Citation Nr: 21027480 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-46 658 DATE: May 5, 2021 ORDER Service connection for bruxism as secondary to service-connected posttraumatic stress disorder (PTSD) is granted. Service connection for a dental condition, other than bruxism, is denied. FINDINGS OF FACT 1. The Veteran's bruxism is the result of his service-connected PTSD. 2. The Veteran does not have a dental condition, aside from bruxism, for which service connection for compensation purposes can be granted. CONCLUSIONS OF LAW 1. The criteria for service connection for bruxism as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The Veteran's dental condition, aside from bruxism, does not meet the requirements for service connection for compensation purposes. 38 U.S.C. §§ 1110, 1712, 5107; 38 C.F.R. §§ 3.303, 4.150. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Navy from August 1990 to November 1993. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision by the Regional Office (RO) of the United States Department of Veterans Affairs (VA). In his VA Form 9, the Veteran requested a Board videoconference hearing. In a September 2016 letter, the Veteran and his representative were notified that a Board videoconference had been scheduled for October 19, 2016. The Veteran did not appear for this hearing and did not provide any cause for his failure to appear. He has not requested an additional hearing. Accordingly, the Veteran's hearing request is considered to have been withdrawn. 38 C.F.R. § 20.704. This matter was previously before the Board in September 2018, at which time it was remanded for additional development. An examination was completed in September 2019. Subsequent development letters were sent to the Veteran to assist in identifying any outstanding treatment records. In July 2020, the Board found that the September 2019 examination was inadequate on the basis that the examiner failed to discuss the dental procedures that the Veteran received in September 1992 while in-service, which is the basis of his claim. Accordingly, the matter was remanded once again for an additional examination. This examination was completed in January 2021, with a corresponding addendum completed in March 2021. Substantial compliance with the Board's prior remand orders is demonstrated. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). This matter was previously characterized solely as a tooth condition. However, as the Board finds that service connection can be granted for bruxism, the matter has been recharacterized, as reflected on the title page. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided in July 2014. The RO associated the Veteran's service and VA and private outpatient treatment records with the claims file. In October 2013, the VA received all service treatment records, aside from a separation examination. Notice indicated that all available medical and dental records had been shipped. Additionally, the Veteran was provided notice in December 2013 to submit any copies of service treatment records within his possession. All released or submitted private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding. Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. As such, VA has satisfied its duty to assist with the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Dental Conditions Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to establish service connection on a direct basis, the record must contain competent evidence of: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. There are two separate types of appellate streams that can be pursued regarding service connection for dental conditions: service connection for treatment purposes and service connection for compensation. The criteria for service connection for treatment purposes is considered by the Veterans Health Administration (VHA) and addressed under 38 C.F.R. § 3.381 and 38 C.F.R. § 17.161. This matter is not currently before the Board. Dental conditions for which service-connected compensation benefits are available are set forth under 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. These conditions include loss of whole or part of the mandible, nonunion or malunion of the mandible, loss of 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. Id. 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 compensation purposes. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See 38 C.F.R. § 4.150. In addition, to be compensable, the lost masticatory surface for any tooth cannot be restorable by a suitable prosthesis. Id. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment and cannot be considered for compensation purposes. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Service Connection for Bruxism as Secondary to PTSD First, although the Veteran has not specifically sought service connection for this condition, the Board finds that service connection is warranted for the Veteran's bruxism as secondary to his service-connected PTSD. In a December 2020 rating decision, the Veteran was granted service connection for PTSD, rated70 percent disabling, effective September 2019. In the September 2019 VA oral and dental conditions examination, it was noted that the Veteran has a diagnosis for bruxism. The examiner specifically stated that he believed the etiology of the bruxism was the Veteran's psychiatric diagnoses and PTSD. Both the diagnosis for bruxism and its relationship to PTSD were confirmed in the January 2021 VA oral and dental conditions examination. Specifically, the examiner stated that the most likely etiology for the bruxism was clenching, multiple crowns and bridges, and PTSD. Accordingly, the Board finds that the evidence is favor of finding that the Veteran's bruxism is secondary to his service-connected PTSD. There is no evidence to the contrary. Therefore, service connection for bruxism secondary to PTSD is warranted. Service Connection for Other Dental Conditions The Veteran contends that he is entitled to service connection for a tooth condition based on what he described as "botched treatment" that he received on the USS Saratoga. In a June 2014 statement, the Veteran reported that he had a "misdiagnosed sinus infection," which was diagnosed as an abscessed tooth infection, despite x-rays coming back normal. He stated that his dentist completed root canals on several teeth to try to fix the problem but could not get the swelling down. The Veteran recalled that after 3 days of treatment from the original dentist, he sought assistance from another dentist, who