Citation Nr: 21010372 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 14-13 239 DATE: February 24, 2021 ORDER Entitlement to service connection for a dental disability is denied. REMANDED Entitlement to service connection for eye disabilities (other than dry eye and pinguecula), to include as secondary to nonservice-connected hypertension, is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected major depressive disorder (MDD), is remanded. Entitlement to an effective date earlier than July 22, 2014, for the award of Dependents’ Educational Assistance Under 38 U.S.C. Chapter 35 is remanded. FINDING OF FACT The Veteran does not have dental condition for which compensation may be granted, nor does he have a dental condition or disability as a result of trauma during his active military service. CONCLUSION OF LAW The criteria for service connection for a dental disorder for purposes of compensation are not met. 38 U.S.C. §§ 1110, 1131, 1721, 5107 (2018); 38 C.F.R. §§ 3.303, 3.381, 4.150, 17.161 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 2001 to March 2002, from October 2002 to June 2003, and from December 2008 to December 2009 with additional service in the Army National Guard, including several periods of active duty for training (ACDUTRA). The Veteran’s appeal was previously before the Board in September 2018, at which time it was noted that his claim for service connection for a dental disorder for the purposes of compensation was inextricably intertwined with his claim for service connection for a dental disorder for the purposes of treatment. The Board directed the agency of original jurisdiction (AOJ) to complete the necessary development for the dental treatment claim. Thereafter, in September 2020, the AOJ sent the Veteran a letter informing him how to initiate a determination regarding his eligibility to dental treatment services. The September 2020 supplemental statement of the case, the AOJ noted that a determination regarding his eligibility had been initiated. Thus, the AOJ has substantially complied with the prior remand directives, and the Board may proceed with the adjudication of the Veteran’s claim for service connection for a dental disorder for the purposes of compensation. Service Connection The Veteran claims entitlement to service connection for a dental disorder for compensation purposes. The Board concludes that the Veteran does not have a dental condition for which service connection may be established. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303, 4.150; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection for a dental claim for compensation purposes can be established only for the specific types of dental and oral conditions listed under 38 C.F.R. § 4.150, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. Compensation is available for loss of teeth only if such is due to loss of substance of the body of the maxilla or mandible. See Simmington v. West, 11 Vet. App. 41 (1998). For loss of teeth, bone loss through trauma or disease such as due to osteomyelitis must be shown for purposes of compensability. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See 38 C.F.R. § 4.150 Note to Diagnostic Code 9913. In this connection, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities. 38 C.F.R. § 3.381. Service treatment records show chronic severe periodontal disease throughout the period of service from December 2008 to December 2009. During that period, at least two teeth were extracted, and the Veteran received a removable partial denture. See May 2009 Service Treatment Record (showing extraction of numbers 26 and 29 teeth). In connection with his claim for service connection, the Veteran underwent a VA examination in February 2013, and he was diagnosed with periodontal disease. The examiner noted that the Veteran has a history of moderate to severe generalized chronic periodontitis. After reviewing the Veteran’s claims file, the examiner concluded that the installation and insertion of the Veteran’s artificial teeth was most likely due to partial edentulism secondary to his history of moderate to severe generalized chronic periodontitis noted in his April 2009 through June 2009 service treatment records. After review of all the medical and lay evidence of record, the Board finds that the Veteran does not have a dental condition for which service connection may be established. As discussed above, the evidence of record reflects a current diagnosis of periodontal disease. Insofar as the Veteran claims that his in-service periodontal disease and subsequent tooth extractions warrant disability compensation, such are simply not considered disabilities under VA regulations for which compensation can be awarded. There is no indication that the Veteran’s dental disability involves bone loss in the maxilla or mandible region. Moreover, there is nothing indicating actual bone loss or other maxillary impairment that causes him to lose teeth, nor has any treatment record indicated such impairment. In addition, the record does not otherwise show that he incurred bone loss through any type of in-service trauma or disease. For compensation purposes, the term “service trauma” does not include the intended effects of therapy or restorative dental care and treatment provided during a veteran’s military service. VAOGCPREC 5-97, 62 Fed. Reg. 15566 (1997); see also Nielson v. Shinseki, 607 F.3d 802, 804 (Fed. Cir. 2010). In summation, the Board is prohibited from awarding service connection for