Citation Nr: 21031841 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 14-20 220A DATE: May 24, 2021 ORDER Entitlement to an evaluation in excess of 10 percent for service-connected residuals of left foot hallux rigidus is denied. Entitlement to a 10 percent rating for service-connected limitation of motion of the temporomandibular joint (TMJ) due to causes other than TMJ disorder is granted. Entitlement to service connection for right shoulder osteoarthritis with rotator cuff tear is denied. Entitlement to service connection for loss of teeth is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder (claimed as major depression) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran has been in receipt of the maximum schedular rating authorized under Diagnostic Code 5281 for hallux rigidus of the left foot. 2. The Veteran's jaw disability causes functional loss due to pain 3. The Veteran's right shoulder disability was not manifest in service, was not manifest within one year of separation and is not related to service. 4. The Veteran's loss of teeth was not manifested by loss of substance of the maxilla or mandible due to trauma or disease such as osteomyelitis during his service and is not caused or aggravated by his limitation of motion of the TMJ. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for service-connected residuals of left foot hallux rigidus, have not been met. 38 U.S.C. § 1155, 5107(b) (2012); 38 C.F.R. § 4.71a, Code 5280 (2020). 2. The criteria for a 10 percent evaluation for limitation of motion of the TMJ are met. 38 U.S.C. §§ 1155, 5107 (2012), 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.150, Diagnostic Codes 9904, 9905 (2020). 3. A right shoulder disability was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). 4. The criteria for service connection for loss of teeth for compensation purposes have not been met. 38 U.S.C. §§ 1131, 1712; 38 C.F.R. §§ 3.381, 4.150 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1979 to December 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge during a December 2017 hearing. A transcript of the hearing has been associated with the claims file. The Board previously remanded these claims for further development in May 2018 and February 2021. Increased Rating Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2020). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his left foot and temporomandibular joint disorder disabilities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Left Foot The Veteran filed a claim for an increased rating that was received by VA in April 2012. The Veteran's has a current 10 percent disability rating for his left foot under the criteria for severe unilateral hallux rigidus. 38 C.F.R. § 4.71a, Diagnostic Code 5281. Pursuant to Diagnostic Code 5281, the only rating is 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5281. The disability should be rated as severe hallux valgus and should not be combined with claw foot ratings. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, Diagnostic Code 5281 was not changed. Foot disabilities are governed by the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5276 through 5284. Diagnostic Code 5280 provides ratings for hallux valgus, unilateral. Under Diagnostic Code 5280, a maximum 10 percent rating is warranted for hallux valgus, operated with resection of the metatarsal head, or for hallux valgus that is severe, if equivalent to amputation of the great toe. 38 C.F.R. § 4.71a. Diagnostic Code 5284 provides ratings for residuals of other foot injuries. Moderate residuals of foot injuries are rated 10 percent disabling; moderately severe residuals of foot injuries are rated 20 percent disabling; and severe residuals of foot injuries are rated 30 percent disabling. A Note to Diagnostic Code 5284 provides that foot injuries with actual loss of use of the foot are to be rated 40 percent disabling. 38 C.F.R. § 4.71a. Factual Background and Analysis The Veteran underwent a VA examination in October 2012. The examiner noted that the Veteran had hallux valgus and hallux rigidus. The Veteran presented with complaints of left great toe pain and that he developed calluses on the bottom of his left great toe. The Veteran had hallux valgus but did not have any symptoms from his hallux valgus. He had mild or moderate symptoms of his hallux rigidus. He regularly used a brace for his right knee disability. He also had degenerative traumatic arthritis of the left foot. There was also bilateral pes planus. The Veteran's left foot disability impacted his ability to work as he had difficulty lifting equipment when his foot was hurting. The Veteran underwent a VA examination in April 2019. The examiner noted that the Veteran had hallux rigidus of the left foot. The Veteran reported sharp pain, aching, numbness and foot tenderness. He also had flare-ups that impacted the function of his foot as he had sharp pain, aching and numbness when walking distances over 2 blocks. He had difficulty with standing and walking for long periods. The examiner noted that the Veteran had mild to moderate symptoms of his hallux rigidus. On examination, there was pain on movement, weight-bearing and non-weight-bearing. The Veteran constantly used a cane to aid with mobility. The Veteran's left foot disability impacted his ability to perform occupational tasks as he had difficulty walking over 2 blocks. Based on the evidence, the Board does not find that the Veteran is entitled to a rating in excess of 10 percent for residuals of left foot hallux rigidus. As noted above, the 10 percent rating is the maximum rating available under Diagnostic Code 5281. As a result, a rating in excess of 10 percent under Diagnostic Code 5281 is not available. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59, and the holdings in DeLuca. DeLuca v. Brown, 8 Vet. App. 202. However, a higher evaluation is not warranted on the basis of functional loss due to pain or weakness in this case. First, the provisions of DeLuca only apply when a Diagnostic Code is predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7, 9 (1996). Here, Diagnostic Code 5281 is not based on limitation of motion. Even assuming DeLuca applies, as noted above, the Veteran has presented with complaints of pain, tenderness and numbness. These symptoms have been reported and remarked upon by VA health care providers throughout the time period on appeal, and have been included and considered in the VA examinations. As such, the Veteran's subjective complaints are fully contemplated by the 10 percent evaluation for residuals of left foot hallux rigidus. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. Although 10 percent is the maximum rating available for hallux valgus, hallux rigidus, or hallux limitus, the Board must consider the assignment of an increased evaluation under other potentially applicable codes. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). However, as the Veteran's disability is hallux rigidus, which is specifically contemplated by Diagnostic Code 5281, evaluation under the general category of Diagnostic Code 5284 for other foot injuries is inappropriate. See Copeland v. McDonald, 27 Vet. App. 333 (2015) (holding that when a condition is specifically listed in the Schedule, it may not be rated by analogy). With respect to Diagnostic Code 5276 related to pes planus, the October 2012 VA examination noted that the Veteran had pes planus. However, service connection is not in effect for this disorder and the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Regardless, the Board also finds that the symptoms of which the Veteran has complained are contemplated by Diagnostic Code 5281, including pain on manipulation and use of the feet. Thus, the Board finds that application of Diagnostic Code 5276 is inappropriate, as the symptoms contemplated by Diagnostic Code 5281 would overlap with the symptoms contemplated by Diagnostic Code 5276. Consequently, assigning a separate rating for the Veteran's bilateral pes planus would constitute impermissible pyramiding. 38 C.F.R. § 4.14. The Board has also considered entitlement to a separate or higher evaluation under Diagnostic Codes 5266 (flatfoot), 5277 (weak foot), 5278 (claw foot), 5279 (metatarsalgia (Morton's disease)), 5280 (hallux valgus), and 5282 (hammer toe). 38 C.F.R. § 4.71a (2017). However, there is no objective medical evidence showing symptomatology that warrants a compensable rating under any of the aforementioned diagnostic codes. Higher ratings are not warranted under Diagnostic Code 5266 as there is no evidence of marked pronation or other deformity in either foot. Higher ratings are not warranted under Diagnostic Code 5278 as there is no evidence of dorsiflexion of the great toe or all toes. As a result, the Board finds that a rating in excess of 10 percent for residuals of left foot hallux rigidus is not warranted. The Board notes that in an April 2021 correspondence, the Veteran's representative claimed that the Veteran should be entitled to a greater level of compensation on an extraschedular basis for his increased rating for residuals of left foot hallux rigidus. According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § § 3.321 (b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director, Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The evidence in this case, however, does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected residuals of left foot hallux rigidus are inadequate. The VA examinations and treatment records establish that the Veteran reported his symptoms of left foot disability which included pain, numbness and tenderness. Here, the rating criteria for Diagnostic Code 5281 reasonably describes the Veteran's disability level and symptomatology for residuals of left foot hallux rigidus. The Board also considers the Veteran's statements and assertions and whether it results in an exceptional disability picture to include marked interference with employment or frequent periods of hospitalization. However, the Board finds the evidence of record does not support a finding that is unusual or different as contemplated by the schedular rating criteria. As the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is therefore, adequate. As such, the Board also finds that referral of the Veteran's residuals of a right ankle injury for extraschedular consideration pursuant to 38 C.F.R. § 3.321 (b)(1) is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating evaluation in excess of 10 percent for residuals of a left foot disability. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. TMJ The Veteran filed a claim for an increased rating that was received by VA in April 2012. The Veteran's has a current noncompensable disability rating for his TMJ disorder under Diagnostic Code 9905. The rating under Diagnostic Code 9905 is based on limited motion of temporomandibular articulation. 