Citation Nr: 21029930 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 07-22 165 DATE: May 17, 2021 ORDER A rating in excess of 50 percent for post-traumatic stress disorder (PTSD) prior to February 1, 2016, is denied. Subject to the laws and regulations governing the award of VA monetary benefits, a 70 percent rating, but no more, for PTSD from February 1, 2016, is granted. An initial rating in excess of 10 percent for nerve damage status post extraction of tooth #17 is denied. FINDINGS OF FACT 1. Prior to February 1, 2016, the Veteran's PTSD consistently manifested in symptoms of depression, anxiety, irritability, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships, resulting in occupational and social impairment with reduced reliability and productivity. 2. From February 1, 2016, the Veteran's PTSD symptoms increased in severity, frequency, and duration such that occupational and social impairment with deficiencies in most areas was demonstrated. 3. Throughout the appeal period, the involvement of cranial nerve XII has, at worst, resulted in moderate, or medium quality, incomplete paralysis with moderate loss of motor function of the tongue. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD prior to February 1, 2016, have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a 70 percent rating, but no more, for PTSD from February 1, 2016, have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411. 3. The criteria for an initial rating in excess of 10 percent for nerve damage status post extraction of tooth #17 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124, 4.124a, DC 8312. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from June 2004 to August 2005. She had additional service in the Army National Guard. Service connection for nerve damage status post extraction of tooth #17 was granted at a noncompensable rate, effective August 22, 2005, in a February 2007 rating decision. The Veteran timely appealed the rating and subsequent to a September 2019 Board decision, the rating was increased to 10 percent from August 22, 2005. Service connection for PTSD was granted at 50 percent, effective August 22, 2005, in a January 2014 rating decision. The Veteran submitted a claim for increase in September 2015. A rating in excess of 10 percent for the nerve damage disability and in excess of 50 percent for PTSD were denied by the Board in September 2019. The Veteran appealed to the Court of Appeals for Veterans Claims (Court) which, in a December 2020 order pursuant to a Joint Motion for Partial Remand (JMPR), vacated and remanded the decision. Favorable ratings in the September 2019 decision were not disturbed. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. PTSD The Veteran was granted service connection for PTSD at 50 percent, effective August 22, 2005, under 38 C.F.R. § 4.130, DC 9411, the General Rating Formula for Mental Disorders. The Veteran submitted a claim for increase on September 15, 2015. In November 2017 and February 2018 rating decisions, a temporary total rating was granted for PTSD from October 30, 2017, to January 1, 2018. Thus, the Board will consider the severity of the Veteran's PTSD from September 15, 2015, (other than the temporary total rating period) as well as whether there was a factually ascertainable increase in severity within the year preceding the increased rating claim. See 38 C.F.R. § 3.400(o)(2). Under 38 C.F.R. § 4.130, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is assignable where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code," and, if so, the "equivalent rating will be assigned." Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." 713 F.3d 112, 117 (Fed. Cir. 2013) ("Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the 'frequency, severity, and duration' of a Veteran's symptoms must play an important role in determining his disability level."). Turning to the evidence of record, in a VA mental health treatment note from November 2014, the Veteran reported that she had been better in recent weeks. Her current prescribed medications included Mirtazapine and Venlafaxine. In December 2014, she noted that she had recently ended a long-term friendship. She had been irritable recently and presented as mildly anxious. She demonstrated a clean appearance, was normal and alert but drowsy, had a cooperative demeanor, was oriented, had normal rate and tone of speech, motor activity was within normal limits, thought process was logical, she had no perceptual disturbances, there was no evidence of psychotic symptoms, she had normal judgment and present insight, she had no homicidal ideation, and she was not deemed to be a suicide risk. In March 2015, she noted that her sons had been taking care of her. In an April 2015 record, she described a very depressed period in recent weeks with self-doubt and disappointment with herself. Multiple VA treatment records from November 2014, December 