Citation Nr: 21026461 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 16-37 059 DATE: May 3, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to the service-connected temporomandibular joint dysfunction (TMJ) with bruxism, is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Air Force from November 1982 to October 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in November 2018 for further development. The matter returns for appellate consideration. In November 2018, the Board reopened the previously denied claim for service connection for sleep apnea, secondary to the service connected TMJ with bruxism, based on a finding of new and material evidence. In addition to the current issue, in November 2018, the Board remanded the issue of service connection for headaches. During the pendency of the appeal, in August 2020 rating decision, the RO granted service connection for chronic headaches. Because the Veteran was granted service connection for this disability and he has not disagreed with the effective date or disability rating, the issue of service connection for headaches is no longer on appeal. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Entitlement to service connection for sleep apnea, to include as secondary to the service connected TMJ with bruxism, is remanded. The Veteran contends that his sleep apnea is secondarily related to his TMJ with bruxism. Pursuant to the November 2018 Board remand, an August 2019 VA examination was obtained. The examiner opined that the Veteran's sleep apnea is less likely than not proximately due to the service connected TMJ with bruxism because there is no indication in the service records of complaints for sleep difficulty/sleep apnea and that sleep apnea is caused by recurrent, functional collapse of the velopharyngeal and/or oropharyngeal airway causing substantially reduced or complete cessation of airflow despite ongoing breathing efforts. Furthermore, the examiner noted that medical literature does not suggest TMJ with bruxism causes functional upper airways collapse or sleep apnea. Lastly, the examiner opined the Veteran's sleep apnea is less likely than not aggravated beyond its natural progression by the service connected TMJ with bruxism because the Veteran reports onset of sleep apnea in 2000 and continues to experience snoring/gasping for air at night, mouth dryness, headaches, daytime fatigue, and inability to concentrate which are suggestive of symptoms of long-term sleep apnea. The examiner concluded there is no indication that the Veteran's sleep apnea has been aggravated beyond its natural progression by TMJ. The Board finds the August 2019 opinion is inadequate. The examiner offered a conclusory opinion without basing it on a sufficient rationale in support. In other words, the examiner simply concluded that the Veteran's current symptoms are indicative of sleep apnea over the course of years. However, the examiner failed to explain how the Veteran's symptoms would or would not be aggravated by TMJ or whether medical principles support an association in this regard. The Board notes that the Veteran submitted medical literature in August 2020 suggesting a link between sleep bruxism, sleep disordered breathing and temporomandibular disorders. Lastly, the Board notes that the current record does not include an adequate medical opinion as to whether the Veteran's sleep apnea is directly related to service. As such, an addendum opinion is warranted to determine the nature and etiology of the sleep apnea. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the August 2019 VA examiner, or another qualified clinician. The clinician providing the opinions must be provided access to the electronic claims file and indicate review of the file in the examination report. If examination of the Veteran is necessary, such should be arranged. The examiner is asked to opine as to the following: (a) Whether the Veteran's sleep apnea is at least as likely as not (50 percent probability or more) aggravated beyond its natural progression by the service connected TMJ with bruxism. "Permanent worsening" of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation. Ward v. Wilkie, 31 Vet. App. 233 (2019). The examiner should discuss the August 2020 medical literature demonstrating a link between sleep bruxism, sleep disordered breathing and temporomandibular disorders. (b) The examiner should also determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's sleep apnea is related to an in-service injury, event, or disease. The examiner must provide a rationale in support of all opinions provided. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Asfaw, 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.