Citation Nr: 21022883 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-62 597 DATE: April 19, 2021 ORDER 1. Entitlement to service connection for residuals of wisdom teeth extraction and post-surgical infection is denied. 2. Entitlement to service connection for carcinoma at the base of the tongue and hypopharynx (also claimed as involving the salivary glands, throat, tonsils, lymph nodes, and jaw), to include as secondary to residuals of wisdom teeth extraction and post-surgical infection, is denied. 3. Entitlement to service connection for a neck disability, to include as secondary to residuals of wisdom teeth extraction and post-surgical infection, is denied. REMANDED 4. Entitlement to service connection for depression, to include as secondary to residuals of wisdom teeth extraction and post-surgical infection, is remanded. FINDINGS OF FACT 1. The evidence does not show that the Veteran lost any teeth due to bone loss of the body of the maxilla or the mandible as a result of trauma or disease during service. 2. The preponderance of the evidence of record is against finding that the Veteran has had any residuals of wisdom teeth extraction and post-surgical infection at any time during or approximate to the pendency of the claim. 3. The preponderance of the evidence is against finding that the Veteran’s diagnosed polymorphous adenocarcinoma at the right base of the tongue and right tonsillar fossa began during active service or is otherwise related to an in-service injury or disease, to include wisdom teeth extraction and post-surgical infection. 4. The preponderance of the evidence is against finding that a neck disability began during active service or is otherwise related to an in-service injury or disease, to include wisdom teeth extraction and post-surgical infection. CONCLUSIONS OF LAW 1. Service connection for residuals of wisdom teeth extraction and post-surgical infection, to include a dental disability for VA compensation purposes, is not warranted. 38 U.S.C. §§ 1131, 1712, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150, 17.161. 2. Service connection for carcinoma at the base of the tongue and hypopharynx (also claimed as involving the salivary glands, throat, tonsils, lymph nodes, and jaw), to include as secondary to residuals of wisdom teeth extraction and post-surgical infection, is not warranted. 38 U.S.C. §§ 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. Service connection for a neck disability, to include as secondary to residuals of wisdom teeth extraction and post-surgical infection, is not warranted. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from February 1980 to February 1984. This case comes to the Board of Veterans’ Appeals (Board) on appeal from a March 2016 Department of Veterans Affairs (VA) rating decision. In October 2019, a videoconference hearing was held before the undersigned. In March 2020, the Board remanded the case to the Regional Office (RO) for additional development of the claims. In January 2021, the Veteran submitted VA Form 20-0996, Decision Review Request: Higher-Level Review, but he did not indicate on the form the specific issues he was appealing and whether he was opting-in to the AMA review system after receipt of a December 2020 supplemental statement of the case. A January 2021 VA letter asked him to complete the form, but he did not. Therefore, the Board reviews his appeal under the legacy review system. Regarding the dental claim, the Board recognizes that a claim for service connection for a dental disorder is also a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302 (1993). Service treatment records (STRs) show the Veteran had his third molars (wisdom teeth) removed during service in 1983. From his statements and testimony, it is evident that his claim is solely on the basis of obtaining disability compensation for the alleged residuals of the teeth removal and subsequent infection, so the Board will only address the compensation claim. Service Connection The Veteran contends that after his wisdom teeth were extracted during service in 1983, he suffered an infection that affected his chin, tongue, and tonsils. He required antibiotics, three incisions (two under his chin and one inside his mouth), and a 10-day hospital stay. He claims that when he underwent surgery in February 2016 to remove a tumor (a polymorphous adenocarcinoma) in that same affected area, he was informed by his doctor that the tumor had existed for a long time. He claims that his military dentist caused the infection through his “incompetence” (because he says he was initially given pain medication in the post-surgical period and was not evaluated for infection), which led to the development of his cancer. He asserts that his 2016 surgery was performed in the “exact place” where an incision was made in 1983 to treat his infection and that the same areas that were painful in 1983 were also painful in 2016. At a October 2019 Board hearing, he testified that his problems in service continued after service and that right after his military separation he sought treatment with private doctors in Quanah in Mexico. Private records of the Veteran’s treatment right after service have not been received. In response to a March 2020 VA letter requesting the Veteran to provide them or a medical release form for the VA to seek them on his behalf, he stated in April 2020 that his records in Mexico prior to 2013 were unavailable (he submitted some records, however, of treatment since 2013). He also indicated that he went to M.D. Anderson Cancer Center for treatment of his adenocarcinoma, and he has submitted various treatment records from that private provider. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases, to include malignant tumors, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service (here, within one year); or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). 