Citation Nr: 21075763 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 10-15 819 DATE: December 21, 2021 ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. Service connection for a back disability is denied. Service connection for a pulmonary disability is denied. Service connection for a stomach disability is denied. Service connection for a recurrent pain disorder, to include fibromyalgia, is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Service connection for a dental disability is denied. FINDINGS OF FACT 1. The Veteran does not have an acquired psychiatric disorder, to include PTSD, due to his service, or that was caused or aggravated by a service-connected disability. 2. The Veteran does not have a back disability due to his service. 3. The Veteran does not have a pulmonary disability due to his service. 4. The Veteran does not have a stomach disability due to his service. 5. The Veteran does not have a recurrent pain disorder, to include fibromyalgia, due to his service. 6. The Veteran does not have a right knee disability due to his service. 7. The Veteran does not have a left knee disability due to his service. 8. The Veteran does not have a dental disability for VA compensation purposes. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310. 2. The criteria for service connection for a back disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for service connection for a pulmonary disability have not been met. 38 U.S.C. §§ 1110, 1710, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 17.400. 4. The criteria for service connection for a stomach disability have not been met. 38 U.S.C. §§ 1110, 1710, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 17.400. 5. The criteria for service connection for a recurrent pain disorder, to include fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 1710, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 17.400. 6. The criteria for service connection for right knee disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 7. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 8. The criteria for entitlement to service connection for a dental disability, to include mouth sores and rotting teeth, have not been met, and the payment of disability compensation is precluded by law. 38 U.S.C. §§ 1110, 1710, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 4.150. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1967 to January 1970. In September 2016, the Board reopened a claim for service connection for PTSD, and remanded claims for service connection for an acquired psychiatric disorder to include PTSD and depression, a thoracolumbar spine disorder ("back disability"), a recurrent pain disorder, to include fibromyalgia, a pulmonary disorder, a stomach disorder, mouth sores, a dental disorder, a right knee disorder, and a left knee disorder, with the claims for a recurrent pain disorder/fibromyalgia, a pulmonary disability, a stomach disorder, mouth sores, and a dental disability ("rotting teeth"), to include as due to exposure to contaminated drinking water while stationed at Camp Lejeune, North Carolina ("CLCW"). Service Connection The Veteran asserts that he has an acquired psychiatric disorder to include PTSD and depression, a thoracolumbar spine disorder ("back disability"), a recurrent pain disorder, to include fibromyalgia, a pulmonary disorder, a stomach disorder, a dental disorder, to include mouth sores and rotting teeth, a right knee disorder, and a left knee disorder, due to his service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. See 38 C.F.R. § 3.303 (d). In such instances, a grant of service connection is warranted only when, "all of the evidence, including that pertinent to service, establishes that the disease was incurred during service." Id. Service connection may also be granted for arthritis when manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Service connection is currently in effect for adenocarcinoma of the prostate gland with residual voiding dysfunction, fecal urgency and incontinence, dermatitis, erectile dysfunction. In order to establish service connection for PTSD, the evidence of record must include a medical diagnosis of the condition in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). There are special considerations for PTSD claims predicated on a personal assault. The pertinent regulation, 38 C.F.R. § 3.304 (f)(5), provides that PTSD based on a personal assault in service permits evidence from sources other than a veteran's service records which may corroborate his or her account of the stressor incident. Examples of these kinds of evidence include, but are not limited to: Records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Id. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: A request for a transfer to another military duty assignment; deterioration in work performance, substance abuse, episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Id. VA has acknowledged that alternative sources for developing evidence of personal assault, including private medical records, civilian police reports, reports from crisis intervention centers, testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, and personal diaries or journals. Personality disorders are not diseases or injuries in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303 (c), 4.9; Winn v. Brown, 8 Vet. App. 510, 516 (1996). Direct service connection for a disability that is a result of a claimant's own abuse of alcohol or drugs is precluded for purposes of all VA benefits for claims filed after October 31, 1990. 38 U.S.C. §§ 101 (16) and 105(a); VAOPGCPREC 7-99, 64 Fed. Reg. 52,375 (1999). Under 38 C.F.R. § 3.307(a)(7) "certain diseases have been associated with exposure to contaminants in the water supply at Camp Lejeune" (i) For the purposes of this section, contaminants in the water supply means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. The diseases listed in §3.309(f) shall have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(7)(ii). A veteran, or former reservist or member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. The last date on which such a veteran, or former reservist or member of the National Guard, shall be presumed to have been exposed to contaminants in the water supply shall be the last date on which he or she served at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987. For purposes of this section, service at Camp Lejeune means any service within the borders of the entirety of the United States Marine Corps Base Camp Lejeune and Marine Corps Air Station New River, North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987, as established by military orders or other official service department records. 