Citation Nr: 21065645 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 12-07 105 DATE: October 26, 2021 ORDER Entitlement to a compensable rating for hypertension prior to March 13, 2001 is denied. Entitlement to a rating in excess of 10 percent for the hypertension since March 13, 2001 is denied. Entitlement to service connection for a right knee disability, to include as due to environmental exposures and/or as secondary to service-connected disability, is denied. Entitlement to service connection for a left knee disability, to include as due to environmental exposures and/or as secondary to service-connected disability, is denied. Entitlement to service connection for a right leg disability (other than already service-connected peripheral neuropathy), to include as due to environmental exposures and/or as secondary to service-connected disability, is denied. Entitlement to service connection for a left leg disability (other than already service-connected peripheral neuropathy), to include as due to environmental exposures and/or as secondary to service-connected disability, is denied. Entitlement to service connection for a dental disability is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to March 13, 2001, the Veteran's diastolic pressure was predominantly less than 100; her systolic pressure was predominantly less than 160; and she did not have a history of diastolic pressure predominantly 100 or more requiring continuous medication for control. 2. Effectively since March 13, 2001, her diastolic pressure has not been predominantly 110 or more, and her systolic pressure has not been predominantly 200 or more. 3. The earliest clinical evidence of a knee disability is not until many years after her separation from service. 4. Although she served in Southwest Asia during the Persian Gulf War, she does not have an undiagnosed illness or a medically unexplained chronic multi symptom illness (MUCMI) of the type contemplated by that service. 5. The most probative (i.e., competent and credible) evidence is against finding that any of the claimed disabilities of her lower extremities was caused or aggravated by her service and/or a service-connected disability or that it initially manifested within one year of her separation from service. 6. She does not have a dental disability caused by impairment of the mandible, loss of a portion of the ramus, loss of a portion of the maxilla, or involving loss of teeth due to trauma or disease such as to osteomyelitis. CONCLUSIONS OF LAW 1. The criteria are not met for entitlement to a compensable rating for hypertension prior to March 13, 2001 or for a rating higher than 10 percent since. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.159, 4.1, 4.3, 4.7, 4.10; 4.104, Diagnostic Code (DC) 7101. 2. The criteria are not met for entitlement to service connection for a bilateral knee disability, a bilateral leg disability (other than the already service-connected peripheral neuropathy), and/or a dental disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.381. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from July 1979 to July 1982 and from March 1989 to February 1993. These claims were most recently before the Board in April 2021 but were remanded back to the local Regional Office (RO) for initial consideration of recently associated evidence and issuance of a Supplemental Statement of the Case (SSOC), which since has been accomplished. (The Board acknowledges that there was also a remand directive to seek authorization to obtain clinical records for sleep apnea; however, this appears to have been an error as the Veteran does not have a claim pending before the Board for service connection for sleep apnea and the Veteran was referred to as another gender.) Complete service treatment records (STRs) from the Veteran's first period of service are not associated with the claims file; however, this is not prejudicial to her. When, as here, at least a portion of the STRs cannot be located, through no fault of the Veteran, VA has a "heightened" obligation to more fully discuss the reasons and bases for its decision and to carefully consider applying the benefit- of-the-doubt doctrine. See, e.g., O'Hare v. Derwinski, 1 Vet. App. 365 (1991). However, the threshold for allowance of a claim is not lowered and the need for probative medical nexus evidence causally relating the current disability at issue to service is not eliminated; rather, the Board's obligation to discuss and evaluate evidence is heightened. Russo v. Brown, 9 Vet. App. 46 (1996). The Veteran has not alleged that any of her claimed disabilities are due to her first period of service, rather, contends they are due to her second period of service and/or service-connected disabilities. Moreover, her November 1988 Report of Medical Examination for enlistment purposes for her second period of service reflects that, upon examination, all pertinent systems were normal. In addition, her corresponding November 1988 Report of Medical History reflects that she denied lameness, arthritis, rheumatism, bursitis, bone, joint or other deformity, or a trick or locked knee. Thus, upon entrance into her second period of active-duty service, which was from March 1989 to February1993, she had no noted disabilities and no complaints. STRs from her second period of active-duty service are associated with the claims file, so the Board has the benefit of these other records concerning the specific portion of her service that is at issue. Increased Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. A disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of its entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, "staged" ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings irrespective of whether an initial or established rating. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In McGrath v. Gober, 14 Vet. App. 28 (2000), the U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC) held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. 1. Entitlement to increased ratings for hypertension The Veteran's hypertension is rated as noncompensable (i.e., zero percent) from July 30, 1997 to March 13, 2001 under DC 7101, which provides for a 10 percent rating when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more, or; the minimum evaluation for an individual with a history of diastolic pressure is predominantly 100 or more and who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. A 40 percent rating is warranted when diastolic pressure is predominantly 120 or more. A 60 percent rating is warranted when diastolic pressure is predominantly 130 or more. Prior March 13, 2001 The Board has reviewed the Veteran's blood pressure readings from prior to the effective date of service connection (to determine the history and when she was on medication), and notes the majority below. Although there may be additional readings in the claims file, they do not present findings concerning the Veteran's hypertension that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. Clinical records note the following readings: 110/80 Apr. 1989 122/76 May 1989 148/106 Feb. 1990 138/90 Feb. 1990 120/78 July 1990 141/86 July 1990 138/80 Nov. 1990 162/78 Dec. 1990 132/80 Dec. 1990 141/86 July 1990 131/85 June 1991 144/91 Aug. 1991 128/64 Sept. 1991 142/77 Dec. 1991 142/100 Feb. 1992 138/86 July 1992 127/88 Aug. 1992 142/84 Oct. 1992 140/82 Feb. 1993 (record notes that she is not on medication and not yet diagnosed with hypertension. See Report of Medical History) 128/84 and 130/86 Apr. 1993 136/74 May 1994 161/92 July 1994 158/86 Sept. 1994 147/93 Dec 1994 138/96 Jan. 1995 (record notes she is not on medication) 130/92 Feb. 1995 147/93 Feb. 1995 142/96 Nov.1995 152/86 Nov.1995 158/96 Feb. 1996 152/99 May 1996 166/86 Nov. 1996 150/84 Apr. 1997 (record notes a slight increase in blood pressure (BP), and to check BP through the week) 134/90, 158/98, June 1997 (record notes "mild" hypertension, and that she is started on medication.) 152/86 Apr. 1998 147/92 June 1998 128/83 July 1998 150/70 Sept. 1998 136/86 Sept.1998 120/78 Jan. 1999 140/90 Mar. 1999 126/83 Apr. 1999 130/84 June 1999 138/81 July 1999 133/85 July 1999 140/86 Nov. 1999 143/93 Nov. 1999 142/92 Jan. 2000 140/90 Mar. 2000 146/88 Apr. 2000 144/84 Sept. 2000 142/86 Dec. 2000 The evidence does not support that it is as likely as not that her diastolic pressure (the bottom number) was predominantly 100 or more, or that her systolic pressure (the top number) was predominantly 160 or more. Moreover, the evidence does not reflect that she had a history of diastolic pressure predominantly 100 or more and required continuous medication for control. Although she had an occasional diastolic pressure over 100, the majority were under 100. In addition, while she began taking medication in 1997 to control her high blood pressure, she did not have a history of diastolic pressure predominantly 100 or more prior to the medication. At a November 2008 examination for hypertension, the Veteran asserted that she was started on medication for hypertension in 1990. In a 2003 VA Form 21-4138, she asserted that in 1994, her blood pressure medication was changed and increased. In a 2000 statement, she reported that VA put her on blood pressure medication in 1995. However, the Board finds that clinical records are more probative than the Veteran's recollection. An April 1993 VA examination report for hypertension reflects her statement that she has had "rare, elevated blood pressure, but has never had any blood pressure re-checks and never been placed on any blood pressure medication," and a January 1995 record notes that she was not on medication. Moreover, the records noted above reflect that she was started on medication in June 1997. Based on the record as a whole, the Board finds that she began medication for hypertension in 1997. From March 13, 2001(rated as 10-percent disabling) The Veteran's hypertension is rated as 10-percent disabling from March 13, 2001. The claims file includes numerous blood pressure readings which support that she does not meet the criteria for a rating in excess of 10 percent. For example, in 2001, she had a reading of 148/98. She also had readings of 150/92, 174/98, 171/95, 171/97, 160/88, 167/89, and 173/92 in 2002. In 2003, she had readings of 158/93, 161/106, 199/109, 170/91, 137/85, 151/87, 134/96, 152/92, 144/87, and 168/105 in 2003. In 2004, she had readings of 146/89, 140/89, 154/104, 162/90. In 2005, she had readings of 170/69, 161/80, 174/90, 132/76 In 2006, she had readings of 122/65, 137/77, 135/80, and 133/74. In 2007, she had readings of 140/88, 132/78, 102/73, 129/85, 102/73, 119/74, and 123/68. In 2008, she had readings