Citation Nr: 22019701 Decision Date: 04/02/22 Archive Date: 04/02/22 DOCKET NO. 13-32 640 DATE: April 2, 2022 REMANDED Entitlement to service connection for temporomandibular joint syndrome (TMJ) with bruxism is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from February 2004 to February 2010. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Seattle, Washington. Jurisdiction of this appeal is currently with the RO in New York, New York. The Veteran testified at a hearing before the undersigned Veterans Law Judge of the Board in June 2020. A transcript of the hearing has been associated with the claims file. This case was most recently before the Board in June 2021, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for appellate action. Service Connection TMJ with Bruxism The Veteran asserts that he has TMJ with bruxism as a result of his active service. Specifically, the Veteran testified at his June 2020 Board hearing that his TMJ symptoms had their onset during service and have continued since; were caused by stress; and that he was prescribed a mouth guard for bruxism during service. See Board hearing transcript, June 19, 2020. As noted above, the claim for entitlement to service connection for TMJ with bruxism was most recently before the Board in June 2021, at which time the claim was remanded to the RO for further development. Specifically, the June 2020 Board remand found that the November 2020 VA etiology opinions were inadequate to decide the claim. The Board also directed the RO to afford the Veteran a VA examination to determine the nature and etiology of his claimed TMJ with bruxism. The Veteran was afforded the directed VA examination for his TMJ with bruxism in January 2022. At that time, the examiner opined the Veteran's TMJ with bruxism was less likely than not due to or the result of the Veteran's service-connected disabilities. In this regard, the VA examiner noted that while theoretically TMJ could arise in any chronic pain syndrome, there was no evidence to establish the Veteran's TMJ with bruxism was the result of his service-connected disabilities. Additionally, the VA examiner noted there was no medical evidence to show the Veteran sought treatment or followed up for TMJ with bruxism. Therefore, a nexus could not be established without resorting to mere speculation. The Board finds the January 2022 VA medical opinion inadequate to decide the claim. In this regard, the VA examiner did not provide supporting rationale for the conclusions reached. Rather, the VA examiner merely stated that the Veteran's TMJ with bruxism was not related to his service-connected disabilities without further elaboration. In addition, the VA examiner also seemed to rely solely on the lack of a diagnosis of a jaw disorder during service. To the extent that this examiner appear to have relied on an absence of a diagnosis of a jaw disorder in service, medical opinions with such rationale are inadequate. Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (2006); Jandreau v. Nicholson, 492 F.3d 1372 (2007); see also Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of an in-service injury and instead relied on the absence of evidence in a Veteran's service treatment record to provide a negative opinion). Additionally, if an examiner cannot provide an opinion without resorting to speculation, he or she must make it apparent that the "inability to provide an opinion without resorting to speculation," reflects the limitation of knowledge in the medical community at large "and not a limitation whether based on lack of expertise, insufficient information, or unprocured testing of the individual examiner." See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). In this case, the examiner appears to have concluded that a nexus between the Veteran's jaw disorder and his service cannot be established without resorting to speculation. The examiner did not however establish that such speculation is due to limitations of knowledge in the medical community at large. For this reason also, the Board finds the January 2022 VA medical opinion inadequate. Finally, the VA examiner failed to provide an opinion as to direct service connection. Rather, the VA examiner only provided an opinion as to secondary service connection. Accordingly, the Board concludes that the Veteran should be afforded a new VA examination to determine the nature and etiology of his TMJ with bruxism. Where VA provides a veteran with an examination in a service connection claim, the examination and medical opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D'Aries, 22 Vet. App. at 105; see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, remand is again required to obtain additional VA addendum opinions that comply with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. at 268, 271 (1998). The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his TMJ with bruxism. Any and all indicated evaluations, studies and tests deemed necessary by the examiner should be accomplished. The need for further in-person examination is left to the discretion of the examiner. The examiner should respond to the following questions: (A) Is it at least as likely as not (50 percent or greater probability) that the Veteran's TMJ with bruxism had onset in service or is otherwise related to his active duty service? (B) Is it at least as likely as not (50 percent or greater probability) that the Veteran's TMJ with bruxism was caused or aggravated by any service-connected disorder? The examiner is reminded that an etiology opinion cannot rely on the absence of a diagnosis of a jaw disorder in service. The examiner should explain the significance, or lack thereof, of the Veteran's testimony that he has been prescribed a mouthguard to be worn while sleeping to guard against teeth grinding. The examiner should also address the Veteran's assertions that a mandible disorder is a stress reflex that originated in service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resorting to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.