Citation Nr: 19129046 Decision Date: 04/16/19 Archive Date: 04/15/19 DOCKET NO. 18-06 027 DATE: April 16, 2019 ORDER Entitlement to service connection for a temporomandibular joint (TMJ) disorder, to include as secondary to posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT Resolving any reasonable doubt in the Veteran’s favor, his bruxism/TMJ is at the very least exacerbated by his service-connected PTSD. CONCLUSION OF LAW The criteria to establish service connection for bruxism/TMJ are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 2001 to July 2005 with service in Kuwait and Iraq. This case originally came before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Claim Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Any increase in the severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disability, will be itself service-connected. 38 C.F.R. § 3.310(b). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert, supra. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for a TMJ disorder, to include as secondary to PTSD The Veteran contends that service connection is warranted for a jaw disorder as secondary to his service-connected PTSD. In his February 2016 statement that accompanied his Notice of Disagreement, the Veteran stated that TMJ had strong correlations to long-term stress and an even higher correlation with PTSD. He contended that his constant PTSD-related stress had led to his TMJ. He believed that he would not have developed TMJ if it were not for his severe PTSD. He believed that “current scientific and medical research” supported his contention that his TMJ was caused by his PTSD. Service connection for PTSD was awarded based on stressors the Veteran incurred during his service in Iraq. In support of his claim, he submitted a July 2016 letter from his private dentist, Dr. D.J., who indicated that the Veteran was seen for evaluation of TMJ pain experienced in May 2012. The Veteran reported daytime clenching and increased stress. Examination revealed pain on palpation of his left and right joint areas for which he was prescribed a hard nightguard to wear at night. The acute onset of his symptoms in 2012 was apparently increased stress, although the dentist noted that TMJ symptoms are often longstanding and episodic. The dentist opined that it was probable that the Veteran’s TMJ symptoms were related to or exacerbated by his PTSD. During a June 2017 VA examination, the Veteran reported that he developed a clenching problem in 2009, which led to a TMJ disorder. He complained of dull mild pain daily in both left and right TMJ, and difficulty chewing hard bread and other hard foods. The examiner found that the Veteran did not meet the criteria for a diagnosis of a TMJ condition. There was no jaw-related pain on normal range of motion during initial and repetitive-use testing. There was no swelling, pain on palpation, unusual deformities, or clicking of the jaw. The examiner acknowledged the Veteran’s private dental records demonstrating evidence of clenching in 2012, but still found no current finding of bruxism or TMJ. The examiner opined that the Veteran’s claimed TMJ disorder was less likely than not proximately due to, or the result of, PTSD. In an August 2017 addendum, the June 2017 VA examiner clarified that the pain on rest was unrelated to the clicking and confirmed that a diagnosis of TMJ was not endorsed because there were no findings of bruxism or a TMJ condition on the day of the examination. The examiner confirmed his prior opinion that is unfavorable to the claim. For the reasons expressed below, the Board resolves any reasonable doubt in the Veteran’s favor in finding that service connection is warranted. The record shows the Veteran was diagnosed with bruxism/TMJ in 2012 by a private dentist based on examination and reports of jaw clenching, clicking, and pain, as well as increased stress, symptoms which the Veteran is competent to report. The June 2017 VA unfavorable opinion was based on the absence of bruxism or a TMJ condition on the day of examination and not necessarily on a lack of a relationship between TMJ and stress. Of note, the private dentist acknowledged that the bruxism/TMJ symptoms that the Veteran experiences are indeed episodic in nature. Therefore, the fact that the condition was not shown during that isolated VA examination is not necessarily fatal to the claim. For this reason, the Board finds the VA opinion to be of less probative value. During the appeal period, the Veteran has continued to report the same jaw symptoms which were the basis of the 2012 bruxism/TMJ diagnosis. See February 2016 notice of disagreement and January 2018 substantive appeal. His statements describing his jaw symptoms are not only competent but also credible. Moreover, the Board finds the 2016 private dental opinion to be the most probative evidence of record addressing a causal link between the Veteran’s current bruxism/TMJ and his PTSD because such opinion is factually accurate and contains sound reasoning. The opinion was based on the dental examination findings and the reports of the Veteran experiencing jaw symptoms, particularly during times of increased stress. This private dental opinion coupled with the Veteran’s competent and credible reports of fluctuating symptoms of continued jaw clenching and pain, particularly in times of stress, supports a finding that the Veteran’s bruxism/TMJ is, at the very least, exacerbated by his service-connected PTSD. Thus, service connection for bruxism/TMJ is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, 3.310. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. R. Lee