of 114/88, 123/74, 124/67, 122/74, 99/67, 133/74, and 119/73. In 2009, she had readings of 123/88, 115/73, 119/80, 110/66, 115/66, 122/75, and 136/79. In 2010, she had readings of 139/74, 160/98, 142/64, 133/71, 116/69, 118/72, 161/79, and 150/70. A September 2010 VA record reflects that she reported that when she checks her blood pressure at home, she gets systolic readings of 140-150, and diastolic readings of 70-90. In 2011, she had readings of 112/71, 116/72, and 137/64. A January 2012 Disability Benefits Questionnaire (DBQ) reflects readings of 140/84, 146/84, and 146/80. An additional 2012 reading was noted to be 135/66. In 2013, she had readings of 131/75, and 140/76. In 2014, she had readings of 139/70, 131/78, and 134/72. In 2015, she had readings of 107/53, 136/69, and 145/73. In 2016, she had readings of 139/74, 119/69, 131/70, and 110/69. In 2017, she had readings of 124/89, 137/72, and 131/67. In 2018, she had readings of 127/65, 131/72, 112/71, and 139/71. In 2019, she had readings of 124/69, and 134/74. In 2020, she had readings of 112/69, 133/58,126/69, and 148/78. A September 2020 VA record reflects that she reported that she does not regularly check her blood pressure at home, but when she does, she does not have blood pressure over 140/90. The evidence is against a finding that an increased rating is warranted for any period on appeal. Finally, the Board notes that a claim for a TDIU may be raised as a derivative claim stemming from a veteran's claim of entitlement to an increased rating for a service-connected disability, provided the disability is at least one of the reasons he or she is unemployable or claims to be so. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board will address entitlement to a TDIU in the Remand section below. Service Connection In general, establishing service connection requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a nexus between the disease or injury in service and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In addition, certain chronic diseases including arthritis (degenerative joint disease) will be presumed to have been incurred in service, absent an intervening ("intercurrent") cause, if they were shown as chronic in service or if they manifested to a compensable degree within a year following separation from service, or if they were noted in service (or within the presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Veteran's DD Form 214 shows she received the Southwest Asia Service (SWA) Medal, and served in SWA from September 1990 to October 1990. Thus, she is considered a Persian Gulf War (PGW) veteran. 38 C.F.R. § 3.317(e). Service connection may be granted for a PGW veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a MUCMI. 38 C.F.R. § 3.317(a)(2)(i). The term chronic means that the disability has existed for 6 months or more, to include intermittent episodes of improvement or worsening over that period. 38 C.F.R. § 3.317(a)(4). Objective indications of a qualifying chronic disability include both signs and symptoms, in the medical sense of objective evidence perceptible to an examining physician, and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost from work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). An undiagnosed illness requires that the illness, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(4). There is no burden on a veteran to demonstrate that a medical professional has eliminated all possible diagnoses before the veteran can be compensated for a disability stemming from an undiagnosed illness. Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014). 2. & 3. Entitlement to service connection for right and left knee disabilities And 4. & 5. Entitlement to service connection for right and/or left leg disabilities The Veteran has alleged various etiologies for a knee and/or leg disability. In an August 2012 written statement, she reported that she believes that her use of prescription birth control has contributed to leg problems. In a December 2012 VA Form 21-4138, she indicated that she believes that her cholesterol medication causes knee and leg pain, and also that she injured herself in May 1989 while running for PT (physical training) and was kicked and "ran over". In a January 2014 VA Form 21-4138, she stated that she believes that her knee pain is secondary to service-connected disabilities. In an October 2014 VA Form 21-4138, she indicated that she believed that there is no clear diagnosis for her knee pain; thus, suggesting that it is an undiagnosed illness which warrants service connection due to her service in SWA from September 1990 to October 1990. In a July 2016 VA Form 21-4138, she alleged that her knee pain was due to her service-connected lumbar spine disability. The Veteran has not been shown to have the experience, training, or education necessary to give a probative opinion regarding a diagnosis and/or the origins of any knee and/or leg condition, including in terms of whether related or attributable to anything that occurred during her time in the military, or due to a service-connected disability. This determination is beyond her lay competence, and as noted above, she has given a variety of possible etiologies. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). See also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). The Veteran's service treatment records (STRs) are unremarkable for chronic knee complaints or a significant knee injury. Her contention that she injured her knee in a May 1989 incident lacks credibility. (Although she referred to the incident as occurring on May 5, 1989, the accompanying STR is dated May 15, 1989; thus, the Board finds that she was mistaken in writing the date.) The May 1989 STR reflects that she complained of pain in the right side after falling out of a PT run, being kicked, and losing consciousness for 10 seconds. Upon examination, there were no signs of any injury. Notably, the STR reflects that her complaint was right side chest pain, and is unremarkable for knee or leg complaints. It seems entirely reasonable that any leg and/or knee complaint would have been noted in the clinical records if she had it. See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely-held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). As to having been "ran over", there is nothing to support that she was run over by a vehicle, but only that she was running when she hurt the right side of her chest, and she got kicked by someone. Regardless, there are no complaints as to the legs or knees in the STRs. An October 1989 STR reflects that she reported cramps in her legs for two weeks with an onset with running. There was no edema, no swelling, and no discoloration. Her gait was normal, and she had a full range of motion. Her legs were nontender. She was assessed with a spasm. There are no STRs noting further complaints of the legs and/or knees. The STRs note that the Veteran had numerous clinical visits during her service, to include for complaints of foot pain (April 1989), feeling dizzy (May 1989), left side chest pain (July 1989), neck pain (August 1989), low back pain (November 1989), stomach pain (February 1990), low back pain (July 1990), an ulcer (October 1990), an ulcer (December 1990), an ulcer (February 1991), heavy menses (August 1991), a fibroid (April 1991), back pain (April 1992), abnormal bleeding (July 1992), and low back pain (September 1992). It seems reasonable that if she had chronic knee and/or leg complaints, she would have reported it and it would have been noted in the STRs as she sought treatment by providers for complaints in other areas. Her February 1993 Report of Medical History for separation purposes reflects that she specifically denied a trick or locked knee, denied bone, joint or other deformity, and denied arthritis, rheumatism, or bursitis. The Board finds that it would have been reasonable for her to report knee complaints if she had them, especially as she reported having, or having had, a fibroid tumor, heavy menses, peptic ulcer disease, and shin splints. Essentially, while the Veteran now contends that she has had problems with her knee since 1989, the 1989 STR is unremarkable for complaints and she was able to serve another three years without complaints. The Board finds that any contention as to knee complaints in service and since service lacks credibility based on the record as a whole, for the reasons and bases discussed. Any clinical opinion based on a less than credible history lacks probative value. See Reonal v. Brown, 5 Vet. App. 458 (1993) (An opinion is only as good and credible as the history on which it was based). The mere fact that an examiner bases an opinion on a history that has been provided by the Veteran, rather than, as an example, additionally on independent review of the claims file, does not automatically invalidate the opinion because the Veteran could be providing a credible history. However, if it shown the history is not credible or that evidence, if considered (but that was not), would affect the examiner's conclusion, then the basis of the opinion is undermined, and it consequently has less probative value or weight. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Coburn v. Nicholson, 19 Vet. App. 427 (2006). With regard to spasms reported in 1989, and shin splints reported in 1993, the evidence does not reflect that the Veteran has a current diagnosis of shin splints or any current diagnosis which may be as likely as not related to her 1989 assessment of muscle spasms or her 1993 complaint of having, or having had, shin splints. The earliest complaint of the knees is more than two years after the conclusion of her active service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See also Horn v. Shinseki, 25 Vet. App. 231, 239 (2012). A June 1995 record from Womack Army Medical Center (at Fort Bragg), where she was seen as a dependent spouse reflects that she reported right knee/posterior thigh pain that night. It was noted that she was a mail carrier. Upon examination, the impression was a probable mild hamstring pull. She was discharged in good condition and her condition upon release had improved. The report is unremarkable for any mention of chronic pain since service. A June 2000 VAMC primary note reflects that the Veteran reported leg cramping and pain behind both knees for one year in duration. This is evidence against chronic knee or leg complaint since service. In Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006), the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) recognized lay evidence as potentially competent to support the presence of a claimed disability, even where not corroborated by contemporaneous