Citation Nr: 21010096 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 20-28 319A DATE: February 24, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for lateral collateral ligament sprain, right ankle is denied. Entitlement to an initial rating in excess of 10 percent for lateral collateral ligament sprain, left ankle is denied. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome with anterior tibial tendonitis, chondromalacia patella, Baker’s cyst, and osteoarthritis, right knee is denied. Entitlement to a separate initial rating of 10 percent rating for symptomatic removal of semilunar cartilage associated with patellofemoral pain syndrome with anterior tibial tendonitis, chondromalacia patella, Baker’s cyst, and osteoarthritis, right knee is granted. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome with strain and osteoarthritis, left knee is denied. Whether new and material evidence has been received to reopen a claim of service connection for entitlement to service connection for dental trauma with loss of tooth is granted. REMANDED Entitlement to service connection for dental trauma with loss of tooth is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s lateral collateral ligament sprain, right ankle has not been manifested by marked limitation of motion of the ankle. 2. Throughout the period on appeal, the Veteran’s lateral collateral ligament sprain, left ankle has not been manifested by marked limitation of motion of the ankle. 3. The evidence demonstrates that the Veteran’s patellofemoral pain syndrome with anterior tibial tendonitis, chondromalacia patella, Baker’s cyst, and osteoarthritis, right knee has been manifested at worst, by range of motion from 0 to 90 degrees, with pain on palpation, no instability on testing, no subluxation, no ankylosis, and symptoms attributed to the removal of semilunar cartilage. 4. The evidence demonstrates that the Veteran’s patellofemoral pain syndrome with strain and osteoarthritis, left knee, has been manifested at worst, by range of motion from 0 to 100 degrees, with pain on palpation, no meniscal condition, no instability on testing, no subluxation, and no ankylosis. 5. The claim for service connection for dental trauma with loss of tooth was previously denied in April 1996 rating decision, the Veteran did not appeal the decision; additional evidence has been submitted that relates to an unestablished fact necessary to substantiate the claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating of 10 percent disabling for lateral collateral ligament sprain, right ankle have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 5271. 2. The criteria for entitlement to an initial rating of 10 percent disabling for lateral collateral ligament sprain, left ankle have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 5271. 3. The criteria for entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome with anterior tibial tendonitis, chondromalacia patella, Baker’s cyst, and osteoarthritis, right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 4. The criteria for a separate initial rating of 10 percent disabling for symptomatic removal of semilunar cartilage associated with patellofemoral pain syndrome with anterior tibial tendonitis, chondromalacia patella, Baker’s cyst, and osteoarthritis, right knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 5259. 5. The criteria for entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome with strain and osteoarthritis, left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 6. New and material evidence has been submitted, and the claim of entitlement to service connection for service connection for dental trauma with loss of tooth is reopened. 38 U.S.C. §§ 1154(a), 5108, 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from January 1980 until July 1981 and from June 1984 until June 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from the August 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). With respect to the Veteran’s claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Increased Rating Legal Criteria Rating Disabilities in General Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran’s condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating Musculoskeletal Disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40 and 4.45, see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. Id. § 4.45. However, pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). 1. Entitlement to an initial rating in excess of 10 percent for lateral collateral ligament sprain, right ankle 2. Entitlement to an initial rating in excess of 10 percent for lateral collateral ligament sprain, left ankle The Veteran contends that he is entitled to initial ratings in excess of 10 percent disabling for his service-connected right ankle and left ankle disabilities, as his symptoms more nearly approximate the criteria for a higher rating. The Veteran’s bilateral ankle disabilities are currently rated as 10 percent disabling under Diagnostic Code 5271. Under Diagnostic Code 5271, a 10 percent rating is warranted where evidence shows a moderate limitation of motion, and a 20 percent rating is warranted where evidence shows a marked limitation of motion. 38 C.F.R. § 4.71a. The terms “moderate” and “marked” as used under Diagnostic Code 5271 are not defined in the Rating Schedule. Rather than applying a mechanical formula to determine when symptomatology is “moderate” or “marked,” the Board must evaluate all of the evidence to ensure an “equitable and just” decision. 