Citation Nr: 21067588 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 06-25 860 DATE: November 4, 2021 ORDER 1. Entitlement to an initial disability rating in excess of 30 percent for oral bullous pemphigoid from April 6, 2012 is denied. 2. Entitlement to an initial disability rating in excess of 10 percent for temporomandibular disorder (TMD) with arthritis due to oral bullous pemphigoid from April 6, 2012 is denied. 3. Entitlement to two, separate 10 percent initial disability ratings, but no higher, is granted for bilateral cranial nerve VII impairment associated with oral bullous pemphigoid from April 6, 2012. 4. Entitlement to a separate, compensable disability rating for burning mouth syndrome (BMS) associated with oral bullous pemphigoid is denied. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's oral bullous pemphigoid has not been manifested by more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy required during a 12-month period on appeal. 2. Prior to September 10, 2017, the Veteran's TMD with arthritis due to oral bullous pemphigoid was not manifested by limited interincisal range of motion to 30 mm or less, and from September 10, 2017, the Veteran's TMD with arthritis due to oral bullous pemphigoid was not manifested by limited interincisal range of motion to 34 mm or less. 3. For the entire period on appeal, the Veteran's cranial nerve VII impairment associated with oral bullous pemphigoid has been manifested by no worse than bilateral incomplete moderate paralysis of the cranial (facial) nerve VII, without any resulting incomplete severe paralysis or complete paralysis of the bilateral cranial nerve VII for any period on appeal. 4. The evidence is at least in equipoise as to whether the manifestations of the Veteran's burning mouth syndrome are a separate and distinct condition from the service-connected oral bullous pemphigoid; however, the Veteran's existing disability ratings for oral bullous pemphigoid, TMD with arthritis due to oral bullous pemphigoid, bilateral cranial nerve VII impairment associated with oral bullous pemphigoid, anosmia associated with TMD with arthritis due to oral bullous pemphigoid, and hypogeusia associated with TMD with arthritis due to oral bullous pemphigoid, adequately contemplate the Veteran's symptoms of BMS, including intraoral burning, pain, dysgeusia or hypogeusia (altered/loss of sense of taste), anosmia (loss of sense of smell), and/or xerostomia (dry mouth), such that a separate, compensable disability rating for BMS would be duplicative of or overlapping with the symptomatology of the other service-connected disabilities and would constitute impermissible pyramiding. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 30 percent for oral bullous pemphigoid have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.118, DC 7815. 2. The criteria for an initial disability rating in excess of 10 percent for temporomandibular disorder (TMD) with arthritis due to oral bullous pemphigoid have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.150, DC 9905. 3. The criteria for two, separate 10 percent initial disability ratings, but no higher, for bilateral cranial nerve VII impairment associated with oral bullous pemphigoid have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.124a, DC 7815-8207. 4. The criteria for a separate, compensable disability rating for burning mouth syndrome associated with oral bullous pemphigoid have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.14, 4.87a, DCs 6275-76, 4.118, DC 7815, 4.124a, DC 8207, 4.150, DC 9905. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1966 to June 1970. By way of procedural history, an April 2016 rating decision of the Department of Veterans Affairs (VA) granted service connection for oral bullous pemphigoid rated as noncompensable from September 16, 2013. A February 2017 rating decision granted separate disability ratings for anosmia (loss of sense of smell) and hypogeusia (loss of sense of taste), each associated with oral bullous pemphigoid with burning mouth, and rated as 10 percent disabling and noncompensable, respectively, each from November 7, 2016. Notably, these separately rated conditions are not the subject of the present appeal and will not be addressed further herein. A subsequent November 2018 rating decision granted a 10 percent initial disability rating for oral bullous pemphigoid with burning mouth and assigned an earlier effective date of April 6, 2012. Thereafter, in October 2019, the Board of Veterans' Appeals (Board) denied an initial compensable rating for oral bullous pemphigoid effective from September 16, 2013, and dismissed as moot the claim for service connection for burning mouth syndrome. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court), and in August 2020, the Court issued an Order which approved an August 2020 Joint Motion for Partial Remand (JMPR) and vacated the October 2019 Board decision with regard to oral bullous pemphigoid and burning mouth syndrome. In the August 2020 JMPR, the Veteran and the Secretary of VA (parties) agreed that remand was warranted for the Board to determine whether the Veteran is entitled to a separate disability rating for burning mouth syndrome. The parties noted that subsequent to the November 2018 rating decision, in October 2019, the Veteran submitted treatise evidence in the form of an article in the Indian Journal of Palliative Care entitled "Burning Mouth Syndrome" that differentiates the symptoms of burning mouth syndrome and those contemplated within the Veteran's current rating under DC 9905 for oral bullous pemphigoid; however, the Board did not discuss this material evidence or explain its finding that the Veteran's burning mouth syndrome was fully compensated within the rating for oral bullous pemphigoid. Additionally, the parties agreed that remand was warranted for the Board to provide adequate reasons or bases as to whether a higher rating is warranted under DC 7815, for bullous disorders, as the Board's October 2019 decision denying a higher rating under DC 7815 was unclear as to how the Board arrived at its findings that the rating criteria for a higher rating were not met, as the Board did not state that it relied on any medical opinion regarding exposed areas. Additionally, the parties noted that the Veteran had previously requested extraschedular consideration for his oral bullous pemphigoid and that the Board should consider whether extraschedular consideration was warranted upon remand. In September 2020, the Board remanded the matters of entitlement to a higher initial rating for oral bullous pemphigoid, including on an extraschedular basis, and entitlement to a separate, compensable rating for burning mouth syndrome for development consistent with the August 2020 JMPR, after which additional relevant medical opinions and/or examinations were obtained in April 2021, May 2021, June 2021, and August 2021, and a related SSOC was issued in August 2021. Given this