medical evidence such as actual treatment records. In other words, the mere absence of evidence does not necessarily equate to unfavorable evidence. There are a line of precedent cases supporting this proposition. See, e.g., Horn v. Shinseki, 25 Vet. App. 231, 239 (2012); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). See also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (cautioning that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence). The Federal Circuit Court also has held however that, while the absence of contemporaneous records does not, in and of itself, render lay testimony not credible, the Board may weigh the absence of contemporaneous records when assessing the credibility of lay evidence. See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record."). Moreover, although the Board cannot reject a claimant's statements merely because he or she is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of other factors. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias...."). In the present situation, not only did she deny knee pains in service, but when seeking treatment for leg cramping in 2000, she noted an onset of one year earlier. This evidence, along with the lack of clinical records noting continuity, weighs against chronic complaints since service. An April 2013 DBQ for her knees and lower legs reflects that the Veteran had a diagnosis of bilateral osteopenia and bilateral mild degenerative joint disease. The Veteran reported that she has been treating for 23 years for her knee conditions after an injury in 1989 when she was trampled by other soldiers when she passed out on a PT run resulting in a sprain for which she was given light duty and no PT for three days. As noted above, this contention lacks credibility. The April 2013 DBQ examiner found it less likely as not that the Veteran had a disability caused by a service, noted that the Veteran had no symptoms of gout, her current uric accident level was within normal limits, there was no medical documentation that she had complained of muscle aches from Depo-Provera or cholesterol medication, or that she was treated for muscle aches while in service. A June 2014 DBQ reflects the opinion of the examiner that it is less likely as not that the Veteran had a disability proximately due to or the result of her service-connected disabilities. The examiner noted that she had found no medical documentation, and no medical research to support that the Veteran's knee pain is caused by or related to her service-connected disability. A January 2019 DBQ reflects that the Veteran does not have an undiagnosed illness or other disability related to environmental exposures in service. The examiner noted that the Veteran has bilateral knee degenerative joint disease, which is not caused by any other condition, and that the Veteran's age is the strongest risk/indicator of osteoarthritis, especially after the age of 50. The examiner, who examined the extensive record, stated that there was no other disability of the knee or cause for the Veteran's knee condition other than degenerative joint disease (osteoarthritis). The examiner also considered the causes of the Veteran's reported muscle cramps, cited to pertinent records, and found that her symptoms of the leg are likely caused by her nonservice-connected neck disability. The 2019 examiner also found that some of the Veteran's sensory/motor complaints may be due to her service-connected lumbar spine disability. The Board notes that she is already in receipt of service connection for bilateral lower extremity peripheral neuropathy. Although the examiner did not use the term "aggravation" in providing an opinion, it is evident from his extensive review of the records and his rationale, that the Veteran does not have an additional disability aggravated by a service-connected disability. An examination report/opinion must be read, as a whole, so in its entire context. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a medical report must be read as a whole in the context of the claim and, even an opinion lacking in detail may be provided some probative value based upon the amount of information and analysis contained therein); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). Not only is the evidence noted above against a finding that service connection is warranted, but there is no probative clinical opinion (i.e., based on review of the pertinent evidence and with an adequate rationale) to the contrary. With regard to her service in Southwest Asia, the evidence does not show objective indications of a qualifying chronic disability. The Veteran has not received a diagnosis or been clinically found to have symptoms of chronic fatigue syndrome (CFS), fibromyalgia, or an undiagnosed illness. She has not been shown to have a MUCMI. She has been found to have bilateral knee degenerative joint disease, which is likely due to her age, and not due to her claimed incidents/events/medications. Her other leg complaints are either already compensated under her ratings for bilateral lower extremity peripheral neuropathy, or are unrelated to service or a service-connected disability. For these reasons and bases, service connection is not warranted. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 6. Entitlement to service connection for a dental disability The Veteran contends that she is unable to wear partials/dentures due to nausea and vomiting as they make her gag, and that this is somehow related to her service-connected peptic ulcer disease with gastritis (see October 2008 Veteran's statement). The Board finds that service-connection for a dental disability is not warranted. Claims for service connection for dental problems are divided into two categories: for service connection for treatment purposes only, and for service connection for compensation and treatment purposes. Service connection will be granted for a dental disease or injury of individual teeth and the investing tissue, shown by the evidence to have been incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.381(a). However, replaceable missing teeth, treatable carious teeth, dental or alveolar abscesses, and periodontal disease are not disabling, and may be considered service-connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. Dental conditions for which service-connected compensation benefits are available are set forth under 38 C.F.R. § 4.150, DCs 9900-9916. Service connection for compensation purposes can only be established for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. For loss of teeth, bone loss through trauma or disease such as to osteomyelitis must be shown. The loss of the alveolar process as a result of periodontal disease is not considered disabling. VA clinical records reflect that the Veteran had chronic periodontitis and upper and lower partials (e.g., see May 2001, and February 2004 clinical records). A March 2005 and April 2007 record reflect that she had not worn her partials because they make her gag. The Veteran has not alleged, and the evidence does not reflect impairment of the mandible, loss of a portion of the ramus, or loss of a portion of the maxilla. See generally, VAOPGCPREC 5-97; 38 C.F.R. § 4.150, Diagnostic Codes 9913-9916. In addition, a January 2019 DBQ reflects that she does not have loss of teeth due to loss of substance of body of the maxilla or mandible, and does not have loss of teeth due to trauma or disease such as osteomyelitis. The January 2019 DBQ also reflects that the Veteran's reported symptoms of gag reflex does not support that her dentures cannot be remade to minimize this reflex. Her gag reflex is not consistent with a chronic multi-symptom illness or a result of environmental exposures in SWA, or otherwise related to service. As noted by the examiner, a gag reflex is a natural mechanism to keep a foreign object from going down the throat. Proper fabrication of dentures can alleviate or minimize the reflex by decreasing the posterior palatal seal of the denture. In sum, while the Veteran no longer has all of her teeth, this is not due to service or a service-connected disability, and is not the type of dental condition for which service-connected is allowable. For these reasons and bases, service connection is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. REASONS FOR REMAND In the present situation, the Veteran has had, in addition to her service-connected hypertension discussed above, a disability (peptic ulcer disease) rated as 40 percent since March 14, 2001, and has had several other disabilities for a combined rating of 70 percent from June 15, 2009. She is also in receipt of a combined 100 percent disabling rating from April 4, 2017. When considering whether a TDIU has been raised as part of her claim for an increased rating for hypertension, the Board must consider all of her service-connected disabilities. The Veteran has reported that she last worked in September 2006; however, a 2009 VA Form 21-8940 (Application for Increased Compensation Based on Unemployability) reflects that she had stopped working in May 2007, and was currently attending graduate school. A subsequent December 2014 VA Form 21-8940 reflects that she had worked for 12 months in 2010. A February 2019 DBQ for PTSD reflects that the Veteran had last been employed as a drug and alcohol counselor in 2006, and that she has a Bachelor's degree in social work in addition two years of graduate work towards her Master's degree in sociology. A June 2009 VA Form 21-4192 reflects she had resigned from her counselor position where she had been employed form March 2006 to September 2006. A September 2007 Social Security Administration (SSA) record reflects that she was found not to be disabled for SSA purposes. The Veteran has asserted that she had VA Vocational Rehabilitation. Records from such are not associated with the claims file, but may be relevant. Thus, they should be obtained prior to Board adjudication. In addition, the Veteran should submit an updated VA Form 21-8940 detailing her employment from September 2006 to present. Thereafter, VA should request that the Veteran's past employers complete VA Form 21-4192. Accordingly, this remaining claim is REMANDED for the following action: 1. Provide the Veteran another TDIU application (VA Form 21-8940) and request that she list all employer information from September 2006 to the present. After receiving the requested employment information, request her past employers to complete VA Form 21-4192s. 2. Obtain all VA, or other, Vocational Rehabilitation records for the Veteran. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Wishard 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.