Citation Nr: 21063242 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-19 205 DATE: October 13, 2021 ORDER Entitlement to service connection for right thumb degenerative arthritis is denied. Entitlement to service connection for a dental disorder for compensation purposes is denied. REMANDED Entitlement to service connection for a dental disability for the purpose of obtaining VA outpatient treatment is remanded. FINDINGS OF FACT 1. The Veteran's right thumb was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran's right thumb degenerative arthritis is not secondary to service-connected right wrist arthritis. 3. The Veteran's wisdom teeth numbers 1 and 16 were extracted during service because they were no longer functional. 4. Veteran's tooth number 19 was removed due to caries. 5. Veteran's tooth number 3 was treated during service and is still present in his mouth. 6. Veteran's teeth numbers 20 and 30 are still present. 7. The Veteran did not lose a tooth during service due to trauma such as an impact to the right side of his mouth. CONCLUSIONS OF LAW 1. The criteria for service connection for right thumb degenerative arthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310. 2. The criteria for establishing service connection for a dental disorder for compensation purposes have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150, 17.161. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1974 to January 1980. These matters come to the Board of Veterans' Appeals (Board) from a November 2015 rating decision issued by the Agency of Original Jurisdiction (AOJ). In February 2021, the Board remanded the appeal for further development. The case was returned to the Board in August 2021. The Board finds that there has been substantial compliance with its directives and may now proceed with a decision. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for right thumb degenerative arthritis. The Veteran contends his right hand disability is related to service. See April 2017 VA Form 9. The question for the Board is whether there is sufficient evidence to find the Veteran's right thumb degenerative arthritis is related to service, to include multiple recreational sport injuries. For the reasons discussed below, the Board concludes the evidence does not support a grant of service connection on a direct or secondary basis. Neither is service connection warranted based on chronicity or continuity of symptomatology. Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Service connection may also be established for certain chronic diseases by satisfying the test for disability compensation for chronic diseases set forth in 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331, 1334 (2013). One method is to show the Veteran has (1) a current chronic disease listed under 3.309(a) and (2) that disease must have been "shown in service." Id. at 1335. As to (1), arthritis is listed under 38 C.F.R. § 3.309(a). As to (2), 38 C.F.R. § 3.303(b) equates "shown in service" with a reliable diagnosis of the chronic disease while in service. Walker, 708 F.3d at 1335. Another method is to show continuity of symptomatology. Continuity of symptomatology may be demonstrated if a claimant can show (1) a condition was "noted" during service; (2) postservice evidence of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Savage v. Gober, 10 Vet. App. 488, 495 (1997). Section 3.303(b) does not require medical evidence of an etiological link between service and a current disability. Walker, 708 F.3d at 1338-40. Also, a Veteran may establish service connection on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Or for any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(b). Entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) requires evidence of three elements: (1) evidence of a current disability that is not service-connected; (2) evidence of a service-connected disability; and (3) evidence of nexus establishing a connection between the service-connected disability and the current disability. 38 C.F.R. § 3.310. In order to prevail on a claim for benefits, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). This is because the Veteran is entitled to the "benefit of the doubt" when the evidence is approximately balanced. Id. at 53. Evidence on an issue is in "approximate balance" when the evidence for and against a finding on that issue is "almost exactly or nearly equal" or "too close to call." Ortiz v. Principi, 274 F.3d 1361, 1364-65 (Fed. Cir. 2001). Beginning with the Veteran's service, at entrance he reported a fracture to his left hand but did not report any problems with his right hand. See December 1973 Report of Medical History. The military doctor who evaluated him did not find any right hand problems. See December 1973 Report of Medical Examination. His service dental records indicate he had an entrance dental exam on January 18, 1974. See SF 608, Dental Health Record. The dental chart associated with that visit does not note any missing teeth. Id. His service dental records also show that, in October 1974, tooth number 3 (upper right side of the jaw) was abscessing, and treated by a root canal, which included another treatment later in time (in November 1974). Id. at Part 17, Diagnosis-Treatment; April 2021 VA Disability Benefits Questionnaire (DBQ) at 3. There are no notes in his service treatment records (STRs) or dental records noting complaints of pieces of medical equipment left in his mouth following those treatments. Neither is there any indication service dental records are missing. The Veteran's STRs show several right hand injuries were incurred throughout the Veteran's service. The first record, dated August 17, 1974, shows he went to the emergency room due to a right wrist injury playing basketball. The doctor ordered X-ray imaging of the hand and it showed a fracture of the right navicular (small bone on the thumb side of the wrist). See August 17, 1974, Record by C.H. The note associated with the visit does not specify that nature of the injury, but it was treated with a cast. Then, on April 1, 1976, the Veteran reported hitting his wrist on a door. Swelling at the right little finger was noticed at the time of the visit but X-ray images did not show any fracture(s). Almost a month later, on April 30, he visited sick-call complaining of an injury to his right middle finger. He reported a baseball hit the right middle finger. His reports led to a request for X-ray imaging that did not show any abnormalities. See May 3, 1976, Record. A few years later, on March 28, 1978, he visited sick-call again complaining of a right wrist injury while playing basketball. Then, on April 10, 1979, he injured his right index finger playing softball. In the whole, his STRs show five right hand injuries. On November 7, 1979, the Veteran underwent a separation examination. The military doctor who evaluated the Veteran did not reference any right hand problems. See Report of Medical Examination. His service dental records note an examination was conducted on November 7, 1979. Those dental