Citation Nr: 21075087 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 17-21 104 DATE: December 17, 2021 ORDER Prior to May 2, 2018, an initial disability rating in excess of 10 percent for service-connected lumbar spondylitic changes at L4-L5 and lumbar degenerative disc disease (DDD) is denied. Since May 2, 2018, a rating in excess of 20 percent for service-connected lumbar spondylitic changes at L4-L5 and lumbar DDD is denied. Beginning May 2, 2018, a rating of 20 percent, but no higher, for service-connected left lower extremity sciatic nerve radiculopathy is granted. Prior to September 10, 2017, an initial compensable disability rating for a service-connected bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums, is denied. Since September 10, 2017, a rating in excess of 10 percent for a service-connected bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums, is denied. FINDINGS OF FACT 1. Prior to May 2, 2018, the Veteran's lumbar spine disability did not result in forward flexion limited to greater than 30 degrees but not greater than 60 degrees; a combined range of motion not greater than 120 degrees; or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. Since May 2, 2018, the Veteran's lumbar spine disability has not resulted in forward flexion limited 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. 3. Beginning May 2, 2018, the Veteran's left lower extremity sciatic radiculopathy has been manifested by moderate symptoms; it has not been manifested by moderately severe or sever symptoms. 4. Prior to September 10, 2017, the Veteran's dental disability did not meet the criteria for a compensable rating under the rating criteria in effect at that time. 5. Since September 10, 2017, the Veteran's dental disability has not resulted in mandible loss of less than one-half, not involving the temporomandibular articulation, which is not replaceable by prosthesis; or, nonunion or malunion of mandible. CONCLUSIONS OF LAW 1. Prior to May 2, 2018, the criteria for a rating in in excess of 10 percent for service-connected lumbar spondylitic changes at L4-L5 and lumbar DDD were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5242. 2. Since May 2, 2018, the criteria for a rating in in excess of 20 percent for service-connected lumbar spondylitic changes at L4-L5 and lumbar DDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242. 3. Beginning May 2, 2018, a rating of 20 percent, but no higher, for service-connected left lower extremity sciatic nerve radiculopathy have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8520. 4. Prior to September 10, 2017, the criteria for a compensable rating for service-connected bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums, were not met. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.150, DCs 9901, 9902, 9903, 9904. 5. Since September 10, 2017, the criteria for a rating in excess of 10 percent for service-connected bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums, have not been met. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.150, DCs 9901, 9902, 9903, 9904. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from October 2004 to June 2014. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In its July 2015 rating decision, the RO granted entitlement to service connection for lumbar spondylitic changes at L4-L5 and for a bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums. The Veteran's lumbar spine disability was assigned an initial 10 percent disability rating, effective July 1, 2014. Her dental disability was assigned an initial 0 percent (noncompensable) disability rating, effective July 1, 2014. In its April 2020 rating decision, the RO continued the previously assigned disability ratings for the Veteran's service-connected lumbar spine and dental disabilities. In its August 2020 rating decision, the RO increased the rating of the Veteran's service-connected lumbar spine disability (now diagnosed as lumbar spondylitic changes at L4-L5 and lumbar DDD) from 10 percent to 20 percent, effective May 2, 2018. Likewise, the RO increased the rating of the Veteran's service-connected dental disability from 0 percent to 10 percent, effective September 10, 2017. As the grant of increased ratings for the Veteran's service-connected back and dental disabilities during the appeal period did not constitute a full grant of the benefits sought for either claim, the issues remain on appeal before the Board. AB v. Brown, 6 Vet. App. 35, 39 (1993). Preliminary Matters Initially, the Board notes that all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, pyramiding, or evaluating the same manifestation of a disability under different diagnostic codes, is to be avoided. See 38 C.F.R. § 4.14. Thus, separate ratings under different diagnostic codes are only permitted if, for example, those separate ratings are assigned based on manifestations of the veteran's disability that are separate and apart from manifestations for which the veteran has already been rated. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Notably, the provision regarding the avoidance of pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. In this case, the Veteran was diagnosed as having TMD related to her service-connected disability of bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums. See May 2015, May 2018, and February 2020 VA dental examinations. The February 2020 VA examiner opined that this condition began in 2009 following the removal of her wisdom teeth. The Veteran was then found entitled to service connection for TMD in an April 2020 rating decision. The Veteran's service-connected TMD was evaluated as 10 percent disabling from November 21, 2019. The subsequent August 2020 rating decision granted an earlier effective date of July 1, 2014, for the award of service connection. To date, the Veteran has not expressed any disagreement with the initial 10 percent rating assigned for her service-connected TMD. Accordingly, the issue of entitlement to an increased initial rating for TMD is not currently before the Board and will not be addressed herein. Additionally, in May 2019, the Board remanded the Veteran's claims for additional evidentiary development. Having obtained all available outstanding medical records and provided the Veteran with updated VA examinations to assess the current severity of his service-connected back and dental disabilities, the Board finds that the RO has substantially complied with the directives of its May 2019 Remand. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Thus, the Board will now proceed with its appellate review of the claims. Finally, the Board notes that the Veteran was granted a separate rating for left lower extremity sciatic nerve radiculopathy, as associated with his lumbar spine, in a July 2015 rating decision. The Veteran has not appealed this initial rating, but because it was granted in conjunction with his lumbar spine disability claim, the Board has taken jurisdiction of this issue and added it for consideration, as reflected above. Increased Ratings Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). The assignment of a particular diagnostic code to evaluate a disability is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. §§ 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). Moreover, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Burton, 25 Vet. App. at 5. The Court of Appeals for Veterans Claims (Court) also held in Correia v. McDonald, 28 Vet. App. 158 (2016) that the final sentence of 38 C.F.R. §§ 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. §§ 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. 1. Entitlement to an initial disability rating in excess of 10 percent for lumbar spondylitic changes at L4-L5 and lumbar degenerative disc disease (DDD), prior to May 2, 2018, and to a rating in excess of 20 percent thereafter. The Veteran contends her service-connected lumbar spine disability is worse than indicated by her initial disability rating of 10 percent prior to May 2, 2018, followed by the 20 percent disability rating thereafter. The Veteran's lumbar spine disability is rated under DC 5242. A. Legal Criteria The General Rating Formula for Disease and Injuries of the Spine DC 5242 provides that with or without such symptoms as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, provides a 10 percent rating if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or there is a vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; if the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or there is guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted if forward flexion of the thoracolumbar spine is 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Note (1) also articulates that neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. Id. Normal back motion is flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left rotation to 30 degrees. 38 C.F.R. § 4.71a, Plate V. If there is evidence of intervertebral disc syndrome (IVDS), a lumbar spine disability can be alternatively rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula). The IVDS Formula provides a 20 percent rating if the adverse symptomatology includes incapacitating episodes having a total duration of at least 2 weeks during the past 12 months, a 40 percent rating if the adverse symptomatology includes incapacitating episodes having a total duration of at least 4 weeks during the past 12 months, and a 60 percent rating if the adverse symptomatology includes incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Diagnostic Code 5243 defines an incapacitating episode as one where the Veteran has physician prescribed bed rest. The Board notes that the regulations pertaining to rating the spine were amended, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). These amendments provide specific ranges of motions required to meet the diagnostic criteria. The Board notes that these amendments are not applicable any earlier than their effective date. As there is no evidence dated after February 7, 2021, these amendments are not for application. B. Evidence Review The Veteran's medical treatment