2014, January 2015, February 2015, March 2015, and April 2015 noted that the Veteran did not go out much and spent most of her time at home and at church. Mental status evaluations repeatedly reflected casual dress, cooperative attitude, slowed speech, sad and tearful affect and mood, goal-directed thought process, no overt psychosis, the denial of perceptual disturbances, motor activity within normal limits, attentiveness and orientation on all spheres, average level of intelligence, fair judgment, and limited insight. The Veteran was deemed not to be a suicide risk. The Veteran underwent a VA examination in April 2015. She reported that she remained divorced and unemployed due to disability. She underwent ongoing VA individual therapy and medication management with Mirtazapine, Venlafaxine, and Alprazolam. She denied any relevant legal and behavioral history or substance abuse history. Current symptoms were listed as depressed mood, anxiety, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. One met criterion of PTSD was noted to be irritable behavior and angry outbursts with little or no provocation typically expressed as verbal or physical aggression toward people or objects. Upon observation, the Veteran was cooperative, friendly, and pleasant during the examination, she was casually attired, and she maintained good eye contact. The examiner diagnosed PTSD and major depressive disorder and found that the symptoms of each condition could not be differentiated. Both disorders resulted in occupational and social impairment with reduced reliability and productivity. Multiple VA mental status evaluations in July 2015 reflected casual dress, cooperative attitude, slowed speech, sad and tearful affect and mood, goal-directed thought process, no overt psychosis, the denial of perceptual disturbances, motor activity within normal limits, attentiveness and orientation on all spheres, average level of intelligence, fair judgment, and limited insight. The Veteran was deemed not to be a suicide risk. A clinician noted that she had a hard time accepting changes and had become reclusive. Venlafaxine was discontinued and Alprazolam was restarted. Another VA examination was conducted in February 2016. The Veteran reported that she was divorced, not currently dating, and she lived with one of her sons. She had limited contact with her father and did not have a relationship with her siblings. She denied participating in family functions. The Veteran had two sons with whom she had "excellent" relationships. She also had a couple of military and non-military friends that she got together with at times and kept in contact with online and over the telephone. She attended sporting events and was fine in those situations unless the gym was really small and there were too many people there. She would feel hot and on guard, get antsy, and need to get up and move around. She also spent time reading and watching television, attending church and weekly bible study, and participating 3 to 4 times a week in other church-sponsored activities. The Veteran had not been employed for several years due to her physical disabilities. She continued to participate in individual counseling through VA and was prescribed Mirtazapine, Trazodone, and Alprazolam. She denied suicide attempts and psychiatric hospitalizations. The Veteran identified recent stressors as the end of a romantic relationship, her ongoing health problems, and the end of a long-term friendship. Current symptoms were listed as depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Upon observation, the Veteran was cleanly, casually, and stylishly dressed and well-groomed in appearance. She was alert, pleasant, and cooperative with the interview. Affect was constricted and dysphoric. Her mood was described as "so-so." Speech was unremarkable, speed of thinking and responding was within normal limits, thought processes were logical and goal-directed, insight and judgment appeared adequate, and there was no overt evidence of mental content symptomology, perceptual disturbance, or gross cognitive confusion. Memory lapses such as trouble recalling appointments and tasks, needing to write things down, and repeating information were described. Her remote memory was noted to be better. Verbal abstract reasoning and interpretation were within normal limits. The Veteran reported that her attention and concentration were poor and that she had difficulty keeping focus. She described situational anxiety when driving in traffic or when feeling boxed in and needing to get out of the car due to feeling trapped. Regarding her depression, the Veteran described feeling a depressed mood 2 to 3 days a week when she did not feel well. She became depressed whenever she was unable to do things due to her physical disabilities. She noted that she cried quite a bit and did not have motivation. She enjoyed spending time with her grandson and reading