immediately diagnosed the swelling as a sinus infection. He stated that after the swelling subsided, the original dentist filled the root canals. He recalled that approximately three or four years after separating from service, his teeth showed signs of cavities. Upon receiving treatment from a private provider at this time, he was told that the original treatment was completed poorly and was the cause of his tooth decay. In a separate statement from April 2015, the Veteran further described that he had initially gone to a doctor on the USS Saratoga for "swelling just below my right eye and just to the left of my nose," and was sent to dental for treatment. He described the scenario relayed above in greater detail but indicated in this statement that his fillings were not completed until after service. On his April 1990 report of medical history, the examiner reported that he had "severe tooth trouble," disclosing that he had previously undergone a root canal in 1988. However, his enlistment examination did not make any notations regarding teeth other than that they were "acceptable" as to dental defects and diseases. His service treatment records (STRs) reflect that he received dental treatment on several different occasions during service, including notation in April 1991 that extractions were recommended for teeth 1, 3, 16, and 32. STRs further reflect that he received dental treatment while on the USS Saratoga in September 1992. Records show that the Veteran was experiencing pain in the upper right front area, although no obvious swelling or drainage was noted. It appears that an "I&D" (incision and drainage) was performed on tooth 7, and the Veteran continued to experience swelling at the incision site the following day. The Veteran came back to the dentist two days after the original procedure, complaining of continued swelling, at which time abscess and necrotic pulp was identified at tooth 7. This tooth was opened to allow drainage, and it was specified that follow-up on the infection was necessary. It appears that the infection was resolving at tooth 7, but that tooth 8 was also opened based on hyperemic pulp and left open to drain. Ultimately, swelling went down, and the Veteran appears to have received fillings at tooth 7 and 8. Notably, the STRs do not reflect any specific mention that the dentists discovered a sinus infection, rather than a dental condition, at the time of the treatment. The Veteran received a VA oral and dental conditions examination in September 2019, at which time he was found to have bruxism and loss of teeth due to accident or extraction. The examiner opined that it is less likely as not that the Veteran's loss of teeth during service was due to loss of substance of body of mandible or due to disease such as osteomyelitis and not due to the loss of the alveolar process as a result of periodontal disease, but is at least as likely as not due to loss of substance of body maxilla or trauma. The examiner stated that the record refers to extractions, but that he had found no reference to cellulitis, osteomyelitis, or sinus infection. Regarding the Veteran's claim that the wrong teeth were treated, the examiner stated that this would be the case if he ultimately was found to have an abscess in the sinus that normally would not be connected to the anterior teeth. It was noted that the Veteran's lower bicuspid was extracted while at the VA and that the evidence shows no periodontal disease in August 2019 but does show bruxism. The examiner then stated that it is less likely as not that the Veteran's loss of teeth during service is due to disease such as osteomyelitis and that it is at least as likely as not that his loss of teeth during service is due to trauma or possibly due to loss of substance of body of maxilla due to his maxillary right abscess or infection. However, as noted above, this corresponding opinion was found inadequate in the July 2020 Board decision. Although the examiner discussed several teeth that had been extracted in-service, he did not address those which were subjected to procedure in September 1992, which form the basis of the Veteran's complaint. Accordingly, this opinion is afforded no probative value. The Veteran received an additional VA oral and dental conditions examination in January 2021. Here, the examiner opined that the in-service tooth condition involving root canals is at least as likely as not related to an in-service injury, event, or disease, including improper diagnosis. The examiner reiterated what the Veteran had previously reported, stating that the dentist completed root canals on several teeth but was unable to get the swelling to go down, and following three days of treatment from the original doctor, the Veteran sought the help of another dentist, who immediately diagnosed the swelling as a sinus infection. However, the examiner clarified that the dentist's decision to complete these root canals could not clearly be identified as a misdiagnosis. Rather, the examiner reasoned that the treating VA dentist may not have known the causes of the abscess and thought that the best course of action was to drain the abscess, and then when this did not happen, determined that they had to drain through the maxillary sinus. Furthermore, in the March 2021 addendum opinion, the examiner concluded that the root canals were not due to loss of substance of maxilla or mandible due to trauma or due to disease such as osteomyelitis, but due to the loss of alveolar process as a result of periodontal disease. Therefore, aside from bruxism, service connection for compensation purposes is not warranted for the Veteran's tooth condition. Specifically, the VA examiner determined that the Veteran's in-service treatment did not involve trauma to the maxilla or mandible and was not due to disease such as osteomyelitis. Since this examiner further specified that the treatments provided in-service were reasonable under the circumstances and not clearly a misdiagnosis, the dental procedures that the Veteran underwent in September 1992 cannot be found to constitute trauma for the purposes of establishing compensable service connection. Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that the Veteran is entitled to a compensable dental condition due to any in-service dental trauma or disease. Thus, service-connection may not be established for compensation purposes for missing or damaged teeth, or periodontal disease, under 38 C.F.R. § 4.150. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S.P. Faris 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.