Citation Nr: 21061861 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 20-14 645 DATE: October 5, 2021 ORDER Service connection for right ear hearing loss disability is granted. An initial disability rating of 50 percent, but not higher, for bilateral hearing loss is granted. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for vertigo is remanded. Entitlement to service connection for a dental condition, to include entitlement for treatment purposes, is remanded. FINDINGS OF FACT 1. Resolving any reasonable doubt in the Veteran's favor, his currently diagnosed right ear hearing loss disability had its onset during active military service. 2. The Veteran's bilateral hearing loss disability has been manifested by hearing acuity no worse than Level VII in the right ear and Level IX in the left ear. CONCLUSIONS OF LAW 1. The criteria to establish service connection for right ear hearing loss are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2020). 2. The criteria for an initial disability rating of 50 percent, but not higher, for bilateral hearing loss are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from May 1965 to April 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2018 rating decision of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). In April 2021, the Veteran testified during a virtual Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. During the April 2021 Board hearing, the undersigned agreed to hold the record open for 90 days to allow for the submission of additional evidence in support of the Veteran's claims. See Board hearing transcript dated April 16, 2021 (Hearing Transcript) at pg. 16. Prior to the expiration of the 90 day period, the representative requested a 30 day extension to allow time for development and submission of additional evidence. See Correspondence received July 12, 2021. The representative notified the Board that attempts to obtain the evidence, specifically, outstanding treatment records relevant to the right knee service connection claim, were unsuccessful and requested that the Board adjudicate the Veteran's claims on the record as presently developed. See Correspondence received August 6, 2021. However, in identifying outstanding treatment records, the representative triggered VA's duty to assist the Veteran in development of that claim, which necessitates remand as set forth below. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). As service connection for right ear hearing loss is granted herein, thus making the Veteran's hearing loss bilateral for VA purposes, the rating procedures governing the rating of single ear hearing loss are no longer applicable, and the Veteran's hearing loss must be rated in accordance with the procedures and criteria governing bilateral hearing loss. As this requires evaluation of both the right and left ear, the claim for an increased rating for left ear hearing loss becomes a claim for an increased rating for bilateral hearing loss, as reflected in the title page. Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection - Applicable Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Sensorineural hearing loss is considered a "chronic" disease under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service must be considered in reviewing the instant claim for service connection for right ear hearing loss. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Here, the record does not demonstrate diagnosis of sensorineural hearing loss until many years after the Veteran's separation from service. Therefore, the provisions of 38 C.F.R. § 3.303(b) and § 3.309(a) are not for application on this record. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A lay person is competent to report on the onset and reoccurrence of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Board must determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107(b)). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Right Ear Hearing Loss The Veteran asserts that his right ear hearing loss is related to his exposure to hazardous noise in-service. See, e.g., VA hearing loss and tinnitus examination report dated January 18, 2018. The Veteran is currently diagnosed with bilateral hearing loss that establishes a hearing loss disability for VA purposes. See VA hearing loss and tinnitus examination report dated January 18, 2018; VA audiological evaluation dated October 15, 2013; 38 C.F.R. § 3.385. Regarding the second element of in-service incurrence, the Board concedes Veteran's exposure to hazardous noise. The Veteran's Certificate of Release or Discharge from Active Duty (DD Form 214) indicates that while in the Army, his military occupational specialty (MOS) was that of Artillery Surveyor, which has been determined by the Department of Defense to involve a moderate probability of hazardous noise exposure. See VA Fast Letter 10-35 (September 2, 2010) (discussing the Duty MOS Noise Exposure Listing). Notably, the Veteran's left ear hearing loss and tinnitus is service connected and is due to the acoustic trauma he sustained in service. See VA hearing loss and tinnitus examination report dated January 18, 2018. Next, with respect to the issue of nexus, evidence favorable to the claim is reflected in a May 2014 VA evaluation of the Veteran's vertigo symptoms. A.K., M.D. noted that the Veteran's bilateral hearing loss and tinnitus were "undoubtedly caused, in part, by exposure to excessive explosive noise while serving in the Army." See VA Otolaryngology note dated May 30, 2014. Doctor A.K. observed