38 C.F.R. § 3.307(a)(7)(iii). Exposure described in paragraph (a)(7)(iii) of this section is an injury under 38 U.S.C. § 101 (24)(B) and (C). If an individual described in paragraph (a)(7)(iii) develops a disease listed in §3.309(f), VA will presume that the individual concerned became disabled during that service for purposes of establishing that the individual served in the active military, naval, or air service. 38 C.F.R. § 3.307 (a) (7) (iv). Under 38 C.F.R. § 3.309 (f) "disease associated with exposure to contaminants in the water supply at Camp Lejeune," if a veteran, or former reservist or member of the National Guard, was exposed to contaminants in the water supply at Camp Lejeune during military service and the exposure meets the requirements of §3.307(a)(7), the following diseases shall be service-connected even though there is no record of such disease during service, subject to the rebuttable presumption provisions of § 3.307(d): (1) Kidney cancer. (2) Liver cancer. (3) Non-Hodgkin's lymphoma. (4) Adult leukemia. (5) Multiple myeloma. (6) Parkinson's disease. (7) Aplastic anemia and other myelodysplastic syndromes. (8) Bladder cancer. For a Camp Lejeune veteran, VA will assume that a covered illness or condition is attributable to the veteran's active duty service at Camp Lejeune unless it is clinically determined, under VA clinical practice guidelines, that such an illness or condition resulted from a cause other than such service. 38 C.F.R. § 17.400(c) As an initial matter, the Board finds that the Veteran is not a credible historian based on the evidence of his in-service disciplinary actions, substance abuse, violent behavior, and poor character. The Veteran's personnel records show that he was a "SPCM Prisoner" (presumably "special court martial") from February 19, 1968 to March 1, 1968, and that he was on unauthorized absence "UA (AWOL)" from January 16, 1969 to January 17, 1969, and from December 31, 1969 to January 25, 1970. The Veteran's discharge (DD Form 214) notes non-pay period/time lost from January 12, 1968 to February 29, 1968, and from December 31, 1969 to January 24, 1970. Unauthorized absence precludes the performance of military duties and thus cannot constitute a minor offense. Stringham v. Brown, 8 Vet. App. 445, 448 (1995). Following separation from service, the Veteran is shown to have long histories of alcohol and substance abuse. See e.g., August 1989 VA hospital report (Axis I diagnoses of alcohol and cocaine dependence, with alcohol use since age 15 and 14 years of continuous drug use, using up to six to seven grams of cocaine a day). A July 1990 VA examination report shows that the Veteran reported using amphetamines and cocaine during service, and that he was in an accident in 1987 while he was driving an 18-wheeler for the postal service while he was under the influence of drugs and alcohol. The Veteran has also reported an in-service history of infractions for disobeying orders and for forgery. See March 2010 VA progress note. Accordingly, the Veteran is found not to be a credible historian. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). 1. Acquired psychiatric disorder, to include PTSD. In a statement in support of claim (VA From 21-0781a), received in September 2009, the Veteran asserted the following: In March 1967, while he was in boot camp, his drill instructor slapped and grabbed him. He stated, "They sent me back one month." He received a summary court martial involving drugs and liquor for which he served three months in the brig. In 1969, he was on a ship and he served a month of brig time based on fighting and drinking. In January 1970, he was asked to leave service because he was too violent. In his appeal (VA Form 9), received in March 2010, he also reported being assaulted by a military policeman "at the gate" during service in Okinawa and being attacked by a sergeant during service at Subic Bay. In another VA Form 9, received in December 2012, he asserted that he had depression while he was in boot camp. In an unappealed and final decision, dated in December 2009, the RO denied a claim for neurobehavioral effects as residual of contaminated water at Camp Lejeune pursuant to 38 U.S.C. § 1710 and 38 C.F.R. § 17.400. See 38 U.S.C. § 7105 (c). The Veteran's service treatment records show that he was noted to have been involved in fights on several occasions. A December 1967 report notes that he is "passive aggressive." He underwent a psychiatric evaluation in January 1968. He was noted to have a long history of poor impulse control and undisciplined behavior. Since the age of 15 he had been in numerous fights and he had been in jail three times. He had a history of a suicide attempt. He hospitalized a man after he hit him in the head with a hatchet. On another occasion, he hit a boy in the face with a 2 x 4 (wooden plank). A mental examination was negative for psychosis, neurosis, depression, anxiety, or organic brain disease. The examiner indicated that the Veteran did not have a neurological disease, and that he had a deep-seated and severe character disorder of the emotionally unstable type, and that he could be homicidal. He used alcohol excessively and he was particularly violent and unstable at those times. He was legally responsible for his behavior. Appropriate discipline and a BCD (bad conduct discharge) were recommended. A memorandum of review from the Office of the Staff Judge Advocate notes that the Veteran had a severe character disorder of the emotionally unstable type with antisocial features. It states, "[H]e is impulsive, easily angered and could be homicidal and further recommended separation from the service. At the time of the psychiatric examination, respondent was pending disciplinary action and there is no evidence to indicate respondent was ever processed for discharge in accordance with the recommendation. Notwithstanding respondent's substandard conduct and the recommendation of the board, it appears that the psychiatric examination conducted in this case discloses a definite character or behavior disorder which indicates respondent is unsuitable for further military service. Therefore, the most appropriate course of action would be to direct respondent's discharge from the service by reason of unsuitability with a general discharge." The Veteran's separation examination report, dated in December 1969, shows that his psychiatric condition was clinically evaluated as normal. There is a notation of "Undesirable Discharge because of six (6) cases of Gonorrhea." See also November 1969 report from Battalion Surgeon to Commanding Officer (noting a severe character disorder of the emotionally unstable type with antisocial features, and recommending separation from service for unsanitary habits). As for the post-service medical evidence, a VA hospital report, dated in August 1989, show Axis I diagnoses of alcohol and cocaine dependence, with a history of a car accident in 1987 that involved a head injury. The Veteran was noted to have used alcohol