development, the Board finds that there has been substantial compliance with prior Board remand directives, such that the matters are properly returned to the Board for adjudication. Additionally, an August 2021 rating decision granted an increased 30 percent initial disability rating for oral bullous pemphigoid, effective April 6, 2012, and a separate 10 percent disability rating for cranial nerve VII impairment associated with oral bullous pemphigoid from April 6, 2012. As these do not constitute a full grant of benefits sought on appeal, the claims remain before the Board. Given the above, and in order to more clearly reflect the relevant issues herein, the Board has listed the issues to include the two specific claims remanded by the Board in August 2020 concerning entitlement to a higher initial rating for oral bullous pemphigoid, including on an extraschedular basis, and entitlement to a separate, compensable rating for burning mouth syndrome, as well the additional disabilities of temporomandibular disorder (TMD) with arthritis and cranial nerve VII impairment, which have also been granted as manifestations due to the service-connected oral bullous pemphigoid. The Board notes here that the Veteran has also pursued an appeal before the Board concerning his claims of entitlement to service connection for sleep apnea, stroke, a seizure disorder, hypertension, and immune/autoimmune disorder, and nutritional disorder. These issues were most recently addressed within a June 2021 supplemental statement of the case (SSOC) following a September 2020 Board remand, and they will be separately addressed within a future Board decision. Finally, the Board acknowledges that an August 2021 submission in response to the August 2021 rating decision addressing the issues listed above) that VA should have addressed entitlement to special monthly compensation (SMC). The following month, in September 2021, the Veteran submitted VA Form 20-0996, Request for Higher-Level Review, seeking review of the August 2021 rating decision concerning entitlement to SMC based upon housebound status. As the Agency of Original Jurisdiction (AOJ) has not yet addressed the September 2021 VA Form 20-0996 Request for Higher-Level Review, the Board does not have jurisdiction to do so in the first instance. Initial Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. The Board has also considered whether the service-connected disabilities addressed herein should be referred for extraschedular consideration. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008). In exceptional situations where the schedular rating is inadequate, the case may be referred for extraschedular consideration. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the Rating Schedule for that disability. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Second, if the schedular criteria are found to be inadequate to evaluate the claimant's disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. If so, then under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. 1. Entitlement to an initial disability rating in excess of 30 percent for oral bullous pemphigoid from April 6, 2012. The Veteran's oral bullous pemphigoid is currently rated as 30 percent disabling from April 6, 2012 under Diagnostic Code (DC) 7815, concerning bullous disorders. Thereunder, bullous pemphigoid is to be rated under VA's General Rating Formula for the Skin. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, pursuant to DC 7815, in relevant part, a 30 percent disability rating is warranted for a skin disability that covers 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent disability rating is warranted for a skin disability that covers more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Or the disability is to be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to DC 7815. Under this formula, in relevant part, a 30 percent disability rating is warranted for having at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent disability rating is warranted for having at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or the disability is to be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. Here, the evidence of record demonstrates that the predominant disability resulting from the Veteran's oral bullous pemphigoid includes bullous lesions, loss of intraoral mucosal integrity, and painful ulcerations. Notably, these were the manifestations of the disease process identified by VA examiners throughout the appeal period, although they have disagreed as to the appropriate diagnosis. Additionally, as noted above, to the extent that the Veteran has experienced related symptoms including anosmia (loss of sense of smell) and hypogeusia (loss of sense of taste), he is already in receipt of separate disability ratings which are not the subject of the present appeal. As such the Board finds that the primary manifestations of the oral bullous pemphigoid disability for purposes of the current appeal are properly rated under DC 7815. Following a review of the evidence, the Board finds that the preponderance of the evidence weighs against an initial disability rating in excess of 30 percent for oral bullous pemphigoid for the entire period on appeal, as the Veteran's oral bullous pemphigoid does not more nearly approximate more than 40 percent of the entire body or more than 40 percent of exposed areas affected, constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during a 12-month period, characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over a 12-month period. A February 2016 VA Dental/Oral Examination Report documents the Veteran's relevant diagnoses of burning mouth syndrome and bullous pemphigoid, with physical findings including moderate to severe xerostomia, chronic generalized moderate gingivitis, and atrophic glossitis. Regarding functional impact of such conditions, the examiner noted that the Veteran's intraoral bullous pemphigoid may potentially restrict or inhibit his speech due to the presence of localized or generalized intraoral ulcerative lesions. The examiner did not make findings as to the approximate percentage of area affected by the disability. Similarly, upon VA Dental examination in December 2017, a VA examiner diagnosed bullous pemphigoid and xerostomia and noted the Veteran's lengthy history of oral symptoms, including "burning mouth" and mucosal ulcerations, consistent with a diagnosis of autoimmune or erosive disease based on oral manifestations and previous biopsy. The Veteran reported difficulty eating, speaking, altered taste sensation, and impaired social interactions as a result of his oral symptoms, which were moderate to intermittently severe, and consistent with his diagnosed disease. The examiner stated that the Veteran's oral condition impacted his ability to work in that his intraoral ulcerative flareups of significant size and duration can impair speech and mastication, ability to concentrate, or perform normal