records note markings that indicate four missing teeth numbers 1, 16, and 19 are missing. Also, wisdom teeth numbers 1 and 16 were removed (on January 16, 1976) due to lack of functionality. The Board notes markings on the dental record suggested tooth 30 was missing, but the Veteran's recent VA dental examination shows tooth 30 is still present. See April 2021 VA DBQ at 10. He separated from the service in January 1980. In March 1980, the Veteran underwent a VA disability examination as part of a service-connection claim for a right wrist disability. He reported complaints of difficulty grabbing objects with his (dominant) right hand. He also reported occasional pain at the right wrist and described the severity as "bothersome." He added that he observes occasional swelling. See Standard Form 513, Consultation Sheet. The Board notes that, in April 1980, the Veteran was granted service connection for right wrist disability manifested by limited motion and occasional discomfort. See Rating Decision. The Board also notes the Veteran is currently assigned a 10 percent disability rating under Diagnostic Code (DC) 5003-5315 for right wrist healed fracture with degenerative arthritis. A June 2015 VA Medical Center (VAMC) record notes arthritis at the base of his right thumb. See June 27, 2015, Record by J.R.S., MD. During an August 2015 VA examination for the Veteran's service connected right wrist disability, he reported pain at his thumb. See VA DBQ at 3. He also reported a decrease in his flexibility, strength, and an inability to bend his wrist without pain. The examiner noted recent X-ray images showed degenerative changes at the right wrist. Id. at 10. The same month, August 2015, he applied for Social Security Administration (SSA) benefits based on arthritis at both hands. With regards to the right hand, he reported the bone adjoining the right thumb to the hand made it difficult to grab and hold objects. See September 2015 SSA Function Report at 1. In September 2015, the SSA found him disabled due to a physical impairment, to include difficulties using his hands. The Veteran sought service-connection for residuals of a right hand injury and loss of teeth in September 2015. In April 2016 the VA received a statement from the Veteran wherein he asserts he has lost three teeth due to in-service dental treatment. He reported that, sometime between June and August 1974, he went to see military dentists due to tooth pains. The dentist decided on a root canal. During the procedure, one of the instruments (a root canal file) broke off inside the root; the dentist did not remove it and the Veteran left the office with the piece still in the canal. Later, another military dentist removed the instrument which weakened the rest of the tooth and, later, the tooth broke. So, he had a partial, sharp tooth. See April 2016 Statement in Support of Claim. The Board notes he did not identify the lost teeth. Also, the VA dentist who conducted the April 2021 Dental DBQ found a root canal was performed on tooth 3, and three teeth were extracted during service: teeth 1, 16, and 19. See VA DBQ at 3. In December 2019, a Board hearing was conducted for the Veteran's claims. With regards to his right hand claim, he reported he injured the hand in 1975 when he tripped and fell on the hand. See Transcript at 2. He then went to the base hospital and discovered he had a broken bone in his right hand. He could not recall what bone it was and whether it was more than one bone. Id at 3, 6. His injury was treated with a cast; however, when it was removed, he still observed some problems with the right hand. He added that the problems continued over the years. He indicated the problem he observed was pain around the right wrist. Id. at 3. Then, after leaving service, he visited a VAMC clinic and was told that arthritis was starting to form at the hand. Id. at 3, 4. It continued to get worse over the years, to the point he could no longer perform his job as a chef. Id. at 3. Now, he observes pain at his right thumb to the wrist. Also, at the wrist, and about an inch above the wrist towards the elbow. As to the severity of the observed pain, he described it as a 7 or 8 (out of 10, with 10 being the most severe pain). Id. at 5, 6, 7. With regards to the Veteran's dental claim, he reported he was doing an activity during service and he was hit on the side of the face. Id. at 7. He went to dental and discovered one of his teeth was knocked out. He did not indicate whether he lost tooth 1, 3, 16, 19, 20, or 30. Id. Neither did he describe the impact to his face or the activity that led to the impact. In February 2020, the VA received private medical records related to a visit to S.C., MD, for complaints of right hand problems. The record shows the Veteran visited Dr. S.C. to help develop the Veteran's increased rating claim for right wrist arthritis. The visit included a review of X-ray imaging which Dr. S.C. noted shows arthritis at the mid-carpal region. The mid-carpal region includes the bones between the wrist and fingers of the hand. See Private Medical Record by Dr. S.C. at 1, 3. After discussing the X-ray imaging he noted he could not determine where the Veteran initially fractured his hand during service and whether the fracture had anything to do with the development of arthritis. Id. at 4. Following a February 2021 Board remand, the Veteran underwent VA disability examinations for his right hand and dental claims. Beginning with the April 2021 disability examination for his right hand, he reported pain, soreness at the base of his right thumb that gradually developed since the 1970s. He currently observes a decrease in strength at the right hand. He denied swelling and flare-ups. See VA DBQ at 3.The examiner found limited range of motion of the right hand with pain at the thumb. Id. at 6, 7. Muscle strength testing showed normal hand strength and none of the fingers were found to be ankylosed. Id. at 17, 18-20. The examiner noted recent X-ray imaging showed arthritis at the right thumb and diagnosed degenerative arthritis. Id. at 2, 21. Then the examiner opined the Veteran's right thumb arthritis is not related to service nor right wrist arthritis; instead, it is due to aging. See April 2021 Medical Opinion at 2, 3. The examiner acknowledged the Veteran's reports of injuries playing sports and hitting his hand on a door, but indicated the injuries were acute and did not persist through service. Acute is defined as having a short and relatively severe course. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (DORLANDS) 24 (33rd ed. 2020). In support of the opinion, the examiner pointed to the lack of continuous care for any of those injuries during service and the lack of reference to hand or finger problems at separation. The examiner considered the Veteran's reports of pain at the right hand but indicated they are not sufficient to support a finding that arthritis at the thumb existed at any time during service. The examiner emphasized the passage of time without symptoms indicates his arthritis is due to aging rather than any of his in-service injuries. With regards to a causal connection between the Veteran's right wrist arthritis and right thumb arthritis, the examiner explained medical literature does not support the proposition that arthritis located at an injured joint (the wrist) would generally lead to the development of arthritis at an uninjured joint (the thumb). Id. at 2. She acknowledged some injuries could cause physiological changes that would lead to such a result but indicated those cases are exceptional, easily identified, and not applicable to the particulars of the Veteran's claim. She also indicated that the severity of the Veteran's right thumb arthritis is consistent with what would be expected during its natural progression. Id. at 3. During the April 2021 VA disability examination for the Veteran's dental claims, he reported an instrument was left in his mouth during a root canal procedure. See VA DBQ at 10. A crown was then placed, which broke off about 10 years later. Id. at 3. Also, he lost a tooth on the right side due to trauma. Id. at 10. The examiner found five missing teeth, to include numbers 1 (wisdom tooth located on the upper right jaw), 16 (wisdom tooth, located at the left upper jaw), 19 (left lower part of the jaw), 21 (left lower part of the jaw), and 32 (wisdom tooth, right lower part of the jaw). Id. at 5. Also, moderate to severe caries throughout the remaining teeth. Id. at 7. Dental caries are tooth decay or cavities. DORLAND'S at 291. The examiner noted the Veteran was diagnosed with an abscessing tooth number 3, which was treated with a root canal that took more than one procedure. Id. at 3. Also, wisdom teeth numbers 1 and 16 were removed because of lack of occlusion on any other teeth. Id. at 3. The examiner noted there is no record of an instrument that was left in the Veteran's mouth during a root canal. Also, examination showed all teeth were present on the right side, except wisdom tooth number 32. Tooth number 30 was believed to be missing and examination showed it is still present. Id. at 10. Then, the examiner opined the Veteran did not suffer tooth loss due to disease or injury. Also, the evidence does not support finding the military dentist performed medical malpractice. The examiner pointed out that two of the teeth believed to be removed (numbers 20 and 30) are still present. Teeth numbers 1, 16, and 19 were extracted due to lack of functionality or caries. See June 2021 VA Medical Opinion at 2. The examiner added that the record does not support finding the Veteran lost any teeth during service due to trauma, to include having an impact to the right side of the face. Neither did the record support finding a file was left in the canal of tooth number 3. See April 2021 VA Medical Opinion at 1, 2. The examiner concluded that the record does not support finding the military dentist failed to exercise the degree of care that is expected of a reasonable dentist. Id. at 2. A. The Veteran's right hand disability claim is a claim for functional impairment due to right thumb degenerative arthritis. Given that the Veteran is already service-connected for right wrist arthritis symptoms, like right wrist pain, the first question is whether his service connection claim is for functional loss caused by an already service-connected wrist disability. VA has been compensating the Veteran for functional loss due to arthritis at the wrist. The schedular criteria for musculoskeletal disabilities contemplate factors such as pain, weakened movement and interference with gripping and lifting. 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca v. Brown, 8 Vet. App. 202, 207 (1995). This means the disability rating the Veteran has been assigned under DC 5003-5215 for right wrist arthritis contemplates functional loss due to pain and limited motion. It also means the Veteran has been compensated for symptoms associated with arthritis at the wrist, to include stiffness, wrist pain, and pain that radiates from the wrist towards the elbow. See Transcript dated December 2019 at 5-7. Accordingly, symptoms solely attributable to right wrist arthritis cannot be considered as part of this right hand entitlement claim. 38 C.F.R. § 4.14. While the record reflects functional loss due to the Veteran's service-connected right wrist disability, it also shows functional loss attributable to right thumb degenerative arthritis. Given that the Veteran has been diagnosed with arthritis located at the carpal metacarpal jointa bone that is not part of the wrist jointthat causes functional loss of the right thumb, the Board finds the record reflects a diagnosed right hand disability this is separate from his already-service connected right wrist disability. The Board recognizes the Veteran has suggested other bones at the right hand may have broken during service; however, he has not reported pain or functional loss due to other portions of the hand, like the ring or middle finger. See Transcript dated December 2019 at 3 (reporting he is not sure which bone in his hand was broken during service). During his Board hearing, and VA disability examinations of the hands, he has consistently maintained he observes difficulty using the right hand due to pain, limited motion of the wrist and thumb. See August 2015 VA DBQ at 3; Transcript dated December 2019 at 6, 7; February 2021 VA DBQ at 3. Given that the Veteran has maintained the functional loss he observes is due to the wrist and thumb, the Board finds the right hand disability at issue in this claim is limited to his right thumb degenerative arthritis. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). B. Entitlement to service connection on a direct basis. Now that the Board has determined that the Veteran's entitlement claim is limited to service connection for right thumb arthritis, the next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(a). That is, on a direct basis. To answer that question, the first issue is whether the Veteran's right thumb degenerative arthritis was incurred during service. The Board acknowledges the Veteran's STRs show five right hand injuries during service. The record shows he initially fractured a bone near the right wrist in August 1974, hit his wrist on a door on April 1, 1976; injured his middle finger playing baseball on April 30, 1976; injured his wrist playing basketball in March 1978; and an injured his wrist playing softball in April 1979. Also, images taken following the first three injuries (August 1974, April 1 and 30, 1976) showed just one injury led to a fracture (August 1974). So, the evidence shows multiple right hand injuries during service, to include one that caused a fracture. See VAMC records dated August 17, 1974; April 1, 1976; April 30, 1976; May 3, 1976; March 28, 1978; April 10, 1979. Although the Veteran's STRs show multiple right hand injuries, none of them show a clear diagnosis of arthritis at the right thumb. First, there is no reference to arthritis in the record. Second, the Veteran's STRs do not show medical complaints of residual symptoms such as pain following his injuries during service, which may help support a later diagnosis of arthritis. Given that he visited sick-call with medical complaints of right hand problems several times during service, the Board finds it is likely he would have visited sick-call with complaints of residual pains due to right hand injuries, if observed. Considering he has not alleged he managed pain observed pain during service through the use of any medications, the Board finds the STRs credible. Even if the Veteran observed pain that did not rise to a level he thought warranted a visit to sick-call, the April 2021 VA Medical Opinion weighs strongly against finding his lay recollections of pain support finding arthritis was shown in service. The Veteran is competent to report observations of pain during service. Layno v. Brown, 6 Vet. App. 465, 469 (1994). But he is not competent to opine that his observed pain indicates the existence of arthritis during service. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (Fed. Cir. 2007). He has not demonstrated he has the medical knowledge, training, or experience to render etiological opinions. In contrast, the examiner who prepared the April 2021 can render such an opinion. The examiner who prepared the April 2021 medical opinion concluded the Veteran's reports of pain do not support finding arthritis was shown during service. She considered the Veteran's injuries and indicated his observed pain reported with each visit were separate and apart from each injury. She also indicated that each injury did not impact the thumb in a way that residual effects persisted through service. See April 2021 VA Medical Opinion at 2. Given that the examiner is qualified to review the evidence and opine on whether each documented injury had lasting effects on the right thumb through service, the Board finds her explanation sufficient to evaluate whether the data she relied on connects to her conclusion. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). So, her opinion was found probative towards evaluating the issue of an in-service incurrence of right thumb degenerative arthritis. So, the opinion was assigned great weight against finding arthritis was shown in service. The Board recognizes the VA has already found residual effects of an in-service injury persisted through service when it granted the Veteran's claim for service-connection for right wrist disability; however, the VA's finding as to the wrist bone(s) does not necessarily extend to all the other bones of that hand. In this case, the carpal metacarpal joint of the thumb. Whether arthritis at the wrist extends to the bones of the thumb is a question neither the Veteran nor the Board is qualified to answer. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). But the April 2021 VA medical opinion addressed the question and explained that, generally, arthritis will not impact a non-injured portion of a joint or limb. See VA Medical Opinion at 2, 3. Given that she acknowledged the exceptional cases and found those particular circumstances do not apply to the Veteran's claim, the Board finds the data she relied on connects to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. So, the Board assigned it significant weight against finding the residual effects of an injury to the wrist extends to the right thumb joint(s) as well. The Board also recognizes the Veteran's lay observations of pain following his right wrist fracture in August 1974; however, they were of little probative value towards evaluating whether right thumb degenerative arthritis was incurred in or shown in service. Inasmuch as he is competent to report observations of pain, a review of his statements during service and within the year after leaving service show reports of right wrist painbut not thumb pain. See March 1980 Standard Form 513, Consultation Sheet (reported occasional pain at the right wrist and described the severity as "bothersome"). Clear reports of right thumb pain do not begin to appear until many years after service, around August 2015. See VA DBQ at 3. Also, his more recent statements do not suggest he observed right thumb pain, limited motion, during service or within a year of leaving service. Considering his lay reports of thumb pain appear in the record long after service, they do not help evaluate whether symptoms of right thumb arthritis existed during service or within a year of leaving service. So, they are of little probative value towards evaluating the issue. Even if the Veteran had recently asserted he observed right thumb pain since the fracture to his hand in August 1974, the Board favors his credible STRs and statements within the year of leaving service. When determining the credibility of lay evidence, the Board may properly consider internal consistency, facial plausibility, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498, 511 (1994). Here, his STRs provide contemporaneous medical evidence of his right hand condition(s) during service that have not been alleged to be inaccurate when developing his claim for his service-connected right wrist disability. With regards to symptoms of pain that may have manifested within the year he left service (November 1979); he did not mention right thumb pain during the March 1980 VA disability examination. See March 1980 Standard Form 513, Consultation Sheet (reported occasional pain at the right wrist and described the severity as "bothersome"). Given that reports to medical providers are generally found reliable, the Board finds his statements at that time highly credible. Based on the consistency of the contemporaneous evidence, any recent lay statement that conflicted with those records would have been found not credible. Caluza, 7 Vet. App. at 511. In this case, the evidence weighs against finding his in-service right hand injuries led to the manifestation of arthritis during service or within a year of leaving service. Although the Veteran injured his right hand several times, the evidence does not support finding he broke or fractured any bone of the right hand other than a wrist bone in August 1974. While he has described observing right wrist pain for many years, the Board finds he has described symptoms of an already service-connected right wrist arthritis disability. Whether those symptoms indicate the existence of right thumb arthritis during service has been addressed by the April 2021 VA Medical Opinion; the examiner did not find arthritis during service. The examiner also explained the Veteran's service-connected right wrist arthritis did not lead to the development of right thumb arthritis. See VA Medica Opinion at 2, 3. Altogether, the evidence weighs against finding an in-service incurrence of right thumb degenerative arthritis. The next issue is whether there is a nexus between the Veteran's right thumb degenerative arthritis and service. While the Veteran's statements and observations are competent to support an in-service injury or incurrence, they are not probative towards evaluating the issue of a nexus. Jandreau, 492 F.3d at 1377. His statements are not competent to