but she noticed a decline in the level of pleasure she got from engaging in such activities. The Veteran denied suicidal ideation or a history of suicide attempts. Regarding irritability and anger, she reported getting angry a lot. She endorsed yelling, cursing, and insulting others in anger, throwing and kicking things, and physical altercations with her sons and husband in the past, with the most recent being in 2009. She denied any recent physical fights. Regarding homicidal ideation, the Veteran stated she had not experienced it recently. When she learned her ex-boyfriend had gotten married, she "wanted to do some bodily harm" to him and his wife. Her appetite was up and down and her weight fluctuated without apparent cause. Regarding sleep, she endorsed initial and middle insomnia and delayed sleep onset for "hours" at times. She denied bothersome or racing thoughts but had occasional nightmares from Iraq. They were not as bad as they used to be and occurred 3 or 4 times a month. Regarding anxiety, the Veteran described intermittent generalized anxiety with worries about her son who is a police officer, her health status, and her future. She endorsed panic attacks characterized by shortness of breath, feeling hot, sweating, racing heart, and lightheadedness. They were triggered when in crowds, around the holidays, and with fireworks. She approximated experiencing two panic attacks in the past year. The Veteran also described random bothersome and intrusive thoughts of her Iraq deployment which were hard to redirect. She noted that she became emotionally reactive when contacted by a former servicemember's family who was killed in action. The examiner stated that these comments suggested survivor's guilt. The Veteran sometimes would eat out or go to movies when there were few people around. She startled easily from loud, unexpected sounds which triggered flashbacks. Regarding hallucinations, the Veteran stated that it sounded like someone was trying to break into her home and she thought she heard something crawling in the wall. She denied delusions and paranoid ideation. The examiner diagnosed chronic PTSD and unspecified depressive disorder. Symptoms attributable to PTSD included reexperiencing, cue avoidance, hyperarousal, and negative alterations in cognition. Symptoms attributable to depression included depressed mood, tearfulness, feelings of helplessness and hopelessness, and suicidal ideation with plan but no intent. And symptoms common to both disorders included sleep disturbance, attention/concentration problems, irritability/anger, reduced interest and participation in activities; feelings of detachment; and social withdrawal. It was impossible for the examiner to differentiate the Veteran's impairment in functioning between the diagnoses. All psychiatric diagnoses resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. Specifically, the examiner indicated that sleep disturbance and resulting fatigue might result in tardiness and low motivation might result in absences from work; irritability and anger and a strong tendency to isolate might result in problems interacting effectively with supervisors, coworkers, and/or customers; attention and concentration difficulties and memory problems might cause reduced work performance and trouble completing tasks correctly and efficiently; difficulty tolerating high amounts of stress would preclude positions involving supervisory or leadership responsibilities or requiring high-level quotas; and problems with anxiety and hypervigilance would likely preclude work with lots of people. In an April 2016 VA mental health treatment record, the Veteran reported that a friend of hers from Iraq had died which upset her and triggered memories, intrusive thoughts, and flashbacks. In October 2016, the treating clinician noted that there were no signs or symptoms of PTSD reported or observed and they decided to taper down the Veteran's use of Alprazolam and discontinue the medication. Treatment records from March 2016, April 2016, May 2016, August 2016, March 2017, May 2017, July 2017, and August 2017 stated that feelings of depression, insomnia, anxiety, and social isolation had been problematic, interfering with mood and functioning; mental status evaluations reflected casual dress, cooperative attitude, slowed speech, sad and tearful affect and mood, goal-directed thought process, no overt psychosis, the denial of perceptual disturbances, motor activity within normal limits, attentiveness and orientation on all spheres, average level of intelligence, fair judgment, and limited insight. The Veteran was deemed not to be a significant suicide risk. In an August 2017 treatment record, the Veteran reported feelings of hurt, hopelessness, inadequacy, and fear. In October 2017, she was admitted to an in-patient VA Psychosocial Residential Rehabilitation Treatment Program (PRRTP) for help with PTSD, anger issues, and panic