workplace functions. Following a review of the record, the examiner opined that the Veteran did not have any immune or autoimmune disorder, apart from his service-connected oral bullous pemphigoid, which was also noted to be "questionable" on a clinical basis, as a biopsy was suggestive but not definitive. Again, the examiner did not make findings as to the approximate percentage of area affected by the disability. Upon subsequent VA Dental examination in July 2018, the Veteran reported difficulty eating, speaking, and opening his mouth, although the examiner noted that this did not appear to be related to the temporomandibular joint but to the mucosal lesions when present. The examiner noted that the Veteran had mucosal lesions in the oral cavity consistent with those seen in the oral manifestations of bullous pemphigoid, which resulted in functional impact upon the ability to work, including pain causing difficulty with chewing and speaking. The examiner remarked that bullous pemphigoid is an autoimmune disease with poorly understood etiology, which can be affected by environmental factors and certain medications. The examiner concluded that the Veteran's burning mouth was not a separate diagnosis but rather the manifestation of the bullous pemphigoid disease confirmed by biopsy. As above, the examiner did not make any findings as to the approximate percentage of area affected by the disability. Upon VA skin examination in March 2020, it was noted that the Veteran was diagnosed with burning mouth syndrome in approximately 2008, after which he was given an oral steroid and medication, which did not help. In 2013, a biopsy was done which showed he had bullous pemphigoid, for which he had received regular treatment since that time. The Veteran reported constant oral pain, bleeding from the gums twice per day, the loss of four molars due to his condition, and the inability to eat spicy or hot-temperature food. He stated that it affected his relationship with his wife, as he sometimes has sores and bleeding in his mouth and he is not able to be intimate, such as kissing with his wife. He also noted that his lip sores make it embarrassing to go out in public sometimes. The examiner noted that his condition required constant or near-constant topical medications, including Prednisone rinse and Clobetasol cream used for oral lesions due to bullous pemphigoid, with no other treatment or procedures. The examiner did not check relevant boxes to indicate that the Veteran's condition had required any systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs over a 12-month period. A physical examination revealed less than 5 percent of total body area and less than 5 percent of exposed areas affected by the bullous pemphigoid. The examiner noted that appearance of three oral erythematous surrounding with whitish mucosal lesions seen on the right cheek area, two oral mucosal lesions seen on left cheek area, and erythematous blistering lesions seen on the lips. An April 2021 VA skin examination documents diagnoses of oral bullous with burning mouth syndrome and oral bullous pemphigoid. The Veteran reported that he had lost four molars on the bottom due to burning mouth syndrome and that he was rejected as a candidate for implants or a bridge due to the conditions. He reported episodes of bullous pemphigoid to the bottom lip and inside of the mouth, with painful sores that bleed and ooze. The examiner noted that the conditions had required treatment with medication in the past 12 months for 6 weeks or more, but not constantly, including topical Clobetasol treatment and an oral steroid rinse during flare ups. The examiner did not check relevant boxes to indicate that the Veteran's condition had required any systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs over a 12-month period. The affected location was the oral mucosa and lips, with no combined total body area and less than 5 percent of combined total exposed areas affected. The Veteran reported that his condition resulted in functional impact including being self-conscious of his appearance and causing relationship issues with his wife, as well as causing him to watch what he eats, as certain foods can cause the conditions to flare, as well as avoiding toothpaste with mint, which can make the issue worse. Upon VA Dental examination in May 2021, a VA examiner did not see signs or symptoms to suggest any major problems. The examiner stated that the Veteran's teeth looked good, with no cavities found, good periodontal health, and no major abscesses or lesions were found. In June 2021, a VA examiner was asked to offer a retrospective opinion over the entire rating period from April 6, 2012 to the present as to whether any exceptional or unusual disability or any exceptional or unusual impairments in functioning associated with oral bullous pemphigoid or burning mouth syndrome or any exceptional or unusual effect, such marked impairment in work functioning or prolonged periods of hospitalization, have been attributable to the oral bullous pemphigoid or burning mouth syndrome. The examiner reviewed the claims file and stated that no extended hospitalization was noted in the medical documentation during the period from April 6, 2012 to present, and the Veteran denied extended hospitalization related to the oral bullous pemphigoid or burning mouth syndrome during that time. The examiner also stated that impairment related to employment duties from April 6, 2012 to the present would include intermittent limitations in speaking to individuals or groups or answering/taking phone calls during his flares. The Veteran was not able to identify how long an oral bullous pemphigoid or burning mouth syndrome flare would last or how often these occur. The examiner concluded that all other employment duties, such as lifting, carrying, pushing, pulling, stairs, standing, walking, climbing, driving, sitting, small skill tasks or computer tasks would not be affected. In August 2021, a VA examiner reviewed the medical record and pathology reports and stated that a diagnosis of bullous pemphigoid was questionable on a clinical basis, as a March 2017 biopsy was noted to be suggestive but not definitive by a December 2013 VA research physician. The examiner stated that oral bullous pemphigoid can only be diagnosed by pathology, and because the diagnosis is not confirmed, any symptoms from April 6, 2012 to the present cannot be attributed to oral bullous pemphigoid. Regarding functional impairment upon the ability to work, the examiner noted that the Veteran had no restrictions for the job activities required. Notably, the VA examinations discussed above do not document that the Veteran's oral bullous pemphigoid has resulted in more than 40 percent of the entire body or more than 40 percent of exposed areas affected, required constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs during a 12-month period. Similarly, the evidence above does not document that the Veteran's oral