render an etiological link between an in-service injury and the development of right thumb degenerative arthritis. The VA examiner who prepared the April 2021 medical opinion considered the Veteran's injuries and reports of pain when rendering her conclusion: She opined that the Veteran's current right hand disability is not related to any of his in-service injuries. See VA Medical Opinion at 2, 3. The examiner also considered her personal examination of the Veteran and the evidence of record. So, the Board finds the examiner was informed of the relevant details of the Veteran's past medical history when rendering her opinion. Nievez-Rodriguez, 22 Vet. App. at 301. The VA examiner indicated the Veteran's in-service injuries were acute and, therefore, did have effects on the thumb that persisted through service. See VA Medical Opinion at 2, 3. Even though the examiner did not separate the Veteran's in-service observations associated with his service-connected right wrist arthritis from observations associated with this right thumb claim, she indicated the evidence does not support finding right thumb arthritis existed during service. Given the Veteran has not asserted right thumb pain during service, and reports following X-ray imaging do not note arthritis, the Board finds the explanation sufficient to evaluate whether the information she relied on connects to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Although the opinion has significant probative value by itself, the weight assigned to it was enhanced by supporting medical evidence in the record. The examiner's opinion is supported by the March 1980 VA disability examination of the right hand, which does not note reports of right thumb pain nor arthritis. Given that the examination was aimed at finding any residual effects of his in-service injuries, the Board finds it is likely he would have reported right thumb pain, if observed. So, the Board finds the Veteran's reports credible at that time highly credible. Considering the VA examiner did not find pain at the thumb either, the Board finds the March 1980 examination supports the April 2021 opinion. Due to the additional, supporting medical evidence, the April 2021 opinion was assigned great weight against a nexus. The Board recognizes the Veteran has provided records from a private medical provider; however, a search of the records did not provide evidence that was helpful towards deciding a nexus. The records related to a February 2020 visit to Dr. S.C. expressly state the Veteran visited Dr. S.C. to develop an increased rating claim for his service connected right wrist disability. See Private Medical Record at 1. Although a search of the record discusses arthritis around the bones of the right thumb, he concluded he cannot determine if a fracture during service caused the arthritis. Id. at 3. So, it was not probative towards finding a nexus. In this case, the evidence is not approximately balanced on this issue of a nexus. The Veteran's lay statements are not competent to diagnose the presence of arthritis during service. In contrast, the VA examiner who prepared the April 2021 VA Medical Opinion is competent to render such an opinion. She concluded arthritis was not shown in service and none of the Veteran's in-service injuries caused residual effects on the thumb that persisted through service. The Board gives this opinion great probative weight as it rendered by a medical professional who is competent to render etiological opinions. Since that opinion was supported by other medical evidence in the record, doubt on this issue could not be resolved in his favor. Gilbert, 1 Vet. App. at 54. As a result, the Board finds there is no nexus between the Veteran's right thumb disability and his service. Because the Veteran has not established a nexus nor an in-service incurrence, he has not established entitlement to service connection under 38 C.F.R. § 3.303. C. Entitlement to service connection based on chronicity and continuity of symptomatology. The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(b). That is, based on chronicity or continuity of symptomatology. To answer that question, the first issue is whether the Veteran has a chronic disability under VA regulations. The Veteran's diagnosed right thumb degenerative arthritis is a disability that falls within 38 C.F.R. § 3.309(a). Thus, the record reflects the Veteran has a chronic disability. Although the record reflects a diagnosed chronic disability, it was not shown in or noted in service. As explained above, there is no evidence in the Veteran's STRs that support finding he had a diagnosis of right thumb arthritis during service. Nor within one year after leaving service. See March 1980 VA Standard Form 513, Consultation Sheet. If there is any question about the Board's review of the record, the April 2021 VA medical opinion is additional medical evidence that weighed against a finding of chronicity during service or within the year after leaving service. After considering the Veteran's reports and evidence of record, the examiner indicated the available evidence does not support finding arthritis existed during service. Given that she concluded arthritis was due to aging and did not exist until several years after service, it is apparent to the Board she also concluded arthritis was not shown within the year the Veteran left service. Given that the examiner is qualified to review the evidence and opine on whether it supports finding arthritis existed during service, the Board finds her explanation sufficient to evaluate whether the data she relied on connects to her conclusion. Nievez-Rodriguez v. Peake, 22 Vet. App. at 301. So, her opinion was found highly probative towards evaluating the issue of whether arthritis was show in service or within the year following service. Even if, for some reason, the probative value of the examiner's opinion was diminished, the March 1980 VA disability examination weighs strongly against finding chronicity within the year following service. See VA Standard Form 513, Consultation Sheet. Given that a medical professional evaluated the right hand for the purpose of identifying signs of any disabilities, it provides contemporaneous medical evidence that is highly probative towards finding a chronic right thumb condition was not present within the year the Veteran left service. In this case, the evidence is not approximately balanced in favor of finding the Veteran's chronic disability was shown in service or within a year he separated from service. A review of the record shows there is not enough evidence of a reliable diagnosis of arthritis during service. Walker, 708 F.3d at 1335. So, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. As to continuity of symptomatology, the Veteran has not asserted he observed continuous symptoms of right thumb arthritis since service, to include pain, stiffness, difficulty grabbing objects. See March 1980 Standard Form 513, Consultation Sheet (reported occasional pain at the right wrist and described the severity as "bothersome"); Transcript dated