Citation Nr: 21007210 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 17-53 496 DATE: February 9, 2021 ORDER Entitlement to service connection for a dental disorder is denied. Entitlement to service connection for an acquired psychiatric disorder is denied. FINDINGS OF FACT 1. The Veteran did not sustain dental trauma in service 2. A dental condition did not originate during active service. 3. A psychiatric disorder did not originate as a result of active service. CONCLUSIONS OF LAW 1. The criteria to establish service connection for a dental condition have not been met. 38 U.S.C. §§ 1712, 5107; 38 C.F.R. §§ 3.306, 3.381 (2020); VAOPGCPREC 5-97. 2. The criteria to establish service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from May 1987 to August 1987 and in the United States Air Force from November 2001 to June 2002. The Veteran also had additional periods of Reserve service. The Veteran’s appeal stems from her January 2015(dental) and May 2015 (psychiatric) service connection claims. While the RO initially denied service connection for dental and psychiatric disorders in a May 2015 rating decision, such decision was not mailed to the address then of record and was returned to sender. As noted in the Board’s 2019 remand, the Veteran was not properly notified of the May 2015 decision, and therefore it did not become final. See 38 C.F.R. § 20.1103. Accordingly, the Veteran’s initial service connection claims were not adjudicated until the July 2017 decision on appeal. As the May 2015 rating decision was not final, it is not subject to collateral attack on the basis of clear and unmistakable error. See 38 C.F.R. § 3.105(a)(1). Accordingly, the Veteran’s claims will be adjudicated as claims for service connection. Entitlement to service connection for a dental disorder The Veteran contends that her in-service dental conditions were not treated properly. The Veteran has specifically stated that she was told by a military dentist that her status as a reservist would prevent the service from treating her dental conditions appropriately. Service connection for treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, or periodontal disease will be considered solely for the purpose of establishing eligibility for outpatient dental treatment. 38 C.F.R. § 3.381 (a). Service connection for compensation purposes is not available for a dental condition other than for injuries sustained as a result of dental trauma. The rating activity will 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 the line of duty during active service. When applicable, the rating activity will 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 (a), (b). To establish entitlement to service connection for loss of a tooth, the Veteran must have sustained a combat wound or other in-service trauma. 38 U.S.C. § 1712; 38 C.F.R. § 3.381 (b). The significance of finding that a dental condition is due to in-service trauma is that a veteran will be eligible for VA outpatient dental treatment, without being subject to the usual restrictions of a timely application and one-time treatment. 38 C.F.R. § 17.161 (c) The Veteran received in-service treatment for dental conditions and experienced pain and other symptoms while in-service. However, there is no evidence that the Veteran experienced an in-service combat wound or other in-service trauma that caused her dental conditions. In the Veteran’s December 1985 Reserve enlistment examination, she checked a box indicating that she had severe tooth and gum trouble. At the Veteran’s July 1987 examination for service separation, she indicated that she was in good health and did not have severe tooth or gum trouble. A November 2001 dental examination revealed generalized oral neglect and after a consultation with a reservist dentist, administrative action was recommended. A November 2001 document indicates that the Veteran’s dental pathology was disqualifying and required treatment that would not be paid for by the Air Force. In a November 2001 pre-deployment health assessment, the Veteran indicated that she had dental problems but was still deemed deployable with a notation that she cleared dental on November 27, 2001. In a May 2002 post-deployment questionnaire, the Veteran checked boxes that she was in very good health and had no unresolved medical or dental problems that were developed during deployment. In September 2017, the Veteran’s brother submitted a lay statement. The Veteran’s brother noted that he witnessed the Veteran’s teeth break and fall out after she returned home from deployment. He also stated that the Veteran was unable to chew solid food due to sore and swollen gums as well as missing teeth. In an October 2017 lay statement, the Veteran reiterated that she was not treated properly for her dental conditions at Lackland Air Force Base. The Veteran stated that her dental conditions worsened which led to the need for more drastic treatments such as root canals. The Veteran also indicated that she should not have been deployed with her pre-existing dental condition. In a March 2020 lay statement, the Veteran’s daughter stated that she watched her mother’s teeth and mental health deteriorate significantly after she returned home from being deployed. The statement notes that the Veteran has spoken about her lack of adequate dental care at Lackland Air Force Base in San Antonio, Texas. The statement specifically indicates that the Veteran was told her teeth would not be cared for due to her status as a reservist. The Veteran’s daughter stated that her mother’s teeth continued to deteriorate after she returned from her deployment