooth #3 was fractured at ML cusp and there was a vertical fracture of the DL cusp through the palatal root, which was non-restorable. Tooth #4 had m-d oblique fracture of the buccal cusp to the crest of buccal plate with pulp exposure. Tooth #12 had a small enamel fracture, which was smoothed. Teeth # 20, 27, and 30 also had enamel fractures. The teeth were repaired. Furthermore, the STRs reveal that the Veteran was seen in May 2005 for evaluation after he experienced loss of consciousness; he was diagnosed with syncopal episode of unknown etiology and fractured mandible. It was noted that he had no other complaints except for episodes of mandibular pains. The Veteran was afforded a DBQ examination for oral and dental conditions in December 2014. The Veteran indicated that he passed out and hit his lower jaw on the ground resulting in a fractured right jaw; he spent two days in the dental chair to fix the teeth that were damaged due to the broken jaw. The Veteran related that tooth #3 was extracted due to the fractured root, and teeth numbers 27, 4, 12 and 20 all had to fixed for minor chips. He currently had 3 broken teeth in his mouth as a result of the inservice incident. Following an examination, the reported diagnoses were malunion or nonunion of mandible, and loss of teeth for reasons other than periodontal disease. The examiner stated that the claimed condition was at least as likely as not incurred in or caused by the claimed inservice injury, event or illness. The examiner stated that, according to Veteran’s dental record, teeth numbers 3, 4, 12, 20 and 27 were damaged and restored/treated after his traumatic injury. It did not state anything about number 13. However, other teeth that the Veteran is having trouble with were listed in his dental records. Therefore, the claimed missing/cracked teeth was at least as likely as not incurred in or caused by the claimed inservice injury, event or illness. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran suffered in-service trauma. Inasmuch as the December 2014 DBQ opinion establishes that the Veteran has residuals of an in-service dental trauma affecting teeth #3, 4, 12, 20 and 27, service connection may be granted for those teeth. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND After examining the record, the Board concludes that further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C. § 5103A (2012). The specific bases for remand are set forth below. 1. Entitlement to service connection for allergies is remanded. The Veteran maintains that service connection is warranted for allergies. In a statement, dated in August 2017, the Veteran’s attorney noted that respiratory system symptoms are specifically identified as signs or symptoms that may be a manifestation of a medically unexplained chronic multi symptom illness. 38 C.F.R. § 3.317 (b). The post-service record on appeal includes VA clinical records, dated from August 2013 to March 2018. These records are entirely silent for a diagnosis of allergies, although the Veteran’s medications include Fluticasone for allergies. To date, the Veteran has not been afforded a VA examination that evaluates his claimed disorder based on the theory that it is a result of his service in Southwest Asia. Consequently, the Board finds it necessary to remand the Veteran’s claim of service connection for allergies, as it falls within the categories of signs or symptoms that may be a manifestation of a medically unexplained chronic multi symptom illness. 2. Entitlement to a gastrointestinal disorder, other than IBS, to include gastroesophageal reflux disease (GERD) is remanded. The Veteran maintains that he developed a gastrointestinal disorder as a result of the large amounts of pain medication he took for the arthritis in his joints. The Veteran also reported that, while on active duty in Guan, he was treated for stomach pain accompanied by chest pain due to severe indigestion; he was treated with medications. The Veteran indicated that, since service, he has experienced chronic intestinal and stomach problems for which he has been hospitalized on several occasions. Submitted in support of the Veteran’s claims are VA progress notes dated from August 2013 through March 2018, which show that the Veteran has received clinical evaluation and treatment for a gastrointestinal disorder, diagnosed as GERD. In August 2013, the Veteran was diagnosed with GERD, controlled with medication management. A July 2014 treatment note reported a history of GERD, with the Veteran presenting with abdominal pain, diarrhea, fever and chills. To date, the Veteran has not been afforded a VA examination that evaluates his claimed GI disorder. As there is at least an indication that a current gastrointestinal disorder may be related to service or a service-connected disability, and there is insufficient medical evidence on file to make a decision on the claim for GERD, the Board finds that a remand is necessary in order to provide the Veteran with a VA examination to determine the etiology of the GERD. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 3. Entitlement to service connection for chronic headaches is remanded. The Veteran maintains that he developed chronic headaches as a result of service. The Veteran maintains that the pain in his jaw has caused chronic headaches. In a statement dated in August 2017, the Veteran’s attorney also argued that his headaches are symptoms that are recognized as possible manifestations of an undiagnosed illness or medically unexplained chronic multi symptom illness for those who served in Southwest Asia during the Persian Gulf War. See 38 C.F.R. § 3.317 (b). Post service treatment records show ongoing complaints of headaches. A treatment note, dated in July 2014, reflects a past medical history of headaches since a MVA one year ago. During a clinical visit in July 2014, it was noted that the Veteran complained of headaches which he believed are associated with blurry vision. When seen in June 2016, the Veteran complained of headaches almost daily; no pertinent diagnosis was noted. As discussed above, the Veteran had qualifying service in the Southwest Asia Theater of operations during the Persian Gulf War. Thus, a remand is warranted to provide the Veteran an in-person Gulf War examination to address the nature and etiology of any headache disorder. The determination as to whether an illness qualifies under the referenced section is “solely a medical determination.” See 38 C.F.R. § 3.317 (a)(2)(i)(B). The Board finds that the record does not contain sufficient medical evidence regarding the etiology of the Veteran’s headaches. Accordingly, a medical opinion that addresses the relevant theories of entitlement should be obtained on remand. 