December 2019 at 3 (reported observing pain at the right wrist after an August 1974 wrist fracture). In any event, the examiner who prepared the April 2021 medical opinion concluded his symptoms of pain during service are not related to his current disability. See VA Medical Opinion at 2. Given that she also explained arthritis at his wrist bone(s) is not related to the development of arthritis at the uninjured bones of the hand, the Board is able to evaluate how she distinguished his lay observations of wrist pain and thumb pain. Nievez-Rodriguez, 22 Vet. App. at 301. The opinion was assigned significant weight against finding continuous symptoms of arthritis since service. In this case, the evidence weighs strongly against finding continuous symptoms of arthritis since service. A chronic disability was not shown during service or within one year after service. A search of the record does not show complaints of symptoms during service that he has referenced when describing his right thumb arthritis. Also, a VA medical professional has determined that the Veteran's right thumb arthritis is not due to any event during service. So, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. Accordingly, the Veteran has not established entitlement to service connection under 38 C.F.R. § 3.303(b). D. Entitlement to service-connection on a secondary basis. The last question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.310(a) or (b). That is, on a secondary basis. Although the record reflects the Veteran is service-connected for four disabilities, to include bilateral hearing loss disability, tinnitus, right wrist disability with degenerative arthritis, and residuals of an ankle injury, he has indicated his right hand disability may be proximately caused by or aggravated by his right wrist arthritis disability. The Board notes he has not indicated his right thumb degenerative arthritis is due to any other service-connected disability. And a search of the record did not raise the inference of a claim for service connection under 38 C.F.R. § 3.310 based on any other service-connected disability. So, his right wrist disability is the only service-connected disability that will be discussed at this time. The next issue is whether the Veteran's right thumb degenerative arthritis was proximately caused by his service-connected right wrist disability. As noted above, the April 2021 medical opinion addressed the matter and explained that, generally, arthritis at an injured joint will not cause the development of arthritis at an uninjured. See VA Medical Opinion at 2. Given the examiner also found the particulars of the Veteran's claim do not suggest it is one of the rarer cases where arthritis at an uninjured joint could develop, the Board is able to connect that data she relied on to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. S0, the Board assigned the opinion significant weight against a finding of causation. As to the issue of causation, the Board finds the evidence is not approximately balanced. The only medical opinion of record that addresses the issue is the April 2021 opinion which concludes the Veteran's service-connected right wrist arthritis did not cause his right thumb arthritis. So, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. The next issue is whether the Veteran's right thumb disability was aggravated by his right wrist disability. The April 2021 medical opinion is the only item of medical evidence that addresses the issue, and it weighs against finding aggravation. Although her explanation is brief, it is apparent to the Board that the examiner concluded the evidence does not support finding the progression of the Veteran's right thumb disability is outside of what is expected for degenerative arthritis. See VA Medical Opinion at 3. Given that the examiner is qualified to opine on what is the natural progression of arthritis, the Board is able to connect the data she relied on to her conclusion Nievez-Rodriguez, 22 Vet. App. at 301. So, the Board assigned the opinion significant weight against a finding of aggravation. As to the issue of aggravation, the Board finds the evidence is not approximately balanced. The only medical evidence of record that addresses aggravation is the April 2021 opinion which concludes the Veteran's service-connected right wrist disability did not aggravate his right thumb arthritis beyond its natural progression. So, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. In sum, the Veteran has not established entitlement to service connection under 38 C.F.R. §§ 3.303 or 3.10. 2. Entitlement to service connection for a dental disorder for compensation purposes. The Veteran contends he lost one or more teeth on the right side of his mouth due to trauma during service. See Transcript dated December 2019 at 7. He also contends he lost a part of tooth 3 because a dentist left a piece of a medical instrument in his mouth during a root canal. See April 2016 Statement in Support of Claim. The question for the Board is whether the Veteran has a dental disorder that meets the criteria for a compensable disability rating based on and of the DCs listed under 38 C.F.R. § 4.150. For the reasons discussed below, the Board concludes the evidence does not support finding a compensable rating is warranted under DCs 9900 through 9918. Neither does the evidence show he suffered tooth loss due to loss of substance of body of the maxilla or mandible due to trauma or certain diseases. VA compensation benefits and outpatient dental treatment may be provided for certain types of service-connected dental disorders. For other types of service-connected dental disorders, the Veteran may receive treatment only. 38 U.S.C. § 1712 ; 38 C.F.R. §§ 3.381, 4.150, 17.161. The Board must construe a claim for service connection for a dental condition as both a claim for compensation and, at a minimum, a claim for Class I outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306-7 (1993). With regards to compensation for dental conditions, it is only available for certain types of dental and oral conditions, which are rated under 38 C.F.R. § 4.150, Diagnostic Codes (DCs) 99009916. Simington v. West, 11 Vet. App. 41, 44 (1998); 38 C.F.R. § 4.150 . Diagnostic Code 9913 applies to service connection claims involving teeth. Compensation is not available for loss of the alveolar process (the ridge on the surfaces of the upper (maxilla) and lower (mandible) jaws containing the tooth sockets) as a result of periodontal disease, since such loss is not considered disabling." 38 C.F.R. § 4.150, DC 9913. Thus, to get compensation benefits for a dental disability, as opposed to outpatient dental treatment solely, the evidence must show there was dental trauma or disease (such as osteomyelitis). Also, the trauma or disease caused a loss of substance of body of the maxilla or mandible resulting in a loss of teeth. When there is not sufficient evidence to find dental trauma, service connection may be considered solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment. Woodson v. Brown, 8 Vet. App. 352, 354 (1995). Treatable carious teeth (teeth showing tooth decay or cavities), replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. 