Citation Nr: A25035182 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 230227-327030 DATE: April 16, 2025 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include persistent depressive disorder with anxious mood, unspecified depressive disorder, and unspecified anxiety disorder, is granted. Entitlement to service connection for a dental condition for compensation purposes is denied. REMANDED Entitlement to service connection for hypertension is remanded. REFERRED The issue of entitlement to service connection for a dental condition for the purpose of obtaining VA outpatient dental treatment was raised in an April 2023 appellate brief and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, the Veteran's acquired psychiatric disorder is at least as likely as not the result of his active service. 2. The evidence of record persuasively weighs against finding that the Veteran has had a current dental disability for VA compensation purposes, such as impairment of the mandible, ramus, or maxilla other than due to periodontal disease, or loss of teeth due to loss of substance of the body of the maxilla or mandible, at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include persistent depressive disorder with anxious mood, unspecified depressive disorder, and or unspecified anxiety disorder, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a dental condition for compensation purposes have not been met. 38 U.S.C. §§ 1110, 1131, 1712, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150, Diagnostic Code 9913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served on active duty in the United States Navy from January 1987 to February 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2022 rating decision and January 2023 rating decision by a Department of Veterans Affairs (VA) Regional Office. In February 2023, the Veteran timely filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and selected the Evidence Submission review option. The Board may therefore consider only the evidence of record at the time of the December 2022 and the January 2023 rating decisions on appeal, as well as any evidence submitted by the Veteran or the Veteran's representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the two rating decisions on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the issue of entitlement to service connection for hypertension, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. See 38 C.F.R. § 3.103(c)(2)(ii). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. Service connection requires evidence of (1) a current disability; (2) the in service incurrence or aggravation of a disease or injury; and (3) a causal relationship, or nexus, between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation: "In the absence of proof of a present [i.e., current] disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997) ("The requirement of a currently existing condition is not contrary to the statute, and in fact comports with the other provisions of the statute as a whole."). A disability is current when it exists near or when a claim is filed, or at any point during the claim's pendency. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt is to be resolved in favor of the claimant. 38 U.S.C. § 5107(b). Evidence is in approximate balance when the evidence in favor of and against an issue is equal or nearly equal. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc). Evidence is not in approximate balance, and the benefit-of-the-doubt rule need not apply, however, when the evidence persuasively favors one side or the other. Id. 1. Entitlement to service connection for an acquired psychiatric disorder. The Veteran seeks entitlement to service connection for an acquired psychiatric disorder, which he claimed as adjustment disorder, anxiety, depression, isolation, sleeplessness, and sadness. See March 2022 VA Form 21-526EZ. He asserts that while he served in the Navy, he felt like the walls of his ship were closing in on him, which made him very nervous and anxious living in such tight quarters, that he was admitted to the psychiatric unit of his ship, and that he was subsequently discharged from the military. See May 2022 VA Form 21-4138. The Board has reviewed the record in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), and expands the Veteran's claim to encompass any acquired psychiatric disorder supported by the record. In that regard, the record confirms the Veteran has a current disability. Here, the AOJ favorably found the Veteran has diagnoses of unspecified depressive disorder and unspecified anxiety disorder. See January 2023 Rating Decision (favorable findings). In addition, a March 2023 private medical evaluation also diagnosed the Veteran with persistent depressive disorder with anxious mood in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See March 2023 Private Medical Evaluation. The AOJ also favorably found that the Veteran has been diagnosed with antisocial personality disorder. See January 2023 Rating Decision (favorable findings). The record also confirms the incurrence of an in-service