Citation Nr: 21004105 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 09-00 577 DATE: January 26, 2021 ORDER Entitlement to service connection for a dental disability for purposes of eligibility for outpatient dental treatment is granted. REMANDED Entitlement to a compensable rating for blowout fracture residuals of the left orbit with diplopia and bilateral cataracts is remanded. FINDING OF FACT Resolving reasonable doubt in favor of the Veteran, the Veteran sustained dental trauma during his active service which ultimately led to significant teeth repair and loss of teeth. CONCLUSION OF LAW The criteria for Class II(a) eligibility for VA outpatient dental treatment are met. 38 U.S.C. § 1712 (2012); 38 C.F.R. §§ 3.381, 17.161 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from June 1972 to February 1985. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) and were previously remanded by the Board in September 2012, March 2016, and January 2019. The Board’s January 2019 remand directed the RO to afford the Veteran a VA dental examination and a VA eye examination, as well as obtain any outstanding VA and private treatment records. The Board finds that there has been substantial compliance with its January remand directives, and it will proceed with adjudication of the issues on appeal. Stegall v. West, 11 Vet. App. 268 (1998). Service connection for a dental disability for purposes of eligibility for outpatient dental treatment Service connection for purposes of outpatient dental treatment may be granted for a dental condition of any tooth and/or and periodontal tissue shown by the evidence to have been incurred in or aggravated by service, so long as the veteran falls under one of a number of specific classifications: Class I - Those having a service-connected compensable dental disability or condition; Class II - Those having a service-connected noncompensable dental condition or disability shown to have been in existence at time of discharge or release from active service, which took place after September 30, 1981, with at least 90 days of service during the Persian Gulf War or 180 days of other active service, and who applied for treatment within 180 days after release from active duty, or prior to October 1, 1981 with at least 180 days of service and who applied for treatment within a year of release from active duty; Class II(a) - Those having a service-connected noncompensable dental condition or disability adjudicated as resulting from combat wounds or service trauma; Class II(b) - Homeless and other enrolled veterans eligible for a one-time course of dental care under 38 U.S.C. § 2062; Class II(c) - Those who were prisoners of war, as determined by the concerned military service department; Class III - Those having a dental condition professionally determined to be aggravating disability from an associated service-connected condition or disability may be authorized dental treatment for only those dental conditions which, in sound professional judgment, are having a direct and material detrimental effect upon the associated basic condition or disability; Class IV - Those whose service-connected disabilities are rated at 100% by schedular evaluation or who are entitled to the 100% rate by reason of individual unemployability; Class V - Those participating in a rehabilitation program under 38 U.S.C. chapter 31, and dental services as are professionally determined necessary for any of the reasons enumerated in § 17.47(g); and Class VI – Those scheduled for admission or otherwise receiving care and services under chapter 17 may receive outpatient dental care which is medically necessary. 38 U.S.C. § 1712; 38 C.F.R. § 17.161. Replaceable missing and broken (fractured) teeth may be considered service connected solely for the purposes of determining entitlement to dental examinations or outpatient dental treatment. See Simington v. West, 11 Vet. App. 41 (1998). Trauma, as defined for purposes of dental treatment eligibility, connotes damage caused by the application of an external physical force during the service member’s performance of military duties. See Nielson v. Shinseki, 607 F.3d 802 (2010) (holding that “service trauma” in 38 U.S.C. § 1712(a)(1)(C) means an injury or wound produced by an external physical force during the service member’s performance of military duties; this definition excludes the intended result of proper medical treatment and psychological stress not the result of malpractice). The Veteran seeks service connection for a dental disability for purposes of eligibility for outpatient dental treatment. Specifically, he contends that suffered dental trauma during service when he opened a car door and it hit his two front top teeth, resulting in their removal and replacement with a bridge prior to separation from service. The Veteran's service treatment records (STRs) show that at the time he entered into active service in November 1971, he had all of his upper and lower teeth. His April 1975 reenlistment examination noted dental caries as to his two top front teeth, and dental restoration was recommended. His July 1979 reenlistment examination shows that his two top front teeth had been removed during his second period of active service. His February 1985 separation examination continues to reflect that his two top front teeth were missing and that his anterior bridge needed replacing. While the Veteran asserts that he received treatment in 1976 from a VA dental clinic in Key West, Florida, VA’s multiple attempts to obtain these records yielded negative results. Post-service VA treatment records reflect that the Veteran was referred to a dental clinic in 1992 for denture replacement, as well as the use of top dentures from 2010 onward. The Veteran underwent a VA dental examination in October 2019. He reported fracturing his two top front teeth around 1974 or 1975 when he was opening a car door during service. He stated that he cracked his front tooth but did not seek immediate dental care. He was later told by his captain to fix his front teeth and a root canal was conducted, followed by the placement of an anterior bridge. He indicated that the bridge came off around the mid 1980’s