causing additional anxiety and depression. In February 2020, the Veteran was afforded a VA examination. The examiner noted that the Veteran had a diagnosis for caries (cavities/tooth decay) since November 2001. The examiner also noted a history of multiple dental appointments with multiple fillings and symptoms including sensitivity to hot and cold, chipping teeth, and needing teeth to be pulled. The examiner stated that the Veteran’s dental condition was not incurred or caused by an in-service injury, event, or illness. The examiner noted that the in-service treatment was for the purpose of alleviating pain and stabilizing her condition. The examiner also indicated that the Veteran left service before treatment could be completed and cited a February 2006 final dental note which stated that the Veteran’s insurance would take effect in March and the Veteran would see a “civ. dentist.” Finally, the examiner indicated that the Veteran’s dental issues likely arose between 1992 to 2001, while she was not on active duty. The Board considers the examiner’s opinion probative as it is predicated upon a thorough clinical examination and evidentiary review and is supported by a sufficiently detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examination report shows that the examiner reviewed and considered the Veteran’s lay statements concerning the onset of her dental condition because claims made by the Veteran are referenced in the report as part of the medical/dental history. The examination report further shows that the examiner reviewed the service treatment records and post-service records because these records are also referenced in the examination report. As noted above, service connection for compensation purposes is not available for a dental condition other than for injuries sustained as a result of dental trauma. The Veteran’s service records do not indicate a dental trauma experienced while on active duty service. The Veteran’s in-service dental treatment was for the purposes of alleviating pain and stabilizing her condition and does not amount to dental trauma. Therefore, service connection is not warranted, and the claim is denied. Entitlement to service connection for an acquired psychiatric disorder The Veteran contends that she has a psychiatric disorder resulting from a combination of factors, including: her ex-husband’s PTSD, her ongoing dental issues, an accident in which she was struck by a vehicle, and her own deployment. The Board finds that the Veteran does not have a current diagnosis of PTSD and that her diagnosed psychiatric disorder, persistent depressive disorder (dysthymia), is not related to service; therefore, service connection is not warranted. Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310 (a) where it is demonstrated that a service-connected disorder has caused a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection for PTSD requires medical evidence diagnosing the condition; 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. In a July 1987 separation examination, the Veteran checked boxes indicating that she did not experience depression or excessive worry or nervous trouble of any sort. Upon examination, the Veteran’s psychiatric condition was noted to be normal. In a 1994 treatment record, the Veteran noted a motor vehicle accident causing a lumbar strain. In a May 2002 post-deployment questionnaire, the Veteran checked boxes that she was in very good health and had no unresolved medical or dental problems that were developed during deployment. The Veteran also checked a box indicating that she did not seek or intended to seek counseling for her mental health during her deployment. In a February 2017 treatment note, the Veteran reported being run over by a car in August 2015. In a March 2017 mental health evaluation note, the Veteran reported being homeless after losing her job and being evicted from her apartment. The Veteran noted she was unable to work after she was struck by a car on her way to work. The clinician also noted mild depression. In a May 2017 statement, the Veteran indicated that her reserve unit was activated in 1990 but that she was not deployed because she was pregnant. She indicated that her husband was deployed and returned a changed man. The Veteran stated that the changes in her husband led to their divorce and she experienced stress and anxiety as a result of her husband’s PTSD. The Veteran also noted that she was lonely and stressed during her husband’s deployment. In a July 2017 memorandum, the Joint Services Records Research Center (JSRRC) stated that there was insufficient information to corroborate that the stressful events described by the Veteran and warrant additional research. In a September 2017 statement, the Veteran stated that she experienced years of stress as a result of her ex-husband’s PTSD. The Veteran indicated that this led to her own PTSD and depression. The Veteran reported that she would like her dental condition corrected to help her confidence and increase her ability to pursue a relationship and find happiness. In September 2017, the Veteran’s sister submitted a lay statement. The Veteran’s sister stated that she had witnessed her sister experience the effects of her ex-husband’s PTSD and also experienced PTSD of her own due to her experiences with the dental clinic at Lackland Air Force Base. In September 2017, the Veteran’s brother submitted a lay statement. The Veteran’s brother noted that he witnessed the Veteran’s teeth break and fall out after she returned home from deployment. He also stated that the Veteran was unable to chew solid