Citation Nr: 21001571 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 16-30 119 DATE: January 11, 2021 REMANDED Entitlement to service connection for bruxism is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2001 to May 2005 and had additional service in the National Guard. Entitlement to service connection for bruxism is remanded. The Veteran asserts that bruxism is the result of service or was aggravated by a service-connected disability. Service medical records show multiple in-service jaw and teeth complaints associated with vaccinations, medications, and headaches. In January 2003, the Veteran reported that two days after taking Gabapentin, for chronic headaches, he developed tremors in the jaw. A May 2003 medical record shows that the Veteran complained of jaw pain nine days after a smallpox vaccination. In July 2004, two days after starting antidepressants, the Veteran reported the onset of tooth pain. In August 2004 the Veteran reported tremors of the jaw and tooth pain. In January 2005, the Veteran was fitted for a temporomandibular joint (TMJ) splint due to “morning discomfort – muscle pain associated with nocturnal clinching.” During a September 2005 VA dental examination, the Veteran complained of “grinding or popping noises” in the jaw which began six to eight months prior. The dentist noted that the Veteran used a bite guard and stated that the examination was negative for TMJ problems. Without a discussion of in-service jaw complaints, a July 2014 VA examiner found that severe bruxism, sleep apnea, and migraine headaches were symptoms of a psychiatric disorder. In January 2017, an oral maxillofacial surgeon stated that the Veteran had severe masseteric hypertrophy with associated temporalis hypertrophy and that the bilateral buccal mucosa, incisal, and occlusal cusps were severely worn down due to severe bruxing. The surgeon stated that Botox injections were medically necessary for treatment of the condition. An October 2017 medical record shows that severe bruxism “worsen[ed the Veteran’s] chronic migraines.” The Board cannot make a fully-informed decision on the issue of whether bruxism is the result of service or is secondary to any service-connected disability, because no VA examiner has opined whether bruxism is related to service, had its onset in service, or was permanently aggravated beyond its normal progression by any service-connected disability. VA’s duty to assist includes providing a medical examination and obtaining an opinion when it is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159. Therefore, remand is necessary to schedule an examination. The matter is REMANDED for the following action: 1. After obtaining any necessary releases, obtain all relevant VA and private treatment records not already associated with the claims file. All attempts to locate records must be documented in the claims file. 2. Schedule the Veteran for a VA examination by a medical doctor to determine the nature and etiology of bruxism. The examiner must review the claims file and should note that review in the report. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. Clearly stated rationales with references to the record, diagnostic tests, medical literature, etc. should be provided. The examiners should provide the following information: (a.) Identify all symptoms and manifestations associated with bruxism, including, but not limited to pain, masseteric hypertrophy, temporalis hypertrophy, and fracture and wearing of the teeth. (b.) Opine whether it is at least as likely as not (50 percent or greater probability) that bruxism had its onset during service, or is otherwise related to service or any event, injury, or disease during service, to include vaccinations, medications, and headaches. The examiner should state the significance of the findings in the service medical records of jaw pain and tremors, tooth pain, and nocturnal clenching. (c.) Opine whether it is at least as likely as not (50 percent or greater probability) that bruxism is proximately due to, the result of, or caused by the service-connected disabilities, to include a psychiatric disability. The examiner should discuss the significance of a July 2014 VA examination which found bruxism was a symptom of a service-connected psychiatric disability, and should reconcile the opinion with that finding. (d.) Opine whether it is at least as likely as not (50 percent or greater probability) that bruxism has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities, to include a psychiatric disability. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.