Citation Nr: 9916403 Decision Date: 06/15/99 Archive Date: 06/21/99 DOCKET NO. 97-33 918A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a stomach disorder, to include service connection secondary to post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for temporomandibular joint (TMJ) syndrome, to include service connection secondary to PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Jennifer Lane, Counsel INTRODUCTION The veteran had active service from February 1969 to September 1970. In a rating decision dated in December 1996, the Regional Office (RO) assigned a 10 percent evaluation for PTSD, previously diagnosed as anxiety reaction, effective in September 1996; and the veteran appealed the decision to not grant a higher disability rating. In another rating decision dated in August 1997, the RO determined that claims for entitlement to service connection for a stomach disorder, to include service connection secondary to PTSD, and service connection for TMJ syndrome, secondary to PTSD, were not well-grounded. The veteran subsequently perfected an appeal of that decision. In a March 1998 rating decision, the RO granted a 30 percent evaluation for PTSD, effective in September 1996. At a RO hearing in July 1998, the veteran withdrew the appeal of the issue of entitlement to an increased evaluation for PTSD. Thus, the only issues that were certified on appeal were entitlement to service connection for a stomach disorder and TMJ syndrome. Additionally, a hearing was held at the RO in December 1998 before the undersigned, a member of the Board of Veterans' Appeals (Board). FINDINGS OF FACT 1. No competent medical evidence is of record that would establish that the veteran currently has a stomach disorder which is causally related to service or to any incident or event therein, or which shows that such a disability is etiologically related to his service-connected psychiatric disorder or has been aggravated by that service-connected disability. 2. All relevant information necessary for an equitable disposition of the appeal of the claim for entitlement to service connection for TMJ syndrome, to include service connection secondary to PTSD, has been developed. 3. The veteran has TMJ syndrome as a result of his service- connected psychiatric disorder. CONCLUSIONS OF LAW 1. The claim for entitlement to service connection for a stomach disorder, to include service connection secondary to PTSD, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. TMJ syndrome is secondary to the veteran's service- connected psychiatric disorder. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Stomach Disorder Initially, the Board notes that entitlement to service connection for a particular disability requires evidence of the existence of a current disability and evidence that the disability resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110 (West 1991). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1998). Additionally, secondary service connection for a disability is warranted when that disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1998). Secondary service connection is also warranted for a disability when that disability is aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board also notes that the veteran must submit evidence that a claim for entitlement to service connection benefits is well-grounded. 38 U.S.C.A. § 5107(a). A well-grounded claim is one which is plausible; that is meritorious on its own and capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Unlike civil actions, the Department of Veterans Affairs (VA) benefit system requires more than just an allegation. The veteran must submit supporting evidence that is sufficient to justify a belief by a fair and impartial individual that the claim is plausible. Tripak v. Derwinski, 2 Vet. App. 609, 611 (1992); Grivois v. Brown, 6 Vet. App. 136, 139 (1994). The three elements of a well grounded claim for service connection benefits are: (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995); 38 C.F.R. § 3.303. This means that there must be evidence of disease or injury during service, a current disability, and a link between the two; or, in the case of secondary service connection, there must be evidence of a current disability and a link between that disability and a service-connected disability. Further, the evidence must be competent. That is, the presence of a current disability requires a medical diagnosis; and, where an opinion is used to link the current disorder to a cause during service or a service-connected disability, a competent opinion of a medical professional is required. See Caluza at 504; Reiber v. Brown, 7 Vet. App. 513 (1995). VA medical records dated in 1995 and 1996 show that the veteran has complained of diarrhea and undergone tests and procedures regarding his gastro-intestinal system, including esophagogastroduodenoscopy and flexible sigmoidoscopy in April 1995. The assessment from the esophagogastroduodenoscopy was hiatal