1. Entitlement to service connection for residuals of wisdom teeth extraction and post-surgical infection The initial question for the Board is whether service connection is warranted for the loss of the Veteran’s wisdom teeth during service. The Board concludes that there is no basis upon which to grant a claim of service connection for a dental disability for compensation purposes. VA compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. For Class I service-connected dental conditions for which disability compensation may be provided, the type of dental conditions covered is loss of teeth due to bone loss of the body of the maxilla or the mandible due to trauma or disease such as osteomyelitis, but not periodontal disease. 38 C.F.R. § 4.150, Diagnostic Code 9913; 38 C.F.R. § 17.161(a). The Veteran entered service in February 1980. STRs including dental records show no complaints or diagnosis referable to his mouth or throat by the time of a July 1983 military separation examination, which showed that the Veteran’s mouth and throat were clinically evaluated as normal. The report also reflects that he underwent a dental examination in June 1983, which was not remarkable. In a report of medical history in connection with the separation examination, the Veteran indicated that he was in “good health” (there was no defect or abnormality noted or reported). Service dental records show that in August 1983, the Veteran was seen for pericoronitis around tooth #32; it was treated with curettage and irrigation with saline. He had a surgical consult for removal of his third molars. On September 22, 1983, he was hospitalized and had all four wisdom teeth (teeth #1, 16, 17, and 32) removed. (A VA examiner in October 2020 stated that the molars were removed to prevent pericoronitis.) Postoperatively, he did well and was discharged the next day, without complaint. Two days later, he began to experience problems with pain and difficulty swallowing and was seen in the emergency room and given analgesics. A day later he was afebrile and tooth socket #17 appeared inflamed (antibiotics were prescribed). A day after that, on September 27, 1983, he was hospitalized with complaints of inability [to swallow] and pain on swallowing, and his temperature was elevated (101 degrees F.). He subsequently underwent an incision and drainage (I&D) after dysphagia and swelling complaints increased. Postoperatively, he did well with decreased temperature and decreased dysphagia. Swelling also moderated, and by the fourth postoperative day he was afebrile. He continued to improve, and his parenteral antibiotics were changed. He was discharged to duty (with convalescent leave for 48 hours) on October 4, 1983, and his final diagnoses were status post extraction of wisdom teeth, left masticator and pharyngeal infection, status post I&D of multicompartment [left lateral pharynx and submandibular spaces] facial cellulitis. An October 11, 1983 dental record notes that the Veteran was healing well and that his infection was resolved; he was to follow-up for scar revision if needed (he did not follow up). In December 1983, the Veteran elected not to undergo a medical examination before his separation. In January 1984, dental records show that he underwent a periodic dental examination; there were notations of any problems or treatment. On a January 1984 dental patient medical history form signed by the Veteran, a dentist noted that he had his third molars extracted recently and had postoperative infection, but was “apparently OK now.” The Veteran was discharged from service in February 1984. Post-service records show that the Veteran was seen decades later at the VA in March 2015 with complaints of pain and stiffness to the throat area and acid reflux. He reported that he had been receiving treatment for the pain and stiffness in Juarez, Mexico. An October 2019 report from Family Hospital in Juarez notes the Veteran’s presentation there in May 2014 and June 2014 with multiple complaints including difficulty swallowing and a sensation of a mass in the throat (the report noted that he did not follow up with diagnostic testing). Eventually, the Veteran underwent testing, including a neck ultrasound, which revealed a left neck mass. A subsequent finding of a mass at the right base of the tongue was revealed by biopsy in August 2015 to be a low-grade neoplasm. A subsequent bilateral tonsillectomy in October 2015 showed adenocarcinoma, low grade in the right tonsil. After applying the relevant dental provisions to the facts of the case, the Board concludes that service connection for a dental disability for the purpose of receiving VA compensation is not warranted. The Veteran does not have the type of dental condition for which compensation is payable. The service medical/dental records do not show, and he does not claim, that he lost any teeth due to bone loss of the body of the maxilla or the mandible as a result of trauma or disease. The removal of his wisdom teeth was not on account of trauma or disease during service. The pertinent regulations expressly prohibit compensation to be paid for such a dental condition. The next question for the Board is whether the Veteran currently has residuals of the in-service wisdom teeth extraction and post-surgical infection. The Board concludes that he does not currently have a diagnosis of any residual disability from his wisdom teeth extraction and post-surgical infection, and that he has not had any residuals at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In October 2020, a VA examiner evaluated the Veteran and found that he did not currently have residuals of his wisdom teeth removal and postoperative infection in service. He stated in a December 2020 report that the Veteran had a diagnosis of Ludwig’s Angina in 1983 after his third molar surgery and that it was treated and resolved. He concluded that for the Veteran’s claimed wisdom teeth condition with extraction, it was resolved. In the absence of a current residual disability from the teeth removal and infection, the preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved. Accordingly, the Veteran’s claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). It is noted that the October 2020 VA examiner also diagnosed nocturnal bruxism [teeth grinding] secondary to stress. In the section to describe the Veteran’s medical/dental history, the examiner wrote that the Veteran “ground his teeth at night due to the stress of the original surgery.” VA disability compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. These conditions include various problems of the maxilla, mandible, or temporomandibular articulation, loss of whole or part of the ramus, loss of the condyloid process or coronoid process, or loss of the hard palate. Compensation is also available for the loss of teeth due to loss of substance of the body of the maxilla or mandible due to trauma or disease such as osteomyelitis, and is not available in cases where the loss of teeth is a result of periodontal disease. See 38 C.F.R. § 4.150, Code 9913. The Veteran’s current diagnosis of bruxism is a condition manifested by the involuntary, nonfunctional, rhythmic or spasmodic gnashing, grinding, and clenching of teeth, usually during sleep, sometimes leading to occlusal trauma. See Dorland’s Illustrated Medical Dictionary, 257 (32nd ed., 2012). However, bruxism is not a dental disability for which service connection may be granted in this case. Service connection for bruxism is only warranted when it causes a dental disability, such as temporomandibular joint dysfunction or a bone infection that results in tooth loss. The Veteran has not identified a dental disability caused by his teeth grinding, nor is such shown by the evidence of record. He did not report having any dental or oral conditions on his October 2020 VA examination, and the VA examiner did not note any abnormalities beyond oral neoplasm (discussed below) and periodontal disease (also not a compensable disability according to 38 C.F.R. § 4.150, Code 9913). Therefore, as the Veteran does not have a current compensable dental disability that has resulted from his bruxism, such as impairment of the mandible, loss of a portion of the ramus, or loss of a portion of the maxilla, the Board finds that he does not have a current disability, and the first element of service connection has not been satisfied. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In the absence of a current disability to include bruxism, the preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved. Accordingly, this claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). While the Veteran believes he has current residuals of wisdom teeth extraction and post-surgical infection, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical/dental education and knowledge of the potential effects of tooth removal complicated by infection. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence presented by the VA examiner in October 2020 and December 2020 reports. 2. Entitlement to service connection for carcinoma at the base of the tongue and hypopharynx (also claimed as involving the salivary glands, throat, tonsils, lymph nodes, and jaw), to include as secondary to residuals of wisdom teeth extraction and post-surgical infection The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of polymorphous adenocarcinoma (treated and resolved), and evidence shows that he underwent the removal of his wisdom teeth during service which was complicated by post-surgical infection, the preponderance of the evidence weighs against finding that his adenocarcinoma began during service or is otherwise related to an injury, event, or disease in service. Post-service VA and private records show that the Veteran developed odynophagia in 2014. According to an October 2019 statement from Family Hospital in Juarez, Mexico, he was seen from May 2014 to June 2014 with complaints of difficulty swallowing, halitosis, regurgitation, weight loss, occasional right-sided otalgia, and a sensation of a mass in his throat (there was no indication of how long he had experienced such symptoms). Medical studies were ordered, but he did not show for a medical follow-up to determine his diagnosis. He then presented to the VA in March 2015 with complaints of neck area pain when swallowing, and stiffness in the throat area. When dysphagia and pain continued, he underwent a neck ultrasound that revealed a left neck mass. On evaluation by an otolaryngologist, a right base of tongue mass was identified, and he underwent a biopsy in August 2015 (which revealed a low-grade neoplasm most compatible with epithelial-myoepithelial carcinoma), which was followed by a bilateral tonsillectomy in October 2015 (biopsy showed adenocarcinoma). The Veteran was seen for further evaluation and treatment at M.D. Anderson Cancer Center. A December 2015 pathology report of a pharyngeal mass biopsy disclosed a salivary neoplasm, favored to be a polymorphous adenocarcinoma. In February 2016, he underwent a tracheotomy, right neck dissection, right paramedian mandibulotomy with mandibular swing, and resection of the right base of tongue and right tonsillar fossa with preservation of and full mobilization of the right lingual nerve. This was followed by reconstruction of an acquired defect of the tongue and lateral pharyngeal wall (using a left radial forearm free flap and skin graft from the groin to the left arm defect with a VAC dressing). A December 2016 VA outpatient record notes that the Veteran had