Citation Nr: 20041978 Decision Date: 06/19/20 Archive Date: 06/19/20 DOCKET NO. 18-49 197 DATE: June 19, 2020 ORDER Entitlement to service connection for bruxism, as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for left foot condition (claimed as left metatarsal muscle injury) is granted. Entitlement to service connection for right foot condition (claimed as right metatarsal muscle injury) is granted. REMANDED Entitlement to a rating in excess of 50 percent for PTSD is remanded. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, the most probative evidence establishes that the Veteran’s bruxism is proximately due to his service-connected PTSD. 2. Resolving reasonable doubt in the Veteran’s favor, the most probative evidence establishes that the Veteran’s bilateral foot conditions are related to his military service. CONCLUSIONS OF LAW 1. The criteria for service connection for bruxism, as secondary to service connected PTSD, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for a left foot condition are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right foot condition are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from October 1965 to July 1968. This matter comes before the Board of Veterans’ Appeals (Board) from the April and July 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Service connection may be established for a disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, in order to prevail on the issue of service connection, the evidence must show: (1) the existence of a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Secondary service connection will be granted if the evidence demonstrates that a current disability is proximately due to or the result of, or aggravated beyond its natural progression, by service connected disability. 38 U.S.C. § 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. 1. Entitlement to service connection for treatment purposes for bruxism, to include as secondary to service-connected PTSD The Veteran contends that his bruxism (teeth grinding) is related to his service-connected PTSD. The Board notes that certain dental disabilities can be service connected for compensation purposes, whereas other disabilities may be service connected for the purposes of receiving VA outpatient dental treatment. Service connection for compensation may be awarded only for missing teeth due to service trauma or bone loss due to trauma or disease in service. See 38 U.S.C. § 1712; Simington v. West, 11 Vet. App. 41, 44 (1998); 38 C.F.R. §§ 3.381, 4.150, 17.161. “Service trauma” for these purposes means an injury or wound produced by an external physical force during the performance of military duties; it does not include the intended result of proper medical treatment or a psychological event. Nielson v. Shinseki, 607 F.3d 802, 808-09 (2010). VA has acknowledged that bruxism may be contemplated as a symptom of craniomandibular disorders, of which temporomandibular disorders under 38 C.F.R. § 4.150, Diagnostic Code (DC) 9905, are a subset, and that “other symptoms of craniomandibular disorders include anxiety, stress, and other mental disorders.” See 82 Fed. Reg. 36080, 36081 (Aug. 3, 2017) (amending the diagnostic codes for dental disorders effective Sept. 20, 2017; citing to medical literature). The Federal Register comments further note that “VA has determined that only secondary service connection for treatment purposes is warranted for [bruxism], both because it is only a secondary condition, not a primary condition, and because its symptoms are already contemplated by the underlying condition.” Id. Thus, VA declined to add a notation about bruxism to DC 9905. Id. In this case, there is no argument or indication that the Veteran had physical trauma during service resulting in missing teeth or bone loss during service. Therefore, direct service connection cannot be awarded for his bruxism. In fact, in a May 2017 correspondence, the Veteran stated that he is only and specifically seeking treatment for his dental condition. The Veteran submitted a January 2017 private dental physician statement that opined that the Veteran needs dental treatment due to damage and breakage from continued grinding and clenching. The dentist stated that he feels that this is related to the Veteran’s service-connected back injury and PTSD. In March 2017, the Veteran underwent a VA temporomandibular joint (TMJ) conditions examination. The examiner noted that the Veteran is diagnosed with bruxism. The examiner opined that the Veterans bruxism is as least as likely as not due to or the result of the Veteran’s service-connected PTSD. The examiner explained that the Veteran’s PTSD has been a major factor with his bruxism as it helps relieve his anxiety. In September 2017, the Veteran underwent another VA dental conditions examination. However, the examiner opined that the Veteran’s bruxism is less likely than not due to or the result of the Veteran’s service-connected PTSD. The examiner explained that the Veteran’s service treatment records note that the Veteran had an occlusal abnormality of occlusal anterior overbite. The examiner stated that this occlusal relationship may contribute to a non-harmonious functional relationship leading to parafunctional movement and wear. The examiner stated that although the Veteran’s PTSD may contribute to the etiologic factors of