event. Here, the Veteran's in-service medical treatment records show that he underwent psychiatric evaluation for suicidal ideation and behavior consisting of placing a loaded gun into his head, and was diagnosed with personality disorder NOS (not otherwise specified) with dependent and antisocial features. See January 1988 Service Treatment Records. For purposes of service connection, a veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C. § 1111. To be "noted" means that the condition is recorded in the entrance examination report. See 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994); 38 C.F.R. § 3.304(b). Where there is no preexisting condition noted upon entry, a veteran is presumed to have entered service in sound condition, and the burden shifts to VA to demonstrate by clear and unmistakable evidence that the condition at issue preexisted service and was not aggravated by service. See 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). Clear and unmistakable evidence is defined as obvious or manifest. 38 C.F.R. § 3.306(b). Clear and unmistakable evidence means that the evidence "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirine v. Shinseki, 22 Vet. App. 390, 396 (2009) (internal quotes omitted). Additionally, personality disorders which are characterized by developmental defects or pathological trends in the personality structure manifested by a lifelong pattern of action or behavior, chronic psychoneurosis of long duration or other psychiatric symptomatology shown to have existed prior to service with the same manifestations during service, which were the basis of the service diagnosis, will be accepted as showing preservice origin. See 38 C.F.R. § 3.303(c). Personality disorders and mental deficiency as such are not diseases or injuries for purposes of service connection and VA disability benefits. See id. However, a personality disorder may be subject to a superimposed disease or injury that may warrant a grant of service connection. See VAOPGCPREC 82-90. Here, the Veteran's June 1986 report of medical examination and clinical evaluation shows that his psychiatric condition was normal at the time of enlistment. Thus, the Veteran is presumed to have been in sound condition at the time of entrance into military service. See 38 U.S.C. § 1111. However, after entering service, the Veteran's medical treatment records show that, during a January 1988 psychiatric evaluation, the Veteran gave permission for his treatment provider to call his mother, and that the Veteran's mother indicated that the Veteran had a history of making suicidal threats to her when he did not get his way, and that he also had a history of running away from home and other antisocial behavior. The Veteran was then diagnosed with personality disorder not otherwise specified, with dependent and antisocial features. See January 1988 Service Treatment Records. Accordingly, the question before the Board is whether the Veteran's current acquired psychiatric disorder had its onset during or is otherwise etiologically related to his active military service; or whether the Veteran's current acquired psychiatric disorder clearly and unmistakably preexisted his service and, if so, whether his acquired psychiatric disorder was clearly and unmistakably not aggravated by his service. There is competing evidence on this issue. Here, a November 2022 VA psychiatric examination is of record. The November 2022 VA examiner met with the Veteran for an in-person examination, and noted a review of the Veteran's claims file. During the in-person consultation, the Veteran reported that he was one of several children, had a great childhood with no history of neglect or abuse, and had a good family, and peer and social relationships. See November 2022 Mental Disorders DBQ at 3-4 (Section II, History). On examination, the November 2022 VA psychologist diagnosed the Veteran with antisocial personality disorder, and opined that the Veteran's antisocial personality disorder was undoubtedly not caused by and existed prior to the military. See id. at 1 (Section I, Diagnosis); and November 2022 Medical Opinion. The examiner explained that the DSM-5 defines antisocial personality disorder as a pervasive problem occurring since the age of 15. Based on that definition, the November 2022 VA examiner concluded that the Veteran's antisocial personality disorder clearly predated his service. See November 2022 Medical Opinion at 5 (Section VIII, Remarks). While the November 2022 examiner's remarks used language similar to that required by 38 U.S.C. § 1111, the examiner did not use or complete the section of the medical opinion concerning whether the Veteran's condition clearly and unmistakably preexisted and was (or was not) aggravated beyond its natural progression by his military service. See id. at 3 (Section V). Consequently, the Board is uncertain whether the November 2022 examiner applied the clear and unmistakable standard required by 38 U.S.C. § 1111 to rebut the presumption of soundness, or whether the examiner applied a different standard. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating an examiner must provide "not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two"); see also Stefl v. Nicholson, 21 Vet. App. 120, 123-124 (2007) ("Without a medical opinion that clearly addresses the relevant facts and medical science, the Board is left to rely on its own lay opinion, which it is forbidden from doing."). Consequently, the November 2022 examiner's opinion does not clearly and unmistakably rebut the presumption of soundness, and has only limited probative value. In December 2022, the Veteran underwent another VA examination to determine the nature and etiology of his claimed acquired psychiatric disorder. See December 2022 Mental Disorders DBQ. The December 2022 psychological examiner met the Veteran through an approved video telehealth conference, and noted a review of the claims file. During the approved telehealth conference, the Veteran reported that he grew up in a stable family, and reported no history of mental health issues prior to the military. See id. at 4 (Section II, History). On examination, the December 2022 VA psychologist diagnosed the Veteran with unspecified depressive disorder, unspecified anxiety disorder, and with antisocial personality disorder, and opined that the Veteran's acquired psychiatric disorder was less likely than not the result of, or aggravated beyond its natural progression by his antisocial personality disorder (ASP). See id. at 1 (Section I, Diagnosis); December 2022 Medical Opinion (unspecified depressive disorder); December 2022 Medical Opinion (adjustment disorder); December 2022 Medical Opinion (isolation); December 2022 Medical Opinion (unspecified anxiety disorder); and December 2022 Medical Opinion (sleeplessness). As support for that opinion, the December 2022 psychologist explained that ASP is characterized by a pervasive pattern of disregard for consequences and for the rights of others, poor judgment, impulsivity, problematic relationships, and instability of mood and behavior that manifests in adolescence, and that the behavior the Veteran's mother previously reported during the Veteran's January 1988 service psychiatric evaluation was typical behavior for someone with ASP. However, the December 2022 examiner did not opine whether the Veteran's condition clearly and unmistakably preexisted and was (or was not) aggravated beyond its natural progression by his military service. Consequently, the December 2022 VA medical opinions do not clearly and unmistakably rebut the presumption of soundness, and have only limited probative value. In April 2023, the Veteran submitted a private psychological assessment, dated March 2023, on the nature and etiology of his acquired psychiatric disorder. See March 2023 Private Psychological Assessment (received April 2023). The March 2023 private psychological evaluator met the Veteran for a live video conference examination, and noted and demonstrated a thorough and careful review of the claims file. During the live video conference consultation, the Veteran reported having a generally positive family environment without any sexual, physical, or emotional abuse. He reported important family relationships prior to service and that, within these relationships, he could share his thoughts and feelings, perceive emotional support and could settle arguments and disagreements without jeopardizing the relationship or becoming overly hostile or withdrawing. He described adequate peer friendships and enjoyable recreation and leisure and participated in high school team sports such as football and basketball. He also reported no mental health issues or concerns prior to service, and that he was generally happy, at home and at school, and participated in high school team sports en route to graduating from high school. See March 2023 Private Psychological Assessment at 1 (social history) and 7 (current self-report). The Veteran reported the onset of mental health difficulties in service aboard his ship. He described how almost immediately on the ship he had struggled adjusting. He was away from his family and friends, he was feeling claustrophobic, feeling trapped in small, confined areas without break or means of escape, he began to see his peers adjust and be respected by each other and superior officers when he could not. He stated that he began to feel completely alone, isolated, judged, and unable to do anything about it. As this continued, he described severe depression including a near total indifference and apathy toward his military career and to his military obligations. He reported joining the military because his brother did, and it was a source of family pride, and yet at the time he was indifferent to this as well. He was not able to sleep, and indicated that, as these issues worsened, he began to feel intense fight or flight urges and panic attack-like episodes so overwhelming that he began to have strong suicidal thoughts. See March 2023 Private Psychological Assessment at 8 (current self-report). The March 2023 private psychological evaluator asked the Veteran about his January 1988 in-service medical records, which