since age 15, and to have had 14 years of continuous drug use. VA progress notes dated in 1989 note cocaine abuse and alcohol abuse. A July 1990 VA report shows that the Veteran reported a history of drinking beginning in his mid-teens, and heavy drug use beginning during service. He lost his job following a motor vehicle accident in 1987, at which time he was driving an 18-wheeler for the postal service under the influence of alcohol and drugs. The Axis I diagnosis was polysubstance abuse, only partially resolved, chronic. The Axis II diagnosis was antisocial personality traits, cannot rule out antisocial personality disorder. The examiner stated, "I see currently no service connection" regarding the Veteran's drug problem or PTSD. A July 1990 psychiatric evaluation from the Evaluation Medical Clinic shows that the Veteran reported a history of psychiatric symptoms during service, to include a plan to blow himself up along with an officer. Following separation from service, he was in a severe motor vehicle accident because, "A guy gave me the finger and I decided I was going to get him." He asserted that this accident "had definitely been a suicidal and homicidal attempt upon himself and the man who had given him the finger." He reported a history of treatment for marijuana, cocaine and alcohol use, and being "heavily into drugs and alcohol" during service, with substance abuse treatment at VA in 1989. The Axis I diagnoses were major depression, and PTSD. A report from Comprehensive Assessments, Inc., received in September 1998, notes complaints that included depression, intrusive thoughts of a 1988 motor vehicle accident, nightmares, angry rumination over perceived abuse by the postal service "for taking his money and his retirement and his benefits," daily marijuana abuse, and daily alcohol abuse. The Veteran reported that he was functioning adequately until "he was involved in an 18-wheeler accident, where the truck flipped and squashed his head against a railroad track." Since that time, he had suffered from PTSD symptoms and chronic post-traumatic cephalgia. He had a period of "severe substance abuse with all sorts of drugs," but stopped all of them except marijuana and alcohol in 1992. It was noted that he was not currently under medical or psychiatric care. A July 1990 report was noted to include a diagnosis of major depressive disorder, PTSD, and post-traumatic cephalgia. On examination, there were hallucinations that could be delusional thinking, and suggestions of paranoid ideation. The Axis I diagnoses included alcohol dependence, cannabis dependence, residual PTSD, and dysthymic disorder. The Axis II diagnosis was probable paranoid features. An October 1998 report shows that the Veteran reported being in a motor vehicle accident in 1988 in which he blacked out and the truck turned over, and he sustained a concussion. On examination, his mental status appeared normal. VA progress notes show that beginning in 2006, the Veteran was noted to have a history of smoking marijuana for the past 40 years, and drinking a six pack of beer a day for the past 13 years. The final impressions included history of substance abuse, and history of a concussion. Beginning in 2008, he was noted to have alcohol dependence, cannabis dependence, rule out intermittent explosive disorder, and "antisocial personality disorder vs. personality NOS," with notations that a personality disorder was his "probable principal diagnosis." Other diagnoses included mood disorder, with a notation of rule out secondary to sleep disorder, intermittent explosive disorder, anxiety disorder NOS, depressive disorder, history of affective disorder, personality disorder NOS, panic disorder, nicotine abuse, alcohol dependence, and cannabis dependence. A March 2008 VA PTSD examination report shows that the Veteran complained that he was having a lot of problems. He reported that he was physically threatened by his drill instructor, and that when he did not back down, he had to repeat his last six weeks under a new drill instructor who called him a "loser," which further inflamed his anger. After that, the Veteran became more aggressive toward everybody and he started drinking, "drugging," and getting into fights. This resulted in two incarcerations. He officially got an early discharge under honorable conditions because of repetitive sexual infections. He reported that he "had to shoot a couple of people"; he later indicated that he missed the second man. It was noted that he had not worked for 15 years due to problems with his lungs and back. He drinks a case of beer and two pints of cognac a week, and he smokes marijuana four times a week. The Axis I diagnoses were panic disorder, intermittent explosive disorder, depressive disorder NOS (not otherwise specified), alcohol dependence, and cannabis dependence. The Axis II diagnosis was personality disorder NOS with paranoid, negativistic, and borderline traits. The examiner concluded that it is as likely as not that the Veteran's exposure to punitive military training exacerbated his pre-existing problems with panic and aggression. A February 2021 VA PTSD DBQ shows that the Veteran reported that his drill sergeant had it in for him in basic training. He stated that this sergeant came up to him in the mess hall and slapped him. The Veteran did not report any feelings of fear, helplessness, or horror, and was disciplined for threatening to retaliate. The diagnoses were unspecified personality disorder, moderate alcohol use disorder, moderate cannabis use disorder, and insomnia disorder. The examiner concluded that it is less likely than not that the Veteran has an acquired psychiatric disability that was incurred in, or caused by, his service. The examiner explained that the results of the Veteran's current examination are consistent with prior rulings that his symptoms are largely due to an unspecified personality disorder, with significant antisocial traits, compounded by substance use. This pattern of impulsive behavior, emotional reactivity, and poor judgment was clearly established prior to military service and continued after the Veteran's discharge. There is no nexus between mental health symptoms or evidence that military service exacerbated symptoms. Rather, the Veteran's history reflects a common pattern of behavior problems beginning in childhood/adolescence and persisting into adulthood. As is common with most personality disorders, the severity of behavior problems has decreased as the Veteran has grown older. A VA medical opinion, dated in June 2021, shows that the examiner indicated that it is less likely than not that the Veteran has an acquired psychiatric disorder that was incurred in, or caused by, his service. The examiner summarized the relevant medical evidence, and noted that with regard to the positive opinion in the 2008 VA examination report, the Veteran's