38 C.F.R. § 4.150 (2020). The applicable rating criteria for dental and oral conditions under 38 C.F.R. § 4.150 were amended, effective September 10, 2017, and the "new" schedular criteria are applicable as of that date. See 82 Fed. Reg. 36080 (August 3, 2017). As such, the Board will consider the "old" schedular criteria for the entirety of the rating period, but the revised criteria only from the effective date of the change in regulation. Under the "old" schedular criteria, Diagnostic Code 9905, limitation of motion of the TMJ warrants a 10 percent rating if there is limitation of inter-incisal range of motion of 31 to 40 mm; or limitation range of lateral excursion of 0 to 4 mm. A 20 percent rating is warranted when inter-incisal range is limited to 21 to 30 mm; a 30 percent rating is warranted when inter-incisal range is limited to 11 to 20 mm; and a maximum 40 percent rating is warranted when inter-incisal range is limited to 0 to 10 mm. A note to Diagnostic Code 9905 provides that ratings for limited inter-incisal movement shall not be separately rated, for combination, with ratings for limited lateral excursion. Under the "new" schedular criteria, Diagnostic Code 9905, inter-incisal range of 0 to 10 mm of maximum unassisted vertical opening; with dietary restrictions to all mechanically altered foods warrants a 50 percent rating; without dietary restrictions to mechanically altered foods warrants 40 percent. Inter-incisal range of 11 to 20 mm of maximum unassisted vertical opening: with dietary restrictions to all mechanically altered foods warrants 40 percent; without dietary restrictions to mechanically altered foods warrants 30 percent. Inter-incisal range of 21 to 29 mm of maximum unassisted vertical opening: with dietary restrictions to full liquid and pureed foods warrants 40 percent; with dietary restrictions to soft and semi-solid foods warrants 30 percent; without dietary restrictions to mechanically altered foods warrants 20 percent. Inter-incisal range of 30 to 34 mm of maximum unassisted vertical opening: with dietary restrictions to full liquid and pureed foods warrants 30 percent; with dietary restrictions to soft and semi-solid foods warrants 20 percent; without dietary restrictions to mechanically altered foods warrants 10 percent. Lateral excursion range of motion of 0 to 4 mm warrants 10 percent. Note (1) of the "new" criteria provides that ratings for inter-incisal movement shall not be combined with ratings for limited lateral excursion. For VA compensation purposes, the normal maximum unassisted range of vertical jaw opening is from 35 to 50 mm. For VA compensation purposes, mechanically altered foods are defined as altered by blending, chopping, grinding or mashing so that they are easy to chew and swallow. There are four levels of mechanically altered foods: full liquid, puree, soft, and semisolid foods. To warrant elevation based on mechanically altered foods, the use of texture-modified diets must be recorded or verified by a physician. Diagnostic Codes 9900-9916 provide various schedular ratings based on whole or partial loss of the mandible or maxilla, or nonunion or malunion of the same. The Board notes that, other than the codes discussed above, no other diagnostic code for dental and oral conditions is applicable during any other period of the Veteran's appeal. The Veteran's residuals of fractured mandible do not include osteomyelitis, complete loss of the mandible, nonunion or malunion of the mandible, loss of condyloid process or hard palate, loss of all upper or lower teeth due to loss of substance of body of maxilla or mandible, loss of maxilla, or malunion or nonunion of maxilla. As these Diagnostic Codes are not applicable, a higher rating is not available under their respective criteria. Factual Background and Analysis The Veteran underwent a VA examination in November 2012. The examiner noted that the Veteran had limitation of motion of the TMJ due to causes other than TMJ disorder. The Veteran reported that since he had oral surgery in 1983, he had occasional jock lock which he had to reduce. Range of motion for lateral excursion was greater than 4mm and there was no objective evidence of painful motion. Range of motion for opening mouth was greater than 40mm with no objective evidence of painful motion. He did not have additional range of motion limitation with repetitive use testing. He did not have any localized pain or tenderness on examination. The examiner noted that the Veteran's reported locking of his jaw could not be reproduced during the examination. In an April 2021 correspondence, the Veteran's representative indicated that the Veteran had painful motion of his jaw. Based on the reported symptomatology of the Veteran's limitation of motion and reported functional impairments at his November 2012 VA examination, the Board finds that when affording the Veteran the benefit of the doubt, that a 10 percent, but no higher, rating is warranted for the Veteran's service-connected TMJ disorder disability. The Board notes that there is no evidence that the Veteran had TMJ, and there is no documentation that inter-incisal range was 31 to 40 mm or lateral excursion was 0 to 4 mm to warrant a 10 percent rating under Diagnostic Code 9905. Notably, the November 2012 VA examiner indicated that the Veteran did not have TMJ and the Veteran also had no loss of mandible. Nevertheless, the Board notes that the examiner noted that the Veteran had limitation of motion of the TMJ due to causes other than TMJ disorder as the