Citation Nr: 21008059 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 17-13 170 DATE: February 11, 2021 REMANDED Entitlement to service connection for temporomandibular joint syndrome (TMJ)) is remanded. REASONS FOR REMAND This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board hearing. A hearing transcript is associated with the claims file. Entitlement to service connection for TMJ is remanded. The Veteran contends that he has TMJ due to or as a result of dental treatment received during his active service. See Hearing Transcript (September 2020). He testified that he began to have pain after the procedure that has continued since service. Id. Alternatively, he contends that his TMJ is secondary to his service-connected posttraumatic stress disorder (PTSD). Id. at a 4. See also, VA 21-4138 (June 2020). A January 2017 statement from the Veteran to VA reflects his report that, following in-service debridement (i.e. removal of subgingival and/or supragingival plaque and calculus), he developed the pain and lock jaw. The Veteran’s service treatment records (STRs) reflect no complaints or symptoms associated with TMJ or findings for TMJ. Also, STRs do not show any “oral surgery.” STRs show dental carries (decay) and treatment. An August 1992 STR reflects no findings for TMJ or report of jaw pain/symptoms when otherwise providing history of symptoms and problems. VA received an original application for benefits in September 2010 – but there was no report of TMJ. VATRs dated from 2010 to 2015 are negative for jaw joint complaints. STR dental records show canceled appointments following debridement. The first documented report for TMJ was on the Veteran’s May 2015 VA disability claim, more than two decades after his service. In support of his claim, the Veteran submitted buddy statements, a September 2014 statement from a chiropractor (noting that Veteran was seen in May 2014 for complaints of right sided jaw pain, assessed as TMJ, and that he was seen on subsequent visits for the same), and a favorable medical opinion. After review of the record, the Board finds that remand is necessary for the following reasons. First, the October 2020 private opinion is adequate to decide the claim. The opinion restates history provided by the Veteran that he had first had symptoms of pain in the TMJ with clicking and locking after “dental work that took three days and you were told it was for a cavity.” Then, the opinion stated conclusory that “You also have PTSD with exacerbates the bruxism at night and adds to the severity of the TMJ symptoms.” Based on this, the opinion concluded that TMJ “is more likely than not that caused by your military service and is worsened by your service connected PTSD.” The opinion is inadequate because (1) it opinion lacks a rationale supporting either favorable conclusion (direct or secondary service connection); (2) it does not reflect review of relevant records to include service dental records; (3) it does not discuss any specific in-service dental treatment received by the Veteran and how it caused the development of TMJ; (4) it does not explaining discuss any specific in-service dental treatment resulted in injury to the jaw and led to TMJ; (5) it does not provide any basis for the conclusion that service-connected PTSD aggravates TMJ. In summary, favorable medical opinion provided by the Veteran is conclusory at best and appears entirely predicated on the Veteran’s history linking his symptoms to dental treatment, without any meaningful discussion of the in-service procedure(s), the onset of symptoms, and progression, to include any explanation as to how debridement procedure(s) are “more likely than not” (as reported by the doctor) the cause of the Veteran’s TMJ. Further, there was no discussion of pre aggravation and post aggravation symptoms to support the conclusion of aggravation of TJM based on service-connected PTSD. It is noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25. Also, “[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). While the opinion is inadequate to decide the appeal, it is sufficient to trigger VA’s duty obtain a medical opinion on the question of secondary service connection. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159(c)(4)(i). Additionally, remand is necessary to obtain relevant outstanding treatment records reasonably identified in the claims file. See 38 U.S.C. § 5103(b). Here, the record does not include complete records of relevant private treatment by a clinicians J.S, (D.M.D., P.C.) and M.R. (D.C.). Also, the record does not contain all relevant VA record to include those of Plymouth Outreach Center. See Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). Therefore, as explained above, remand is necessary to ensure that VA has satisfied its duty to assist. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2018 to present, to include records of the Plymouth Outreach Center. 2. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for symptoms of TMJ since service discharge, to include for J. Sapia (Family and Cosmetic Dentistry) and M. Recupero (South Shore Integrated Health). Make two requests for the authorized records from all identified sources unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s TMJ is at least as likely as not (1) proximately due to service-connected PTSD), or (2) aggravated beyond its natural progression by service-connected PTSD disability. A negative medical opinion may not rely solely on the absence of medical literature or research supporting causation or aggravation without discussing specific facts pertaining to this Veteran. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. A. Macek, 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.