diagnostics are more likely consistent with an unspecified personality disorder, alcohol use disorder, cannabis use disorder, and insomnia. Regarding the alcohol use disorder, the February 2021 VA DBQ indicated that the onset of the Veteran's use of alcohol was within the service. However, a July 1990 evaluation indicated, "Regarding the alcohol use, he states this started in his mid-teens and has decreased since he was in the drug and alcohol program for 21 days last August and September." This supports the use of alcohol pre-service versus an onset during service. The alcohol use disorder was less likely than not caused by service. With regard to the Veteran's cannabis use disorder, this has also been noted to have an onset while in service in a July 1990 report. However, a 1998 report noted that the Veteran used cannabis to cope with pain related to his 1998 motor vehicle accident (when read in context this is presumably a typographical error and should read "1988"). Reports dated in 2006 note a 40-year history of use of cannabis, and that cannabis was used to elicit sleep and help with relaxation. Thus, per three evaluations, the cannabis use began within service. Giving benefit to the Veteran, the cannabis use disorder, at least as likely as not, began within service. With regard to insomnia, the onset is unknown, however, sleep problems were clearly noted during his examination in 2008, although a diagnosis of insomnia was not provided. Other records, dated between 2011 and 2014, also noted sleep problems, but did not include a diagnosis of insomnia. The examiner concluded, "Given the lack of evidence, the insomnia was, less likely than not, due to or caused by service." In addition, with regard to the possibility of service connection for insomnia on a secondary basis, the Veteran's September 2018 VA prostate cancer examination noted increased anxiety related to rising PSAs (prostate-specific antigens). However, other records do not support insomnia elicited by, or aggravated by, the Veteran's service-connected prostate cancer/residuals. The examiner explained that it is not unreasonable to have insomnia secondary to prostate cancer/residuals, however, the evidence within the records does not support this relationship. Given the lack of evidence, the insomnia was less likely than not aggravated by the prostate cancer/residuals. As an initial matter, the Board finds that the evidence is insufficient to show that the Veteran has PTSD. There is evidence of PTSD that is dated many years ago. See e.g., 1998 report. However, the Veteran has repeatedly been afforded diagnoses other than PTSD since that time. The February 2021 VA PTSD DBQ shows that the Veteran was determined not to have met the criterion "A" through "I" for PTSD. The examiner's conclusion is considered highly probative, as it is the most current and comprehensive opinion of record, it is shown to have been based on a current examination and a full review of the Veteran's claims file, and it includes an analysis of all of the criteria for PTSD. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Accordingly, PTSD is not shown. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). With regard to an acquired psychiatric disorder other than PTSD, the Board first notes that notwithstanding the June 2021 VA examiner's conclusion that the Veteran's cannabis use disorder at least as likely as not began within service, service connection may not be granted for cannabis abuse on a direct basis. 38 U.S.C. §§ 101(16) and 105(a); VAOPGCPREC 7-99. The Board parenthetically notes that service connection may also not be granted for a personality disorder, alcohol abuse, or for claims for service connection for disability based on a veteran's addiction to nicotine. Id.; see also 38 U.S.C. § 1103; 38 C.F.R. § 3.300 and § 3.303(c). The Veteran is shown to have multiple disciplinary problems during service. He was found to have a personality disorder. He is not shown to have been diagnosed with an acquired psychiatric disorder. Upon separation from service, his psychiatric condition was clinically evaluated as normal. Accordingly, a chronic condition is not shown during service. See 38 C.F.R. § 3.303. Following separation from service, the earliest evidence of relevant treatment is treatment for alcohol and substance abuse in 1989. This is about 18 years after separation from service, and as previously stated service connection may not be granted for alcohol or drug abuse on a direct basis. The claims file includes one opinion in favor of the claim, dated in March 2008. However, there are three competent opinions against the claim, dated in July 1990, February 2021, and June 2021. In particular, the June 2021 opinion is afforded great probative value, as it is the most recent and comprehensive opinion of record, it is shown to have been based on a review of the Veteran's claims file, and it accompanied by a sufficient explanation and supported by clinical findings. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Neives-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The June 2021 examiner clearly reviewed the March 2008 opinion and found it unpersuasive. With regard to the possibility of service connection for insomnia on a secondary basis, which the RO appears to have incorporated into the claim for an acquired psychiatric disorder, there is no favorable opinion of record in support of such a claim. The only competent opinion is the June 2021 opinion, and this opinion weighs against the claim. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the claim is denied. 2. Pulmonary disability. The Veteran's separation examination report, dated in December 1969, shows that his chest and lungs were clinically evaluated as normal. A chest X-ray was noted to show scarring of the right costophrenic angle. A report from Comprehensive Assessments, Inc., received in September 1998, notes that the Veteran smokes two packs of cigarettes a day. He reported a history that included "black lung problems," and that a doctor had told him that this was due to his heavy smoking. An October 1998 report notes that the Veteran reported that he had been told that he has black spots on his lungs. He reported smoking a pack and a half of cigarettes a day. On examination, auscultation of the anterior, lateral, and posterior lung fields demonstrated no rales or wheezes. The Veteran had good breath sounds throughout. A chest X-ray did not show infiltrate. The examiner stated, "I see no clear demonstration of medical disability on this patient." Private treatment reports show that in 2006, the Veteran was treated for complaints of cough. VA progress notes show that beginning in 2006, the Veteran was noted to have a history of smoking a half a pack of cigarettes a day for the past 20 years, and smoking marijuana for the past 40 years. The final impressions included history of