food due to sore and swollen gums as well as missing teeth. In an October 2017 lay statement, the Veteran reiterated that she was not treated properly for her dental conditions at Lackland Air Force Base. The Veteran stated that her dental conditions worsened which led to the need for more drastic treatments such as root canals. The Veteran also indicated that her dental condition led to PTSD, stress, and anxiety. The Veteran also indicated that she should not have been deployed with her pre-existing dental condition. In a March 2020 lay statement, the Veteran’s daughter stated that she watched her mother’s teeth and mental health deteriorate significantly after she returned home from being deployed. The statement notes that the Veteran has spoken about her lack of adequate dental care at Lackland Air Force Base in San Antonio, Texas. The statement specifically indicates that the Veteran was told her teeth would not be cared for due to her status as a reservist. The Veteran’s daughter stated that her mother’s teeth continued to deteriorate after she returned from her deployment causing additional anxiety and depression. In February 2020, the Veteran was afforded a VA examination. The examiner noted that the Veteran did not have a diagnosis for PTSD but did have a diagnosis for persistent depressive disorder. The examiner noted that the Veteran received no mental health treatment during military service but reported having psychological distress during her military service. The Veteran reported experiencing a depressed mood approximately three days per week. The examiner noted that the Veteran’s condition was not incurred in or caused by the Veteran’s service. The examiner noted no history of inpatient psychiatric hospitalizations and no history of suicide attempts. The examiner also indicated that the Veteran’s accident from 2017 caused residual neck pain and difficulty sleeping. The examiner specifically noted that the Veteran reported that the last time she had two consecutive months of euthymic mood was “before my accident.” (Referring to the accident from 2017). The examiner noted that the Veteran had recently participated in group therapy sessions twice a week with the focus of her treatment being chronic pain from her 2017 accident. The examiner concluded that the Veteran’s depressed mood (dysthymia) is caused by chronic pain from her 2017 accident in which she was struck by a vehicle as a pedestrian. In an April 2020 addendum opinion, the examiner reiterated that the Veteran did not have a current diagnosis for PTSD but did have a diagnosis for persistent depressive disorder which began as a result of chronic pain the Veteran has experienced following her 2017 accident. It appears the examiner was referencing the August 2015 accident in which the Veteran was struck by a vehicle. This accident was reported by the Veteran in 2017. However, the Veteran also described a similar event as being more recent in a March 2017 mental health evaluation medical record. The Board considers the examiner’s opinions from February 2020 and April 2020 as probative because they are predicated upon a thorough clinical examination and evidentiary review and is supported by a sufficiently detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examination report shows that the examiner reviewed and considered the Veteran’s statements regarding the onset of her psychiatric symptoms because claims made by the Veteran are referenced in the report. The examination report further shows that the examiner reviewed the service treatment records and post-service records because these records are also referenced in the examination report. The Board has considered the Veteran’s assertions that her acquired psychiatric disorder is caused by her military service. The Veteran’s lay statements and the lay statements of others are competent to report symptoms that they experienced or observed. However, this issue of whether the Veteran’s current psychiatric disorder is related to an event in service or post-service events is complex question and the Veteran and lay witnesses are not competent to offer an opinion as to the etiology of this type of medical condition due to the medical complexity of the matter involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A preponderance of the evidence is against a finding that the Veteran’s acquired psychiatric condition originated during service. The Veteran was first seen for depression in March 2017, many years after service separation, and there is no competent medical evidence that the Veteran’s current depression began in or as a result of service. The Veteran does not have a diagnosis for PTSD, which is required to establish entitlement to service connection for that disorder. See Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). With regard to the diagnosed disorder of persistent depressive disorder (dysthymia), the examiner considered the Veteran’s current symptoms presentation and provided history, including the lay evidence of record, but found that her current persistent depressive disorder (dysthymia) is not related to her symptoms in service but a post-service events or circumstances. Therefore, service connection is not warranted, and the claim is denied. (Continued on the next page)   The Veteran has also stated that her dental condition has led to her depression. However, the Veteran’s dental condition is not service connected, thus secondary service connection is not warranted. TRACIE N. WESNER Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Wozniak, Associate 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.