records show she has been treated for back pain throughout the appeal period. The Veteran underwent VA thoracolumbar spine examinations in May 2015, May 2018, and January 2020. At his May 2015 VA spine examination, the Veteran was diagnosed as having lumbar spondylitic changes with a prominent bulging at L4-L5 (based on MRI findings), lumbar radiculopathy, and muscle spasm of the mid/lower back. The Veteran reported experiencing constant back pain rated as a 7 out of 10 in terms of severity; she indicated that her current pain resulted in the following limitations: she can only walk 30 feet, she can only stand for approximately 30 minutes, she can only sit for approximately 30 minutes, she is unable to run, and she can only climb 1.5 flights of stairs. She reported having flare-ups of pain when bending down and that the intensity of the pain was a 10 out of 10 and that she rested, used ice, and took Motrin/Flexril to alleviate the pain. She reported that it would usually take 4-5 days for the pain to come down and then that pain would remain at a level 10 for four days until it gradually came down. She reported experiencing flare-ups at least twice a month and that she had taken two days off from work since she had started her job two months ago. The Veteran described her functional loss/functional impairment as being unable to walk when the pain is a 10 out of 10 during a flare-up and that her parents have to carry her to the restroom. She stated that she then required bedrest for three days to recuperate. Range of motion testing revealed forward flexion to 80 degrees; extension to 15 degrees; right lateral flexion to 20 degrees; left later flexion to 20 degrees; right lateral rotation to 25 degrees; and left lateral rotation to 25 degrees. Pain was noted on the examination but was deemed not to result in or cause functional loss. There was no evidence of pain with weight bearing but there was objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. There was no additional loss of function or range of motion after repetitive-use testing. The examiner noted that, while there was evidence of muscle spasm and localized tenderness, it did not result in abnormal gait or abnormal spinal contour. The examiner found no evidence of guarding. The examiner noted that the Veteran did not have any other neurologic abnormalities, ankylosis, or IVDS. The examiner noted that imaging studies from September 2012 did not reveal any arthritis affecting her thoracolumbar spine. The examiner opined that it was not possible without mere speculation to estimate additional loss of function or limitation of motion during flare-ups or when the joint was used over a period of time because there was not conceptual or empirical basis for making such a determination without directly observing function under these circumstances. The Veteran underwent another VA spine examination in May 2018. During that examination, the Veteran reported that her back was progressively worse than when she was previously examined and that she was currently experiencing a significant amount of back pain. She reported experiencing a constant stabbing back pain with pain radiating down to her left lower extremity and described as "very painful, electric/burning, numbing and achy shooting pain...trigger[ed]...by prolonged walking." The examiner reviewed the evidence of record and conducted a thorough evaluation of the Veteran's lumbar spine. The examiner diagnosed the Veteran as having lumbar spine spondylitic changes at L4-L5 and lumbar degenerative disc disease. Range of motion testing revealed forward flexion to 70 degrees; extension to 15 degrees; right lateral flexion to 25 degrees; left lateral flexion to 20 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees. The examiner noted that the Veteran's pain caused functional loss. There was no evidence of pain with weight-bearing. Repetitive use testing revealed forward flexion to 60 degrees; extension to 15 degrees; right lateral flexion to 25 degrees; left lateral flexion to 20 degrees; right lateral rotation to 25 degrees; and left lateral rotation to 25 degrees. The Veteran reported experiencing flare-ups which occur two to three times per month and are sharp and more intense than her daily back pain. She described it as a 10 out of 10 in terms of intensity. The Veteran reported that pain usually lasted two to three days and then reduced in terms of intensity to a 4 to 5 out of 10. She reported using heat, ice, rest, and medication to control her flare-ups and the indicated that her back pain was caused/worsened by prolonged sitting, standing, walking, and bending over. She reported missing 2 to 3 days from work every month over the past twelve months due to her back pain. The examiner found no evidence of muscle spasm but note that there was evidence of guarding not resulting in abnormal gait or spinal contour. The examiner noted that there was evidence of pain during all ranges of motion tested but that the pain was more problematic with forward flexion, bending, and rotation of the spine to the left. There