compensation purposes for any dental problems without evidence of underlying bone disease or loss, or prior evidence of in-service trauma. As such, the benefit sought on appeal must be denied. REASONS FOR REMAND 1. Service Connection for Hypertension In September 2018, the Board remanded the Veteran’s claim of entitlement to service connection for hypertension so that an addendum opinion could be obtained that addressed whether his hypertension was secondary to his service-connected MDD. In doing so, the Board directed the examiner to address the Veteran’s August 2017 contention that depression can cause or aggravate hypertension, as well as a medical article cited in the August 2017 appellate brief that concluded that “[p]eople who experience symptoms of depression or anxiety are at increased risk of developing hypertension.” The Veteran underwent a VA examination in February 2019 and, after noting the Veteran’s diagnosis, the examiner concluded that it was less likely than not that his hypertension was proximately due to, or the result of, his service-connected MDD. The examiner noted that the cited study indicated that depression was a risk factor for hypertension, which meant that patients with depression were more likely to develop hypertension due to epidemiological factors related to lifestyle, but that it did not mean that depression was a direct cause of hypertension. Furthermore, the examiner noted that, although emotional stress associated to depression may increase blood pressure during an acute phase of the disease, this effect was not permanent; therefore, the examiner concluded that the Veteran’s hypertension was not aggravated by his service-connected MDD. Recently, the United States Court of Appeals for Veterans Claims (Court) held in Ward v. Wilkie, 31 Vet. App. 233 (2019) that aggravation under 38 C.F.R. § 3.310(b) (2020) does not require that there be “permanent” worsening of the nonservice connected disability. In addition, and crucially, the Court also found that service connection is warranted for any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. Ward, 31 Vet. App. at 240. Given the Court’s holding, the Board finds that an addendum opinion is necessary to address the question at issue. On remand, the AOJ should associate with the record any outstanding VA treatment records that are not currently associated with the claims file. Records dated through August 25, 2020, are currently of record. Additionally, the Veteran should be given the opportunity to identify any outstanding pertinent evidence. 2. Service Connection for Eye Disabilities (Other than Dry Eye and Pinguecula), and Earlier Effective Date for Dependents’ Educational Assistance Under 38 U.S.C. Chapter 35 As noted in the September 2018 remand, the Veteran’s claim of entitlement to eye disabilities (other than dry eye and pinguecula) as secondary to his hypertension is inextricably intertwined with his claim for service connection for hypertension. Likewise, his claim for an effective date earlier than July 22, 2014, for the award of Dependents’ Educational Assistance Under 38 U.S.C. Chapter 35 is inextricably intertwined with his service connection claims. See Parker v. Brown, 7 Vet. App. 116 (1994) and Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on the claim for the second issue). As such, the Board will defer further consideration of both issues at this time. The matters are REMANDED for the following action: 1. Associate any VA treatment records dated after August 25, 2020, with the Veteran’s claims file. 2. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. After any outstanding records have been associated with the claims file, return the claims file to the examiner who provided the February 2020 VA opinion (or to another qualified medical professional if the February 2020 examiner is unavailable), to provide a response to the questions posed below. The record must be made available for the examiner’s review. The need for an additional examination is left to the discretion of the medical professional selected to write the addendum opinion. Upon review of the record, the reviewing medical professional is asked to respond to each of the following: Is it at least as likely as not that the Veteran’s hypertension was caused or aggravated by his service-connected MDD? In this regard, the Board notes that causation and aggravation are two separate inquires and both must be addressed. With respect to aggravation in particular, the reviewing clinician should consider whether there is any incremental increase in hypertension attributable to the Veteran’s service-connected MDD, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward, 31 Vet. App. at 240. In providing the opinion, the medical professional should address the medical literature cited in the August 2017 Brief (“Science Daily: March 24, 2000, Source: Center for the Advancement of Health: “People who experience symptoms of depression or anxiety are at increased risk of developing hypertension, suggest the results of a two-decade study”). The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If responses to the questions above cannot be provided without an in-person or virtual examination or interview, such should be scheduled. 4. Thereafter, conduct any additional development warranted as a result of the above and then readjudicate the issues on appeal. D. C. JOHNSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James R. Springer, 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.