that the Veteran served in the artillery with 8-inch guns when they were being fired, and he noted temporary hearing threshold shifts during service. Id. Evidence unfavorable to the claim includes the January 2018 VA examiner's opinion, indicating that the Veteran's right ear hearing loss is not related to military noise exposure/acoustic trauma during service because his STRs do not reflect hearing loss. Though, this same VA examiner concluded that the Veteran's left ear hearing loss and tinnitus was specifically related to service because he was exposed to excessive noise (acoustic trauma) during service. Upon review, the Board finds the January 2018 VA examiner's opinion in regard to right ear hearing loss inadequate. Notably, the VA examiner solely relied on the lack of documented hearing loss during service, he failed to note that the handwritten May 1965 induction audiometer readings are generally illegible, the STRs include an undated in-service audiogram indicates right ear hearing loss at 4000 Hertz, and that the separation audiological examination results are incomplete. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992) (The fact that a clinical diagnosis was not rendered during service is not fatal to the claim); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based upon an inaccurate factual premise has no probative value). In contrast, the VA examiner specifically noted that the Veteran reported that his tinnitus began in the 1965 during service. While the examiner noted and accepted the Veteran's reports of excessive exposure to noise from artillery and machine guns firing at close range without ear protection during service in the context of his left ear hearing loss and tinnitus symptoms, the examiner concluded that because the Veteran was found to have normal right ear hearing in service, his current right ear hearing loss is less likely than associated with in-service acoustic trauma. See VA hearing loss and tinnitus examination report dated January 18, 2018 at pg. 4. Evidence in support of the claim includes the Veteran's statements during the April 2021 Board hearing describing his in-service exposure to the firing of eight-inch guns without hearing protection in carrying out his duties as an Artillery Surveyor, and that he noticed bilateral hearing loss during service. See Hearing Transcript at pgs. 3-4. Neither the STRs nor the service personnel records reflect that hearing protection was worn at all times, if at all. Therefore, the Board accepts the Veteran's statements and concludes that symptoms of the now diagnosed bilateral hearing loss onset during service. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The Board considered requesting an additional etiology opinion; however, the Board finds highly probative the May 2014 treatment notes of Doctor A.K. and the Veteran's lay statements regarding the onset of hearing difficulties and his indicating that the symptoms of the disability, to include his right ear hearing loss symptoms, continued since service, as they are consistent with the medical evidence and the fact that he is service-connected for tinnitus based on the same assertions. Thus, in light of the current diagnoses of bilateral hearing loss disability for VA purposes, the conceded in-service noise exposure, and the competent and credible evidence of continuity of symptomatology since service, the Board finds that, at the very least, the evidence is in equipoise on the question of whether the Veteran's current right ear hearing loss was incurred in service. Resolving any reasonable doubt in the Veteran's favor, the Board finds that, based on competent and credible evidence of in-service incurrence and continuous post-service symptoms, presumptive service connection for right ear hearing loss is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating - Applicable Laws and Regulations Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second (Hertz). To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from level I, for essentially normal acuity, through level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100 (Table VII). The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85, DC 6100. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). Left Ear Hearing Loss The Veteran's service-connected left ear sensorineural hearing loss disability is assigned a noncompensable disability rating under 38 C.F.R. § 4.85. See Rating Decision dated January 19, 2018 at pg. 3; Statement of the Case dated February 23, 2020 at pg. 28. The Veteran asserts that his hearing loss is more severe than as reflected by the assigned rating. Regarding the January 2018 VA hearing examination, the audiometric data indicates right ear puretone thresholds of 65 decibels, 65 decibels, 70 decibels, 80 decibels, and 90 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Left ear audiometric data indicates left ear puretone thresholds at 70 decibels, 60 decibels, 70 decibels, 95 decibels, and 95 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Puretone threshold averages (the average of puretone thresholds from 1000 through 4000 Hertz) were 76 for the right ear and 80 decibels for the left ear. The Veteran's speech discrimination was noted as 62 percent for the right ear and 36 percent for the left ear. A puretone threshold average of 76 decibels in the right ear and 80 decibels in the left ear with speech discrimination at 62 percent and 36 percent for the right and left ears, respectively, is assigned numeric designations of VII for the right ear and IX for the left ear. The point where designation VII and IX meet in Table VII yields a 50 percent disability rating for bilateral hearing loss. See 38 C.F.R. § 4.85. As the Veteran's hearing loss meets the exceptional pattern of impairment under 38 C.F.R. § 4.86(a), i.e., pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) was 55 decibels or more, Table VI or Table VIa may be utilized in determining the Roman numeral designation for hearing impairment, "whichever results in the higher numeral." 