nicotine abuse. There is an April 2006 notation that the Veteran had been smoking one pack of cigarettes a day up until a week ago. In 2011, he was noted to be smoking one pack of cigarettes a day. In February 2017, he reported an employment history that included work in construction with rare dust exposures for one year, and exposure to tar fumes laying roofs for 10 years. He was treated for evaluation of hemoptysis, which occurred several before during a URI (upper respiratory infection) at which time he also experienced epistaxis. His symptoms were noted to have resolved. A VA respiratory DBQ, dated in March 2021, notes that a current X-ray showed a nodule at the base of the left lung. A pulmonary function test had been completed, but the results could not be assumed to be accurate as the report lacked indicia of repeatable results. The Veteran's history was noted to include a 1989 chest CT (computerized tomography) scan that showed multiple small axillary nodes without clinical significance. There was no pulmonary nodule identified. There is minimal focal pleural thickening seen in the lateral posterior aspect of the right lung base. A small focal density adjacent to the left diaphragmatic crews suggested normal variation. The examiner concluded that it is less likely than not that the Veteran has a lung disability that was incurred in, or caused by, his service. With regard to the possibility of service connection on a direct basis, the examiner explained that the Veteran's dates of service were between February 1967 and January 1970. He did not have any issues with the lungs while in service. The lung spots seen on a September 1989 CT scan were axillary nodes, unrelated to the chest, and there was pleural thickening seen in the right lung base which is consistent with smoking. This Veteran has a longstanding 20-year history of smoking cigarettes as well as smoking marijuana. An October 1998 chest X-ray was negative for any infiltrate process in the parenchyma. A March 2021 chest X-ray showed a nodule in the base of the left lung. Regardless, there were not any "lung spots" noted during his time on active duty. The Veteran is not shown to have been treated for pulmonary or respiratory symptoms during service. Upon separation from service, a chest X-ray was noted to show scarring of the right costophrenic angle. However, his chest and lungs were clinically evaluated as normal, and there was no evidence that scarring was associated with a disease process. Accordingly, a chronic condition is not shown during service. See 38 C.F.R. § 3.303. Following separation from service, there is no medical evidence of a pulmonary disability until 1989. This is about 18 years after separation from service. There is no competent opinion of record in favor of the claim. The only competent opinion of record is the March 2021 VA opinion, and this opinion weighs against the claim. Accordingly, the claim is denied on a direct basis. 3. Back disability. The Veteran's service treatment records show that in December 1967, he was treated for low back pain. There was a notation of acute low back strain. The next day he was noted to have improved somewhat. The Veteran's separation examination report, dated in December 1969, shows that his spine was clinically evaluated as normal. As for the post-service medical evidence, a July 1990 psychiatric evaluation from the Evaluation Medical Clinic shows that the Veteran reported having back pain, and a history of a back injury during service. The Axis III diagnoses included strain of lumbosacral spine. Private treatment reports, dated between 1997 and 2007, note multiple treatments for complaints of back pain. See e.g., report from Comprehensive Assessments, Inc., received in September 1998. Of particular note, an October 1998 report notes treatment for back pain in June 1997, and that the Veteran is on disability because of his back. He reported being in a motor vehicle accidence in 1988 in which he blacked out and the truck turned over. On examination, the bony skeleton appeared to be within normal limits. The examiner stated, "I see no clear demonstration of medical disability on this patient." VA progress notes show that beginning in 2006, the Veteran was noted to have chronic back pain, with low back pain "since the late 1980s." The final impressions included chronic back pain. In 2007, the Veteran reported a six-to-seven-year history of low back pain of unknown etiology. He was noted to have spinal stenosis. A magnetic resonance imaging study (MRI) notes multilevel disc bulges. A VA spine examination report, dated in April 2011, shows that the Veteran reported an onset of back pain during service, in 1968, after running and marching. An X-ray was noted to show probable mild compression fractures at T8 and T9, and mild DJD (degenerative joint disease) of the mid to lower thoracic spine. The diagnosis was multilevel lumbar spondylosis of the lumbar spine, and probable mild compression fractures of T8 and T9, and mild DJD of the mid to lower thoracic spine. The examiner concluded that the Veteran's back condition was not caused by, or a result of, service. The examiner explained that the Veteran had a low back strain in December 1967. The low back strain was transient and temporary. He had a negative back examination in June 1968. In August 1968, he reported a history of muscle spasms, but he was not given any other treatment before his discharge in January 1970. The Veteran has not submitted any medical records dated prior to 2006, at which time he complained of chronic low back pain. After his discharge from the military, the Veteran has never sought any medical treatment for a low back condition for over two decades. Therefore, the examiner concluded that the Veteran's low back condition was not caused by, or a result of, his service. A VA back DBQ, dated in March 2021, shows that the Veteran's history was noted to include complaints of back pain as early as 1997. Thereafter, there were complaints of back pain in March 2006, with a finding of spondylosis of the lumbar spine, that were due to a truck accident in 1998. The findings in the April 2011 VA spine examination report were summarized. The relevant diagnoses were lumbar strain, thoracic strain, and lumbar spondylosis, with dates of diagnoses of 2011 or later. The examiner concluded that it is less likely than not that the Veteran has a back disability that was incurred in, or caused by, his service. The examiner explained: After my review of the Veteran's history, physical exam, and medical records, it is in my professional medical opinion that the lower back condition is less likely than not incurred in service. His dates of service were between February 1967 and January 1970. Service treatment records show low back strain in 1967. There is no evidence in the medical records to show chronicity of the disease. The examiner could not locate any other mention of back pain until 1997 and 1998, following an MVA. The Veteran was treated for back symptoms during service in December 1967, with no record of subsequent treatment during his remaining period of active-duty service, a period of about two years. Upon separation from service, his spine was clinically evaluated as normal. Accordingly, a chronic condition is not shown during service. See 38 C.F.R. § 3.303. There is no competent evidence to show that arthritis of the back that was manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307, 3.309. Following separation from service, there were complaints of back pain in 1990, with no medical evidence of a back disability until 1997. This is about 16 years after separation from service. There is no competent opinion of record in favor of the claim. The only competent opinion of record are the April 2011 and March 2021 VA opinions, and these opinions weigh against the claim. Accordingly, the claim is denied on a direct basis. 