Citation Nr: 20021726 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 16-18 460 DATE: March 26, 2020 ORDER Entitlement to service connection for compensation purposes for dental disorder, to include loss of teeth, is denied. FINDING OF FACT The Veteran has not been diagnosed with a dental disorder, to include loss of teeth and due to injury or trauma to the mandible or maxilla or related components and processes for which service-connected compensation is payable. CONCLUSION OF LAW The criteria for service connection for compensation purposes for dental disorder, to include loss of teeth, have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.381, 4.150, 17.161 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from September 1986 to May 1995 and from December 2001 to October 2002. To the extent this is a claim for VA dental treatment, the Veteran should file application with the appropriate VA medical center. This is not a decision on that issue. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2019). Establishing service connection generally 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 in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Veteran has asserted in his reports to the December 2019 VA examiner that he believes his dental disorder may be due to exposure to some agent such as Agent Orange or to Gulf War exposure. The following paragraphs provide relevant information concerning possible presumptive service connection concerning such exposures. Exposure to an Herbicide Agent, to Include Agent Orange A veteran who, during active military, naval or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during his or her service to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C.§ 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). The following diseases will be deemed service connected if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin’s disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin’s lymphoma; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson’s disease, and ischemic heart disease. 38 C.F.R. § 3.309 (e). To benefit from the presumption of service connection for diseases associated with herbicide-agent exposure, the Veteran must have one of the diseases set forth in 38 C.F.R. § 3.309 (e). However, when diseases do not appear under the regulation, a veteran can still proceed to establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1045 (Fed. Cir. 1994). Gulf-War Syndrome The Veteran served in the Southwest Asia theater of operations during the First Gulf War. For veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multi-symptom illness (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome). See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Section 3.317 explicitly acknowledges that a claimant’s “signs or symptoms” need not be shown by medical evidence; however, the regulation does specifically require some “objective indications” of disability. 38 C.F.R. § 3.317 (a). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). Entitlement to service connection for compensation purposes for dental disorder, to include loss of teeth. Initially, it is noted that the Veteran did not serve in Vietnam, and is not otherwise shown to have been exposed to Agent Orange. The Veteran asserts he is entitled to service connection for compensation for a dental disorder, to include loss of teeth. Dental disabilities which may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, loss of the maxilla, nonunion or malunion of the maxilla, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916 (2019). It is noted that none of these compensable dental conditions have been shown. Turning to the record, the dental service treatment records (STRs) show that, in February 1987 and May 1988 dental visits, cavities were detected and filled. The Veteran lost tooth fillings in different teeth in January 1990 and May and September 1996. Each was later replaced within several weeks. An August 1999 examination revealed early periodontitis. The post-service treatment record shows, after a tooth was filled in private treatment in June 2004, the Veteran presented at VA between December 2004 and August 2005 with sensitivity in the tooth, ultimately resulting in the insertion of a crown. Examinations in this period showed disorders leading to diagnoses of likely irreversible pulpitis, fractured tooth syndrome, and mild to moderate chronic periodontitis. The treatment provider concluded this was a treatable tooth, recommended root canal therapy and noted that the endodontist must first confirm that the tooth is treatable. A February 2006 VA dental note shows a diagnosis of unspecified dental caries. The Veteran received a crown for one tooth and severe decay was noted in another. In June 2010, the Veteran was diagnosed with chronic periodontitis. X-rays revealed temporomandibular joints were within normal limits, oral tissues were inflamed, there were localized areas of alveolar bone loss associated with tooth number 3. Three teeth received periodontal scaling/root planing with an ultrasonic device and curettes. An August 2010 VA dental note shows the Veteran underwent a tooth extraction due to periodontal disease. The Veteran was informed that the procedure is being performed for medical benefit and the treatment does not