was no evidence of ankylosis or IVDS. The examiner opined that imaging studies from September 2012 confirmed that there was arthritis and lumbar spondylitic changes at L4-L5 with a small, more focal central disc protrusion at this level. The Veteran was afforded a third VA spine examination in January 2020. During that evaluation, the Veteran stated that her lower back pain had worsened, that it was a constant 7 out of 10 in terms of severity, and that once every two months it intensified to a 10 out of 10 in terms of severity during flare-ups. She reported that she often had to take two days off from work each month for her back pain. She reported taking medication to alleviate the pain but that the pain makes it unbearable to stand or bend over. She reported that she had been using a cane to help ambulate for one and a half years. Range of motion testing revealed forward flexion to 70 degrees; extension to 15 degrees; right lateral flexion to 25 degrees; left lateral flexion to 25 degrees; right lateral rotation to 25 degrees; and left lateral rotation to 25 degrees. Pain causing functional loss was noted on examination though there was no evidence of pain with weight bearing. The Veteran was unable to perform repetitive use testing, but the examiner indicated that pain, weakness, fatiguability, or incoordination did not limit the Veteran's functional ability with repeated use over time. The examiner found that the examination was medically consistent with the Veteran's statements describing functional loss during flare-ups and that pain and lack of endurance caused functional loss during her flare-ups. Nevertheless, the examiner indicated that, because she was not being examined during an active flare-up, there was no basis upon which to offer estimates on additional losses of function or range of motion during flare-ups. The examiner noted the Veteran's self-report that she had significant difficulty with walking during flare-ups and needing to use a cane to ambulate. The examiner further noted that the Veteran had reported needing assistance getting out of bed and going to the bathroom during flare-ups of pain. The examiner found no evidence of muscle spasm but noted guarding not resulting abnormal gait or spinal contour. The examiner found that the Veteran did not have ankylosis, any other neurological abnormalities, or IVDS. The examiner noted that imaging studies showed evidence of arthritis affecting the thoracolumbar spine. The examiner diagnosed the Veteran as having lumbar spondylitic changes at L4-L5, lumbar degenerative disc disease, and left side lumbar radiculopathy. C. Analysis Prior to May 2, 2018, the evidence does not indicate the Veteran's lumbar spine disability was worse than indicated by his 10 percent rating. While the Veteran reported symptoms such as pain and trouble bending, the objective testing showed no loss of range of motion significant enough to warrant a higher disability rating. Objective testing also did not show the Veteran had ankylosis of any sort in his back. From May 2, 2018, it is clear the Veteran's lumbar spine disability worsened with range of motion decreasing sufficient to warrant a 20 percent rating. However, evidence from this time does not indicate the Veteran's back range of motion warranted a higher evaluation due to forward flexion of less than 30 degrees or any form of ankylosis. The Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as DeLuca, supra, Mitchell, supra, Burton, supra, Correia, supra; and Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Veteran's functional losses do not equate to the criteria required for a higher rating at any time on appeal. In coming to these conclusions, the Board has reviewed the Veteran's statements of her symptoms along with the objective evidence of record. Regarding all of the Veteran's claim, the Board acknowledges and has considered the Veteran's statements that her lumbar spine disability bothers her, causes her pain, and limits her ability to perform certain motions. The Board also recognizes the Veteran continues to seek medical treatment for her back problems and has considered the Veteran's statements regarding her symptoms and severity of her lumbar spine disability. However, while the Veteran is competent to report the symptoms of her disability, she is not competent to opine on matters requiring medical knowledge, such as determining the severity of her medical condition at any given time. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board places more probative weight on the objective evidence of record, which includes the examinations discussed above. The Board finds these examinations adequate because the examiners reported and considered the Veteran's statements of her symptoms and performed all necessary testing. While the Veteran's lumbar spine disability clearly bothers her a great deal and causes the Veteran many problems, it is important for her to understand that this is the basis for the current findings. The Board acknowledges that the Veteran's back condition constantly bothers her and causes her pain. If her back symptomology did not cause her problems, there would be no basis for compensable ratings. However, the only question is the degree. Unfortunately, the relevant findings from the May 2015, May 2018, and January 2020 VA examination reports and the objective medical records in the claims file simply do not meet the regulatory criteria that must be met before the Board can assign a higher rating. Put simply, the Veteran's disability picture and symptomatology do not warrant ratings in excess of 10 percent prior to May 2, 2018, and in excess of 20 percent since May 2, 2018. The potential applications of various provisions of Title 38 of the Code of Federal Regulations have been considered as required by the holding of the Court in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). However, neither the Veteran nor her representative has identified any other rating criteria that would provide a higher rating or an additional rating. Regarding all the above, the Board has considered the applicability of the benefit of the doubt doctrine. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57(1990). 2. Entitlement to an initial rating in excess of 10 percent for service-connected left lower extremity sciatic nerve radiculopathy. As noted above, neurologic abnormalities resulting from a spine disability are evaluated separately under an appropriate diagnostic code. In this case, the Veteran's left lower extremity sciatic nerve radiculopathy is separately rated 10 percent disabling (from July 1, 2014) under the criteria of DC 8520, which pertains to complete and incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. A. Legal Criteria Mild incomplete paralysis warrants a 10 percent rating; moderate warrants a 20 percent rating; moderately severe warrants a 40 percent rating; and, severe incomplete paralysis with marked muscular atrophy warrants a 60 percent rating. Complete paralysis warrants an 80 percent rating, and is shown when the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexions of the knee is weakened or (very rarely) lost. Id., DC 8520. A note prior to the rating criteria pertaining to diseases of the peripheral nerves, which contains DC 8520, explains that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at the most, the moderate degree. Id. Disability ratings with respect to neurological conditions are ordinarily rated in proportion to the impairment of motor, sensory or mental function. 38 C.F.R. § 4.120. In evaluating peripheral nerve injuries, attention therefore is given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. Id. Special consideration is given to complete or partial loss of use of one or more extremities. 38 C.F.R. § 4.124a. B. Evidence Review The Veteran's medical treatment records show she has been treated for left knee pain throughout the appeal period. The Veteran underwent VA thoracolumbar spine examinations in May 2015, May 2018, and January 2020. At his May 2015 VA spine examination, the Veteran described having flare-ups of shooting pain to the left leg down to the toes with constant numbness involving the third, fourth, and fifth toes. Based on testing, the examiner diagnosed the Veteran as having left lower extremity radiculopathy affecting the sciatic nerve. The examiner found that the Veteran's radiculopathy was causing mild incomplete paralysis of the left lower extremity sciatic nerve and that her symptoms were manifested by mild intermittent pain, mild paresthesias/dysesthesias, and mild numbness. The Veteran underwent another VA spine examination in May 2018. During that examination, the Veteran reported experiencing pain radiating down to her left lower extremity. She described the pain as "very painful, electric/burning, numbing and achy shooting pain...trigger[ed]...by prolonged walking." The examiner noted that the Veteran's lumbar spine disability resulted in left lower extremity radiculopathy affecting the sciatic nerve. Based on muscle strength, reflex, sensory, and straight leg raise testing, the examiner indicated that the Veteran's radiculopathy was causing moderate incomplete paralysis of the left lower extremity sciatic nerve and that her symptoms were manifested by moderate intermittent pain, moderate paresthesias/dysesthesias, and moderate numbness. The Veteran was afforded a third VA spine examination in January 2020. During that evaluation, the Veteran described having pain radiating down her left leg to her toe and numbness in her toes. The examiner found that the Veteran had radiculopathy of the left lower extremity which resulted in moderate incomplete paralysis of the sciatic nerve and was manifested by moderate intermittent pain and moderate numbness. C. Analysis Based on a review of the evidence, the Board finds that a 20 percent disability rating is warranted beginning May 2, 2018, the date of the VA spine examination demonstrating that the Veteran's left lower extremity sciatic radiculopathy was "moderate" in terms of severity. While a 20 percent rating is warranted, effective May 2, 2018, the evidence does not reflect that the Veteran's symptomatology and disability picture was moderately severe or severe at any time during the appeal period. Accordingly, the Board is granting a increased rating of 20 percent, but no higher, for the moderate incomplete paralysis of the sciatic nerve caused by the Veteran's service-connected left lower extremity radiculopathy. 