4. Stomach disability. The Veteran's service treatment records show treatment for stomach pain in September 1967. There was no diagnosis. The Veteran's separation examination report, dated in December 1969, shows that his abdomen was clinically evaluated as normal. As for the post-service medical evidence, VA progress notes show that beginning in 2006, the Veteran reported symptoms that included an upset stomach. In 2017, he was taking medication for stomach symptoms. A VA stomach DBQ, dated in March 2021, shows that the Veteran stated that he doesn't know when his condition started, but that he was having a lot of cramping, bloating, gas, constipation and diarrhea, and pain in bowel movements. He said that he thinks he was given medication, but he did not know the name of it. The Veteran stated that he does not have any current symptoms and that he has not had any current treatment. The DBQ notes that the Veteran was treated for stomach pain in September 1967. In 1998, he was treated for indigestion and gas, chronic reoccurring diarrhea, pain in his rectum with his bowel movements, and black and tarry bowel movements. He was referred to a physician. The diagnosis was stomach pain of unknown etiology, resolved, with a date of 1967. The examiner concluded that the Veteran's stomach condition is less likely than not incurred in service. The examiner explained that the Veteran denies any current stomach condition and that it can be considered resolved. In addition, the Veteran's service treatment records showed no evidence of any stomach condition during service, nor is there mention of a stomach condition in the Veteran's claims file other than an acute, apparently viral, illness while on active duty. A VA stomach and duodenal conditions DBQ, dated in May 2021, notes that the Veteran does not have incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. The examiner stated that there is no objective evidence to support a diagnosis for the claim of stomach disorder at this time. The Veteran was treated for stomach symptoms on one occasion during service, in September 1967, with no subsequent evidence of treatment during his remaining period of active duty, a period of over two years. Upon separation from service, his abdomen was clinically evaluated as normal. Accordingly, a chronic condition is not shown during service. See 38 C.F.R. § 3.303. Following separation from service, a stomach disability is not shown. The March 2021 and May 2021 VA opinions both show that it was concluded that the Veteran does not currently have a stomach disability. Accordingly, the claim is denied. Gilpin. 5. Recurrent pain disorder, to include fibromyalgia. The Veteran's service treatment records, to include his separation examination report, dated in December 1969, do not show any treatment, findings, or diagnoses involving a pain disorder or fibromyalgia. As for the post-service medical evidence, a VA DBQ, dated in March 2021, shows that the examiner stated that fibromyalgia is mentioned only in VA administrative documents and not addressed as a principal diagnosis in examination reports or clinic notes. The Veteran was noted not to be taking continuous medication for control of fibromyalgia symptoms, or to currently be undergoing treatment for fibromyalgia. The examiner stated that he could not find an official diagnosis. The Veteran does not currently have any findings, signs, or symptoms attributable to fibromyalgia. The Veteran does have chronic back and knee pain, but the examiner does not believe that he meets criteria for a fibromyalgia diagnosis. The examiner concluded, "For the claimant's claimed condition of fibromyalgia there is no diagnosis because I could not find an official diagnosis of this. He does have chronic back and knee pain, but I don't believe he meets criteria for a fibromyalgia diagnosis." An addendum opinion, dated in May 2021, notes that a diagnosis of fibromyalgia is not supported by the records in the Veteran's claims file. The Veteran has minimal medical documentation of subjective complaints of headaches and chronic back pain. There are no objective findings (exam findings or diagnostic studies) to support these subjective pain complaints. It is also not clear on what dates these pain conditions started. The extensive CLCW epidemiologic studies did not find an association with headaches, chronic back pain, or any pain disorder. Furthermore, the contaminants found in the CLCW have not been associated with any pain disorder in the medical literature. A VA medical opinion, dated in June 2021, shows that the examiner indicated that it is less likely than not that the Veteran has a pain disorder that was incurred in, or caused by, his service. The examiner explained that a review of the Veteran's clinical treatment records has not shown a condition or pathology that is related to a recurrent pain condition. The Veteran's service treatment records do not support a clinical history of a recurrent pain condition. There are no specific symptoms that would support a clinical history of a recurrent pain condition. The Veteran's medical records shows specific complaints of back pain and foot pain that are specifically related to a lumbar spine pathology and foot condition. The Veteran's medical treatment records show no further clinical history of symptoms, or complaints, indicating a recurrent pain condition that was incurred during the Veteran's time in service. The Veteran's service treatment records do not show any treatment, findings, or diagnoses involving a pain disorder or fibromyalgia. A pain disorder, or fibromyalgia, was not noted upon separation from service. Accordingly, a chronic condition is not shown during service. See 38 C.F.R. § 3.303. Following separation from service, a pain disorder, to include fibromyalgia, is not shown. The March 2021, May 2021, and June 2021 VA opinions all show that it was concluded that the Veteran does not currently have a pain disorder or fibromyalgia. Accordingly, the claim is denied. Gilpin. 