attacks. Medications were again adjusted with Escitalopram, Topiramate, and Trazodone substituted for daily use. The Veteran noted that the medications were effective in managing her PTSD and insomnia. Treatment records from January 2018, February 2018, March 2018, April 2018, May 2018, June 2018, July 2018, September 2018, and October 2018 noted that feelings of depression, insomnia, anxiety, and social isolation had been problematic, interfering with mood and functioning; mental status evaluations reflected casual dress, cooperative attitude, slowed speech, sad and tearful affect and mood, goal-directed thought process, no overt psychosis, the denial of perceptual disturbances, motor activity within normal limits, attentiveness and orientation on all spheres, average level of intelligence, fair judgment, and limited insight. The Veteran was deemed not to be a suicide risk. In a March 2018 treatment record, the Veteran stated that a new romantic relationship was taking a toll on her emotionally. In April 2018, her Escitalopram dosage was increased to focus on mood and irritability. A June 2018 treatment record noted that she was doing much better on the increased dose. Her relationship with her two sons was better and her mood had improved. In July 2018, the Veteran began having anxiety attacks when getting her hair cut. She described the attacks as resulting in profuse sweating, heart palpitations, sweaty palms, diarrhea, and feeling as if she might pass out. She also was experiencing mild insomnia and a screening was suggestive of moderate depression. Hydroxyzine was prescribed. The Veteran underwent another VA examination in November 2018. She reported that her sons took turns living with her due to her illnesses. She noted that she could be distant from her family, had trouble being around people, and could not celebrate the holidays with her family. She had a few military friends but mostly did things by herself, avoiding crowds and sitting in the back of places like church or the movies. The Veteran continued to be unemployed due to her myasthenia gravis. She started online classes in September 2017 but had to withdraw when she began inpatient psychiatric treatment. She currently spent her days reading and watching television. The Veteran continued participating in therapy following the 45-day inpatient program and took Escitalopram and Topiramate as prescribed. Current symptoms were noted to be depressed mood, anxiety, panic attacks occurring weekly or less often, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. Upon observation, the Veteran was well-groomed and fashionably dressed, alert and oriented, and speech was clear and logical. She described decreased interest, poor concentration, fatigue, and interrupted sleep despite her medications. At times she became so depressed with dealing with her health problems that she had trouble motivating herself to get out of bed. She reported spending 3 to 4 days in bed and having her sons make her get up. She stated that her sons feared she was relapsing and would need to be hospitalized again. The examiner diagnosed PTSD and major depressive disorder, recurrent, moderate, with anxious distress. The examiner determined that the conditions had overlapping symptoms such that it would be impossible to attribute each symptom to a separate disorder. The Veteran's psychiatric condition resulted in occupational and social impairment with reduced reliability and productivity. Multiple treatment records from January 2019, February 2019, August 2019, and November 2019 noted that feelings of depression, insomnia, anxiety, and social isolation had been problematic, interfering with mood and functioning; mental status evaluations reflected casual dress, cooperative attitude, slowed speech, sad and tearful affect and mood, goal-directed thought process, no overt psychosis, the denial of perceptual disturbances, motor activity within normal limits, attentiveness and orientation on all spheres, average level of intelligence, fair judgment, and limited insight. The Veteran was deemed not to be a suicide risk. In February 2019, the Veteran endorsed continued fatigue, social withdrawal, lethargy, anhedonia, anxiety, and insomnia. She reported that she had support from her sons, other family members, and friends. She also relied heavily on her faith. In August 2019, the Veteran reported severe PTSD symptoms of significant anxiety, hypervigilance, and depression but she emphatically denied thoughts of self-harming behaviors, suicidal or homicidal ideation, audiovisual hallucinations, and paranoia or mania. Later in August 2019, the Veteran stated that she had had a brief period of social isolation and depression but she took a vacation by herself which helped. She had a good mood on her current medications. She experienced mild anxiety for two to three weeks without a specific cause. She noted that she started sweating profusely and had heart palpitations while getting her hair cut. In November 2019, the Veteran stated that her nightmares had increased in frequency averaging 4 times per week. Topiramate was effective in managing her irritability and anger but she requested an increase in Escitalopram. In March 2020, she endorsed mild mood issues and depression but denied suicidal or homicidal ideation and psychosis. In June 2020, the Veteran stated that her medications were helpful with depression, anxiety, and PTSD symptoms, her appetite was good, and she denied suicidal and homicidal ideation and audiovisual hallucinations. (a.) A rating in excess of 50 percent for PTSD prior to February 1, 2016, is denied. Prior to February 1, 2016, the Veteran's PTSD consistently manifested in symptoms of depression, anxiety, irritability, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. The Board finds that her symptom presentation is best approximated by occupational and social impairment with reduced reliability and productivity. Prior to February 1, 2016, occupational and social impairment with deficiencies in most areas was not demonstrated. There was no evidence of suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships, or symptoms of a similar severity. Although she endorsed periods of depression, she also noted multiple periods of improved symptoms, suggesting depression was not near-continuous. The April 2015 examiner indicated that one met criterion of PTSD included irritable behavior and angry outbursts with little or no provocation. However, VA treatment records reflected that the Veteran's irritability was due to specific causes and stressors including ending a long-term friendship, arguing with her sons when they did not listen to her, and when her physical disabilities were bothering her. She also later noted that she had not been physically violent with anyone since 2009. As such, the Board finds that the Veteran's irritability did not result in impaired impulse control that caused deficiencies in most areas. Indeed, despite such irritability she maintained close relationships with her sons, occasional relationships with friends, and an active life with her church. Similarly, although a July 2015 clinician noted that the Veteran had a hard time accepting changes, the Board finds that this did not result in difficulty in adapting to stressful circumstances such that occupational and social impairment with deficiencies in most areas was demonstrated. During fluctuations in her physical health and being medically boarded out from the Army National Guard, the Veteran continued to present with a clean appearance, with normal speech and thought processes, without perceptual disturbances, with normal judgment, and without any cognitive difficulties. Her mood and affect remained relatively stable and she consistently denied suicidal thoughts. She maintained her relationships with her sons and continued to be active in her church. As such, although she had a hard time accepting changes, it did not appear to cause significant functional impairment. Based on the foregoing, the Board finds that occupational and social impairment with deficiencies in most areas was not demonstrated prior to February 1, 2016. As such, a rating in excess of 50 percent prior to that date is not warranted. (b.) A 70 percent rating, but no more, for PTSD from February 1, 2016, is granted. The Board finds that a 70 percent rating, but no more, for PTSD is warranted from February 1, 2016. The VA examination conducted on that date reflected a worsening in the severity, frequency, and duration of the Veteran's psychiatric symptoms. She described increased symptoms of anxiety, worsened memory, poor attention and concentration, increased irritability (including yelling, cursing, and insulting others in anger, and throwing and kicking things), homicidal ideation on one occasion, intrusive thoughts, and hallucinations of someone breaking into her home. The Board finds that this increased symptomology and the frequency with which her symptoms worsened resulted in occupational and social impairment with deficiencies in most areas. As such, a 70 percent rating is warranted as of the date of the examination, but no earlier. Other than during the temporary total rating period from October 30, 2017, to January 1, 2018, a rating in excess of 70 percent is not warranted as total occupational and social impairment has not been demonstrated. There is no evidence of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name, or symptoms of a similar severity. Although the Veteran described a hallucination of someone breaking into her home, there is no indication of persistent hallucinations anywhere in the record. Further, although, as noted in the JMPR, the February 2016 examiner listed suicidal ideation with plan but no intent as a symptom attributable to depression, it is not clear that the symptom was actually diagnosed