referenced a phone call to his mother, who reported that the Veteran routinely made suicidal threats to "get his way." The Veteran said that his mother's account was inaccurate, and that he recently asked his mother about it, and she told him that she does not even recall having a conversation with a psychologist from the Navy at all during his service. He reported he had and continues to have a positive relationship with his mother. See March 2023 Private Psychological Assessment at 7 (current self-report). On examination, the March 2023 private psychological evaluator diagnosed the Veteran with persistent depressive disorder with anxious mood in accordance with the DSM-5, and opined that the Veteran's acquired psychiatric disorder is due to, the result of, or was otherwise incurred during his military service. See March 2023 Private Psychological Assessment at 10 (diagnostic opinion, and nexus). As support of that opinion, the March 2023 private psychological evaluator noted the conflicting VA medical examinations and opinions, and the Veteran's January 1988 in-service psychiatric evaluation. The March 2023 private evaluator explained that Antisocial Personality Disorder (ASPD) is characterized by a pervasive pattern of disregard for consequences and for the rights of others, impulsivity, poor judgment, problematic relationships as well as instability of mood and behavior that manifests in adolescence. To make this diagnosis, a clinician must not only establish the presence of ASPD as an adult, but must also establish a pervasive pattern of disregard for and violation of the rights of others since age 15, as indicated by three or more of the following: consistent irresponsibility; impulsivity; failure to conform to social norms; deceitfulness; irritability and aggressive defined by multiple physical fights or assaults; lack of remorse; and or reckless disregard for the safety of others. See March 2023 Private Psychological Assessment at 11 (rationale). The March 2023 private psychological evaluator further explained that the DSM-5 emphasizes that such behaviors must be established as a chronic and maladaptive means of being, inflexible and problematic and present across various settings rather than isolated incidents. The private psychological evaluator stated that an examiner must also account for the fact that periods of maladaptive behavior and intense negative emotions as a youth are not synonymous with DSM-5 defined psychopathology; and that research has established that it is normal for teenagers to experience mood swings and risk-taking behaviors that can be intense and counter-productive, and struggle with peer groups and peer pressure. See March 2023 Private Psychological Assessment at 11-12. Addressing the Veteran's January 1988 in-service psychiatric evaluation and his mother's assertions from that time, the March 2023 private evaluator explained that, in isolation, such evidence is a prototypical example of the warning cited by the DSM-5 and clinical research. The March 2023 private evaluator emphasized that the Veteran's January 1988 psychiatric evaluation is a single report, defining a specific behavior, with no additional context regarding the noted behavior, nor any context into the relationship between the Veteran and his mother. The March 2023 private evaluator further noted that when the Veteran was asked about this phone call with his mother during his examination, the Veteran reported and explained the inaccuracy, and reported that he recently asked his mother about it, and she told him she does not even recall having a conversation with a psychologist from the Navy at all during his service. See March 2023 Private Psychological Assessment at 12-13. Based on this, the DSM-5 criteria, and the clinical research, the March 2023 private evaluator stated that there was no evidence of sustained symptoms or impairment from which the VA examiners could diagnose the Veteran with ASPD, or opine that the Veteran's acquired psychiatric disorder preexisted his service. See March 2023 Private Psychological Assessment at 12-14. Rather, the March 2023 private evaluator explained that the record evidence showed that the Veteran was psychiatrically hospitalized for suicidal ideation and behavior during service, that this represents the first documented emergence of mental health issues, and thus that the Veteran's current persistent depressive disorder with anxious mood is at least as likely as not due to, the result of, or otherwise incurred in service. See March 2023 Private Psychological Assessment at 14-16. The Board finds that the March 2023 private psychological evaluation carries substantial probative weight, as it is based on a live video teleconference with the Veteran, a thorough review of the claims file, a lengthy and painstaking explanation of the DSM-5 criteria and the evidence, and a compelling explanation on the shortcomings of the competing medical evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 123-124 (2007). On review, the Board finds that the March 2023 private psychological evaluation is the most probative evidence