6. Bilateral knee disabilities. The Veteran's service treatment records include a separation examination report, dated in December 1969, which shows that his lower extremities were clinically evaluated as normal. As for the post-service medical evidence, an October 1998 report notes that the Veteran reported that he has joint pain and swelling "basically of a generalized nature." He also reported numbness and shooting pains in his arms and legs. On examination, the bony skeleton appeared to be within normal limits. The examiner stated, "I see no clear demonstration of medical disability on this patient." Private treatment reports show that in 2006, the Veteran was treated for a two-to-three-day history of right knee symptoms. VA progress notes, dated in December 2010, show complaints of a four-to-five-day history of left knee swelling and pain. The impressions and assessments note knee pain, joint effusion, tripartite patella, and degenerative joint space narrowing. Beginning in 2011, the Veteran received treatment for knee pain, with bilateral knee injections. He was noted to report left knee pain for three days, for "several years," and for two years. He was noted to have left knee osteoarthritis based on an MRI. Another notation appears to indicate bilateral knee DJD based on X-rays. In March 2021, VA medical opinions were obtained. For the left knee, the Veteran's history was noted to include evidence as of 2010 or later of arthritis and a tear in the medial meniscus, chondromalacia patella, and knee injections. For the right knee, the Veteran's history was noted to include complaints of swelling in 1998, with injections in 2012, with a normal X-ray. The examiner concluded that it is less likely than not that the Veteran has a right knee disability, or a left knee disability, that was incurred in, or caused by, his service. For the right knee, the examiner explained: After my review of the Veteran's history, physical exam, and medical records, it is in my professional medical opinion that the right knee condition is less likely than not incurred in service. His dates of service were between February 1967 and January 1970. In September 1998, the Veteran reported right knee swelling. In February 2012, he had hyaluronate injection in the right knee. An April 2012 X-ray of the right knee was normal. There is no evidence in the service treatment records regarding the left (when read in context this is presumably a typographical error, should be "right") knee during his time on active duty. For the left knee, the examiner explained: After my review of the Veteran's history, physical exam, and medical records, it is in my professional medical opinion that the left knee condition is less likely than not incurred in service. His dates of service were between February 1967 and January 1970. In December 2010, he kneeled on the floor putting pressure on the knee which caused left knee pain and swelling. He was seen again for left knee pain on three occasions in 2011. X-rays revealed left knee joint effusion, tripartite patella, and degenerative joint space. A May 2012 MRI showed osteoarthritis (OA) in the medial tibial femoral compartment, chondromalacia patella, and suspected tear of medial meniscus. He received Supartz injections in 2012 and repeated the series in 2013 and 2014. There is no evidence in service treatment records regarding the left knee during his time on active duty. The Veteran was not treated for knee symptoms during service. Upon separation from service, his lower extremities were clinically evaluated as normal. Accordingly, a chronic condition is not shown during service. See 38 C.F.R. § 3.303. There is no competent evidence to show that arthritis of either the right knee or the left knee was manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307, 3.309. Following separation from service, there is no medical evidence of a knee disability until 2006. This is about 35 years after separation from service. There is no competent opinion of record in favor of the claim. The only competent opinions of record are the March 2021 VA opinions, and these opinions weigh against the claims. Accordingly, the claims are denied on a direct and presumptive basis. 7. Dental disability, to include mouth sores. The Board first notes that there are notations in VA progress notes indicating that the Veteran has been found to be eligible for Class IV dental treatment. See 38 U.S.C. § 1712; 38 C.F.R. § 17.161. Dental disabilities which may be awarded compensable disability ratings are now set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Rating activity should consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in line of duty during active service and, when applicable, to determine whether the condition is due to combat or other in-service trauma, or whether the veteran was interned as a prisoner of war. 38 C.F.R. § 3.381 (b). For loss of the teeth, bone loss through trauma or disease, such as osteomyelitis, must be shown for compensable purposes. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See 38 C.F.R. § 4.150, Diagnostic Code 9913. In addition, to be compensable, the lost masticatory surface for any tooth cannot be restorable by suitable prosthesis. Id. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease (pyorrhea) are not disabling conditions. See 38 C.F.R. § 3.381. The Veteran's service treatment records show several restorative treatments in 1967. The Veteran's separation examination report, dated in December 1969, shows that his mouth was clinically evaluated as normal. The dental portion of the report notes that teeth #16, #19, and #31 were missing, and that teeth #1, #2, #12, #13, #14, #15, #17, #21, #26, #29, and #32 were restorable. As for the post-service medical evidence, an October 1998 report notes that the Veteran reported that he has gum or dental problems. On examination, he had a few missing teeth, and occasional caries. Private treatment reports show that between 2004 and 2006, the Veteran was treated for dental abscesses, and an abscess in his mouth. VA progress notes show that beginning in 2006, the Veteran was noted to have periodontitis "diagnosed since 2005." In 2010, the Veteran was treated for pain in his teeth and gum swelling, with a finding of caries and gingivitis. Beginning in 2011, he was noted to have painful white sores in his mouth. Thereafter, he received dental care on a number of occasions, to include prophylactic care, with multiple findings of a negative oral cancer screen. Beginning in 2013, he was noted to have an unspecified disorder of the teeth and supporting structures. In 2017, he was provided with partial dentures. The diagnosis was "partially edentulous." In 2018, he was