38 C.F.R. § 4.6. To that extent, the Board notes that the normal range of motion for the ankle is as follows: dorsiflexion to 20 degrees and plantar flexion to 45 degrees. 38 C.F.R. § 4.71, Plate II. The Veteran filed a claim for service connection for his bilateral ankle disabilities in September 2017. The Veteran underwent a VA examination for his ankles in May 2018. The examination report measured the range of motion for the Veteran’s right ankle as 35 degrees of plantar flexion and 20 degrees of dorsiflexion. The range of motion for the Veteran’s left ankle measured as 35 degrees of plantar flexion and 15 degrees of dorsiflexion. Pain was noted on rest and with palpation to the medial aspect of both ankles, which was characterized as mild. The examination also revealed pain with weight bearing. For both ankles, there was no additional functional loss following repetitive testing, and the examiner noted the pain contributed to the Veteran’s functional loss. During the examination, the Veteran reported that after repeated use over time, his loss of range of motion was variable and dependent on how strenuously the joints were used. The examiner documented that there was no ankylosis of either the right or left ankle. No ankle instability or dislocation was found on testing. Further, upon examination, no deformity and no loss of bone or muscle strength was found. There was no report of flare ups. Additionally, the examination report noted the Veteran’s right and left ankles causing a functional impairment manifested by limitations in prolonged walking and standing. The Board finds that the weight of the evidence is against the finding that manifestations of the Veteran’s right ankle or left ankle disability is that of marked limitation of motion. The Board notes that while the Veteran’s bilateral ankles are noted with limitation in range of motion; the limitation in not of such severity to warrant an increased rating in excess of 10 percent. Indeed, the medical evidence indicates he maintains only slightly decreased plantar flexion and normal dorsiflexion of the right ankle. Similarly, the Veteran only has slightly decreased plantar flexion and dorsiflexion for the left ankle. While he is noted to have pain for both ankles, to include with prolonged standing and walking, such as been characterized as variable and not of such a severity to more closely approximate marked limitation of motion. Moreover, there is no evidence of instability of the joint, muscle impairment, or flare ups. In conclusion, while the Veteran’s contentions have been respectfully considered, a higher evaluation is not warranted based on the evidence of record. As discussed, the weight of the evidence is against the Veteran’s claims for increased disability ratings for both the right ankle and left ankle disabilities. Accordingly, the reasonable doubt doctrine is not for application and the claims must be denied. 3. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome with anterior tibial tendonitis, chondromalacia patella, Baker's cyst, and osteoarthritis, right knee The Veteran contends that he is entitled to an initial rating in excess of 10 percent disabling for his service-connected right knee disability, as his symptoms more nearly approximate the criteria for a higher rating. Degenerative or traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5024. Flexion and Limitation of the Lower Extremity Diagnostic Code 5260 provides a noncompensable rating when leg flexion is limited to 60 degrees or more. A 10 percent rating is warranted for leg flexion limited to 45 degrees. A 20 percent evaluation is for leg flexion limited to 30 degrees. A 30 percent evaluation is for leg flexion limited to 15 degrees. Diagnostic Code 5261 provides a noncompensable rating when extension is limited to 5 degrees or less. A 10 percent rating is warranted for leg extension limited to 10 degrees. A 20 percent evaluation is for leg extension limited to 15 degrees. A 30 percent evaluation is for leg extension limited to 20 degrees. A 40 percent evaluation is for leg extension limited to 30 degrees. A 50 percent evaluation is for leg extension limited to 45 degrees. In VAOPGCPREC 9 - 2004 (Sept. 17, 2004), it was held that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. As such, if the evidence of record reflects compensable loss of both flexion and extension of either leg, the Veteran would be entitled to the combined evaluation under Diagnostic Codes 5260 and 5261, per the combined ratings table in 38 C.F.R. § 4.25. Instability of the Knee Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code (Diagnostic Code 5257), without violating the prohibition on pyramiding. See VAOPGCPREC 23-97. Diagnostic Code 5257 is predicated on instability, rather than limitation of motion, therefore, an analysis under DeLuca does not apply. See Johnson v. Brown, 9 Vet. App. 7 (1996). Under Diagnostic Code 5257, for recurrent subluxation or lateral instability of the knee, a 10 percent evaluation is warranted for slight knee impairment. A 20 percent evaluation is warranted for moderate knee impairment. A 30 percent evaluation is warranted for severe knee impairment. Words such as “mild”, “slight”, “moderate”, “marked”, and “severe” are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Veteran filed a claim for service connection for his bilateral knee disabilities in September 2017. The Veteran underwent a May 2018 VA examination. He reported having constant knee pain, to include when going to bed and when driving. The Veteran