Veteran reported that since he had oral surgery in 1983, he had occasional jock lock which he had to reduce. This indicates functional loss. Notably, while the November 2012 VA examiner indicated that there was no loss of motion and no additional limitation of motion after repetitive use, it was also specifically noted that the Veteran was unable to reproduce his reported locking of the jaw at the time of the November 2012 examination. Therefore, the minimal compensable rating under Diagnostic Code 9905 is warranted pursuant to 38 C.F.R. § 4.59 ("actually painful joints due to healed injury [are] entitled to at least the minimum compensable rating for the joint."). See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. As a result, based on the reported symptomatology of the Veteran's reported functional impairment at his November 2012 VA examination, the Board finds that when affording the Veteran the benefit of the doubt that a higher 10 percent rating for limitation of motion shall be assigned. However, the claim for a rating in excess of 10 percent is denied as the criteria for a higher rating are not met nor more nearly approximated, and the 10 percent rating accounts for the Veteran's symptoms as neither the lay nor medical evidence reflects the functional equivalent of impairment required for a higher evaluation in excess of 10 percent. As noted above, under the old criteria, a 20 percent rating was warranted for inter-incisal range limited to 21 to 30 mm while a rating in excess of 10 percent under the new criteria requires inter-incisal range of 30 to 34 mm of maximum unassisted vertical opening with dietary restrictions to soft and semi-solid foods. In this instance, there is no evidence that the Veteran's diet was restricted by a physician, as required in Note 3 or that his interincisal range was limited to less than 34 mm as required for a higher rating under Diagnostic Code 9905. The Board has considered whether factors such as functional impairment and pain addressed under 38 C.F.R. §§ 4. 10, 4.40, and 4.45 would warrant a higher rating for the Veteran's jaw disability during the rating period under consideration. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). However, the Board finds that even accounting for the Veteran's occasional painful jaw locking, his symptoms do not rise to the level for a 20 percent rating. The lay and medical evidence reflects that the Veteran's pain has not been so severe, frequent and/or prolonged to warrant a 20 percent rating. In sum, an evaluation in excess of 10 percent rating for limitation of motion of the TMJ due to causes other than TMJ disorder is not warranted. Accordingly, the Board finds that the evidence supports the assignment of a 10 percent rating for a limitation of motion of the TMJ due to causes other than TMJ disorder disability. However, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 10 percent for a limitation of motion of the TMJ due to causes other than TMJ disorder disability. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020). Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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). 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 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as arthritis is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. 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). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Right Shoulder Factual Background and Analysis An August 1983 service treatment report noted diffuse myalgias in the back and upper extremities. The diagnosis was acute onset of severe diffuse myalgias of unknown cause. It was noted that at the time of his discharge, that he had a gradual resolution of his myalgias and only had some minor residual discomfort in the right shoulder. A November 1983 service treatment record noted unspecified musculoskeletal pain. Notably, the Veteran declined a separation examination. The Veteran underwent a VA examination in October 2012. The diagnosis was right shoulder osteoarthritis and a rotator cuff tear. The Veteran reported pulling a muscle in his right shoulder at airborne school but the symptoms went away. However they worsened and several years ago he could not lift up his arm. The examiner opined that it was less likely than not that the Veteran's right shoulder disability was incurred in or caused by his military service. The examiner noted that the Veteran during service was treated for multiple myalgias including right shoulder myalgia. However, there was a report of "gradual resolution, minor residual discomfort of right shoulder". There was no actual evidence of right shoulder pathology until 2010 which was more than a 20-year gap since he was discharged from the military. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for a right shoulder disability is not warranted. As there is a current diagnosis of osteoarthritis of the right shoulder with a rotator cuff tear, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). As noted above, service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis, if such disease is shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for a right shoulder disability on a presumptive basis is not warranted as the record does not show evidence of arthritis of the right shoulder during the Veteran's period of active military service, or within one year of his separation from active duty. Accordingly, service connection for a right shoulder disability on a presumptive basis is not warranted as a chronic disease did not manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. To the extent that the Veteran asserted that he experienced right shoulder pain and continuing symptoms thereafter, the Board acknowledges that a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). As a result, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Accordingly, service connection for a right shoulder disability on a presumptive basis for substitution purposes is not warranted as the Veteran's arthritis did not manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. Regarding service connection on a direct basis, the Board again notes that the Veteran's service treatment records demonstrate that the Veteran presented with complaints of diffuse myalgia with an unknown origin. However, despite these complaints, the service treatment records were negative for any or diagnoses of any right shoulder disability. The record reflects that his right shoulder complaints were medically addressed in service and the subsequent service treatment records were negative for complaints, treatments or diagnoses related to a right shoulder disability. Furthermore, the only medical opinions addressing the etiology of the right shoulder disability weigh against the claim. As noted above, the October 2012 VA examiner opined that it was less likely than not that the Veteran's right shoulder disability was incurred in or caused by his military service. The Board affords the VA examiner's October 2012 opinion, which is supported by a detailed rationale and medical knowledge, great probative value. In forming his opinion, the VA examiner specifically discussed the in-service complaints of myalgia and noted the Veteran's lay assertions regarding his right shoulder disability when as the examiner indicated that while the Veteran during service was treated for multiple myalgias including right shoulder myalgia and there was a report of "gradual resolution, minor residual discomfort of right shoulder", there was no actual evidence of right shoulder pathology until 2010 which was more than a 20 year gap since he was discharged from the military. None of the competent medical evidence of record refutes these conclusions, and the Veteran has not presented or identified any such existing medical evidence or opinion. Thus, the Board finds the examiner's October 2012 opinions to be persuasive. In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the appellant's claim of entitlement to service connection for a right shoulder disability. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). Loss of Teeth Dental disabilities that may be awarded compensable disability ratings include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, loss of the maxilla, nonunion or malunion of the maxilla, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, and loss of teeth due to the loss of substance of the body of the maxilla or mandible without loss of continuity. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities, but may be service connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 C.F.R. §§ 3.381, 17.161. Compensation is only paid for loss of teeth due to loss of substance of the body of maxilla or mandible without loss of continuity as a result of trauma or disease such as osteomyelitis, and not the loss of alveolar process as a result of periodontal disease, since such loss is not considered disabling. See 38 C.F.R. § 4.150, Diagnostic Code 9913. The Board notes that, in a precedent opinion, VA's General Counsel held that dental treatment of teeth, even extractions, during service did not constitute dental trauma. See VAOPGCPREC 5-97, 62 Fed. Reg. 15,566 (1997). The Veteran contends that service connection is warranted for his loss of teeth as a result of his service-connected limitation of motion of the TMJ disability. Notably, the Veteran underwent elective cosmetic orthognathic surgery in 1985. The Veteran underwent a VA examination in October 2004. The examiner noted that the Veteran underwent jaw surgery while in service in 1982. He presented to the examination with complaints of a loose bridge on his right lower jaw as well as occasional lock jaw. On examination, the TMJ was benign but he had multiple fractured teeth with visible roots and chronic and acute gingivitis and periodontitis. The examiner opined that he did not think that the present dental condition was related to the 1982 oral surgery. The Veteran underwent a VA examination in November 2012. The examiner provided a diagnosis of limitation of motion of the TMJ due to causes other than TMJ disorder. The Veteran also had periodontal disease. The examiner noted that a review of the claims file demonstrated that the Veteran was discharged in 1985 and had no problems with his teeth until around 2009 when he claimed that he started losing his teeth. He only had 4 remaining mandibular teeth and all 4 had moderate recession and chronic periodontal disease. His old surgery on his mandible had completely healed and his restoration of the bone was consistent with a long term denture wearer. The Veteran reported that he had elective cosmetic orthognathic surgery in 1983. On examination, he had not lost any part of the mandible or mandibular ramus. He did not have any injury resulting in malunion or nonunion of the mandible or maxilla. He had not lost any part of the maxilla. The loss of teeth was not due to the loss