38 C.F.R. § 3.381(a). These conditions and other dental conditions or disabilities that are noncompensably rated under § 4.150 may be service connected for purposes of Class II or Class II(a) dental treatment. Id. at (b). But the decision on whether a Veteran can be service connected for treatment purposes must be made by the Veterans Health Administration (VHA) in the first instance. Id. The VHA is a separate from the Veterans Benefits Administration (VBA) (to include the Board) within the VA. The VBA adjudicates claims for service connection of a dental condition for treatment purposes after VHA determines a veteran meets the basic eligibility requirements of § 17.161. Id. at (a). A. The Veteran's service connection claim for loss of teeth is limited to 1, 16, and 19. Given that the June 2021 VA dental examination shows some teeth believed to be missing are still present, the first matter is determining which teeth are part of the Veteran's dental claim. Although the Veteran has five missing teeth, the Board finds his service connection claim for loss of teeth is limited to teeth numbers 1, 16, and 19. See April 2021 VA DBQ at 5 (noting teeth numbers 1, 16, 19, 21, and 32 are missing). The VA dentist who evaluated the record notes three teeth were extracted during service, to include number 1 (located on the upper right), 16 (located at the left upper jaw), and 19 (left lower part of the jaw). See June 2021 VA Medical Opinion at 2. The Veteran's STRs do not indicate any other teeth were lost during service. Considering the Veteran has not indicated he lost more than three missing teeth, the Board finds there is sufficient evidence to find teeth number 1, 16, and 19, make up the Veteran's dental claim for disorders involving loss of teeth. Given that his assertions regarding teeth 1, 16, and 19, are limited to reports of loss of teeth, the Board finds 9913 is the only DC applicable to his claims for teeth 1, 16, and 19. For a compensable disability rating under 9913, the Veteran must have suffered bone loss of the upper (maxilla) and/or lower (mandible) jaw that, in turn, caused tooth loss. Also, the bone loss must have been due to diseases other than periodontal disease 38 C.F.R. § 4.150, DC 9913. B. Entitlement to service connection for wisdom tooth number 1. Beginning with wisdom tooth number 1 (located on the upper right of the jaw) the issue is whether it meets the criteria DC 9913 requires for a compensable disability rating. The Veteran's STRs weighs strongly against finding he lost wisdom tooth number 1 due to bone loss of his upper of lower jaw due to trauma or disease. His service dental records, note tooth 1 was removed on January 16, 1976, because it was found not to serve any purpose. Given the purpose of the procedure was documented at the time it was performed, the Board finds it highly credible towards determining whether the Veteran's tooth loss meets the criteria DC 9913 requires for a compensable disability rating. Because it shows the tooth was not removed due to bone loss of the upper or lower jaw, it was assigned great weight against finding a compensable rating is warranted. If there is a question about the Board's interpretation of the notes and terminology found in his service dental records, the April 2021 VA DBQ and June 2021 VA medical opinion weigh against finding tooth 1 was removed for any other reason. The VA examiner who prepared those items of evidence is a dentist; therefore, he is qualified to review the dental charts, interpret medical abbreviations particular to the field of dentistry, and retrospectively opine on the cause of the tooth extraction. After reviewing the record, he concluded it does not support finding tooth 1 was removed due to an injury or illness. He also noted there is no indication of malpractice. See June 2021 Medical Opinion at 2. The Board acknowledges the Veteran's recent statements indicate he lost a tooth following unspecified trauma to the right side of his mouth; however, the Board favors his STRs and June 2021 VA DBQ over his recent statement. See Transcript dated December 2019 at 7 (reporting he was hit on the side of the face and later discovered one of his teeth was knocked out).When determining the credibility of lay evidence, the Board may properly consider internal consistency, facial plausibility, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498, 511 (1994). Here, his recent statements of tooth loss due to trauma are not plausible in light of other credible evidence of record. As noted in the April 2021 VA DBQ and June 2021 medical opinion, the only missing teeth on the right side of his mouth are wisdom teeth numbers 1 (upper right) and 32 (lower right). See VA DBQ at 3, 5. The STRs show tooth number 1 was removed due to nonfunctionally and 32 was removed following service. See VA DQB at 10; June 2021 VA Medical Opinion at 2. Given that the only tooth loss on the right side of the face was for dental treatment purposes, it is not plausible he would have had another tooth knocked out on that side of the face during service. The lack of medical complaints of trauma to the mouth that caused him to lose tooth number 1 or any other tooth on the right side of the face supports the Board's credibility determination. Because he reported at least five other injuries of less severity than tooth loss, like an injury to a finger while playing softball, the Board finds it likely he would have sought medical attention for an impact to the face of such severity it knocked a tooth out. Even if the Veteran intended to say an impact to the right side of his jaw loosened a tooth, his STRs do not show a tooth was lost on the right side of the mouth, except wisdom tooth 1. Any contention that the event occurred after tooth 1 was removed (in January 1976) would also lack plausibility as the June 2021 VA DBQ shows one additional tooth was lost between January 1976 and June 2021wisdom tooth 32. Although the reason(s) he lost tooth 32 are not known, his service dental records indicate it was there during service. In this case, the evidence weighs strongly against finding he lost tooth number 1 due to bone loss of either jaw. His service medical, dental records show he lost one tooth on the right side of the mouth (tooth 1) and it was removed because it no longer served a purpose. The dentist who prepared the April 2021 VA DBQ and June 2021 Medical Opinion reviewed the record and did not find evidence that indicate otherwise. See VA DBQ at 3; Medical Opinion at 3. While the Veteran believes it may have been lost due to some form of trauma to his face, the Board finds the STRs more reliable and probative towards deciding the issue. In light of the evidence, the Board concludes the Veteran has not demonstrated he meets the criteria DC 9913 requires for a compensable disability rating. Accordingly, the Veteran's service-connection claim for a compensable disability rating must be denied. 