3. Entitlement to an initial compensable disability rating for a bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums, prior to September 10, 2017, and to a rating in excess of 10 percent thereafter. The Veteran is service connected for a bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums (hereafter "mandible deformity"). As noted above, her service-connected mandible deformity was initially assigned a noncompensable rating under DC 9904 (malunion of the mandible). See July 2015 rating decision. Subsequently, the RO increased the rating of her service-connected mandible deformity from 0 percent to 10 percent rating, effective September 10, 2017, under the criteria of DC 9902 (unilateral or bilateral loss of the mandible, including ramus). See August 2020 rating decision. The question for the Board is whether the Veteran is entitled to an initial compensable disability rating for her service-connected mandible deformity prior to September 10, 2017, and to a rating in excess of 10 percent thereafter. A. Legal Criteria Dental and oral conditions affecting the mandible (jaw or jawbone) are rated under 38 C.F.R. § 4.150, DCs 9901-9904. Under DC 9901, a 100 percent rating is warranted for complete loss of mandible between the angles. See 38 C.F.R. § 4.150, DC 9901. Under DC 9902, for loss of mandible, including ramus, unilaterally and bilaterally, a disability is warranted as follows: a 70 percent rating for loss of one-half or more involving temporomandibular articulation and not replaceable by prosthesis and a 50 percent rating for loss of one-half or more involving temporomandibular articulation replaceable by prosthesis; a 40 percent rating for loss of one-half or more not involving temporomandibular articulation and not replaceable by prosthesis and a 30 percent rating for loss of one-half or more not involving temporomandibular articulation replaceable by prosthesis; a 70 percent rating for loss of less than one-half involving temporomandibular articulation and not replaceable by prosthesis and 50 percent rating for loss of less than one-half involving temporomandibular articulation replaceable by prosthesis; a 20 percent rating for loss of less than one-half not involving temporomandibular articulation and not replaceable by prosthesis and a 10 percent rating for loss of less than one-half not involving temporomandibular articulation replaceable by prosthesis. See 38 C.F.R. § 4.150, DC 9902. Under DC 9903, for nonunion of mandible, confirmed by diagnostic imaging studies, a 30 percent rating is warranted for severe malunion with false motion, and a 10 percent rating is warranted for moderate malunion with false motion. See 38 C.F.R. § 4.150, DC 9903. Under DC 9904, for malunion of mandible, a 20 percent rating is warranted for displacement of mandible causing severe anterior or posterior open bite; a 10 percent rating is warranted for displacement of mandible causing moderate anterior or posterior open bite; and a noncompensable rating is warranted for displacement of mandible not causing anterior or posterior open bite. See 38 C.F.R. § 4.150, DC 9904. B. Evidence Review Dental records from April 2014 reflect that the Veteran was experiencing persisting pain in the right mandible at a pain level of 7 to 10 out of 10 in terms of severity. No visible swelling was noted. There was positive palpation to the masseter over angle of the mandible. On VA dental examination in May 2015, the VA examiner noted that the Veteran had undergone multiple surgeries in the area of tooth #32, with an extraction in approximately 2009 and her last surgery in that area in 2014. The Veteran reported having pain in the area of the angle of the jaw. The examiner found that the intra-oral tissues were intact, with no abnormal appearance. The examiner noted that the Veteran had a bony defect of her right mandible in the site of the removed impacted third molar. The examiner found that the Veteran had not lost either condyle or coronoid process of the mandible and that the Veteran had not sustained an injury resulting in malunion or nonunion of the mandible. Panographic/ intraoral imagining showed no bony defects of the maxilla or hard palate, but approximately 2-3 centimeters defect site of tooth #32. The examiner noted that the Veteran's symptoms of pain in the right jaw following extraction of the third molar (tooth #32) were more consistent with a temporomandibular disorder (TMD) but that range of motion was 38-40mm and there was no deviation during movement. The examiner also noted that it was not visibly affected by repetitive motion. On VA dental examination in May 2018, the VA examiner noted that the Veteran continued to report pain in the area of an extracted third molar at the angle