Citation Nr: 21022928 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-23 064 DATE: April 19, 2021 ORDER Service connection for a dental disorder is denied. REMANDED Entitlement to service connection for basal cell carcinoma. Entitlement to service connection for squamous cell carcinoma. Entitlement to service connection for diabetes mellitus (DM). Entitlement to service connection for diabetic neuropathy of the lower extremities. Entitlement to service connection for diabetic neuropathy of the upper extremities. FINDINGS OF FACT 1. The Veteran served on active duty from April 1967 to March 1969, to include service in the Republic of Vietnam. 2. A compensable dental disorder as defined by VA regulations is not shown. CONCLUSION OF LAW A dental disorder was not incurred in service, nor may it be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.159, 3.381, 4.150 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION The appeal was previously before the Board in September 2019, at which time all claims were denied. The Veteran appealed that decision to the Veterans Claims Court, and in August 2020, the Court Clerk granted a Joint Motion for Remand (JMR), vacating the September 2019 Board decision to the extent required, and remanded the appeal to the Board for action consistent with the Joint Motion. Turning to the applicable laws and regulations, the dental conditions for which service-connected compensation benefits are available are set forth under 38 C.F.R. § 4.150, DCs 9900-9916. These conditions include loss of whole or part of the mandible, nonunion or malunion of the mandible, loss of whole or part of the ramus, loss of whole or part of the maxilla, nonunion or malunion of the maxilla, loss of the condyloid or coronoid process, or loss of any part of the hard palate. Compensation is also available for loss of teeth only if such is due to loss of substance of body of maxilla or mandible. See Simmington v. West, 11 Vet. App. 41 (1998). For loss of the teeth, bone loss through trauma or disease, such as osteomyelitis, must be shown for compensable purposes. In addition, to be compensable, the lost masticatory surface for any tooth cannot be restorable by suitable prosthesis. Absent a demonstration of dental trauma, service connection may be considered solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment. See Woodson v. Brown, 8 Vet. App. 352, 354 (1995). A claim for service connection for a dental disorder is also a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. 38 C.F.R. § 3.381(a). Service connection for compensation purposes can only be established for certain 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 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 to osteomyelitis must be shown. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See Note to DC 9913. Replaceable missing teeth, treatable carious teeth, dental or alveolar abscesses, and periodontal disease are not disabling, and may be considered service connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. 38 C.F.R. § 3.381. As the Veteran does not have loss of substance of the mandible or maxilla, or loss of teeth due to bone loss from trauma or disease, he does not have a dental disability for which monthly compensation may be granted. The Veteran asserts that he developed gum disease and tooth decay as a result of living in an old French fort during the Vietnam War, where the water was not good for brushing teeth, if he had the chance to brush his teeth. He reported that he sought treatment for his teeth within two weeks and was diagnosed with gingivitis. However, the evidence does not show that he has a currently diagnosed dental disorder compensable under VA regulations. A January 2014 private treatment note relates that the Veteran had dental problems secondary to radiation for pharyngeal cancer. An April 2019 letter from Dr. MAV stated that the Veteran was a patient for many years and that he had many problems from dental decay and periodontal disease with multiple loose teeth. Dr. MAV indicated that the causes of these problems were numerous but included poor or no dental care while in Vietnam and that herbicides could not be ruled out. An April 2017 VA examination included panographic imaging which revealed the teeth, mandible, and maxilla were within normal limits. Notably, a September 2016 gastroenterologist note references a finding of upper and lower dentures as part of the physical examination, and such a finding was not reported by the VA examiner. Hence, the VA examiner’s comment that the teeth were within normal limits is questionable and renders the examination inadequate to that extent. Nevertheless, replaceable missing teeth, treatable carious teeth, dental or alveolar abscesses, and periodontal disease are not disabling, and may be considered service connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. 38 C.F.R. § 3.381. But compensation requires loss of substance of the mandible or maxilla, or loss of teeth due to bone loss from trauma or disease. Regardless of the Veteran having dentures to any degree, the evidence does not reflect that he has loss of substance of the mandible or maxilla. Moreover, while service connection is in effect for laryngeal cancer, and a January 2014 private treatment note indicates that he experienced dental problems as a result of radiation treatment for the cancer, the evidence does not establish that the lost teeth due to bone loss from trauma or disease. Moreover, given the apparent upper and lower dentures, the evidence does not show that any loss of masticatory surface cannot be restored by suitable prosthesis. Thus, the Veteran does not have a dental disability for which compensation may be granted. The Board has considered the lay statements that he has a dental disorder caused by service. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal for service connection for a dental disorder is denied. REASONS FOR REMAND As noted by the JMR, the Veteran was not afforded an examination to assess the etiology of basal cell and squamous cell carcinoma. The evidence reflects that he has a current diagnosis, and exposure to herbicides is presumed given his service in the Republic of Vietnam. Moreover, two private opinions suggest a relationship between the current diagnoses and his exposure to herbicides. Accordingly, the Board remands the issues so a VA opinion may be obtained. Next, in September 2019, the Board denied service connection for DM on the basis that affirmative evidence established that the DM was due to pancreatitis rather than presumptive to exposure to herbicides during his service in the Republic of Vietnam. Among the evidence in support of this finding was an April 2015 VA opinion that noted that pancreatic cysts had been present since 2009, prior to the DM, and found therefore that the DM was due to the pancreatic cysts. However, the examiner provided no other rationale for the opinion other than the timing of the onset of each disorder, and the fact that the DM developed after the pancreatitis does not preclude herbicides from playing a role in its development. Therefore, another opinion is necessary that provides a complete rationale addressing whether the DM at least as likely as not developed as a result of the Veteran’s exposure to herbicides apart from any role the pancreatitis had in its development. Regarding the peripheral neuropathy of the upper and lower extremities, as these disabilities have been associated with the DM, the claims are inextricably intertwined. Thus, the peripheral neuropathy appeals must also be remanded. The matters are REMANDED for the following actions: 1. Undertake appropriate development to associate any outstanding, relevant treatment notes with the claims file. 2. Direct the claims file to a clinician to obtain an opinion as to the etiology of the Veteran’s squamous cell and basal cell carcinomas. Based on review of the record, the clinician is asked to offer an opinion as to the following: • whether it is at least as likely as not (i.e., a 50 percent or better probability) that the Veteran’s basal cell and/or squamous cell carcinoma was due to exposure to herbicides in service, or was otherwise due to any disease, incident, or injury in service. The rationale for any opinion expressed must be provided. If the clinician is unable to provide the opinions requested, he or she should explain why. An examination need not be scheduled unless the clinician cannot answer the question presented without one. 3. Direct the claims file to a clinician to obtain an opinion as to the etiology of the Veteran’s DM. Based on review of the record, the clinician is asked to offer an opinion as to the following: • whether it is at least as likely as not (i.e., a 50 percent or better probability) that the Veteran’s exposure to herbicides caused or contributed to his DM, regardless of any role his pancreatitis and/or pancreatic cysts played in its development. The rationale for any opinion expressed must be provided. If the clinician is unable to provide the opinions requested, he or she should explain why. An examination need not be scheduled unless the clinician cannot answer the questions presented without one. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. M. Schaefer, 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.