Citation Nr: 21070560 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-17 655 DATE: November 24, 2021 REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for right upper extremity radiculopathy is remanded. Entitlement to service connection for left upper extremity radiculopathy is remanded. Entitlement to a rating in excess of 20 percent for bruxism, status post temporomandibular joint (TMJ) syndrome from March 14, 2019, is remanded. REASONS FOR REMAND The appellant served on active duty in the U.S. Navy from October 1989 to September 1994. This matter comes before the Board of Veterans' Appeals (Board) from an October 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, denied entitlement to service connection for a cervical spine disability and bilateral upper extremity radiculopathy, and denied entitlement to a rating in excess of 20 percent for bruxism, status post TMJ syndrome. The appellant filed a timely Notice of Disagreement (NOD), received in November 2016. A Statement of the Case (SOC) was issued in March 2017. A timely substantive appeal was received in March 2017. The Board, in pertinent part, denied entitlement to a rating in excess of 20 percent for bruxism, status post TMJ syndrome, prior to March 14, 2019, and remanded the issues of entitlement to service connection for a cervical spine disability and bilateral upper extremity radiculopathy, and entitlement to a rating in excess of 20 percent for bruxism, status post TMJ syndrome, from March 14, 2019, in August 2019. Supplemental Statements of the Case (SSOC) were issued in June 2021 and July 2021. 1. Entitlement to service connection for a cervical spine disability. 2. Entitlement to service connection for right upper extremity radiculopathy. 3. Entitlement to service connection for left upper extremity radiculopathy. The appellant contends that his service-connected bruxism, status post TMJ syndrome, caused him to develop his current cervical spine disability. See July 2021 statement. The appellant also submitted an excerpt from a dental website which appears to suggest that TMJ disorders can result in neck and shoulder pain. In accordance with the Board's August 2019 remand directives, a medical opinion regarding service connection for a cervical spine disability on a direct basis was obtained in April 2021. However, the Board finds that remand is warranted in order to obtain an addendum opinion which addresses the secondary service connection theory of entitlement. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As resolution of the claim of entitlement to service connection for a cervical spine disability may have an impact on the appellant's claims of entitlement to service connection for right and left upper extremity radiculopathy, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). 4. Entitlement to a rating in excess of 20 percent for bruxism, status post TMJ syndrome from March 14, 2019. As directed by the Board in its August 2019 remand, the appellant was most recently afforded a contracted examination to determine the severity and manifestations of his bruxism, status post TMJ syndrome, in April 2021. At that time, inter-incisal distance measured 21-29 mm. The appellant reported that he could not chew hard or chewy foods, so he had to cut food into small pieces. He reported that he wore a mouth guard at night to stop grinding teeth, but it hurt his jaws. However, since that time, the appellant appears to have reported worsening symptoms. A May 2021 VA dental note states that he appellant reported that he could not open his mouth more than the width of one finger. Steroid injections had been performed in the past. He was willing to have an evaluation for surgery. VA medical records also reveal that TMJ range of motion was measured as greater than 30 mm and less than 45 mm in May 2021 and greater than 30 mm in June 2021. In a statement received in July 2021, the appellant stated that he was unable to fully close his jaw. He also reported that he saw Dr. D.C. and was told that he may need surgery for his jaw disc and that an MRI would be needed to confirm. Based upon the appellant's contentions of worsening symptoms since the April 2021 examination, the Board finds that the appellant should be afforded a new examination to assess the severity and manifestations of his service-connected bruxism, status post TMJ syndrome. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician as to the nature and etiology of the appellant's cervical spine disability. Access to the claims file should be made available to the examiner for review. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that a cervical spine disability had its onset in service or is otherwise related to the appellant's active service, to include an injury in which he was struck in the face by a door? If not, is it at least as likely as that a cervical spine disability was proximately due to or the result of service-connected bruxism, status post TMJ syndrome? If neither, is it at least as likely as not that a cervical spine disability was aggravated (made worse) by service-connected bruxism, status post TMJ syndrome? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) the September 2016 VA examination report in which the appellant reported that he experienced neck stiffness since an in-service injury in which he was struck in the face by a door until a 2000 motor vehicle accident which caused a week-long exacerbation of neck stiffness before returning to baseline; (b) the April 2021 contracted medical opinion; and (c) the appellant's July 2021 written argument and the excerpt from a dental website which appears to suggest that TMJ disorders can result in neck and shoulder pain. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. In providing the requested opinions, the clinician should consider the appellant's reported injury and symptoms in service and thereafter. If there is any medical reason to accept or reject the proposition that the appellant's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the appellant's reports about his injury and symptoms align with how the disability is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? The Board has made no credibility determination at this juncture. (Continued on the next page) If the clinician determines that an examination of the appellant is necessary, one should be scheduled. 2. Afford the appellant an examination, conducted by a clinician with the appropriate expertise, to determine the current severity and manifestations of his service-connected bruxism, status post TMJ syndrome. Access to the claims file should be made available to the examiner for review in connection with the examination. The examination report should identify all symptoms and pathology associated with the service-connected bruxism, status post TMJ syndrome, and the functional effects of such symptoms, if any. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Behlen, 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.