and that in 1998, a civilian dentist made a partial denture to replace his front teeth. In 2010, his remaining teeth were removed, and he was fitted with additional dentures. The VA examiner opined that, based on the Veteran’s reports and his current examination, it is at least as likely as not that his claimed dental trauma, which caused his two top front teeth to be removed, was incurred during active service. Based on a review of the relevant evidence of record, the Board finds that service connection for a dental disability for purposes of eligibility for outpatient dental treatment is warranted. The Veteran’s STRs show that he entered service with two top front teeth and left service without them due to unspecified damage resulting in the need for an anterior bridge. His post-service VA treatment records reflect the need for further dental treatment with dentures. The Veteran is considered competent to report the observable manifestations of his claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Here, the Veteran has consistently asserted that he lost his two top front teeth during service due to dental trauma, and such loss is capable of lay observation. While the 2019 VA examiner provided a positive nexus opinion establishing that the Veteran’s claimed dental trauma was incurred during active service, basing his opinion on the Veteran’s self-reports, the Board finds no reason to doubt the credibility of the Veteran’s lay statements. As such, resolving reasonable doubt in favor of the Veteran, service connection for a dental disability for purposes of eligibility for Class II(a) VA outpatient dental treatment is warranted. 38 C.F.R. § 17.161(c). REASONS FOR REMAND Entitlement to a compensable rating for blowout fracture residuals of the left orbit with diplopia and bilateral cataracts is remanded. This matter was first remanded by the Board in September 2012 to afford the Veteran a new VA examination to assess the current severity of his service-connected blowout fracture residuals of the left orbit, as well as to determine whether any other diagnosed eye disability is related to service or his service-connected blowout fracture residuals of the left orbit. The October 2012 VA examination found evidence of diplopia, glaucoma suspect, and cataracts, opining that the Veteran’s diplopia is due to his service-connected left eye orbital fracture residuals. A June 2013 VA addendum opinion also linked the Veteran’s diagnosis of cataracts to his service-connected left eye orbital fracture residuals. Thereafter, an August 2014 rating decision granted service connection for occasional diplopia and incipient cataracts and evaluated these disorders together with the Veteran’s service-connected left eye orbital fracture residuals, continuing a noncompensable rating. The March 2016 Board decision remanded the matter again to clarify whether the August 2014 rating decision granted service connection for bilateral cataracts in connection with the Veteran’s service-connected left eye orbital fracture residuals. An October 2018 rating decision clarified that the Veteran’s service-connected eye disability included blowout fracture of the left orbit with occasional diplopia and bilateral incipient cataracts with a noncompensable evaluation. The January 2019 Board decision remanded the matter once more to afford the Veteran a new VA examination for his vision, as well as to obtain a copy of the 2012 Goldmann chart that appeared to be missing from the claims file. A copy of the 2012 Goldmann chart was associated with the claims file and the Veteran underwent an additional VA examination in September 2019. The examiner noted a diagnosis of bilateral open-angle glaucoma which required medication and contributed to loss of visual field in the Veteran’s left eye. To date, while VA examiners have identified that the Veteran’s bilateral open-angle glaucoma contributes to his visual impairment, the etiology of this disability has not been determined. VA regulations require that an examiner identify the pathological process responsible for any visual impairment. See 38 C.F.R. § 4.75(b). Therefore, the matter must be remanded for an addendum medical opinion to clarify the nature and etiology of the Veteran’s diagnosed bilateral open-angle glaucoma. The matter is REMANDED for the following action: 1. Send the Veteran’s claims file to an appropriate medical professional to obtain an addendum opinion regarding the etiology of the Veteran’s bilateral open-angle glaucoma. The Veteran’s electronic claims file must be made accessible to the designated professional for review. A detailed rationale for any opinion expressed should be provided. Following the review of the claims file, the medical opinion provider is then requested to respond to the following: a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral open-angle glaucoma had its onset in service or is otherwise directly related to service? b) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral open-angle glaucoma is proximately due to or caused by the Veteran’s service-connected blowout fracture residuals of the left orbit with diplopia and bilateral cataracts? c) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral open-angle glaucoma underwent any incremental increase in disability, regardless of its permanence, due to the Veteran’s service-connected blowout fracture residuals of the left orbit with diplopia and bilateral cataracts? The term “incremental increase in disability” means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any “incremental increase in disability” need not be permanent. If the requested opinions cannot be provided without a new examination, one should be scheduled. 2. After completing all indicated development, the Agency of Original Jurisdiction should readjudicate the Veteran’s claim. If the benefit sought on appeal remains denied, the Veteran should be furnished with a supplemental statement of the case, given the opportunity to respond, and the case should thereafter be returned to the Board for further appellate review, if warranted. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Houle, 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.