reported flare ups, during which he has to stop what he is doing or slow down. He described his functional loss as pain that limits long standing, walking, driving, and taking stairs. The physical examination showed the following range of motion measurements for the right knee: flexion from 0 to 90 degrees and extension from 90 to 0 degrees. There was no additional functional loss following repetitive testing. The Veteran reported that after repeated use and flare ups, the loss of his range of motion depended on how strenuously he used the joint; at worst, he stated that he cannot move the joint at all due to pain but that there were other times were his range of motion loss was minimal. The examiner noted pain on palpation of the knee, characterized as mild. The examiner also reported that the Veteran’s functional impairment resulted in disturbance of locomotion, interference with sitting, interference with standing, and pain on movement. No ankylosis or instability was shown on examination. However, the examiner noted the Veteran’s right knee with a history of meniscal tear (semilunar cartilage condition) with frequent episodes of joint locking, joint pain, and joint effusion. Based on a review of the evidence, a rating in excess of 10 percent under DC 5260 is not warranted. A 10 percent rating is warranted for leg flexion limited to 45 degrees. The Veteran’s right leg flexion is limited at 90 degrees, at worst, due to pain. The Veteran is currently is receipt of 10 percent for limitation of motion (painful motion). As the Veteran’s right knee flexion is not limited to 30 degrees or less, a rating in excess of 10 percent is not warranted. Furthermore, a separate, compensable rating under DC 5261 is not applicable. A 10 percent rating is warranted for leg extension limited to 10 degrees. The Veteran’s right leg has shown not to be limited in extension. As such, the Veteran is not entitled to a compensable rating based on DC 5261. Additionally, a rating under DC 5256 is not for application because the evidence of record is against a finding of ankylosis. Ankylosis is “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland’s Illustrated Medical Dictionary (28TH Ed. 1994) at 86). The medical evidence reflects that the Veteran’s right knee, at worst, has range of motion from at least 0 to 90 degrees in regard to flexion, and the evidence is against a finding of ankylosis; thus, a rating under DC 5256 is not warranted. The Veteran would be entitled to a rating under DC 5257 if the evidence reflected that he had severe, moderate, or slight recurrent subluxation or lateral instability. Joint instability can be objectively diagnosed upon clinical examination. Thus, even if the Veteran sincerely believes that his knee experiences stability, instability itself, can be clinically tested for and diagnosed. Thus, the Board finds the objective testing reflecting no instability or subluxation probative in this instance. As such, a rating under this diagnostic code is not applicable. A rating under DC 5258 is not warranted because the evidence does not reflect dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. The Board finds, however, that a separate rating under DC 5259 is warranted, as the evidence reflect symptoms attributed to the removal of semilunar cartilage. As such the Board finds that a separate 10 percent rating is warranted, which is the maximum under this diagnostic code. A rating under DC 5262 is not warranted because the evidence does not reflect that the Veteran has malunion or nonunion of the tibia and fibula. A rating under DC 5263 is not warranted because the evidence does not show that he has acquired genu recurvatum. In reaching these determinations, the Board acknowledges the Veteran’s functional limitations on standing, walking, and the effect on his occupation due to the pain associated with his right knee disability, to include during flare-ups. However, pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). VA medical examinations note the Veteran’s right knee disability functional effect as decrease mobility. However, limited mobility/decrease range of motion is appropriately contemplated within the criteria. As such, the Board does not find that an increased rating is warranted for the Veteran’s noted functional loss in excess of the provided 10 percent already granted for painful and limited motion. In addition to the clinical findings, the Board has also considered the Veteran’s statements regarding his pain and weakness. However, the Board finds that the Veteran’s listed disability symptoms do not warrant any additional increased ratings at this time as his impairments are contemplated in the currently assigned ratings. In conclusion, based on the objective clinical evidence, to include the Veteran’s subjective complaints, the Board finds that an increased rating in excess of 10 percent disabling for patellofemoral pain syndrome with anterior tibial tendonitis, chondromalacia patella, Baker’s cyst, and osteoarthritis, right knee is denied and a that a separate 10 percent rating under DC 5259 is warranted. 4. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome with strain and osteoarthritis, left knee The Veteran contends that he is entitled to an initial rating in excess of 10 percent disabling for his service-connected left knee disability, as his symptoms more nearly approximate the criteria for a higher rating. The Veteran’s left knee disability is rated under Diagnostic Code 5003-5060, pertaining to arthritis and limitation of motion of the lower extremity. Thus, the diagnostic criteria under Diagnostic Codes 5003, and 5256-5263, as described above, will be considered. The Veteran underwent a May 2018 VA examination. He reported having constant knee pain, to include when going to bed and when driving. The Veteran reported flare ups, during which he has to stop what he is doing or slow down. He described his functional loss as pain that limits long standing, walking, driving, and taking stairs. The physical examination showed the following range of motion measurements: flexion from 0 to 100 degrees and extension from 100 to 0 degrees. There was no additional functional loss following repetitive testing. The Veteran reported that after repeated use and flare ups, the loss of his range of motion depended on how strenuously he used the joint; at worst, he stated that he cannot move the joint at all due to pain but that there were other times were his range of motion loss was minimal. The examiner also reported that the Veteran’s functional impairment resulted in disturbance of locomotion, interference with sitting, interference with standing, and pain on movement. No ankylosis or instability was shown on examination. Based on this evidence, a rating in excess of 10 percent under DC 5260 is not warranted. A 10 percent rating is warranted for leg flexion limited to 45 degrees. The Veteran’s left leg flexion is limited at 100 degrees, at worst, due to pain. The Veteran is currently is receipt of 10 percent for limitation of motion (painful motion). As the Veteran’s left knee flexion is not limited to 30 degrees or less, a rating in excess of 10 percent is not warranted. A separate, compensable rating under DC 5261 is also not applicable. A 10 percent rating is warranted for leg extension limited to 10 degrees. The Veteran’s left leg has shown not to be limited in extension. As such, the Veteran is not entitled to a compensable rating based on DC 5261. A rating under DC 5256 is not for application because the evidence of record is against a finding of ankylosis. The medical evidence reflects that the Veteran’s left knee, at worst, has range of motion from at least 0 to 100 degrees in regard to flexion, and the evidence is against a finding of ankylosis; thus, a rating under Diagnostic Code 5256 is not warranted. The Veteran would be entitled to a rating under Diagnostic Code 5257 if the evidence reflected that he had severe, moderate, or slight recurrent subluxation or lateral instability. Joint instability can be objectively diagnosed upon clinical examination. Thus, even if the Veteran sincerely believes that his knee experiences stability, instability itself, can be clinically tested for and diagnosed. Thus, the Board finds the objective testing reflecting no instability or subluxation probative in this instance. As such, a rating under this diagnostic code is not applicable. A rating under Diagnostic Code 5258 is not warranted because the evidence does not reflect dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. A rating under Diagnostic Code 5259 is not warranted because the evidence does not reflect symptoms in regard to the removal of semilunar cartilage. A rating under Diagnostic Code 5262 is not warranted because the evidence does not reflect that the Veteran has malunion or nonunion of the tibia and fibula. A rating under Diagnostic Code 5263 is not warranted because the evidence does not show that he has acquired genu recurvatum. The Board acknowledges the Veteran’s functional limitations on standing, walking, and the effect on his occupation due to the pain associated with his right knee disability, to include during flare-ups. However, pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). VA medical examinations note the Veteran’s left knee disability functional effect as decrease mobility. However, limited mobility/decrease range of motion is appropriately contemplated within the criteria. As such, the Board does not find that an increased rating is warranted for the Veteran’s noted functional loss in excess of the provided 10 percent already granted for painful and limited motion. In addition to the clinical findings, the Board has also considered the Veteran’s statements regarding his pain and weakness. However, the Board finds that the Veteran’s listed disability symptoms do not warrant any additional increased ratings at this time as his impairments are contemplated in the currently assigned ratings. In conclusion, based on the objective clinical evidence, to include the Veteran’s subjective complaints, the Board finds that an increased rating in excess of 10 percent disabling for patellofemoral pain syndrome with strain and osteoarthritis, left knee is denied. 5. Whether new and material evidence has been received to reopen a claim of service connection for entitlement to service connection for dental trauma with loss of tooth Legal Criteria New and material evidence In general, RO decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.200. An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The Board must consider the question of whether new and material evidence has been received because it goes to the Board’s jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Barnett, supra. Further analysis, beyond consideration of whether the evidence received is new and material is neither required nor permitted. Id. at 1384. See also Butler v. Brown, 9 Vet. App. 167, 171 (1996). “New” evidence is existing evidence not previously submitted to agency decision makers. “Material” evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, lay assertions of medical causation cannot serve as the predicate to reopen a claim under § 5108. See Moray v. Brown, 5 Vet. App. 211, 214 (1993). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends, and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. The VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the appellant in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999); but see 38 U.S.C. § 5103A (eliminating the concept of a well-grounded claim). Analysis The Veteran’s claim for entitlement to service connection was denied by the RO in April 1996. In denying the claim, the RO determined that the evidence did not show a disabling condition subject to service connection for compensation (versus for purposes of dental treatment only). The Veteran did not appeal the decision and it became final. The Veteran requested that his claim for entitlement to service connection be reopened and was subsequently denied in the August 2018 rating decision on appeal. The evidence received since the last final denial includes additional medical records and lay statements in regard to the claim of entitlement to service connection for dental trauma with loss of tooth, which includes evidence regarding the current nature of the claimed disability. The Board finds that some of the additional evidence raises a possibility of substantiating the claim for entitlement to service connection for dental trauma with loss of tooth. In this regard, the Board is mindful of the low threshold for reopening a previously denied claims. Shade, 24 Vet. App. at 110. The additional medical records and the Veteran’s supplemental statements were not within the claims folder at the time of the April 1996 denial. The new medical records and lay statements go to the basis of the Veteran’s claim for entitlement to service connection. Thus, the Board finds the additional medical records new and material. Accordingly, the Board concludes that evidence has been received which is new and material, and the claim for service connection for dental trauma with loss of tooth is reopened. REASONS FOR REMAND 1. Entitlement to service connection for dental trauma with loss of tooth is remanded. The Veteran asserts that VA compensation for a dental disability of teeth numbers 9, 10, and 11 is warranted based on an in-service injury and orthodontic intervention that ultimately resulted in an in-service extraction of the 10th tooth. A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. § 1110. Dental disorders are treated differently than other medical disorders in the VA benefits system. Under current VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. These conditions include, in relevant part, loss of teeth due to loss of substance of the body of the maxilla or mandible due to trauma or disease such as osteomyelitis rather than as a result of periodontal disease. Simmington v. West, 11 Vet. App. 41 (1998); see also 38 C.F.R. § 4.150, Diagnostic Code 9913, at Note. Treatable carious teeth, replaceable missing teeth, and dental or alveolar abscesses are not considered disabling conditions and may be considered service connected solely for establishing eligibility for VA outpatient dental treatment. 38 C.F.R. § 3.381. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that “service trauma” for this purpose “means an injury or wound produced by an external physical force during the service member’s performance of military duties” and “excludes the intended result of proper medical treatment.” Nielson v. Shinseki, 607 F.3d 802, 808 (Fed. Cir. 2010). The Federal Circuit also stated, in Nielson, that “an unintended result of medical treatment due to military negligence or malpractice” could be “service trauma,” depending upon the facts of the case. Id. The Board notes that the Veteran has not been provided with an adequate VA dental examination and opinion in regard to the claimed condition and the evidence does not otherwise address whether the claimed disorder exist and is related to service. VA’s duty to assist requires it to provide an adequate examination and/or obtain a medical opinion if the evidence is not sufficient to decide the claim. In this case, without adequate examination and medical opinion regarding to the Veteran’s claimed condition, the Board finds the current evidence to be insufficient to decide the claims. Therefore, a VA examination and medical opinion is required by VA’s duty to assist the Veteran in developing evidence to substantiate his claim to service connection. The matter is REMANDED for the following action: 1. Obtain all outstanding VA and private medical records pertinent to the claim. 2. Schedule the Veteran for a VA dental examination for the claim for service connection for dental trauma with loss of tooth. An opinion shall be obtained from an appropriately qualified examiner. The claims file, to include this remand, should be made available for the examiner to review and the examination report should reflect that such review was accomplished. The examiner must provide the following opinions: (a) Whether it is at least as likely as not that the Veteran has any dental condition, related to an in-service injury (trauma), event, or disease, and (b) Whether it is at least as likely as not that the Veteran has any dental condition as a result of an unintended result of medical treatment due to military negligence or malpractice. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brandon A. Williams, 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.