require the VA to provide replacement for the extracted tooth. In November 2010, the Veteran presented with complaints of a left-side broken tooth and sensitivity when chewing. He was assessed with a class II fracture, some caries in another tooth and otherwise normal periodontium. The tooth received a temporary (sedative) filling to alleviate discomfort. January and March 2011 visits to VA revealed cavities, as well as the treatment provider noting that by this time, the Veteran was missing five teeth. The March 2011 treatment provider noted the fractured tooth and its planned restoration procedure and discussed with the Veteran the inclusion of buttercrunch toffee in his diet may account for his current problems. A VA dental note in November 2011 shows the Veteran presented to the dental emergency clinic with complaints of having lost a tooth restoration. In December 2019, the Veteran underwent a VA examination for dental and oral conditions. At the outset, the VA examiner stated the Veteran has never been diagnosed with an oral or dental condition. At the same time, his report includes what appears to be a standing diagnosis of arthralgia of bilateral temporomandibular joint. The December 2019 VA examiner noted the Veteran’s reported history of his teeth as follows: [They] seem to break down with no apparent reason. He feels this may be due to exposure of some agent such as agent orange or gulf war exposure. I explained the literature does not, at this point, anno[]tate any direct dental effect to such agents. As we discussed[,] this is usu[]ally due to normal dental wear and tear as teeth are restored and age. Examination revealed good oral health and a few missing teeth. Review of the record indicated to the December 2019 VA examiner “routine dental care while in military. No sign of trauma, etc.” The December 2019 VA examiner found no dental or oral condition in the mandible, including anatomical loss or bony injury (NOT due to edentulous atrophy or periodontal disease); in the maxilla, including anatomical loss or bony injury (NOT due to edentulous atrophy or periodontal disease); or in the teeth, including anatomical loss or bony injury leading to loss of any teeth (other than that due to the loss of the alveolar process as a result of periodontal disease). He further found no osteomyelitis/osteoradionecrosis/osteonecrosis of the jaw, as well as no disorder regarding the mouth, lips and tongue, including scars and no tumors or neoplasms. He opined as follows: [T]here is no dental disability per se. He does need routine dental care, but this is normal and not a disability. Nothing in the records would indicate anything related to his military history. As to an opinion, since he has no dental disability, there can be no relationship to his routine care in the military. As a first matter, the evidence of record does not indicate the Veteran’s dental disorder is included under 38 C.F.R. § 3.309 (e) as a disease due to exposure to an herbicide agent, to include Agent Orange. Additionally, as shown above, nothing in the medical evidence of record supports the notion that the Veteran’s dental disorder can be characterized for Gulf-War Syndrome purposes for presumptive service connection as a chronic disability which cannot be attributed to a known clinical diagnosis, that is to say, an undiagnosed illness or for a medically unexplained multi-symptom illness. On the contrary, the record shows the identification of causes of the Veteran’s dental disorder to be unequivocally due to the tooth decay and surrounding bone and tissue loss associated with periodontal disease. Therefore, presumptive service connection due to exposure to an herbicide agent or to exposures associated with Gulf-War service are not available to the Veteran. Additionally, for the reasons just stated, as well as stated below, nothing further in the medical evidence of record gives indication of a direct causal relationship of the Veteran’s current disorder with active service to include Gulf-War service or service which might have included exposure to an herbicide agent, to include Agent Orange. The foregoing summary of the record of treatment shows no competent medical or dental evidence of loss of teeth due to loss of substance of the body of the maxilla or mandible due to bone loss through trauma or any other condition on which service connection could be allowed. While records demonstrate missing teeth, dental restorations, caries, and generalized bone loss, these conditions have been determined to be due to severe systemic periodontitis. The Veteran has never at any time during the course of the appeal alleged incurring an injury or trauma to the mandible or maxilla. Consequently, the rating criteria summarized earlier for compensation upon service connection would be inapplicable. As the record provides no medical evidence that the Veteran has any current dental disorder for which compensation is payable, the Board finds, as a matter of law, there is no basis for service-connected VA disability compensation for a current dental disorder. Therefore, for the foregoing reasons and based on the objective medical evidence, the preponderance of evidence is the claim for service connection. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claim, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.