4. Entitlement to an initial compensable rating for mandibular malunion, s/p fracture (claimed as jaw pain & jaw clicking) is remanded. The Veteran maintains that his service-connected fractured jaw is more disabling than reflected by the rating currently assigned. The Veteran indicates that, ever since his jaw was broken, he has experienced chronic pain, clicking of his jaw, and recurring episodes of teeth breaking off. The Veteran also indicates that he has occasionally developed infections for which he has to take several rounds of antibiotics. The Veteran’s service-connected disability has been evaluated under DC 9903 for nonunion of the mandible. 38 C.F.R. § 4.150. In this regard, the Board notes that, while the Veteran was afforded a DBQ examination in December 2014 for evaluation of his dental condition, the Veteran’s attorney argues that the examination is inadequate. Significantly, he notes that, during the examination, the Veteran reported experiencing pain and locking up of his jaw; however, the examiner did not go into detail about the Veteran’s pain or jaw function. Consequently, the attorney argues that the DBQ examination is inaccurate for rating purposes. Another VA examination is needed in order to ascertain the current level of severity of the service-connected mandibular malunion, status post fracture. See 38 C.F.R. §§ 3.327 (a), 4.2; Allday v. Brown, 7 Vet. App. 517, 526 (1995) (indicating that, where the record does not adequately reveal the current state of the claimant’s disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Ensure that the Veteran is scheduled for a VA examination to determine whether any allergies were incurred or aggravated by any period of service or are otherwise the result of his military service. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. After examination of the Veteran and review of the claims file, the examiner should identify any allergic condition found. Then, the examiner should opine whether the Veteran’s allergic condition at least as likely as not (50 percent or greater probability) began in or is otherwise related to the Veteran’s military service, to include his service in the Persian Gulf. For any symptoms or clusters of symptoms that cannot be identified with a diagnosis, the examiner should state whether such is considered a qualifying chronic disability or medically undefined chronic multi symptom illness as defined under 38 C.F.R. § 3.317. If such is found to be a qualifying chronic disability/medically undefined chronic multi symptom illness, the examiner should opine whether it at least as likely as not began in or was caused by his service in the Persian Gulf. 3. Ensure that the Veteran is scheduled for an appropriate VA examination to determine the nature of his gastrointestinal problems, claimed as GERD. The Veteran's entire claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The examiner should elicit a full history from the Veteran. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. All pertinent symptomatology and all clinical findings should be reported in detail. The examiner should specify any identified diagnoses (other than IBS) associated with the Veteran's reported gastrointestinal problems, i.e., GERD. For any conditions found, other than IBS, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its clinical onset during active service or is related to any incident of service, to include environmental exposures in Southwest Asia. In providing this opinion, the examiner must acknowledge the Veteran's complaints of experiencing stomach pain, indigestion, chest pain and diarrhea since 2004. The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran regarding symptomatology must be specifically acknowledged and considered in formulating any opinions concerning the onset of his disability. If the examiner rejects the Veteran's reports regarding the onset of symptoms, the examiner must provide a reason for doing so. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 4. Ensure that the Veteran is scheduled for an examination with an appropriate VA clinician to determine the nature and etiology of his headaches. The claims file, including a copy of this remand, must be made available to and be reviewed by the examiner. Following review of the claims file, the clinician should address the following: (a) State whether the symptoms of the Veteran’s headaches are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran’s disability pattern is either (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis. (c) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s headaches had their onset directly during service or are otherwise causally related to any event or circumstance of his service, including environmental exposures during service in the Southwest Asia theater of operations? 5. Ensure that the Veteran is scheduled for a VA dental/oral examination to determine the nature and severity of the mandibular malunion, status post fracture residuals. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. All indicated tests should be performed. The examination report should address whether there is malunion or nonunion of the mandible, and comment on the degree of motion and relative loss of masticatory function. The examiner must discuss the underlying rationale for all opinions expressed. (Continued on the next page)   6. Readjudicate the claims that are the subject of this Remand. If any benefit sought is not granted in full, the AOJ must furnish to the Veteran and his attorney a supplemental statement of the case (SSOC) that takes into consideration all evidence of record including that added to the record after the SOC was issued. Afford an appropriate period of time for response. Thereafter, the case should be returned to the Board, if in order. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs