Citation Nr: 21025443 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 15-27 130 DATE: April 28, 2021 ORDER Entitlement to service connection for a spine condition/injury, to include arthritis, back pain, and spinal impairment (also claimed as cervical spine degenerative joint disease), is denied. Entitlement to service connection for sternoclavicular joint with tear and rupture of the interior ligament, to include collarbone injury, is denied. Entitlement to service connection for residuals of a head injury is denied. REMANDED Entitlement to service connection for a dental disability for compensation purposes is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. FINDINGS OF FACT 1. The Veteran’s spine disability did not manifest in-service and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 2. The Veteran’s sternoclavicular joint disability did not manifest in-service and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 3. There is no evidence of record which establishes that the Veteran has a current diagnosis of residuals of a head injury or functional impairment equivalent thereto. CONCLUSIONS OF LAW 1. The criteria for service connection for a spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309, 3.310. 2. The criteria for service connection for sternoclavicular joint disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309, 3.310. 3. The criteria for service connection for a head disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from March 1971 to March 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified at a Board hearing. The transcript of the hearing is of record. However, the Veterans Law Judge (VLJ) who conducted those hearings and signed the previous Board remand is no longer available to participate in the Veteran’s appeal. The Veteran was given another opportunity to appear at a hearing before a VLJ who would decide the claims. However, the Veteran did not invoke his right to appear at an additional hearing, and as such, the Board will proceed with adjudication. See March 2021 Hearing Request. By way of background, in March 2019, the Board remanded the issues on appeal for further evidentiary development. That development having been completed the issues are once again before the Board. Service Connection Generally, to establish service connection a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 1. Entitlement to service connection for a spine condition/injury, to include arthritis, back pain, and spinal impairment (also claimed as cervical spine degenerative joint disease), is denied. After a review of the record, the Board finds that the Veteran does not meet the criteria for service connection as the preponderance of the evidence supports a finding that a spine disability did not manifest during service, and have not been shown to be causally or etiologically related to an in-service event, injury or disease. Regarding the first element of service connection (a current disability), the Board finds that in the December 2019 VA examination the Veteran was diagnosed with lumbosacral strain and in the July 2020 VA examination the Veteran was diagnosed with cervical strain and degenerative arthritis of the spine. See December 2019 C&P Exam and July 2020 C&P Exam. As such, the first element of service connection has been met. Concerning the second element of service connection (in-service incurrence or aggravation of a disease or injury), the Board finds that there is no in-service incurrence or aggravation of a spine-related disease or injury. In the October 2018 hearing, the Veteran stated that he was a combat engineer assigned to the Second Bridge Company United States Marine Corp. The Veteran attested that he worked with very heavy equipment and bridge pieces. The bridge pieces were loaded and unloaded and built by hand by the engineers. The Veteran stated that he fell off trucks and jumped off trucks and as a result got “banged up.” The Veteran attested that he did not seek treatment for his spine condition in service as he was discouraged to go to sick bay calls. The Board finds the Veteran’s statements about injuring his spine during service not persuasive as the contemporaneous records do not show any specific spine pain, diagnosis, or treatment in service or within the first year after service. A review of the military personnel records shows that the Veteran was a combat engineer and that he had proficient skills in selecting, erecting, and maintaining standard bridge equipage. See March 2013 Military Personnel Record. However, the service treatment records show normal spine and neck in the September 1970 pre-induction examination and March 1973 separation examination. See March 2014 STR – Medical. The Veteran did not complain of any spine or neck-related pain or injuries even in his separation examination. Further, more than 20 years after service, in a February 1997 VA treatment record, it was noted that the Veteran had a seven-month history of lumbar pain of unclear etiology. See March 2014 Medical Treatment Record – Government Facility. The Veteran did not claim then that his spine pain manifested in service or that he has had back pain since service. Further, an October 1996 x-ray scan of the lumbar spine revealed normal findings. See July 2020 CAPRI. The Board finds it logical that if the Veteran had spine related injuries the Veteran would have complained of his pain at least in his separation examination. Further, it is also logical that if his spine related pain persisted since service, he would have indicated it in the February 1997 VA treatment record, or at any time since service. Instead, it was noted that the Veteran only had a seven-month history of lumbar pain of unclear etiology. Accordingly, the Board finds the lack of findings pertaining to the spine during service and shortly thereafter more probative than his assertions made many years later that he had injured his spine during service. Thus, the most probative and ultimately persuasive evidence does not indicate an in-service spine injury occurred. As for presumptive service connection based on chronic disease, the Board finds the preponderance of the evidence does not support a finding that the Veteran’s spine disability manifested to a compensable level in the first post-service year. 38 C.F.R. § 3.309(a). Based on the records, the Veteran’s initial complaint of spine pain was in 1996, more than 20 years after service. Even then an October 1996 x-ray scan of the lumbar spine revealed normal findings with no evidence of arthritis. See July 2020 CAPRI. As for the Veteran’s cervical spine disability, in a November 2017 magnetic resonance imaging (MRI) scan of the thoracic spine, the Veteran had degenerative disease and uncal vertebral DJD at C6-C7. As such, there is no evidence of a spine disability within the first post-service year. Accordingly, service connection for a spine disability based on the presumption in favor of chronic disease is not warranted in this case. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. The Board notes that the Veteran was afforded a VA examination in December 2019 with addendum opinions in July 2020 and October 2020. In the December 2019 VA examination, the examiner opined that the Veteran’s condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that after reviewing medical records dated “1/22/97, 02/27/97, 12/15/97, 12/18/97, 01/12/18, 09/17/18, 03/21/19” it is less likely as not that the Veteran’s current lumbosacral strain and cervical strain is service connected as a result of the in-service “snoring, falls, boxing, impacts from equipment, handling heavy equipment, and various falls and accidents” as there are no medical records showing diagnosis, complaint, or treatment of a neck and/or back condition while the Veteran was in service. In the July 2020 VA addendum opinion, the same examiner opined that it is less likely as not that the Veteran’s current cervical strain with degenerative joint disease was a result of in-service “snoring, falls, boxing, impacts from equipment, handling heavy equipment, and various falls and accidents” as there are no medical records showing complaint, diagnosis, or treatment of a neck condition or any related cervical spine condition while the Veteran was in service. Rather, the examiner determined that the degenerative changes to the cervical spine is related to age. In the October 2020 VA addendum opinion, the same examiner reiterated the December 2019 opinion. Additionally, the examiner opined that there is no pathology or diagnosis to render an opinion for arthritis of the back as there is no diagnosis of arthritis. The Board affords little probative value to the examiner’s assessments as it is not based on the entire record. Further, the Board finds that the examiner did not provide any rationale for his/her assessment. The Board finds that although the medical assessments are incomplete, it does not warrant a remand as the Board finds that there is no in-service injury or event. Here, the service treatment records do not show any complaints, signs, or symptoms of a spine disability. Moreover, the records show that the Veteran had a seven-month history of low back pain in 1996, more than 20 years after service. The Veteran did not claim then that his back pain originated in service or that the back pain persisted since service. As there is no indication that the disability, or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, the Board finds that a new VA medical opinion is not needed. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In sum, the criteria for service connection for a spine disability have not been met. The evidence does not show that the spine disability is directly related to his military service. Accordingly, service connection for a spine disability must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to service connection for sternoclavicular joint with tear and rupture of the interior ligament, to include collarbone injury, is denied. After a review of the record, the Board finds that the Veteran does not meet the criteria for service connection as the preponderance of the evidence supports a finding that a sternoclavicular joint disability did not manifest during service, and have not been shown to be causally or etiologically related to an in-service event, injury or disease. Regarding the first element of service connection (a current disability), the Board finds that in a July 2019 VA treatment record the Veteran was diagnosed with arthritis of the right sternoclavicular joint. See October 2019 CAPRI. As such, the first element of service connection has been met. Concerning the second element of service connection (in-service incurrence or aggravation of a disease or injury), the Board finds that there is no in-service sternoclavicular joint related injury or event. In the October 2018 hearing, the Veteran stated that he injured his sternoclavicular joint from one of those falls off bridge equipment and/or truck in service. The Board finds the Veteran’s statement about injuring his sternoclavicular joint during service not persuasive as the contemporaneous records do not show any specific sternoclavicular joint pain, diagnosis, or treatment in service or within the first year after service. A review of the service treatment records shows normal upper extremities in the September 1970 pre-induction examination and March 1973 separation examination. See March 2014 STR – Medical. The Veteran did not complain of any sternoclavicular joint pain -related pain or injuries even in his separation examination. Moreover, even though the Veteran complained of lumbar pain in a February 1997 VA treatment record, the Veteran did not complain of sternoclavicular joint-related pain. See March 2014 Medical Treatment Record – Government Facility. The Board finds it logical that if the Veteran had sternoclavicular joint related pain the Veteran would have complained of his pain at least in his separation examination. Further, it is also logical that if his sternoclavicular joint related pain persisted since service, he would have indicated it in the February 1997 VA treatment record when he complained of low back pain. Instead, the Veteran did not complain of any sternoclavicular joint related pain. Accordingly, the Board finds the lack of findings pertaining to the sternoclavicular joint during service and shortly thereafter more probative than his assertions made many years later that he had injured his sternoclavicular joint during service. Thus, the most probative and ultimately persuasive evidence does not indicate an in-service sternoclavicular joint injury. Even a review of the post service treatment records shows that in an August 2016 VA treatment record, there no note that there was anything wrong with either side of the sternoclavicular joint. See October 2019 CAPRI. In a December 2017 VA treatment record, it was noted that there was no sternoclavicular pathology. Only in a February 2019 VA treatment record, an ultrasound of the sternoclavicular joint showed a hypoechoic lesion extending from the right sternoclavicular joint. The differential was broad and included prior trauma, post infectious process, post inflammatory causes such as secondary to rheumatoid arthritis and ganglion cyst. The Board finds that although the February 2019 ultrasound showed evidence of prior trauma, it still did not show that the Veteran sustained a sternoclavicular joint injury in service. The Veteran was afforded a VA examination in December 2019 with an addendum opinion in November 2020. In the December 2019 VA examination, the examiner diagnosed the Veteran with right shoulder strain but did not diagnose the Veteran with sternoclavicular joint disability as there were no findings, signs, and/or symptoms to support a diagnosis. In the November 2020 VA addendum opinion, the examiner opined that it is less likely as not that the Veteran’s current degenerative changes of the right glenohumeral joint and tear of the posterior inferior labrum or rotator cuff tendinosis are service connected as there are no medical records showing diagnosis, progressive complaints, or treatment for a right shoulder condition or any related shoulder condition until 2013, which is 40 years after release from service. In support of his claim, in a September 2017 private treatment record, Dr. Lichty wrote that the Veteran’s left shoulder and right anterior sternoclavicular joint rupture are at least as likely as not due to his military service. See October 2017 medical Treatment Record – Non-Government Facility. The Board affords little to no probative value to this medical opinion as Dr. Lichty stated that he only included this language per the Veteran’s request to help him with the VA. Dr. Lichty did not indicate whether he agreed with this assessment. Accordingly, in this case, the Board finds that a quoted statement does not equate to a medical opinion without affirmation from the physician. The Board acknowledges that the Veteran has not been afforded a VA examination with respect to his sternoclavicular joint disability but finds no such examination is required because the evidence does not indicate that the claimed disability, or symptoms thereof, may be associated with the Veteran’s active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Under McLendon, VA is obligated to provide an examination when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Here, the service treatment records do not show any complaints, signs, or symptoms of a sternoclavicular joint disability. Moreover, the records show that the Veteran had sternoclavicular joint disability in 2017, more than 40 years after service. Additionally, when the Veteran complained of low back pain in 1997 the Veteran did not complain of any sternoclavicular joint-related pain or discomfort. As there is no indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, the Board finds that a new VA medical opinion is not needed. As for presumptive service connection based on chronic disease, the Board finds the preponderance of the evidence does not support a finding that the Veteran’s sternoclavicular joint disability manifested to a compensable level in the first post-service year. 38 C.F.R. § 3.309(a). Based on the records, the Veteran had sternoclavicular joint no earlier than 2017, more than 40 years after service. As such, there is no evidence of a sternoclavicular joint disability within the first post-service year. Accordingly, service connection for a sternoclavicular joint disability based on the presumption in favor of chronic disease is not warranted in this case. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. In sum, the criteria for service connection for a sternoclavicular joint disability have not been met. The evidence does not show that the sternoclavicular joint disability is directly related to his military service. Accordingly, service connection for a sternoclavicular joint disability must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Entitlement to service connection for residuals from a head injury is denied. In the October 2018 hearing, the Veteran stated that bridge equipment fell off the trailers and sometimes his helmet would come off and his head would get “banged up.” Despite the Veteran’s contentions, based on a review of the record, the Board finds that he does not meet the requirements of service connection for a head injury as the weight of the evidence is against a finding of current disability. Regarding the first element of service connection (a current disability), the medical evidence does not reflect a diagnosis for residuals from a head injury. A review of the service treatment records shows normal head and face in the September 1970 pre-induction examination and March 1973 separation examination. See March 2014 STR – Medical. In fact, the service treatment records do not reflect any complaints, treatment, or diagnosis of a head related impairment. Moreover, a review of the post service treatment records shows no references to a head injury. In fact, a May 2018 computerized tomography (CT) scan of the brain revealed no evidence of acute intracranial hemorrhage or acute infarction. See October 2020 CAPRI. The CT scan essentially revealed unremarkable findings with no evidence of past head injury. The Board acknowledges that the Veteran has not been afforded a VA examination with respect to his claim for service connection for a head injury but finds no such examination was required because the evidence does not indicate that the claimed disability, or symptoms thereof, may be associated with the Veteran’s active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Under McLendon, VA is obligated to provide an examination when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Here, the service treatment records do not show any complaints, signs, or symptoms of a head injury. There are no third-party statements attesting to witnessing the Veteran’s head injury. Further, the Veteran did not attest to any specific head injury, but instead reported general injuries and being “banged up.” The Board finds it logical that if the Veteran really sustained a traumatic head injury, a reasonable person would have sought treatment or at the least recall a specific head injury. However, no such incident was included in his service treatment records or recalled at the October 2018 hearing. As such, the Board finds that there is no evidence establishing an in-service head-related event, injury, or disease. The Board notes that the existence of a current disability is the cornerstone finding, of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, as noted above, the evidence does not establish that the Veteran currently experiences a diagnosable residual from a head injury. In the absence of a current disability, the analysis ends, and the claim for service connection for residuals from a head injury cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). REASONS FOR REMAND 1. Entitlement to service connection for a dental disability for compensation purposes is remanded. In the October 2018 hearing, the Veteran stated that he participated in boxing and sustained trauma to his mouth. A review of the service treatment records shows that in the April 1971 initial examination, the Veteran’s tooth 31 was already missing. Then about nine days later, the Veteran had his tooth number 14, 29, and 30 extracted. There was no note of boxing or any other mouth and/or face trauma. In support of his claim, in February 2015, Dr. Davis, a dentist, stated that the Veteran had tooth 30 and 31 extracted while in service. Due to these teeth extraction with no replacement, it resulted in the extrusion of tooth 3 and 4 which has led to the Veteran’s malocclusion. See March 2015 Third Party Correspondence. In December 2015, Dr. Davis again opined that the Veteran’s current malocclusion of the right side is due to the Veteran’s in-service dental work in 1971. See December 2015 Third Party Correspondence. The dentist noted that the Veteran does not have other known history to contribute or explain the state of this severe malocclusion other than the dental work performed during his military service. The severe malocclusion more likely than not has caused a collapsed bite. The dentist explained that malocclusion causes abnormal mandibular alignment and abnormal bite. The dentist stated that the Veteran’s x-rays shows anterior root canal treatments that were completed after his service. The dentist noted that the three adjacent root canal treatments indicates frontal impact trauma. In September 2016, Dr. Davis stated that the dental x-rays on file show 3 adjacent root canals on the anterior teeth completed in 1974, a year after the Veteran’s service. See October 2016 Medical Treatment Record – Non-Government Facility. The root canals are in the right maxillary central incisor, the right maxillary lateral incisor, and the right maxillary canine. The dentist opined that this dental condition is due to frontal facial trauma, impact incidents or accidents, and equipment impacts. The dentist determined that this indicates multiple frontal impact trauma events and that it is at least as likely than not cause and aggravate the medical condition. The Veteran was afforded a VA examination in December 2019 with an addendum opinion in September 2020. In the December 2019 VA examination, the examiner diagnosed the Veteran with loss of teeth due to trauma and opined that the Veteran’s condition is at least as likely as not incurred in or caused by the claimed in service injury, “due to the in-service snoring, falls, boxing, impacts from equipment, handling heavy equipment, and various falls and accidents.” In the September 2020 VA addendum opinion, the examiner opined that there is sufficient evidence that the Veteran had a jaw/dental condition in service and as such it is at least as likely as not that the Veteran’s dental disability incurred in service. The examiner explained that x-rays from Dr. Davis showed several dental frontal maxilla root canals and crowns due to multiple head injury/facial trauma impact injuries. Further, the examiner noted that there are anterior root canals from USMC frontal impact traumas. The Board finds that the 1974 x-ray scan of the three adjacent root canals are not associated with the file. As Dr. Davis has a copy of the x-ray scan, a remand is warranted to obtain the 1974 x-ray scan. 2. Entitlement to service connection for obstructive sleep apnea is remanded. In the October 2018 hearing, the Veteran stated that he snored in service. Additionally, the Veteran reported that he was tired and fatigued during the day. In the alternative, the Veteran stated that his malocclusion caused his mandible not to connect which caused a bit of his airway to close. See also March 2015 VA 21-4138 Statement in Support of Claim. In support of his claim, a third-party statement was submitted wherein a serviceman stated that he recalled the Veteran snoring in service. See October 2018 Buddy/Lay Statement. In the December 2019 VA examination, the examiner diagnosed the Veteran with obstructive sleep apnea and opined that the Veteran’s condition is less likely than not incurred in or caused by the claimed in-service “snoring, falls, boxing, impacts from equipment, handling heavy equipment, and various falls and accident.” The examiner explained that snoring is multifactorial in nature, including genetic factors, environmental factors, drug abuse, lifestyles, body habitus, sinus infections, sinus pressure, upper respiratory conditions, and/or diet. Thus, there is no direct causality between snoring and obstructive sleep apnea. Although snoring is one of the many symptoms of sleep apnea, it is not a contributing factor or cause of sleep apnea. In December 2015, Dr. Davis opined that the Veteran’s current malocclusion of the right side more likely than not has caused a collapsed bite which as likely as not reduced the airway passage and likely as not contributed to and aggravated his sleep apnea. The Board finds the claim for entitlement to service connection for sleep apnea cannot be adjudicated as it is intricately intertwined with the outcome of the Veteran’s service connection claim for a dental disability, which is currently being remanded in this decision. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). As such, the claim for entitlement to service connection for sleep apnea is deferred. The matters are REMANDED for the following action: 1. Contact the Veteran and obtain the 1974 x-ray scan of the three adjacent root canals. 2. After development for step 1 is completed, obtain an addendum opinion from a different examiner to determine the nature and etiology of any dental disability. The claims file, including a copy of this remand, must be made available to be reviewed by the examiner. Dental disability - For each diagnosed dental disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the dental disability had its onset in service or is otherwise etiologically related to service. The examiner must address the February 2015, December 2015, and September 2016 private medical opinions from Dr. Davis. In February 2015, Dr. Davis stated that the Veteran had tooth 30 and 31 extracted while in service. Due to these teeth extraction with no replacement, it resulted in the extrusion of tooth 3 and 4 which has led to the Veteran’s malocclusion. See March 2015 Third Party Correspondence. In December 2015, Dr. Davis opined that the Veteran’s current malocclusion of the right side is due to the Veteran’s in-service dental work in 1971. See December 2015 Third Party Correspondence. The dentist determined that a severe malocclusion more likely than not caused a collapsed bite. The dentist explained that malocclusion causes abnormal mandibular alignment and abnormal bite. In September 2016, Dr. Davis stated that the dental x-rays on file show 3 adjacent root canals on the anterior teeth completed in 1974, a year after the Veteran’s service. See October 2016 Medical Treatment Record – Non-Government Facility. The root canals are in the right maxillary central incisor, the right maxillary lateral incisor, and the right maxillary canine. The dentist opined that this dental condition is due to frontal facial trauma, impact incidents or accidents, and equipment impacts. The examiner should address whether root canals in the right maxillary central incisor, the right maxillary lateral incisor and the right maxillary canine are at least as likely as not due to frontal facial trauma. Sleep apnea - The examiner must state whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran’s sleep apnea was (a) caused by or has been (b) aggravated (worsened beyond the natural progress of the disorder) by malocclusion of the right side. The examiner should address the December 2015 medical opinion from Dr. Davis wherein the dentist opined that the Veteran’s current malocclusion of the right side more likely than not has caused a collapsed bite which as likely as not reduced the airway passage and likely as not contributed to and aggravated his sleep apnea. Sarah Campbell Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Noh, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.