on the issue of nexus. As explained above, the March 2023 private psychological evaluation carries substantial probative weight, as it is based on a live video teleconference with the Veteran, a thorough review of the claims file, a lengthy and painstaking explanation of the DSM-5 criteria and the evidence, and a compelling explanation on the shortcomings of the competing medical evidence. In contrast, the Board does not find the November 2022 or the December 2022 VA medical opinions to be more probative than the March 2023 private psychological evaluation. As explained above, those opinions do not establish that the Veteran's current acquired psychiatric disorder clearly and unmistakably preexisted and was not aggravated by his military service and, therefore, do not rebut the presumption of soundness that was clinically noted at the time of the Veteran's entry to service. The Board has also considered the Veteran's lay assertions. Lay testimony is competent to prove personal knowledge of symptoms and events capable of observation by lay persons, and the Veteran is competent to report his mental health and family history, and his symptoms, history, and experiences with his acquired psychiatric disorder. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this regard, the Board finds the Veteran's assertions of his childhood, and the inaccuracies of his mother's January 1988 report, to be credible and probative. The Board has also considered the November 2022 written statements offered by the Veteran's niece, who asserts that she resided with the Veteran and his family as a child, and that she remembers the Veteran as being a normal child and teenager, that his parents never had any trouble with the Veteran, and that the Veteran had friends and got along with everybody. See November 2022 VA Form 21-4138 (submitted by L.A.). The Board finds that the November 2022 statements from Veteran's niece are consistent with the pre-service history the Veteran reported at the November 2022 and December 2022 VA examinations, and the March 2023 private evaluation, and that her statements are credible and probative. After resolving reasonable doubt in his favor, the Board finds that the evidence does not establish that the Veteran's current acquired psychiatric disorder clearly and unmistakably preexisted and was not aggravated by his service. As such, the presumption of soundness on entry has not been rebutted. See 38 U.S.C. § 1111. Rather, the competent, credible, and probative evidence is at least in approximate balance as to whether the Veteran's current acquired psychiatric disorder had its onset during or is otherwise etiologically related to his military service. As such, the Board finds that service connection for the Veteran's acquired psychiatric disorder is warranted. Entitlement to service connection for an acquired psychiatric disorder, to include persistent depressive disorder with anxious mood, unspecified depressive disorder, and or unspecified anxiety disorder, is granted. 2. Entitlement to service connection for a dental condition for compensation purposes. The Veteran claims entitlement to service connection for a dental condition, claimed as inability to chew properly, as a result of his military service. See November 2022 VA Form 21-526EZ. The Veteran asserts that six to eight of his teeth were removed during service, with no bridge replacement, and that he subsequently developed pain, abcess, swollen gums, and improper chewing. See November 2022 VA Form 21-526EZ; November 2022 Oral and Dental Conditions DBQ; see also April 2023 Appellate Brief. As a preliminary matter, a claim for service connection for a dental disorder includes a claim for VA outpatient dental treatment under 38 C.F.R. § 3.381. See Mays v. Brown, 5 Vet. App. 302, 305-306 (1993). In oral and dental claims, the VA Regional Office adjudicates the claim for entitlement to service connection, while the Veterans Benefits Administration (VBA) adjudicates the claim for outpatient treatment. As this matter stems from an adverse determination by a VA Regional Office, the appeal of this issue is limited to entitlement to service connection for a dental disorder for the purpose of compensation. However, the issue of entitlement to service connection for a dental condition for the purpose of obtaining outpatient dental treatment was raised in an April 2023 appellate brief. Thus, the claim for service connection for a dental disorder for the purpose of obtaining VA outpatient dental treatment is REFERRED to the AOJ for additional referral to VBA and the appropriate VA medical facility. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161. The Board's decision here is limited to entitlement to service connection for a dental condition for compensation purposes. Service connection for compensation purposes may be established only for the specific types of dental and oral conditions listed under 38 C.F.R. § 4.150, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. Compensation is available for loss of teeth only if due to loss of substance of the body of the maxilla or mandible. See Simington v. West, 11 Vet. App. 41, 44 (1998). For loss of teeth, bone loss through trauma or disease such as due to osteomyelitis must be shown for purposes of compensability. 