38 C.F.R. § 4.86(a). Here, Table VIa provides a Level VI hearing impairment in the right ear and a Level VII hearing impairment in the left ear, corresponding to a 30 percent rating in Table VII. Given that Table VI (rather than VIa) provides the higher 50 percent rating, the Board finds that use of Table VI is appropriate in determining the initial rating. 38 C.F.R. §§ 4.7, 4.85, 4.86, DC 6100. In sum, the Board finds that the evidence warrants the assignment of an initial 50 percent rating for bilateral hearing loss. There are no valid medical audiometric examinations or other competent medical evidence of record that demonstrate hearing loss at a level that would warrant a higher initial rating. Finally, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Right Knee As noted above, the Veteran's representative has identified outstanding VA and private treatment records relevant to the Veteran's claim for entitlement to service connection for a right knee condition. See Correspondence received August 6, 2021. Additionally, during the April 2021 Board hearing, the Veteran stated he received treatment from a doctor who also recommended right knee replacement surgery, and treatment at Peconic Bay Hospital. See Hearing Transcript at pg. 7. When, as here, VA is put on notice of the existence of potentially relevant treatment records, VA must attempt to obtain these records before deciding the appeal as part of the duty to assist. 38 C.F.R. § 3.159(c); Golz v. Shinseki, 590 F.3d 1317, 1323 (2010). Therefore, on remand VA must comply with its duty to assist in the development of the Veteran's claim by attempting to obtain the aforementioned private and VA treatment records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Vertigo VA treatment records reflect that the Veteran reported the onset of vertigo along with hearing loss after his exposure to artillery fire at Fort Sill, Oklahoma. See Hearing Transcript at pgs. 4, 10. He also asserts noticing vertigo symptoms immediately after an in-service truck crash at Fort Dix. Id. The Veteran is competent to report the onset of vertigo symptoms during and after service as such symptoms are readily observable. See Layno, 6 Vet. App. at 469-70. Post-service treatment records reflect that the Veteran's vertigo, hearing loss, and tinnitus have been evaluated in the context of his in-service exposure to acoustic trauma from artillery. See, e.g., VA audiology consults dated September 24, 2013 and October 15, 2013; VA otolaryngology note dated May 30, 2014. This evidence and the Veteran's Board testimony raise a claim for secondary service connection for vertigo as due to the service-connected bilateral hearing loss and tinnitus disabilities. See Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (holding that the Board is obligated to address all issues reasonably raised by the evidence of record). As the record includes competent evidence of a current disability, evidence of an event or injury in service, and an indication that the disability or recurrent symptoms of a disability may be associated with a veteran's service or with another service-connected disability, remand is warranted to afford the Veteran a VA examination to ascertain the likely etiology of his current disorder. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Dental A claim for service connection for a dental disorder is also considered to be a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302 (1993). Thus, in the current case, adjudication of the Veteran's claim for service connection must also include consideration of service connection for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. Therefore, the issue on appeal has been recharacterized to include entitlement for treatment purposes. However, in this case, the Board is unable to determine whether a claim for service connection for treatment purposes has been referred to Veterans Health Administration (VHA) for a determination on the relevant questions. The regulation relating to service connection of dental conditions for treatment purposes was amended, effective February 29, 2012, in order to clarify existing regulatory provisions and to reflect the respective responsibilities of the VHA and Veterans Benefits Administration (VBA) in determinations concerning eligibility for dental treatment. The amended version of 38 C.F.R. § 3.381 clarifies that VBA will adjudicate a claim for service connection of a dental condition for treatment purposes after VHA determines that a veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and requests that VBA make a determination on relevant questions. 