Citation Nr: 20016533 Decision Date: 03/03/20 Archive Date: 03/03/20 DOCKET NO. 16-14 058 DATE: March 3, 2020 ORDER Entitlement to service connection for a sleep disorder is denied. Entitlement to service connection for grinding teeth (bruxism) is denied. REMANDED Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently rated as 70 percent disabling, is remanded. Entitlement to an increased rating for the Veteran’s service-connected left shoulder disability, currently rated as 20 percent disabling, is remanded. FINDINGS OF FACT 1. The Veteran does not have sleep apnea; his sleep impairment is either contemplated by the rating assigned for his service-connected PTSD or related to a nonservice-connected condition. 2. There is no argument or indication that the Veteran’s bruxism (grinding teeth), considered to be a manifestation of his PTSD, has resulted in a dental disability for which VA compensation may be granted. CONCLUSIONS OF LAW 1. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for grinding teeth (bruxism) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1988 to January 1993. This matter comes before the Board of Veterans’ Appeals (Board) from August 2014 and June 2015 rating decisions. The August 2014 rating decision denied higher ratings for the Veteran’s PTSD and left shoulder disability. The June 2015 rating decision denied service connection for sleep apnea and grinding teeth (bruxism). In October 2018, the Board issued a decision wherein it denied higher ratings for the Veteran’s PTSD and left shoulder disability. Dissatisfied with these denials, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In June 2019, the Board granted a joint motion for partial remand (JMPR) filed by the parties, vacating the relevant portions of the October 2018 Board decision and remanding the matters back to the Board for additional action. Regarding the issues of service connection for sleep apnea and grinding teeth, the Board notes that the Veteran, in his March 2016 substantive appeal, requested hearing at both the RO and Board levels. 03/29/2016, Form 9. The record shows that the Veteran was scheduled for a DRO hearing in February 2018 and a Board hearing in March 2019. The Veteran, however, failed to appear at both hearings, and has not shown good cause for his failure to appear. In view of this, the Board concludes that the Veteran has waived his right to appear at a Board hearing. 1. Entitlement to service connection for sleep apnea is denied. 2. Entitlement to service connection for grinding teeth (bruxism) is denied. The Veteran seeks service connection for a sleep disorder, to include sleep apnea, to include on a secondary basis. 11/24/2014, Statement in Support of Claim. He has indicated that he has difficulty going to, and staying, asleep, has nightmares, and is always moving around and grinding his teeth in his sleep. Id. VA treatment records show sleep impairment related to the Veteran’s GERD and PTSD. 03/28/2016, CAPRI, at 34 & 63; see also 07/29/2014, C&P Exam, at 27. There is, however, no indication that the Veteran has a diagnosis of sleep apnea. Insofar as the Veteran believes that he has a diagnosis of sleep apnea, the Board notes that he is not competent to provide such a diagnosis in this case. The issue is medically complex, as it requires the ability to interpret complicated diagnostic medical testing of the body’s respiratory and other systems. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As such, the Board finds the Veteran’s opinion in this regard to lack competency and weight. Consequently, the Board gives more probative weight to the competent medical evidence, which is consistently negative for a diagnosis of sleep apnea. The Veteran is not service-connected for GERD, and while he has claimed service connection for GERD, and this issue was recently the subject of a February 15, 2020, statement of the case, the Veteran has not, as of this decision, perfected an appeal for that issue. As service connection for GERD has not been established, service connection for any sleep impairment caused by the Veteran’s GERD is not warranted. The Veteran is service-connected for PTSD, currently rated as 70 percent disabling. The rating criteria for mental health disabilities include sleep impairment caused by the relevant mental health disability. Accordingly, in this case, the Board finds that any sleep impairment caused by the Veteran’s PTSD is encompassed and compensated by the rating assigned for the service-connected PTSD. Regarding the issue of service connection for grinding teeth, the Board notes that the Veteran referenced teeth grinding in the context of his PTSD-related sleep impairment. The medical term for this type of teeth grinding is bruxism. Bruxism is defined in Dorland's Illustrated Medical Dictionary as "involuntary, nonfunctional, rhythmic or spasmodic gnashing, grinding, and clenching of teeth (not including chewing movements of the mandible), usually during sleep, sometimes leading to occlusal trauma." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 257 (32st ed. 2012). As the above definition suggests, bruxism is a manifestation of a psychiatric disorder. In other words, bruxism is not a disability in and of itself. Bruxism, however, could result in a dental disability, such as TMJ disorder or possibly an infection of the bone that results in tooth loss. Such additional dental disability, if present, could warrant a separate grant of service connection. In this case, there is no argument that the Veteran’s bruxism has resulted in a dental disability. Similarly, VA treatment records do not show a dental disability during the appeal period. Rather, prior to the Veteran’s claim, his most recent dental examination was in September 2010. 