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 (Note). Here, the Veteran's January 1987 service dental treatment records note periodontal disease and the need to extract teeth numbers 1, 2, 3, 14, 15, 16, 17, 18, and 19, at the time of entry. See January 1987 STR Dental (initial dental examination). The Veteran's teeth 1, 2, 3, 14, 15, 16, 17, 18, and 19, which include his third molars, were extracted the same month that he entered service, i.e., January 1987. In November 2022, the Veteran underwent a VA examination to evaluate his dental condition. See November 2022 Oral and Dental Conditions DBQ. The November 2022 VA examiner met with the Veteran for an in-person examination, and noted a review of the claims file. During the in-person consultation, the Veteran reported that his dental condition began in 1987 with the removal of six to eight teeth by the Navy, followed by pain, abcess, swollen gums and improper chewing, and that all symptoms currently persisted. See November 2022 Oral and Dental Conditions DBQ at 2 (Section II, History). On examination, the November 2022 dental examiner diagnosed malocclusion (unspecified), and partial loss of teeth (unspecified cause). See November 2022 Oral and Dental Conditions DBQ at 2 (Section I, Diagnosis). The November 2022 dental examiner found no anatomical loss or bony injury of the Veteran's mandible to include the ramus, no anatomical loss or bony injury of the Veteran's maxilla, no anatomical loss or bony injury of the Veteran's teeth other than that due to the loss of alveolar process as a result of periodontal disease, no disfiguring scars, injuries, impairments, or loss of the Veteran's mouth, lips, or tongue, no osteomyelitis, no osteoradionecrosis, and no osteonecrosis of the Veteran's jaw, and no tumors and no neoplasms. Although the November 2022 VA dental examiner noted that the Veteran reported anxiety, being alone, agitated, mood swings, stress, and sleep loss, the November 2022 VA dental examiner found that the Veteran's dental condition did not impact his ability to work. There were no other pertinent physical findings, complications, conditions, signs. See November 2022 Oral and Dental Conditions DBQ at 3-5 (Section III, Dental and Oral Conditions) and 6 (Functional Impact). On review, the evidence persuasively weighs against finding the Veteran has had a current dental disability for VA compensation purposes. Here, there is no evidence of impairment of the mandible, ramus, or maxilla, other than due to periodontal disease. Additionally, there is no evidence of loss of teeth due to loss of substance of the body of the maxilla or mandible. Consequently, the Veteran does not have, and has not had, a current dental disability for VA compensation purposes. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board has also considered the Veteran's lay assertions regarding the events, onset, and symptoms of his dental condition. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). While the Board has no reason to doubt the problems that the Veteran experiences with his current dental condition, the Board's ability to grant service connection for VA disability compensation purposes is limited to the oral and dental conditions listed in VA regulations, at 38 C.F.R. § 4.150. See Simington v. West, 11 Vet. App. 41, 44 (1998) (discussing 38 C.F.R. § 4.150). And as stated above, the evidence is persuasively against a finding that the Veteran has had a current dental disability for VA compensation purposes, as a matter of law. Based on the foregoing, the Board finds that the competent, credible, and probative evidence persuasively weighs against finding the Veteran has had a current dental disability for VA compensation purposes, such as impairment of the mandible, ramus, or maxilla other than due to periodontal disease, or loss of teeth due to loss of substance of the body of the maxilla or mandible, at any time during or approximate to the pendency of the claim. Entitlement to service connection for a dental condition for compensation purposes is denied. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. The Veteran claims entitlement to service connection for hypertension as a result of stress, anxiety, sleeping in close quarters, and not being able to adjust to his life at sea during his active military service. See November 2022 VA Form 21-526EZ; December 2022 Hypertension DBQ (Section II, Medical History); see also April 2023 Appellate Brief. The record confirms the Veteran has a current disability. Here, the AOJ favorably found that the Veteran has been diagnosed with hypertension. See January 2023 Rating Decision (favorable findings). The record also indicates that the Veteran's current disability may be associated with his active service in the Navy. Here, the Veteran asserts he began having symptoms of hypertension in his 20s, with a lot of stress in the military. See November 2022 VA Form 