bruxism, several other factors are contributory as well to include diet, home care, and parafunctional habits. However, the September 2017 examiner did not discuss the March 2017 positive nexus opinion. The Board notes that the Veteran is competent to report symptoms, such as jaw clenching and grinding of teeth, which are both capable of lay observation. Layno v. Brown, 6 Vet. App. 465 (1994); 38 C.F.R. § 3.159 (a)(2) (2018). Likewise, the Board finds no reason to doubt the credibility of the Veteran’s lay assertions regarding his personal experience with and the severity of his current bruxism. In fact, the Veteran’s lay assertions that his bruxism has recently resulted in the destruction of dental work is corroborated by his private dentist’s January 2017 medical statement. The Veteran’s credible and competent lay statements regarding the severity of his bruxism during the appellate period are entitled to significant probative value in this appeal. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current bruxism is proximately due to his service connected PTSD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for bruxism is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for left foot condition (claimed as left metatarsal muscle injury) 3. Entitlement to service connection for right foot condition (claimed as left metatarsal muscle injury) The Veteran contends that his bilateral foot conditions are related to his military service. Specifically, the Veteran stated in an April 2017 statement, as well as throughout the record, that the issues with his feet began in basic training. He noted that he reported that he was experiencing constant pain to his instructor and that his complaint was dismissed. The Veteran stated that prior to his basic training graduation he was almost unable to walk or stand due to his sore and painful feet. The Veteran reported that he has had constant foot pain ever since his basic training and receives frequent cortisone injections in both feet in order to live a “normal life.” The Veteran has a current diagnoses of hallux valgus, hallux rigidus, and plantar fasciitis as evidenced by his June 2017 VA examination. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of the claim. In February 2017, the Veteran’s private orthopedic physician submitted a statement with the opinion that the Veteran’s foot conditions are more likely than not related to the Veteran’s military service. The physician stated that the Veteran’s X-rays confirmed moderate to severe bilateral pes planus, with secondary osteoarthritis, calcaneal spurs, and hallux valgus. The examiner stated that the Veteran’s conditions are a magnification of the underlying injuries endured while enlisted in the military. In June 2017, the Veteran underwent a VA foot examination. The examiner noted that the Veteran is diagnosed with hallux valgus, hallux rigidus, and plantar fasciitis. The examiner opined that the Veteran’s foot conditions are at least as likely as not related to his military service. The examiner stated that the Veteran does not have a prior history of foot or toe pain prior to his enlistment and complained of symptoms during his basic training. The examiner noted that the Veteran admits to not having an evaluation for his feet while in service, but since service has had treatments for pain and uses orthotics. The examiner also stated that the Veteran has had a sedentary lifestyle after his military discharge and has not performed general labor since his military service. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current bilateral foot conditions are related to his military service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for left and right foot conditions are warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a rating in excess of 50 percent for PTSD The Veteran contends that he is entitled to a rating in excess of 50 percent for his service-connected PTSD. The Board notes that the Veteran’s claims file contains a May 2018 correspondence requesting that his PTSD examination be rescheduled. The Veteran stated that he missed his examination because he was traveling due to sick family members. However, it does not appear that the Veteran’s examination has ever been rescheduled. Therefore, a remand is warranted to schedule the Veteran for a VA PTSD examination to determine the current severity of his disability. 2. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities As the resolution of the claim for an increased rating for the Veteran’s PTSD might be determinative of the TDIU claim, the issues are inextricably intertwined, and the TDIU claim must also be remanded. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected PTSD. The examination should include all studies, tests, and evaluations deemed necessary by the examiner. The examiner should report all manifestations related to the service-connected disability. All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. (Continued on the next page)   2. Following completion of the above, and a review of any additional evidence received, the RO should also undertake any other development it deems to be necessary, to include, if warranted, an addendum medical opinion which considers any newly received evidence. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Mountford, 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.