by the examiner. Indeed, it was noted that the Veteran denied suicidal ideation and had no history of suicide attempts. She repeatedly denied suicidal ideation numerous times throughout the record (once emphatically so) and was never deemed a suicide risk by treating clinicians. She expressed a desire to harm her ex-boyfriend and his wife on one occasion but has not subsequently repeated such an inclination. As such, persistent danger of hurting self or others has not been demonstrated. Accordingly, the severity, frequency, and duration of the Veteran's psychiatric symptoms have not been shown to result in total occupational and social impairment. Therefore, a rating in excess of 70 percent is not warranted. The Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule. 2. Nerve Damage Service connection for nerve damage status post extraction of tooth #17 was granted effective August 22, 2005, at a noncompensable rate under 38 C.F.R. § 4.124a, DC 8312, pertaining to neuritis of the twelfth (hypoglossal) cranial nerve. The Veteran timely appealed and the rating was increased to 10 percent, effective October 18, 2017. Pursuant to the September 2019 Board decision, a 10 percent rating was granted throughout the entire appeal period in a September 2019 rating decision. Accordingly, the Board will consider entitlement to a rating in excess of 10 percent from August 22, 2005. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. Similarly, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum rating equal to moderate incomplete paralysis. 38 C.F.R. §§ 4.124, 4.124a, DC 8629, 8729, 8630, 8730. Under DC 8312, a 10 percent disability rating is warranted for moderate incomplete paralysis of the twelfth (hypoglossal) cranial nerve. A 30 percent disability rating is warranted when there is severe incomplete paralysis of the twelfth cranial nerve, and a maximum 50 percent rating is for application when there is complete paralysis of the twelfth cranial nerve. The ratings for the cranial nerves are for unilateral involvement; when bilateral, the ratings are combined but without the bilateral factor. 38 C.F.R. § 4.124a. A Note to DC 8212 indicates that these ratings are dependent upon loss of motor function of the tongue. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. The Board does note, for reference and illustrative purposes only, that accepted definitions for "moderate" include of average or medium quantity, quality, or extent. See Webster's II New College Dictionary at 704 (1995). In addition, accepted definitions for "severe" include extremely intense. Id. at 1012. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Turning to the evidence of record, the Veteran stated to VA clinicians in September 2005 that she had had numbness in her face since the tooth #17 extraction. A VA dental examination was conducted in December 2005. The examiner stated that there was no functional impairment due to motion. Mastication was only affected in that the Veteran could not perceive touch normally to that side of her face, particularly the lip. Probing revealed no sensation medial to #19 and in the areas of #22 and 23. The lateral aspect of the tongue and part of the posterior dorsum of the tongue were not reactive to sticking with a sharp probe. There was no limitation of inter-incisal range of motion. Maximal opening was approximately 45 mm. Lateral excursion, both left and right, was approximately 7 mm. The examiner's conclusion was that there was evidence sufficient to support the Veteran's claim of nerve damage resulting from the extraction of tooth #17. The Veteran underwent a VA general medical examination in January 2006. She denied having any facial injury or trauma but reported numbness in her face on the left side of her mouth and lip since the #17 tooth extraction in service. A neurological examination yielded essentially normal results without any evidence of focal neurological deficits. January 2007, February 2007, and April 2007 VA treatment records reflected normal facial strength and sensation. Multiple records from June 2007 noted mild decreased facial strength but normal sensation. One June 2007 record stated that cranial nerves II through XII were intact bilaterally. Intact cranial nerves were noted in August 2007, October 2007, April 2008, and May 2008. In a June 2008 VA treatment record, clinicians noted that the Veteran's facial muscles were weak with some weakness in jaw closure. Later that month, the Veteran's face was symmetric with normal strength and sensation. In September 2008, decreased strength on smile was noted. Later that month, facial strength without deficit was listed. In multiple March 2009 treatment records, facial weakness on both sides with normal sensation was indicated. Regarding the cranial nerves, clinicians stated that the Veteran's face was symmetric with normal strength and sensation in multiple February 2010 and June 2010 