afforded restorative care on his teeth. He was noted to have 24 missing teeth. He stated that he disliked his partial dentures, and that he wants bridges. A VA oral and dental DBQ, dated in March 2021, indicates that the Veteran reported a history of an oral or dental condition beginning in 1970. On examination, there was no anatomical loss or bony injury to the mandible, maxilla, teeth (to include anatomical loss or injury leading to loss of any teeth), mouth, osteomyelitis, osteoradionecrosis, osteonecrosis, tumors, neoplasms, or other dental or oral conditions. A December 2020 X-ray showed dental restorations. The examiner indicated that it is less likely than not that the Veteran has an oral or dental condition that was incurred in, or caused by, his service. The Veteran's rotting teeth and decaying teeth are a result of poor hygiene and self-care. When those things are longstanding they will lead to tooth and gum pain, and tooth loss. Mouth sores are caused by poor hygiene, gum irritation, and stress to the oral flora leading to mouth discomfort and sores. Removing the offending and decaying teeth resolved the Veteran's condition. In addition, that there is no evidence that any chronic condition currently exists. For the Veteran's claimed condition of mouth sores there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. For the Veteran's claimed condition of rotting teeth, there is no diagnosis because the client has had extensive dental treatment completed and he is in a healthy state. The Board finds that the claim must be denied. With regard to the claim based on mouth sores, these are not shown during service, or until 1989. This is about 18 years after separation from service. There is no competent opinion of record in favor of the claim. The only competent opinion is the March 2021 VA opinion, and this opinion weighs against the claim. Accordingly, service connection for mouth sores is not warranted. With regard to the claim for a dental disability, the Veteran is not shown to have been a prisoner of war. Although the Veteran underwent restorative dental treatment during service, this does not qualify as dental trauma under VA regulations. The evidence does not show that the Veteran sustained compensable "dental trauma" in service. There is no evidence to show that the Veteran has one of the dental disorders listed under 38 C.F.R. § 4.150, and there is therefore no basis for an award of compensation based on the Veteran's claim. As the Veteran does not have a compensable dental disorder, there is no basis for an award of compensation. Accordingly, the claims for mouth sores and a dental disability must be denied. 8. Camp Lejeune Contaminated Water claims. The Veteran asserts that service connection for chronic pain, to include fibromyalgia, a pulmonary disability, a stomach disorder, mouth sores, and a dental disability ("rotting teeth"), is warranted as the claimed disabilities were incurred as the result of his exposure to contaminated drinking water while stationed at Camp Lejeune, North Carolina. The Veteran served with the Marine Corps and was stationed at Camp Lejeune, North Carolina, from November 1968 to November 1969. The Veteran is therefore shown to have had at least 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953 and ending on December 31, 1987. In June 2020, a VA examiner was requested to provide an opinion as to the Veteran's claims for service connection for fibromyalgia, a stomach condition, lung spots, rotting teeth, and mouth sores, based on exposure to CLCW. The examiner noted that the Veteran's service treatment records showed no evidence of rotting teeth or mouth sores. There is no mention of rotting teeth in the Veteran's claims file, other than in documents addressing the Veteran's claim. Diagnoses involving rotting teeth and mouth sores are not documented at all in their medical records. The examiner indicated that it is less likely than not that the Veteran has mouths sores, or a dental disability, that was/were incurred in, or caused by, his service. The examiner further noted that the Veteran's service treatment records showed no evidence of a stomach condition during service. Nor is there mention of a stomach condition in the Veteran's claims file other than documents addressing the Veteran's claim. The examiner indicated that it is less likely than not that the Veteran has a stomach condition that was incurred in, or caused by, his service. With regard to the claim for a pulmonary disability, "lung spots" were seen on CT scan in 1989, which was 21 years after the CLCW exposure. These are better identified as a pleural thickening and are associated with cigarette smoking. For all four CLCW claims, the examiner explained that per literature review, the extensive epidemiologic studies did not find an association with any of the claimed conditions and CLCW exposures. The Veteran's service treatment records were available and show no record of any of the claimed conditions while at Camp Lejeune. The examiner discussed studies related to CLCW, and stated that NIOSH (National Institute for Occupational Safety and Health) recognizes occupational exposure to PCE for more than five years as an occupational hazard. The exposure would be expected to be more concentrated and at higher doses in occupational settings in dry cleaners and other industries. Thus, the preponderance of the exposure evidence indicates that the contribution of the relatively low potential exposures at Camp Lejeune were not as significant as the multiple other risk factors, most importantly cigarette smoking, and advancing age. The examiner noted that the Veteran had a total of about 428 days of exposure to contaminated water at Camp Lejeune, with diagnoses for the claimed conditions made dozens of years after the exposure, "which makes it an unlikely cause." The examiner concluded, "As such, I opine that the Veteran's diagnoses discussed in detail above, are less likely than not caused by or the result of the Veteran's exposure to contaminated water at Camp Lejeune during military service." (Continued on the next page) The Veteran is not currently shown to have a recurrent pain disorder, to include fibromyalgia, or a stomach disorder, Gilpin, and none of the demonstrated conditions are specifically recognized by VA as residuals of contaminated water at Camp Lejeune pursuant to 38 U.S.C. § 1710 and 38 C.F.R. § 17.400. There is no medical evidence or opinion of record to show that the Veteran has any of the claimed disabilities as a residual to exposure to contaminated water at Camp Lejeune. Combee. The only competent opinions of record as to the CLCW issues are the June 2020 VA opinions, all of which weigh against the claims. Accordingly, the claims must be denied on this basis. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S.E., 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.