bullous pemphigoid has resulted in characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or required constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs over a 12-month period. As such, the VA examinations of record do not weigh in favor of an initial disability rating in excess of 30 percent for oral bullous pemphigoid for any period on appeal. Similarly, VA treatment records document the Veteran's ongoing oral complaints and treatment with prescribed medications; however, they do not document that the Veteran's condition has affected more than 40 percent of the entire body or more than 40 percent of exposed areas affected or required constant or near-constant systemic therapy or other immunosuppressive drugs over a 12-month period. The Board acknowledges that VA treatment records document that the Veteran was prescribed ongoing prescription medication for his service-connected oral bullous pemphigoid, including regular topical treatment and intermittent systemic treatment. Specifically, VA treatment records document prior systemic treatment with prescription minocycline tablets in August 2015 and December 2015, although the Board notes that such records also document that the Veteran ceased taking this minocycline treatment in January 2016, as he was experiencing increased headaches, and preferred to avoid minocycline in the future. Upon follow up in August 2016, it was noted that the Veteran's oral mucosal blistering disease symptoms were mostly controlled with topical treatment, including prednisolone solution and clobetasol ointment. In January 2017, the Veteran was restarted on minocycline; however, after 30 days without any improvement, the prescribed minocycline was stopped, as his provider noted that it should have provided some relief after 30 days. Therefore, the Board acknowledges this evidence of some prior systemic therapy for the Veteran's service-connected oral bullous pemphigoid; however, the Board finds that the intermittent use of minocycline does not more closely approximate "constant or near-constant" systemic therapy or other immunosuppressive drugs over a 12-month period in order to warrant an increased disability rating for any period on appeal. Likewise, private treatment records document that the Veteran's oral conditions required prescription medications throughout the appeal period, including ongoing topical treatment and intermittent systemic medication. For example, in July 2013, the Veteran had recently been started on minocycline and Lidex ointment for his mouth symptoms. By September 2013, the Veteran had stopped taking minocycline due to findings of low blood pressure and low sodium. In December 2013, he was advised to continue taking minocycline; however, in October 2014, he reported that he recently took a vacation to Maine and did not take his medications. Similarly, in February 2015, the Veteran reported that he had stopped taking minocycline due to a history of headaches that other treatment providers felt was due to that particular medication. In August 2015, he was against advised to continue taking minocycline, but again in March 2016, he again reported that he had stopped taking minocycline due to ongoing headaches and high blood pressure. Therefore, there is evidence of some prior systemic therapy for the service-connected oral bullous pemphigoid; however, the Board finds that the intermittent use of minocycline does not more closely approximate "constant or near-constant" systemic therapy or other immunosuppressive drugs over a 12-month period in order to warrant an increased disability rating for any period on appeal. To the extent that the Veteran asserts that his service-connected oral bullous pemphigoid is more severe than the currently assigned 30 percent disability rating, he is competent to report observable symptoms, to include oral lesions and mouth pain. However, he does not specifically assert, and the medical evidence of record does not otherwise show, that the Veteran's oral bullous pemphigoid more nearly approximates the criteria for a higher initial disability rating based upon the affected area or use of systemic therapy or immunosuppressive drugs. Additionally, the Board affords more probative value to the objective findings contained within the medical records discussed above as opposed to the subjective assertions of the Veteran as a layperson. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to an initial disability rating in excess of 30 percent for oral bullous pemphigoid for the entire period on appeal. As the preponderance of evidence weighs against the claim, there is no reasonable doubt to be resolved, and the claim is denied. The Board finds that remand is not warranted for referral to the VA Director of Compensation Service for consideration of an extraschedular disability rating concerning the Veteran's oral bullous pemphigoid. While the symptoms of oral lesions and pain are not specifically contemplated by the rating criteria, as the specific diagnostic code for bullous disorders directs the adjudicator to apply the General Rating Formula for the Skin, the Board finds that the manifestations of the skin condition are contemplated generally by the rating criteria concerning the area affected or the medication prescribed for treatment of the condition. To the extent that the Veteran has asserted impaired social interactions, including with his wife, the Board finds that this is not contemplated by the relevant rating criteria. Nevertheless, the Board finds that the evidence of record does not reflect that the Veteran's oral bullous pemphigoid has resulted in marked interference with employment or frequent hospitalizations for any period on appeal. Notably, the June 2021 VA examiner stated that no extended hospitalization was noted in the medical documentation during the period from April 6, 2012 to present, and the Veteran specifically denied extended hospitalization related to the oral bullous pemphigoid or burning mouth syndrome during that time. Additionally, while the examiner noted "intermittent" employment limitations involving speaking during flare ups of his mouth conditions, the examiner concluded that "all other employment duties" would not be affected. Given the above, the Board finds that the Veteran's oral bullous pemphigoid has not resulted in marked interference with employment or frequent hospitalizations for any period on appeal. Therefore, referral for consideration of an increased evaluation on an extraschedular basis is not warranted. 2. Entitlement to an initial disability rating in excess of 10 percent for temporomandibular disorder (TMD) with arthritis due to oral bullous pemphigoid from April 6, 2012. The Veteran's TMD with arthritis due to oral bullous pemphigoid is currently rated as 10 percent disabling from April 6, 2012 under DC 7200-9905. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the Veteran's TMD is currently rated as an injury of the mouth (DC 7200) under the criteria for TMD (DC 9905). During the pendency of the appeal, VA amended the criteria for rating TMD, effective September 10, 2017. As noted previously, claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied, although the Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Under DC 9905 prior to September 10, 2017, limited range of motion of lateral excursion of 0 to 4 millimeters (mm) warrants a 10 percent disability rating. Additionally, limited interincisal range to 31 to 40 mm warrants a 10 percent disability rating, limited interincisal range to 20 to 30 mm warrants a 20 percent disability rating, limited interincisal range to 11 to 20 mm warrants a 40 percent disability rating, and limited interincisal range to 0 to 10 mm warrants a maximum 40 percent disability rating. Effective September 10, 2017, under the revised version of DC 9905, limitation of the interincisal range is rated as follows: a range of 30 to 34 mm of maximum unassisted vertical opening without dietary restrictions to mechanically altered foods warrants a 10 percent disability rating, with dietary restrictions to soft and semi-solid foods warrants a 20 percent disability rating, and with dietary restrictions to full liquid and pureed foods warrants a 30 percent disability rating. An interincisal range of 21 to 29 mm of maximum unassisted vertical opening without dietary restrictions to mechanically altered foods warrants a 20 percent disability rating, with dietary restrictions to soft and semi-solid foods warrants a 30 percent disability rating, and with dietary restrictions to full liquid and pureed foods warrants a 40 percent disability rating. An interincisal range of 11 to 20 mm of maximum unassisted vertical opening without dietary restrictions to mechanically altered foods warrants a 30 percent disability rating, and with dietary restrictions to mechanically altered foods warrants a 40 percent disability rating. An interincisal range of 0 to 10 mm of maximum unassisted vertical opening without dietary restrictions to mechanically altered foods warrants a 40 percent disability rating, and with dietary restrictions to all mechanically altered foods warrants a maximum schedular 50 percent disability rating. Additionally, a lateral excursion range of motion limited to 0 to 4 mm warrants a 10 percent disability rating. 38 C.F.R. § 4.150, DC 9905 (effective September 10, 2017). Under both the old and revised versions of DC 9905, ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. 38 C.F.R. § 4.150, DC 9905, Note (1). Moreover, for VA compensation purposes, mechanically altered foods are defined as altered by blending, chopping, grinding, or mashing so that they are easy to chew and swallow. There are four levels of mechanically altered foods: full liquid, puree, soft, and semisolid foods. To warrant elevation based on mechanically altered foods, the use of texture-modified diets must be recorded or verified by a physician. 38 C.F.R. § 4.150, DC 9905, Note (3). Following a review of the evidence, the Board finds that the preponderance of the evidence weighs against an initial disability rating in excess of 10 percent for TMD with arthritis due to oral bullous pemphigoid for the entire period on appeal as the Veteran's TMD does not more nearly approximate limited interincisal range to 30 mm or less prior to September 10, 2017, or limited interincisal range to 34 mm or less with resulting dietary restrictions from September 10, 2017. Upon VA TMD examination in June 2018, the VA examiner stated that the Veteran did not have a temporomandibular joint condition. The Veteran reported difficulty opening his mouth; however, the examiner stated that this appeared to be due to intra-oral lesions rather than related to the joint itself. Upon physical examination, initial range of motion measurements included an inter-incisal distance greater than 34 mm and bilateral lateral excursion to greater than 4 mm, without any pain noted upon examination, no evidence of pain with chewing (mastication), no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no evidence of crepitus or clicking of joints or soft tissue. There was no additional functional loss of range of motion after three repetitions. The examiner stated that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time, and the examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time, as the examiner stated that the Veteran's pain is likely not related to joint function. Rather, the examiner noted that the Veteran's jaw motion seemed to be chiefly limited by pain due to oral lesions. Additionally, the examiner documented that the Veteran did not require a mechanically altered foods diet, which has been physician verified or documented, due to the temporomandibular disorder. The only other documented findings were difficulty chewing and speaking due to oral manifestations of the autoimmune disease bullous pemphigoid. Significantly, the June 2018 VA examination findings discussed above do not warrant an initial disability rating in excess of 10 percent under either the old or revised rating criteria of DC 9905, as the Veteran's condition did not result in the requisite limitation of interincisal distance or lateral excursion or resulting dietary restrictions in order to warrant in increased disability rating. Upon subsequent VA TMD examination in May 2021, the VA examiner diagnosed bilateral temporomandibular joint (TMJ) arthritis and TMD with unspecified joint pain-dysfunction. The Veteran reported a history of pain to the bilateral jaw and mouth for over 10 years and noted that he was diagnosed with oral bullous pemphigoid in 2013 after he was evaluated by dermatology and confirmed to have no cutaneous or other mucosal pemphigoid other than the oral cavity. The Veteran stated that he began to notice noises in the joints nearly 10 years ago and occasional popping of the right and left jaw. He noted that his condition had been treated with topical clobetasol steroid ointment and prednisone rinse, as well as prior systemic minocycline that was discontinued due to complications. He reported that continuous bilateral clicking and cracking noises of the right and left TMJ and pain to muscles of mastication worsening for the past six months, with pain to the jaw is mainly during pemphigoid breakouts causing ulcerations to the buccal mucosa bilaterally. The Veteran stated that his current symptoms were the same as before but more frequent for the past six months, with occurrences of lesions causing the masticatory pain and pain with chewing and swallowing, which limited his diet and intake causing less frequent intake and restricted to soft, mashable foods, and well as crepitation and cracking to the joints which causes decreased motion to the sides. The examiner documented the Veteran did not currently have any treatment of the TMJ flare ups, which resulted in general soreness of his jaw joints and muscles of mastication during the day while eating. The Veteran reported that during