03/28/2016, CAPRI, at 109. To summarize, the weight of the evidence is against a finding that the Veteran has sleep apnea. While he experienced sleep impairment, this is related to either his GERD (not service-connected) or his service-connected PTSD. Any sleep impairment related to PTSD is encompassed by the rating assigned for PTSD. Finally, there is no argument or indication that the Veteran’s bruxism, a manifestation of his PTSD, has resulted in a separate dental disability. As bruxism is not a disability in and of itself, service connection for it is not warranted.   REASONS FOR REMAND 1. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently rated as 70 percent disabling, is remanded. The Veteran seeks a higher rating for his PTSD. 04/30/2014, Third Party Correspondence. His PTSD is currently rated as 70 percent disabling. To warrant a higher rating of 100 percent, the evidence must show that the Veteran’s PTSD results in total social and occupational impairment. The Veteran underwent a VA examination in July 2014. The examination report indicates that the Veteran was at the time employed full-time a VA peer support supervisor. He reported problems at work and having received disciplinary/negative evaluations. The examiner concluded that the Veteran had social and occupational impairment with reduced reliability and mood. In his June 2015 notice of disagreement, the Veteran’s representative argued that the July 2014 VA examination was inadequate. Specifically, the Veteran’s representative noted that the VA examiner failed to address a statement from the Veteran’s girlfriend, regarding their relationship problems. The Veteran’s representative also suggested that examiner did not take into consideration the Veteran’s negative evaluations and disciplinary actions at work, his reports of a recent, conflictive situation at work, and his recent report of suicidal ideation. The Board agrees that the July 2014 VA examination does not show adequate consideration of the relevant evidence. Significantly, the examiner’s assessment of the Veteran’s occupational impairment does not seem to account for his reported problems at work. Furthermore, the examination report provides practically no insight into the Veteran’s social impairment, to include family and friends. Based on the above, the Board finds that a new VA examination is warranted.   2. Entitlement to an increased rating for the Veteran’s service-connected left shoulder disability, currently rated as 20 percent disabling, is remanded. The Veteran seeks a higher rating for his service-connected left shoulder disability. 02/28/2014, Fully Developed Claim. This disability is currently rated as 20 percent disabling under DC 5003-5201. The Veteran underwent a VA examination in July 2014. The VA examiner conducted range of motion testing for the Veteran’s left shoulder. The examiner commented that the Veteran experienced pain with range of motion testing, and that the Veteran’s limited range of motion caused functional loss. However, the examiner failed to state at what point in the range of motion pain began, or to what extent the pain was disabling. Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011) (“It is important for the medical examiner to note” “the point during range of motion any limitation of motion that was specifically attributable to pain.”). The July 2014 VA examiner also summarized the Veteran’s reports of flare-ups in his left shoulder, stating that he experienced “difficulty with lifting/carrying heavy objects, pushing, [and] pulling” during periods of flare-ups. After taking note of these reports, the examiner opined that the Veteran’s range of motion would decrease by an addition five degrees, from a baseline of his initial range of motion testing, during periods of flare-ups. However, the examiner did not obtain information from the Veteran about the severity, frequency, duration, and precipitating and alleviating factors of his flare-ups. Therefore, per the JMPR the July 2014 VA examiner’s estimation of the functional loss that the Veteran experiences is inadequate. See Sharp v. Shulkin, 29 Vet. App. 26, 35 (2017) (requiring an examiner to provide “flare opinions based on estimates derived from information procured from relevant sources, including the lay statements of veterans.”). As the July 2014 VA examination does not comply with the requirements of Mitchell and Sharp, a remand for a new VA examination is necessary. Finally, the Board notes that VA treatment records were last associated with the claims file in February 2018. On remand, VA should obtain any outstanding VA treatment records. The matters are REMANDED for the following action: 1. Obtain any VA treatment records since February 2018. 2. After completing #1, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner is to provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria, to include any problems at work and his social impairment. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected psychiatric disorder alone. 3. After completing #1, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left shoulder disability. The examiner is to provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements.   If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. López, 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.