mild persistent dysphagia and a speech impediment. A March 2018 VA outpatient record notes the Veteran complained of side effects from his 2016 surgery, such as foul taste in mouth, excessive salivation, and dysphagia. In an August 2019 statement, a treating provider at William Beaumont Army Medical Center stated that the Veteran was diagnosed with tongue cancer in January 2016, and that although he recovered well, he continued to struggle with symptoms that persisted from his surgery. A VA examiner in October 2020 noted the Veteran’s report of sensitivity in his throat when the weather was too hot or cold, difficulty talking, numbness of the tongue, excessive salivation, and stomach pain and diarrhea. The examiner also observed two unusual scars on the Veteran’s arm, where skin was removed to graft onto the base of his tongue, and four additional scars on his neck. As shown, the medical treatment records reflect that the Veteran’s claimed adenocarcinoma was not diagnosed until 2015, decades after his February 1984 separation from service. While he is competent to report having experienced dental/oral symptoms of some variety and frequency since service (he was somewhat ambiguous at the Board hearing about the type of problems that continued after service, stating that they involved his throat and tongue), he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of the adenocarcinoma found in 2015. The issue is medically complex, as it requires knowledge of the etiology of the Veteran’s type of cancer and interpretation of complicated diagnostic medical testing including cancer biopsies. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the October 2020 VA examiner opined that the Veteran’s polymorphous adenocarcinoma is not at least as likely as not related to an in-service injury, event, or disease, including the wisdom teeth extraction and post-surgical infection. In a December 2020 report, the examiner acknowledged the Veteran’s “severe” infection after the removal of his third molars in 1983 and his allegation that the tumor identified in 2015 had occurred in the same area as the in-service infection and was a result of the infection (presenting several articles and a private medical opinion to support such a claim). The examiner disagreed with the private opinion of Dr. RR, stating that it was probable that the physician arrived at his opinion in part because the Veteran relayed that he had a salivary gland infection resulting from the molar surgery, when in fact he had Ludwig’s angina. He also stated that the private physician failed to consider the Veteran’s type of tumor, which was currently accepted to be a particular type that was not environmentally mediated but a genetic mutation. Thus, he stated that the articles presented by the Veteran had no bearing on his case because his tumor type was “not environmentally mediated.” The VA examiner further concluded that there was no medical connection between the postoperative complication of Ludwig’s angina and the polymorphous adenocarcinoma for the following reasons: In addition to the type of tumor being one that was not environmentally induced, because it arose from a known “PRKD1 mutation” which was not common, he stated that the tumor was not in the same location as the original infection. He explained that Ludwig’s angina was an acute infection of the mouth, generally secondary to a dental infection that is characterized by bacteria invading submandibular, submental, and sublingual “spaces” and causing severe swelling. Even if the tumor was in the same location as the infection, he stated that the infection cleared up completely in a couple of weeks and that for bacteria to initiate cancer it had to be a chronic infection. In the Veteran’s case, he stated there was no long-term irritation to cause the tumor because Ludwig’s angina is not a chronic infection. The VA examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The record contains a conflicting medical opinion regarding whether the Veteran’s polymorphous adenocarcinoma is at least as likely as not related to an in-service injury, event, or disease, including the wisdom teeth extraction and post-surgical infection. As already cited, in a December 2019 private medical report, the Veteran’s treating physician in Mexico, Dr. RR, for the past six years opined that there was a 50 to 80 percent probability that the Veteran’s post-surgical infection in service was the cause of the development of the cancer “due to the severity and location of the tumor, being that it has an incidence of 15 to 20%.” However, Dr. RR provides no rationale for his conclusion and does not cite to any medical literature or studies to support his finding. It is also unclear whether he reviewed pertinent service and post-service treatment records to inform his opinion. Without the ability to determine whether the opinion is based on accurate medical history and given that it lacks an explanation containing clear conclusions and supporting data, see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008), the Board gives more probative weight to the VA examiner’s opinion. The Veteran believes his polymorphous adenocarcinoma is related to the wisdom teeth extraction with the complicating post-surgical infection in service. He submitted medical evidence and scientific/medical articles in support of his claim, which discuss how some cancerous lesions have been present for several decades, how some cancers are caused by treatable infections, and the signs and symptoms of the Epstein-Barr Virus (EBV) infection and its link to cancer. He contends that the documented in-service infection led to his adenocarcinoma, asserting that he shared the same symptoms as are found in EBV infection during service and that a link existed between EBV infection and cancer, specifically malignant salivary gland tumors. (He also claimed at one point (in December 2020) that the October 2020 VA examiner based his medical opinion on the “wrong type of cancer,” but there is no evidence to substantiate this. The examiner’s diagnoses included pleomorphic adenocarcinoma on one report, but when addressing the etiology of the cancer, he specifically references the polymorphous adenocarcinoma that was confirmed by biopsy in February 2016.) The Veteran also testified at the October 2019 Board hearing that he went to doctors in Mexico right after service because he still had swelling around his lymph node and he felt pain (in describing his symptoms, it was noted for the record that he was identifying the portion of the neck area below his jaw). He also stated that after his surgery in service, he had problems with talking, constant salivating, and low/no energy (which were the reasons why he did not re-enlist). He said these symptoms have persisted ever since his in-service surgery and he sought medical assistance in Mexico right after his military discharge. He said his doctors in Mexico gave him medication and took X-rays and an ultrasound, finding “little balls… the size of beans.” (The Veteran was requested to obtain his treatment records from his doctors in Mexico, but in April 2020 he informed the VA that he was unable to obtain any records prior to 2013, stating that the small offices of the doctors he saw do not retain records.) The Veteran’s contentions, the medical articles he submitted, and the December 2019 private medical opinion were reviewed by the October 2020 VA examiner, who explained in detail in his December 2020 report how Dr. RR’s opinion was based on an inaccurate medical history and how the medical articles were not relevant to the Veteran’s particular claim. Moreover, the Veteran is not competent to provide a nexus opinion regarding this issue. Once again, the issue is medically complex, as it requires knowledge of cancer pathology and the ability to interpret diagnostic medical studies. Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the October 2020 VA examiner’s opinion. Regarding the Veteran’s testimony about persistent symptoms during and after service, prompting him to seek treatment from doctors in Mexico, his service medical/dental records do not corroborate his claims of ongoing symptomatology. He declined (without explanation) to undergo (another) separation physical examination after his teeth extractions/infection episode and before his discharge in February 1984. He did undergo a periodic dental examination in January 1984, which did not find any problems at that point. In fact, on a dental questionnaire at that time, when he had the opportunity to do so, he did not report any ongoing symptoms, and after noting the Veteran’s surgical history, the dentist remarked that he was now “OK.” Therefore, from the standpoint of the service records, which the Board finds to be a more reliable reflection of the Veteran’s condition than his current recollection of events that are subject to the vagaries of memory due to the passage of time (more than 30 years), there is no contemporaneous evidence to show continual symptoms from the surgery in service, and his statements to the contrary about ongoing symptoms during his period of service are not credible. Furthermore, while the Board has no reason to doubt that the Veteran sought medical treatment after service from doctors in Mexico for symptoms related to his mouth/throat/neck area, there is no evidence – and the Veteran does not claim – that the doctors in Mexico ever rendered a diagnosis of polymorphous adenocarcinoma. According to the Veteran, there were some positive findings on scans or X-rays, but the timing of those findings, the identification of the findings, and the etiology of the findings (i.e., whether they are even related to the in-service wisdom teeth extraction and infection) are not known. As was earlier noted, the Veteran is not competent to provide a diagnosis in this case or determine that his symptoms were manifestations of the adenocarcinoma found in 2015. The VA regulations provide that the Veteran’s malignant tumor is a disease that may be presumed related to service, absent an intercurrent cause, if (1) it is shown as chronic in service, (2) if it manifested to a compensable degree within the one-year presumptive period following separation from service in February 1984, or (3) it was noted in service or within the one-year presumptive period with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Here, the Veteran’s tumor was not shown in service, to have manifested by February 1985, or to have been noted in service or within the first post-service year with symptoms continuing since then. Moreover, a VA examiner has attributed the cancer to a genetic mutation. Therefore, service connection on a chronic disease presumptive basis is not warranted. 3. Entitlement to service connection for a neck disability, to include as secondary to residuals of wisdom teeth extraction and post-surgical infection The question for the Board is whether the Veteran has a current neck disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. This claim appears to be closely related to the adenocarcinoma matter, previously discussed, because the Veteran claimed his cancer involved the neck area (he seems at times to have referred interchangeably to his neck and throat). As earlier noted, when his complaints of pain in the neck area on swallowing and stiffness to the throat area were worked up in 2015, he was found to have polymorphous adenocarcinoma that affected his right base of tongue and right tonsillar fossa. In February 2016, he underwent a tracheotomy, right neck dissection, right paramedian mandibulotomy with mandibular swing, and resection of the right base of tongue and right tonsillar fossa. The February 2016 pathology report indicates that the numerous lymph nodes in the neck were negative for tumor. A March 2016 VA outpatient record indicates his surgical scar on the neck was healing well. He is currently shown to have scars on his neck related to his February 2016 cancer surgery, as observed by the October 2020 VA examiner. The Board concludes that, while the Veteran has a current diagnosis of polymorphous adenocarcinoma (treated and resolved) that resulted in surgical scars on his neck, and evidence shows that he underwent removal of his wisdom teeth during service, which was complicated by post-surgical infection, the preponderance of the evidence weighs against finding that any neck disability began during service or is otherwise related to an in-service injury, event, or disease. To the extent that the neck disability claim is associated with his adenocarcinoma for which service connection is denied, the neck claim must also be denied. The Veteran has not alleged a different (not part and parcel of his adenocarcinoma claim) theory of entitlement for his neck disability. The Board finds that a causal relationship between the current disability and a disease or injury in service in not shown, and the third element of a service connection claim has not been established. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Consequently, the preponderance of the evidence is against this claim, and there is no reasonable doubt to be resolved. Accordingly, the appeal in this matter must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 4. Entitlement to service connection for depression, to include as secondary to residuals of wisdom teeth extraction and post-surgical infection The Board cannot make a fully-informed decision on the issue of service connection for depression because no VA examiner has opined whether he has a psychiatric disability that is related to an injury or disease in service. At the time of the October 2019 Board hearing, the undersigned noted that the record did not show the Veteran has a diagnosis of the claimed depressive disorder. The undersigned informed him that to substantiate his claim, he would need evidence to show a current disability, as well as evidence that the disability is secondary to his cancer. The claim of service connection for carcinoma is denied in this decision; however, the Veteran in December 2019 submitted two brief statements, unaccompanied by any treatment records or explanation of rationale, from the Veterans One Stop Clinic through Emergence Health Network, wherein treatment providers stated that he has a diagnosis of major depressive disorder, and was receiving mental health counseling and medication management services. Notably, one of the providers stated that the Veteran “continues to struggle with depression” that she felt was related to “a history of trauma resulting from an infection that developed after removal of his wisdom teeth” while serving in the Air Force. Therefore, the evidence shows the Veteran has a current diagnosis of a mental disorder that appears to be related to his dental treatment and infection in service (rather than to the nonservice-connected cancer that was alleged to be the result of the in-service dental treatment and infection). An examination to clarify the nature and etiology of his claimed psychiatric disorder is needed. The matter is REMANDED for the following action: 1. Secure for the claims file all updated (since April 2020) VA records of the Veteran pertaining to evaluation and/or treatment he received for psychiatric disability. Also ask him to furnish any private records pertaining to mental health evaluations and/or treatment (any records not already associated with the claims file), to include any from the Veterans One Stop Clinic of Emergence Health Network, or alternatively provide a medical release authorizing VA to obtain the records on his behalf. If he submits authorization, obtain those records. 2. Then, arrange for the Veteran to be examined by a psychiatrist or psychologist to determine the likely etiology of all current (since the filing of his claim in March 2015) psychiatric disability he is shown to have, to include major depressive disorder. The claims file must be reviewed by the examiner. The examiner should identify (by diagnosis) each psychiatric disability found/shown by the record. Regarding each diagnosed psychiatric disability entity, the examiner should opine whether it at least as likely as not (a 50 percent or greater probability) that it is related to his service from February 1980 to February 1984, to include his treatment then for an oral infection that developed after removal of his wisdom teeth. In providing the requested opinion, the examiner should consider (1) the December 2019 private medical opinion associating the Veteran’s diagnosed major depressive disorder to “a history of trauma resulting from an infection that developed after removal of his wisdom teeth” while serving in the Air Force, and (2) any of the Veteran’s descriptions (documented and undocumented) of mental health symptoms, both in service and after service. If there is a medical reason to accept or reject any reported symptoms in service and thereafter as representative of the onset of his current disability, this should be noted and explained in detail. (Stated another way, do the Veteran’s reports about his symptoms comport with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally implausible or inconsistent with medical knowledge?) All opinions must include rationale that cites to supporting factual data and medical principles. George R. Senyk Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Debbie Breitbeil, 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.