the pemphigoid ulcerative flare ups, which occur every week or two, there is acute development of pain to the right and left mastication muscles and soreness when functional use of the TMJ occurs. The Veteran noted that this mainly occurs when chewing and stretching of the oral cavity open, which limits his diet and restricts it to mainly soft, mashable and liquid diet for 7-10 days at a time. Upon physical examination, initial range of motion findings included inter-incisal distance to greater than 34 mm, bilateral lateral excursion to greater than 4 mm, without pain noted on examination. There was evidence of pain with chewing (mastication), and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The examiner noted that there was crepitation audibly and palpable to examination upon the entire opening and closing of the right and left TMJ, which the examiner stated was not related to bullous pemphigoid; rather, the examiner stated that the crepitation is osteoarthritis of the joint and may be more related to age. There was no additional loss of function or range of motion upon repetition, although the examiner noted that pain and fatigue significantly limited the Veteran's functional ability with repeated use over time and during flare ups, which the examiner described in terms of range of motion as inter-incisal distance to greater than 34 mm and bilateral lateral excursion to greater than 4 mm. The examiner also noted additional contributing factors of disability as buccal mucosal lesions secondary to the bullous pemphigoid, which create direct pain to the muscles of mastication upon functional use and limit the masticator muscles rendering the joint to have limited function, pain with chewing, speech, and swallowing, and lesions only in the oral cavity accounting for 20 percent of the oral cavity. The examiner stated that the Veteran required a mechanically altered foods diet due to TMD, including dietary restrictions to soft and semi-solid foods. Other pertinent findings included bilateral joint crepitation and masticatory pain. Finally, the examiner noted resulting functional impact upon the Veteran's ability to work and stated that the Veteran previously worked in insurance sales and lost approximately one week of work time in the last 12 months due to severe pain to the oral cavity and muscles of the mastication, although the Veteran had been retired since 2014. As above, the May 2021 VA examination findings discussed above also do not warrant an initial disability rating in excess of 10 percent under either the old or revised rating criteria of DC 9905, as the Veteran's condition did not result in the requisite limitation of interincisal distance or lateral excursion in order to warrant in increased disability rating. While the May 2021 examiner found that the Veteran's condition required a mechanically altered foods diet of soft and semi-solid foods, this finding alone does not warrant an increased disability rating in the absence of the requisite limitation of motion findings also required under the revised rating criteria. To the extent that the Veteran believes that his service-connected TMD with arthritis due to oral bullous pemphigoid is more severe than the currently assigned 10 percent disability rating, the Board acknowledges that he is competent to report observable symptoms, to include pain in his oral cavity and jaw muscles. However, he does not specifically assert, and the medical evidence of record does not otherwise show, that TMD with arthritis due to oral bullous pemphigoid more nearly approximates the criteria for a higher initial disability rating based upon limitation of motion. Additionally, the Board affords more probative value to the objective findings contained within the medical records discussed above as opposed to the subjective assertions of the Veteran as a layperson. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to an initial disability rating in excess of 10 percent for TMD with arthritis due to oral bullous pemphigoid for the entire period on appeal. As the preponderance of evidence weighs against the claim, there is no reasonable doubt to be resolved, and the increased-rating claim is denied. Additionally, the Board finds that remand is not warranted for referral to the VA Director of Compensation Service for consideration of an extraschedular disability rating concerning the Veteran's TMD with arthritis due to oral bullous pemphigoid. The Board finds that the manifestations of the Veteran's TMD with arthritis due to oral bullous pemphigoid are specifically contemplated by both the old and revised rating criteria concerning limitation of motion of the jaw and related dietary restrictions. Additionally, the record does not indicate that the Veteran's TMD with arthritis due to oral bullous pemphigoid has resulted in marked interference with employment or frequent hospitalizations for any period on appeal. Therefore, referral for consideration of an increased evaluation on an extraschedular basis is not warranted. 3. Entitlement to an initial disability rating in excess of 10 percent for cranial nerve VII impairment associated with oral bullous pemphigoid from April 6, 2012. The Veteran's cranial nerve VII impairment associated with oral bullous pemphigoid is currently rated as 10 percent disabling from April 6, 2012 under DC 7815-8207. Here, the hyphenated diagnostic code indicates that the Veteran's cranial nerve VII impairment associated with oral bullous pemphigoid is currently rated as a bullous disorder (DC 7815) under the criteria for paralysis of the seventh (facial) cranial nerve (DC 8207). The Board finds that this is consistent with the probative evidence, which shows that the Veteran's cranial nerve impairment is associate with his service-connected oral bullous pemphigoid, and the relevant rating criteria for bullous disorders (DC 7815), which directs the adjudicator to rate complications and residuals of mucosal involvements separately under the appropriate diagnostic code. Under DC 8207, a 10 percent disability rating is warranted for incomplete, moderate paralysis of the seventh (facial) cranial nerve, a 20 percent disability rating is warranted for incomplete, severe paralysis of the seventh (facial) cranial nerve, and a maximum schedular 30 percent disability rating is warranted for complete paralysis of the seventh (facial) cranial nerve. A Note to DC 8207 explains that such ratings are dependent upon relative loss of innervation of facial muscles. Additionally, disability ratings for the cranial nerves are for unilateral involvement; when bilateral, the ratings are combined without application of the bilateral factor. Following a review of the evidence, the Board finds that the preponderance of the evidence weighs against an initial disability rating in excess of 10 percent for cranial nerve VII impairment associated with oral bullous pemphigoid for the entire period on appeal as the Veteran's cranial nerve VII impairment does