of the jaw. The examiner noted that the extraction had occurred approximately fourteen years ago and that the pain was more consistent with TMD rather than from the surgical site. The examiner noted that the Veteran had not reported any paresthesia in the area and that there was still a residual defect in the area of tooth #32. The examiner essentially found that things remained unchanged since 2015 (the defect had not changed at all) and that testing was not definitive that this defect was the source of the pain. The examiner noted that there appeared to be a recurring cyst, but that imaging of the area was inconclusive. On VA dental examination in December 2019, the examiner reviewed the Veteran's dental records and noted the following: The patient's condition began in 2009 following the removal of wisdom teeth. The condition began, "after my wisdom tooth surgery the dentist put the packing too far down in the cavity. My gums grew over it and despite multiple appts we would not really look into the tissue. It became infected and that's when I was referred to another dentist and an oral surgeon." The symptoms were "pain, swelling, and eventually a huge bruise broke out on the right side of my face." The current symptoms are, "pain that radiates and occasional swelling." The patient has "had 6 surgeries to attempt to correct this, to include an OR visit. After multiple follow-up visits, I was told that I had a low tolerance for pain. It was discovered years later the bone never grew back." The current treatment is taking Aleve to reduce the pain. The examiner diagnosed the Veteran as having TMD. The examiner noted that the Veteran had lost less than 1/2 of the mandible including the ramus, not involving the temporomandibular articulation. The examiner noted that the Veteran's symptoms were consistent with TMD and that post-surgical pain was unlikely after 10 years. The examiner noted the Veteran's complaints of flare-ups of pain which were commonly associated with patients who suffer from TMD. The examiner no evidence of functional loss on examination. In an August 2020 addendum report, the December 2019 VA examiner added that there was a radiolucency that could be observed on the patient's panoramic x-ray taken on December 18, 2019 and that the radiolucency appeared to be in the same location where tooth #32 was extracted. C. Analysis The Board finds that a compensable rating for fracture of mandible is not warranted, prior to September 10, 2017, and that a rating in excess of 10 percent is not warranted since that date. A 10 percent rating was assigned for the Veteran's bony deformity of the mandible, status post wisdom tooth removal, including scars/sore gums based on the findings of the December 2019 VA examination showing mandible loss of less than one-half, not involving temporomandibular articulation, which is replaceable by prosthesis. An effective date of September 10, 2017 was assigned to that rating because that was the date of the change in the rating schedule evaluation criteria that allowed for a compensable evaluation of the Veteran's condition. In any event, the Veteran is now service connected for TMD which accounts for the symptoms of pain that she was experiencing throughout the appeal period. And while the Veteran's non-TDM symptoms warrant a 10 percent rating, effective September 10, 2017, there is no evidence in the record that her condition warranted a compensable rating prior to September 10, 2017. Likewise, since September 10, 2017, there is no evidence demonstrating that she has experienced mandible loss of less than one-half, not involving the temporomandibular articulation, which is not replaceable by prosthesis. Lastly, the Veteran does not experience nonunion or malunion of mandible. As a result, the Veteran's dental condition does not meet the criteria for a higher rating under DCs 9901, 9902, 9003, or 9004. The Board has considered the Veteran's contentions. However, the objective medical evidence in this case simply does not demonstrate that the Veteran's dental disability, diagnosed as a bony deformity of the mandible, status post wisdom tooth removal, to include scars and sore gums, warrants a compensable rating prior to September 10, 2017 or that it warrants a rating in excess of 10 percent since that date. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a higher disability rating for the Veteran's dental disability either prior to or since September 10, 2017. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. See Gilbert, 1 Vet. App. at 54. Final Considerations The Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, there is no indication in the record that the Veteran is unemployed or contends that her service-connected lumbar spine disability renders her unable to obtain or maintain substantially gainful employment. Thus, the Board finds that the claim of entitlement to a TDIU has not been raised by record. As a final matter, the Board observes that neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael L. Marcum, 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.