of substance of body of the maxilla or mandible without loss of continuity. The loss of teeth was not due to trauma or disease. X-rays demonstrated moderate bone loss due to chronic periodontal disease and long term denture wear. The examiner opined that it was less likely than not that the Veteran's loss of teeth were proximately due to or the result of the Veteran's service-connected disability. The examiner noted that there was no evidence that the post-surgical procedure performed in 1983 contributed in any way to the loss of the Veteran's teeth. It was also not likely that the surgical procedure caused the loss of his teeth and did not aggravate the loss of his teeth as it happened over 20 years after the surgery. The examiner noted that the Veteran's 4 remaining teeth had chronic periodontal disease and his oral hygiene was poor. Bacteria around the teeth and heavy smoking contributed to the advancement of tooth loss and orthognathic surgery usually prevented loss of teeth by correcting the congenital malocclusion. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against a finding that service connection for loss of teeth for compensation purposes is warranted. The evidence of record does not show that the Veteran experienced dental trauma during service. As noted above, the service treatment records document extensive dental treatment as the Veteran underwent jaw surgery. However, the Veteran has never claimed that he experienced any sort of trauma. In this case, the evidence of record is unremarkable for any compensable dental condition ("Class I" eligibility). See 38 C.F.R. § 17.161 (a). That is, there is no diagnosis of record for loss of whole or part of the mandible, nonunion or malunion of the mandible, loss of whole or part of the ramus, loss of whole or part of the maxilla, nonunion or malunion of the maxilla, loss of the condyloid or coronoid process, or loss of any part of the hard palate, for which service-connected compensation could be granted. See 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Significantly, the October 2012 VA examiner opined that it was less likely than not that the Veteran's loss of teeth were caused or aggravated by the Veteran's service-connected disability as there was no evidence that the post-surgical procedure performed in 1983 contributed in any way to the loss of the Veteran's teeth. The examiner additionally noted that the Veteran had not lost any part of the mandible or mandibular ramus, did not have any injury resulting in malunion or nonunion of the mandible or maxilla, had not lost any part of the maxilla and his loss of teeth was not due to the loss of substance of body of the maxilla or mandible without loss of continuity. The loss of teeth was also not due to trauma or disease as x-rays demonstrated moderate bone loss due to chronic periodontal disease and long term denture wear. As a result, although there is post-service evidence of loss of teeth, there is nothing to suggest that it is due to the loss of substance of body of maxilla or mandible during service through trauma or disease such as osteomyelitis. Again, the loss of the alveolar process as a result of periodontal disease is not considered disabling. See 38 C.F.R. § 4.150, Diagnostic Code 9913. For secondary service connection, the Veteran must have a "current dental disability," which must be a disability such as tooth loss caused by bone loss of the maxilla or mandible due to trauma or disease or TMJ dysfunction. The Veteran does not have a "current dental disability" for service-connected compensation purposes. While service connection may be established for treatment purposes for replaceable missing teeth and periodontal disease, the regulations listed above clearly prohibit service connection for purposes of compensation where the disability involves replaceable missing teeth or periodontal disease. As neither condition is recognized by the applicable regulations as a disability for which VA compensation may be granted, the Veteran's claim is not warranted. See 38 C.F.R. § 3.381 (periodontal disease is not a disability for compensation purposes). In addition, there was no evidence of any in-service dental trauma which resulted in residuals, additional loss of teeth, malunion or nonunion of the maxilla, or loss of body of the maxilla or mandible. See generally, VAOPGCPREC 5-97; 38 C.F.R. § 4.150, Diagnostic Codes 9913-9916. Consequently, there is no basis for entitlement to service connection for the Veteran's claimed loss of teeth for compensation purposes. In conclusion, a preponderance of the evidence is against the Veteran's claim for loss of teeth. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107 (b). All Disabilities The Board notes the Veteran's contentions regarding the etiology of his claimed right shoulder and loss of teeth disabilities. To the extent that the Veteran himself contends that a medical relationship exists between his claimed disabilities and service, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that right shoulder and loss of teeth disabilities are not disabilities subject to lay diagnosis as these diagnoses require medical training. More significantly, the Veteran and his representative do not have the medical expertise to provide an opinion regarding right shoulder and loss of teeth disabilities etiologies. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Additionally, the VA examiners provided detailed rationales in support of their opinions and cited to the relevant evidence. For this reason, the VA examiners' opinions are the most probative evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). As the preponderance of the evidence is against these claims, the benefit-of-the-doubt doctrine does not apply, and the claims for entitlement to service connection for right shoulder and loss of teeth disabilities must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claims remaining on appeal. Regarding the Veteran's claim for entitlement to service connection for an acquired psychiatric disorder (claimed as major depression), the Board remanded this matter in May 2018 for further development. In its remand, the Board instructed the RO to provide an addendum opinion which specifically addressed whether the Veteran's major depression as at least as likely as not proximately due to the service-connected left foot residuals of hallux rigidus/limitus or whether it was aggravated beyond its natural progression by the service-connected left foot residuals of hallux rigidus/limitus. The May 2018 Board remand specifically noted that in a January 2018 statement, the Veteran's wife explained that following his foot surgery in 1992, the Veteran had a long recovery and was never physically the same after that as she noted that during this time, his depression began to set in. Per the May 2018 Board remand instructions, the Veteran underwent a VA examination for his claimed acquired psychiatric disorder disability in September 2020. The examiner opined that it was less likely than not that the Veteran's acquired psychiatric disorder was caused or aggravated by his service-connected left foot residuals hallux rigidus/limitus. However, the rationale provided was that no VA examiner had found that the Veteran's claimed depressive disorder was aggravated beyond its natural progression by the service-connected left foot disability. The examiner further noted that the Veteran's wife stated that the Veteran's depression began to set in during his long recovery from his left foot surgery and that records indicated that the Veteran's father also died around this time which "might account for some of the depressive symptoms that were reported". Additionally, the examiner also specifically noted that the Veteran's left foot residuals hallux rigidus/limitus was a medical diagnosis that was relevant to the understanding or management of the Veteran's mental health disorder. As a result, while the examiner opined that it was less likely than not that the Veteran's acquired psychiatric disorder was caused or aggravated by his service-connected left foot disability, the rationale provided seems contradictory to this conclusion. The Board also notes that the rationale provided did not specifically address the Veteran's wife's contentions that the Veteran's depression began during his long recovery from left foot surgery as again, there are seemingly conflicting statements regarding whether the Veteran's acquired psychiatric disorder was caused or aggravated by his service-connected left foot residuals hallux rigidus/limitus. As a result, the Board finds that while the AOJ has made a good faith effort to further develop the claims, it has not "substantially complied" with the previous Board remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Thus, this issue is once again being remanded to ensure compliance with the May 2018 remand directives in order to provide a medical addendum for a full rationale for whether the Veteran's the Veteran's acquired psychiatric disorder was caused or aggravated by his service-connected left foot residuals hallux rigidus/limitus. Finally, the Board notes that further development and adjudication of this claim may provide evidence in support of his claim for TDIU. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. After the development requested above has been completed to the extent possible, provide the claims file, including this remand, to an appropriate VA examiner to provide an opinion regarding the etiology of the current acquired psychiatric disorder disability as secondary to a service-connected left foot disability. If, and only if, the examiner determines that an actual physical examination is necessary, one should be scheduled. Based on a review of the record the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's has a current acquired psychiatric disorder disability that is related to any incident of the Veteran's active duty service. The examiner should also provide an opinion as to whether if it is at least as likely as not (at least a 50 percent probability) that any such current acquired psychiatric disorder disability is caused or aggravated by his service-connected left foot disability. If the examiner finds that the Veteran has a current acquired psychiatric disorder disability that has been permanently aggravated/worsened by a service-connected left foot disability, the degree of worsening should be identified. In forming this opinion, the examiner should acknowledge the Veteran's spouse's contentions that the Veteran's depression began to set in during his long recovery from his left foot surgery. All opinions expressed by the examiner must be accompanied by a complete rationale. Adequate reasons and bases for any opinion rendered must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 3. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James A. DeFrank, 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.