not more nearly approximate incomplete, severe paralysis or complete paralysis of the seventh (facial) cranial nerve. Upon VA cranial nerves examination in June 2021, the VA examiner found that the Veteran had been diagnosed with a cranial nerve condition identified as intraoral bullous pemphigoid/burning mouth syndrome. The Veteran reported that several nerves were affected, with symptoms of headaches, loss of sense of smell and taste, lost teeth, regular eye checks, functional impact upon physical activities, lack of interest in being out in public, and affecting the way he eats. The examiner documented that the affected nerves as cranial nerve I (affected loss of sense of smell/taste) and cranial nerve VII (facial). As discussed previously, the Veteran is already in receipt of separate disability ratings for his loss of sense of taste and smell, which are not part of the current appeal. The examiner further documented findings including severe intermittent pain bilaterally on the side of the mouth and throat, moderate difficulty speaking, and severe decreased salivation. Muscle strength testing and sensory evaluation was all normal bilaterally. Finally, the examiner identified the relevant affected cranial nerve and severity as bilateral incomplete, moderate paralysis of cranial nerve VII, with no resulting functional impact upon the ability to work. VA and private treatment records do not document any additional probative findings concerning the severity of the Veteran's cranial nerve impairment and therefore, they are less probative in the context of his claim for a higher initial disability rating. However, given the probative findings of the June 2021 VA examination concerning bilateral incomplete, moderate paralysis of cranial nerve VII, the Board finds that two, separate 10 percent disability ratings are warranted based upon bilateral involvement. To that limited extent, the Veteran's claim is granted, and he now has two, separate 10 percent disability ratings for (1) left cranial nerve VII impairment associated with oral bullous pemphigoid and (2) right cranial nerve VII impairment, each effective from April 6, 2012. However, the Board finds that the preponderance of the evidence weighs against an initial disability rating in excess of 10 percent for the left and right cranial nerve VII impairments associated with oral bullous pemphigoid for the entire period on appeal, as the probative evidence of record does not show that the Veteran's condition has resulted in incomplete, severe paralysis of the cranial nerve VII for any period on appeal. As the preponderance of evidence weighs against the claim, there is no reasonable doubt to be resolved, and entitlement to an initial disability ratings in excess of 10 percent for left and right cranial nerve VII impairments associated with oral bullous pemphigoid are denied. Additionally, the Board finds that remand is not warranted for referral to the VA Director of Compensation Service for consideration of an extraschedular disability rating concerning the Veteran's cranial nerve VII impairment associated with oral bullous pemphigoid. The Board finds that the manifestations of the Veteran's bilateral cranial nerve VII impairment are contemplated by the relevant rating criteria concerning paralysis of the cranial VII (facial) nerve. Additionally, the record does not indicate that the Veteran's cranial nerve VII impairment has resulted in marked interference with employment or frequent hospitalizations for any period on appeal. Therefore, referral for consideration of an increased evaluation on an extraschedular basis is not warranted. 4. Entitlement to a separate, compensable disability rating for burning mouth syndrome associated with oral bullous pemphigoid. Finally, the Board has considered whether the Veteran is entitled to a separate disability rating for burning mouth syndrome, as directed by the parties to the August 2020 JMPR. Specifically, the parties noted that in October 2019, subsequent to the November 2018 rating decision which partially granted the Veteran's increased rating claim, the Veteran submitted additional treatise evidence in the form of an article from the Indian Journal of Palliative Care entitled "Burning Mouth Syndrome" that differentiates the symptoms of burning mouth syndrome and those contemplated within the Veteran's current rating under DC 9905 for oral bullous pemphigoid; however, the Board did not previously discuss this material evidence or explain its finding that the Veteran's burning mouth syndrome was fully compensated within the rating for oral bullous pemphigoid. As such, the Board will address this deficiency below. The Veteran has submitted a 2016 article from the Indian Journal of Palliative Care (IJPC) entitled, "Burning Mouth Syndrome." The article defined burning mouth syndrome (BMS) as a chronic pain disorder characterized by burning, stinging, and/or itching of the oral cavity "in the absence of any organic disease." The authors noted that "[b]ecause of the complex clinical behavior, the exact cause of BMS is currently unknown." Additionally, the authors noted that "mimickers of BMS may include stomatitis, atypical facial pain, atypical odontalgia, idiopathic facial arthromylagia, pemphigoid, pemphigus, neoplastic lesions in the oral cavity, acoustic neuroma, denture design or tooth restoration failures, herpes simplex or herpes zoster, and trauma to lingual or mandibular nerves after dental surgery. Detailed history and physical examination are crucial to differentiate above medical conditions." The article concluded that "BMS is a relatively common chronic intraoral pain disorder classically characterized by intractable burning that may be associated with dysgeusia and xerostomia," with a "multifactorial" etiology that "remains an important medical condition which often places a significant burden on the patient and healthcare system and requires diligent recognition and treatment." The Board is mindful that the article submitted by the Veteran defines BMS as symptoms "in the absence of any organic disease." Notably, the probative evidence of record, including as discussed below, documents that the Veteran's symptoms have been variously diagnosed as alternate, or at least concurrent, conditions. As such, following a review of the record, and as discussed further below, the Board finds that the preponderance of the evidence weighs against the Veteran's claim of entitlement to a separate, compensable disability rating for burning mouth syndrome associated with oral bullous pemphigoid. There is conflicting medical evidence as to whether the Veteran's BMS and service-connected oral bullous pemphigoid are separate and distinct conditions. For example, a June 2012 VA dental/oral examination found that the Veteran's diagnoses included atrophic glossitis and BMS. The examiner opined that the Veteran's BMS was less likely than not due to or the result of his GERD, as there was no finding of direct