38 C.F.R. § 3.381(a). Here, the record does not reflect a VHA determination or VBA adjudication of the Veteran's claim. Accordingly, the Board finds that remand is necessary. Additionally, the Veteran asserts sustaining in-service dental trauma and identifies outstanding STRs relevant to this claim. In a statement dated December 2016, the Veteran asserted that while on garbage detail at Fort Dix in 1965, he was involved in a truck accident and was treated at the Naval Hospital on Staten Island, New York (NHSI) for lacerations, broken and lost teeth, and a concussion. See Veteran's statement received November 2017; Veteran's statement submitted to Congressman Lee Zeldin received by VA January 9, 2017. Dental records dated shortly after the Veteran's May 1965 enlistment reflect no abnormalities for teeth numbered 23-25; however, in November 1966, his dental charts reflected damaged or missing teeth numbered 23-25 for which a bridge was fitted in November 1966. See Dental Health Record entries dated May 19, 1965 and November 11-30, 1966. Notwithstanding that the STRs include no explanation for the damaged or missing teeth or the bridge, an in-service injury is indicated by the service dental records. In March 2017, the Veteran submitted a National Archives and Records Administration form requesting that VA obtain NHSI records reflecting treatment for these injuries from October to November 1965. See Request Pertaining to Military Records (Form SF-180) received March 16, 2017. However, the record reflects that the AOJ took no action to request records from NHSI during the development of the Veteran's claim. As VA was put on notice of the existence of potentially relevant federal records, VA must attempt to obtain these records before deciding the appeal as part of the duty to assist. 38 C.F.R. § 3.159(c); Golz, 590 F.3d at 1323. Therefore, on remand VA must comply with its duty to assist in the development of the Veteran's claim by attempting to obtain the aforementioned records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The matters are REMANDED for the following action: 1. Implement the Board's decisions herein granting: (i) service connection for right hearing loss; and (ii) assignment of an initial 50 percent rating for service-connected bilateral hearing loss. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Contact the Veteran and request that he provide information regarding all outstanding private and VA medical treatment that the Veteran received for his right knee condition, including treatment from the physician(s) who recommended right knee replacement surgery, and treatment, if any, at PECONIC BAY HOSPITAL as reflected in the Veteran's April 2021 Board hearing testimony (pg. 7), providing the Veteran with appropriate VA consent and authorization forms for this purpose. Also advise him that he may submit such records if he so chooses. Allow a reasonable time for reply. If VA attempts to obtain any outstanding records that are unavailable, the Veteran and his representative should be notified pursuant to 38 C.F.R. § 3.159(e). 4. Contact all pertinent records repositories, to include Department of Defense if applicable, and to request the Veteran's treatment records from the Naval Hospital on Staten Island for the period 1965 through 1966, including records of treatment for injuries sustained in a truck accident at Fort Dix. Any outstanding available records should be obtained for inclusion in the electronic claims file. Document all efforts in this regard in the electronic claims file. If VA attempts to obtain any outstanding records that are unavailable, the Veteran and his representative should be notified pursuant to 38 C.F.R. § 3.159(e). 5. Then, obtain an opinion from an appropriately qualified VA examiner as to the nature and etiology of the Veteran's vertigo. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. *The need for another examination(s) is left to the discretion of the medical professional offering the opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to provide an opinion with complete rationale addressing the following: (a) Identify all currently diagnosed vertigo disorders that have been present at any point during the appeal period, which commenced on November 30, 2017. (b) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed vertigo disorder(s) onset during service, manifested within one year after service separation, or is otherwise etiologically related to service, to include as due to injuries claimed by the Veteran to have been sustained in a truck accident at Fort Dix. (c) If the answer to (b) is negative, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the currently diagnosed vertigo was CAUSED or AGGRAVATED by the service-connected hearing loss and/or tinnitus. *Any increase/aggravation is sufficient; permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). *Note to examiner: To ensure that the correct legal standard is applied, which is essential for adjudication of this claim, each opinion MUST BE STATED IN TERMS OF whether the disorder was CAUSED or AGGRAVATED by the service-connected disorder. The examiner must provide a complete rationale for all opinions proffered. 6. Thereafter, ensure that the examiners have substantially responded to the questions posed by the Board, and if not, take corrective action. 7. Refer the Veteran's claim for entitlement to service connection for a dental condition for treatment purposes to the appropriate VA Medical Center (VAMC) to obtain a VHA determination as to whether the Veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161. If the VAMC/VHA determines that the Veteran meets the basic eligibility requirements, ensure that a determination is obtained from VBA, and readjudicate the claim, to include service connection of a dental condition for compensation purposes. 8. Then, after undertaking any additional development deemed necessary readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.