treatment records. Decreased strength and normal sensation were noted in September 2010 records. Normal facial strength and sensation were reflected in numerous December 2010, March 2011, June 2011, February 2012, and March 2012 treatment records. Another VA dental examination was conducted in May 2012. The Veteran described paresthesia of the left cheek since the #17 tooth extraction which had not gotten worse. Imaging was within normal limits. Multiple treatment records from June 2012, August 2012, October 2012, November 2012, December 2012, January 2013, June 2013, October 2013, November 2013, July 2015, August 2015, September 2015, November 2015, April 2016, November 2016, December 2016, February 2017, March 2017, and May 2017 demonstrated normal facial strength and sensation. Significant weakness of the orbicularis oculi muscles was reflected in October 2013 and November 2013 records and bilateral facial weakness to cheek puff was noted in May 2015 and June 2014. No numbness and tingling were indicated in March 2016, December 2016, January 2017, July 2017, and October 2017 records. A VA cranial nerve examination was conducted in October 2017. The Veteran described sudden onset left cheek numbness and tingling with some tingling sensation of the left side of the tongue following the surgical extraction of the left lower wisdom tooth in service. Symptoms were indicated to be moderate paresthesias/dysesthesias and numbness in the left mid-face, mild paresthesias/dysesthesias in the left side of the mouth and throat, moderate difficulty chewing, mild difficulty swallowing, mild difficulty speaking, and mild increased salivation. Muscle strength testing involving cranial nerve XII was moderate on the left. A sensory examination yielded normal results. The examiner determined that the involvement of cranial nerve XII was incomplete, moderate. There were no functional limitations. Numbness and tingling were denied in January 2018, April 2018, August 2018, September 2018, March 2019, July 2019, and September 2019 records. Normal facial strength and sensation were indicated in February 2018, June 2018, August 2018, September 2018, January 2019, February 2019, August 2019, and November 2019 records. In a December 2019 VA treatment record, the Veteran described residual paresthesia from extraction of the #17 tooth with numbness from the mandibular angle to the approximately #22 tooth area. (a.) An initial rating in excess of 10 percent for nerve damage status post extraction of tooth #17 is denied. The Board finds that a rating in excess of 10 percent is not warranted for the Veteran's facial nerve damage at any point during the appeal period. Decreased sensation or weakness has been noted upon several occasions throughout the record but on the vast majority of occasions, normal strength and sensation was noted in the Veteran's face. The Board finds that such intermittent presentation of symptoms is more appropriately characterized as moderate involvement and that if decreased sensation and strength were noted upon the majority of clinical evaluations, a characterization of severe symptomology would likely be appropriate. Further, although there was numbness in the tongue at the December 2005 examination, there was no loss of motor function. At the October 2017 examination, difficulty chewing and swallowing were determined to be moderate at worst. Without a demonstration at any point of loss of motor function of the tongue that was more pronounced, extreme or intense involvement has not been demonstrated such that a rating for severe incomplete paralysis is warranted. As such, for this particular disability, the Board finds that the intermittent decreased sensation and strength, numbness, and difficulty chewing equate to moderate, or medium quality, involvement of cranial nerve XII. As such symptomology has not been shown to be constant upon clinical evaluation and has not resulted in extreme or intense loss of motor function of the tongue, the Board finds that severe involvement of cranial nerve XII has not been demonstrated. Accordingly, an initial rating in excess of 10 percent for nerve damage status post extraction of tooth #17 is not warranted. The Board has considered the applicability of other diagnostic codes relevant to a dental condition. However, service connection for compensation purposes is not available for a dental condition other than for injuries sustained as a result of dental trauma. Dental disabilities which may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, DC 9900-9916. As the Veteran's #17 tooth extraction was not due to trauma or disease and none of the other dental disabilities have been demonstrated, additional or alternative ratings under diagnostic codes pertaining to dental conditions are not warranted. The Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rachel E. Jensen, 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.