irritation or damage to the intraoral mucosa or teeth due to GERD, and GERD is not known as a primary etiologic factor in BMS in the literature. Additionally, the examiner opined that BMS was less likely than not aggravated beyond its natural progression by GERD, which was not a primary causative or contributing factor for BMS, there was no clinical evidence of irritation or physical tissue damage caused by GERD, and physical or chemical irritation have not been determined to be significant causes of BMS. In September 2012, an alternate VA examiner concurred with the June 2012 VA examiner's opinion. Upon VA dental/oral examination in April 2013, the Veteran was again diagnosed with atrophic glossitis, BMS, and xerostomia. The Veteran reported a history of glossitis/burning mouth syndrome since December 2011, with intraoral ulceration, dry mouth, and pain, which resulted in potential difficulty speaking due to painful intraoral ulcerations and dry mouth. The VA examiner opined that the Veteran's BMS was at least as likely as not due to or the result of his GERD medication. Upon VA dental/oral examination in February 2016, the Veteran's diagnoses included BMS and bullous pemphigoid. The examiner noted that BMS is a dental disorder that is characterized by a burning sensation in the tongue or other oral sites, usually in the absence of clinical and laboratory findings, and despite reports suggesting a significant relationship between burning mouth syndrome and mucosal ulcerative or erosive lesions, periodontitis and geographic tongue, most studies have reported no significant changes in intraoral soft or hard tissues. Similarly, the examiner stated that chemical irritation and allergic reactions to dental materials and galvanic currents between dissimilar metals have not been found to be important causes of burning mouth syndrome, therefore the examiner opined that the Veteran's BMS was as likely as not a separate and distinct condition than his bullous pemphigoid. The examiner further noted that the Veteran's bullous pemphigoid was a distinct dental condition from his BMS based on reported etiologic factors for both conditions; however, the examiner could not provide a definitive opinion without speculation regarding whether either of these dental disorders are as likely as not related to the Veteran's active service, because the examiner was unable to review relevant service treatment records. In April 2016, a VA examiner opined that it was less likely than not that the Veteran's BMS is related to his period of military service, since the symptoms themselves are in effect the disorder and they were not documented as present during service. Additionally the examiner noted that chemical irritation and allergic reactions to dental materials and galvanic currents between dissimilar metals have not been found to be important causes of BMS, therefore it was less likely than not that the Veteran's BMS was proximately due, the result of, or aggravated by the Veteran's GERD or posttraumatic stress disorder (PTSD), particularly since his military health records are silent with regard to BMS signs or symptoms, and as noted there is no clear consensus on the etiology of BMS. The examiner stated that the Veteran's bullous pemphigoid, which is a genetic autoimmune disorder, was clearly present prior to his entry on active duty, although it may not have manifested with clinical signs and symptoms of mucosal abnormalities or ulceration during that period. As such, the examiner opined that it is as likely as not that the Veteran's bullous pemphigoid, without clinical symptoms, was present during his military service, although less likely than not caused by it since it is a genetic disorder. In July 2018, a VA examiner opined that the Veteran's BMS and xerostomia were not separate diagnoses, but rather the oral manifestation of the Veteran's bullous pemphigoid. The examiner reviewed the medical record and conflicting medical evidence and concluded that all of the Veteran's complaints are related to the oral lesions associated with an autoimmune disease progress, and that they were not separate conditions. In April 2021, another VA examiner opined that the Veteran's service-connected bullous pemphigoid was a distinct dental condition from BMS based on reported etiologic factors for both conditions detailed in medical literature. The examiner stated that the conditions of oral bullous pemphigoid and mouth pain, including any impairment in speaking and any impairment in masticatory function, are not medically related as the oral bullous pemphigoid is a separate entity entirely from the mouth pain, any impairment in speaking, and any impairment in masticatory function and unrelated to it. Regarding burning mouth syndrome, the examiner stated that it is characterized by both positive (burning pain, dysgeusia and dysesthesia) and negative (loss of taste and paresthesia) sensory symptoms involving the lips and tongue, mainly the tip and anterior two-thirds, and that most of the common laboratory tests suggested for burning mouth syndrome patients will be negative as well. The examiner stated that burning mouth syndrome is best subcategorized as primary, with no other evident disease, or secondary, which is defined as oral burning from other clinical abnormalities. Given the conflicting evidence above, the Board concedes that there is evidence which weighs for and against a finding that the Veteran's burning mouth syndrome is a separate and distinct condition from his service-connected oral bullous pemphigoid disability. As such, the evidence is at least in equipoise as to whether the manifestations of the Veteran's burning mouth syndrome are a separate and distinct condition from the Veteran's service-connected oral bullous pemphigoid. Significantly, however, the Board finds that the Veteran's existing disability ratings, including for oral bullous pemphigoid, TMD with arthritis due to oral bullous pemphigoid, bilateral cranial nerve VII impairment associated with oral bullous pemphigoid, anosmia associated with TMD with arthritis due to oral bullous pemphigoid, and hypogeusia associated with TMD with arthritis due to oral bullous pemphigoid, which disabilities combine to 60 percent, adequately contemplate the Veteran's symptoms of BMS, including intraoral burning, pain, dysgeusia or hypogeusia (altered/loss of sense of taste), anosmia (loss of sense of smell), and/or xerostomia (dry mouth), such that a separate, compensable disability rating for BMS would be duplicative of or overlapping with the symptomatology of the other service-connected disabilities and would constitute impermissible pyramiding. As such, the Board concludes that the evidence weighs against the claim for a separate, compensable disability rating for burning mouth syndrome associated with oral bullous pemphigoid, and the claim is denied. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Chad Johnson, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.