21-526EZ; December 2022 Hypertension DBQ (Section II, Medical History). However, the Board is unable to make a fully-informed on the Veteran's claim of entitlement to service connection for hypertension, because the medical evidence is not adequate for adjudication. In December 2022, the Veteran underwent a VA examination to determine the nature and etiology of his hypertension. See December 2022 Hypertension DBQ. The December 2022 VA examiner met the Veteran for an in-person examination, and noted a review of the claims file. On examination, the December 2022 VA clinician confirmed a current diagnosis of hypertension. See id. at 2 (Section I, Diagnosis). However, the December 2022 VA examiner opined the Veteran's current hypertension is less likely than not proximately due to or the result of his general medical condition, to include his acquired psychiatric disorder. See December 2022 Medical Opinion (Section IV, Medical Opinion for Secondary Service Connection). As support for that negative opinion, the December 2022 VA examiner explained that essential hypertension is a currently understood as a multifactorial disease arising from the combined action of many genetic, and environmental and behavioral factors, and that evidence points to a causal link between a chronically high salt intake and the development of hypertension. In conjunction with this primary causal factor, a number of adjunctive factors, such as obesity, diabetes, aging, emotional stress, lifestyle, and low potassium intake may increase the probability of developing hypertension. The December 2022 VA examiner then noted that the Veteran's service medical records were silent for findings of elevated blood pressure, and concluded it is less likely than not that the Veteran's hypertension is due to his acquired psychiatric disorder. However, a lack of contemporaneous medical records may not form the sole basis for a negative opinion. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Moreover, the December 2022 VA examiner did not alternatively consider whether the Veteran's acquired psychiatric disorder aggravated his hypertension. A negative etiology opinion on secondary service connection is inadequate if it does not address both causation and aggravation. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013); Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2007) (once VA undertakes the effort to provide a medical examination, the examination must be adequate). This is a pre-decisional error. Thus, while the Board regrets the further delay, a remand of this matter is needed to obtain an adequate VA medical etiology opinion, and to correct a pre-decisional error VA's duty to assist. See 38 U.S.C. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2007). This matter is therefore REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's current hypertension is at least as likely as not due to, and or aggravated by his service-connected acquired psychiatric disorder, taking any further development that may be needed to ensure that the decision on secondary service connection is fully informed. The examiner must review claims file in its entirety, to include a copy of this remand and these directives, and should note the examiner's review of the record in the examination report. The examiner must provide a rationale in support of each opinion. If the examiner relies upon medical literature, studies, or other sources in rendering an opinion, the examiner should identify and cite each source used. The examiner is advised that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence in favor of a conclusion is at least approximately balanced or nearly equal, if not higher, than any evidence against it. The examiner is further advised that, for consideration of secondary service connection, the term "aggravated" does not mean, and does not require a "permanent worsening" of the Veteran's nonservice-connected disability. Rather, it refers to "any incremental increase in disability [any additional impairment of earning capacity] in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase-regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (emphasis added); and 38 C.F.R. §3.310(b). The examiner is reminded that the Veteran is competent to report symptoms, treatment, and injuries, as well as events that the Veteran has personally experienced and observed, and that the Veteran's assertions must be considered and addressed in formulating an opinion. The examiner may not rely solely on an absence of diagnosis or treatment in service, or a lack of medical documentation, as the basis for a negative opinion. The examiner should discuss any competing, contrasting, or contradictory evidence in the claims file and reconcile that evidence with the examiner's findings. If the examiner cannot provide an opinion without resorting to speculation, the examiner must explain why this is so, and in doing so address whether the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Cory M. Picton Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Galindo 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.