38 C.F.R. §§ 3.381; 4.150; Gilbert, 1 Vet. App. at 54. Now that the Board has decided the Veteran does not have a compensable service-connected dental disability, he does not meet the requirements for Class I VA outpatient dental treatment. A service-connected compensable dental disability is required for Class I dental treatment. 38 C.F.R. § 17.161(a). C. Entitlement to service connection for teeth numbers 16 and 19. Given that wisdom teeth numbers 16 (upper left) and 19 (lower left) are both on the left side of the face, the Veteran's lay statements asserting he suffered a tooth loss due to trauma to the right side of the face are not applicable to this portion of his dental claim. Because he has not alleged any other dental condition associated with losing teeth numbers 16 and 19, the Board finds DC 9913 is the only code applicable to this claim. 38 C.F.R. § 4.150. The Veteran's STRs weighs strongly against finding he lost wisdom tooth number 16 due to bone loss of either jaw due to trauma or disease. His service dental records note tooth 16 was removed the same day tooth 1 was removed, on January 16, 1976. Like tooth 1, it was removed because it was found not to serve any purpose. Because his STRs provide a record clearly showing the cause of its removal, they are highly credible towards determining whether the Veteran's tooth loss meets the criteria DC 9913 requires for a compensable disability rating. Considering the record reflects the tooth was removed for reasons other than bone loss of the jaw, it was assigned great weight against finding a compensable disability rating is warranted. With regards to tooth number 19, the STRs are not as clear about the cause of its removal; however, the VA dentist who prepared the June 2021 Medical Opinion indicates it was not removed due to bone loss of either jaw due to injury or disease. See Medical Opinion at 19. He indicates it was removed due to cavities. Given that the VA examiner is qualified to review the dental charts, interpret medical abbreviations particular to the field of dentistry, and retrospectively opine on the cause of the tooth extraction, the Board finds the examiner's conclusion highly probative towards evaluating the issue. Considering the Veteran has not alleged he lost tooth number 19 due to disease or injury to the bone of either jaw, the evidence is consistent with the examiner's opinion. So, it was assigned great weight against finding a compensable disability rating is warranted. In this case, the evidence weighs strongly against finding he lost teeth numbers 16 and 19 due to bone loss of either jaw. His service medical and dental records show tooth 16 was removed because it no longer served a purpose. Although the cause of the loss of tooth 19 was not as apparent, the dentist who prepared the June 2021 VA DBQ and Medical Opinion reviewed the record and expressed it was due to caries. See VA DBQ at 3; Medical Opinion at 2. Diagnostic Code 9913 distinguishes between tooth loss due to periodontal disease (to include carious teeth) and tooth loss due to 'loss of substance of body of maxilla or mandible.'" Simington, 11 Vet. App. at 44. Because the Veteran lost teeth numbers 1, 19, for reasons not listed in 9913, he has not established entitlement to a compensable disability rating for losing them. Accordingly, the Veteran's service-connection claim for a compensable rating must be denied. 38 C.F.R. §§ 3.381; 4.150; Gilbert, 1 Vet. App. at 54. Now that the Board has decided the Veteran does not have a compensable service-connected dental disability, the Board also finds he does not meet the requirements for Class I outpatient dental treatment. As noted above, a service-connected compensable dental disability is required for Class I dental treatment. As noted above, he has not established entitlement to a compensable disability rating. 38 C.F.R. § 17.161(a). D. Entitlement to service connection for tooth number 3. Unlike the dental claims discussed above, DC 9913 does not apply to the Veteran's service-connected claim for tooth number 3 (located on the left side of the face) because parts of tooth 3 are still present. Also, the crown placed on his tooth was the intended result of dental treatment. See June 2021 VA DBQ at 3, 5. The unintended results of treatment due to negligence is relevant to a determination of eligibility for Class II(a) outpatient dental treatment, which is a matter the VHA must decide in the first instance. 38 C.F.R. § 3.381(a). Given that the Veteran has not alleged, nor does the record reflect, he suffers from any of the disabilities that meet the criteria for compensable disability ratings under DCs 9900 through 9918, like chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible (9900), loss of the mandible (9901), nonunion and malunion of the mandible or maxilla (9903, 9904), the Board finds the Veteran does not have a dental disability for VA compensation purposes. 38 C.F.R. § 4.150. Accordingly, he has not established entitlement to a compensable disability rating under any DC listed in 38 C.F.R. § 4.150 and, therefore, his service connection claim for tooth number 3 must be denied. Now that the Board has explained why entitlement to a compensable disability rating under any of 38 C.F.R. § 4.150 is not warranted for tooth number 3, the Board finds he was seeking service connection for outpatient treatment purposes. Because the VHA has not made the initial determination on that matter and VA regulations require it do so, the matter cannot be addressed by the Board at this time. 38 C.F.R. § 3.381(a). REASONS FOR REMAND 1. Entitlement to service connection for a dental disability for the purpose of obtaining VA outpatient treatment is remanded. Although the Board regrets the delay, the Veteran's claim must be remanded before it is able to decide on the merits. VA regulations provide the VBA (which includes the Board) will adjudicate a claim for service connection of a dental condition for dental treatment purposes after the VHA makes an eligibility determination. 38 C.F.R. §§ 3.381(a), 17.161. Here, the Veteran has reported dental treatment by service medical providers was negligent. Although negligence may constitute trauma for VA outpatient treatment purposes, the VHA has not adjudicated the matter in the first instance when evaluating eligibility for VA outpatient treatment. Nielson v. Shinseki, 607 F.3d. 802, 808 (Fed. Cir. 2010). Accordingly, a remand is required for VHA to adjudicate the issue of eligibility for VA dental treatment in the first instance. The matters are REMANDED for the following action: 1. Refer the claim for dental treatment to the appropriate VAMC to determine if the Veteran meets the basic eligibility requirements for VA outpatient dental treatment under 38 C.F.R. § 17.161. If the VAMC determines that the Veteran meets the basic eligibility requirements for VA outpatient dental treatment and requests the VBA make a determination, then adjudicate the claim. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dean, Michael S. 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.