hernia, mild gastritis and mild duodenitis. The assessment following the flexible sigmoidoscopy was rule out inflammatory bowel disease/rule out Kaposi's sarcoma. The veteran also underwent a colonoscopy in June 1995, and the findings included diverticula. Additionally, VA outpatient treatment records dated in 1996 include assessments or impressions of left sided colitis and acute gastroenteritis. Thus, there is competent evidence tending to show that the veteran has a stomach disorder. At the Board hearing, the veteran essentially testified that he began having problems with constipation and diarrhea in service due to tension. He also testified that he was treated for dysentery while in service and that he was given a separate toilet while in boot camp. The service medical records show no treatment for stomach complaints or dysentery. Moreover, the report of the veteran's separation medical examination in September 1970 shows that pertinent clinical evaluation was normal. However, the Board finds the veteran's testimony credible for the purpose of determining whether his claim for entitlement to service connection for a stomach disorder is well-grounded. Additionally, at a hearing before a RO hearing officer in December 1997, the veteran indicated that he had had stomach problems since service but that Prozac seemed to make the problems a little worse. Regardless of whether or not the veteran had gastro- intestinal complaints in service, almost three decades ago, he has not submitted sufficient competent evidence linking any current stomach disorder to service or to his service- connected psychiatric disorder. At the RO hearing in December 1997, the veteran's representative submitted a copy of text from the Physician's Desk Reference. According to that text, 12.3 percent of patients using Prozac reported experiencing diarrhea as compared to 7 percent taking a placebo, 4.5 percent of patients using Prozac reported experiencing constipation as compared to 3.3 percent taking a placebo, and 1 percent of those taking Prozac reported having gastroenteritis as compared to 1.4 percent taking the placebo. Similar comparisons regarding reports of other digestive related complaints were also provided. While this evidence is competent evidence tending to show that some of those who have taken Prozac have reported having gastro-intestinal related complaints, including diarrhea and constipation, and gastroenteritis, the evidence is not sufficient evidence with which to link the veteran's stomach disorder to treatment for his service-connected psychiatric disorder for the purpose of finding the claim at issue well-grounded. This evidence does not address the veteran's particular case. Moreover, the evidence shows that the difference between the number of those taking Prozac who experienced the gastro-intestinal complaints and those not taking Prozac who experienced the same complaints is relatively small. The Board also notes that a VA physician, in April 1998, related that the veteran had been advised that stress, such as that from PTSD, "may be" a contributing factor in his gastro-intestinal condition. It is unclear if that VA physician advised the veteran that stress might be a factor in his gastro-intestinal condition, or if that physician merely noted that the veteran reported that he had been advised at another time that such was the case. Assuming that the April 1998 VA physician advised the veteran that stress, such as that from PTSD, might be a contributing factor in his gastro-intestinal condition, in saying that stress "may" be a factor in the veteran's gastro-intestinal condition, the implication was that stress may not have been a factor. See Obert v. Brown, 5 Vet. App. 30 (1993). Under the circumstances, the Board finds the April 1998 VA physician's statement too speculative to constitute a nexus between a current stomach disorder and the veteran's service- connected psychiatric disorder for the purpose of finding the veteran's claim for entitlement to service connection for stomach disorder, secondary to PTSD, well-grounded. See Tirpak v. Derwinski, 2 Vet. App. 609 (1992). The Board also points out that the physician was did not say with any degree of certainty if the veteran's stress was from PTSD, nor did the physician specify the veteran's gastro-intestinal diagnosis. Additionally, there is no competent evidence tending to show that any current stomach disorder had its onset in service or is otherwise related to the veteran's history of gastro- intestinal complaints in service. Therefore, the Board finds the claim for entitlement to service connection for a stomach disorder, to include service connection secondary to PTSD, not well-grounded. Where the veteran has not met the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that a claim for service connection benefits is well-grounded, the VA has no duty to assist him in developing facts pertinent to such claim. 38 U.S.C.A. § 5107. Further, if the veteran does not submit a well- grounded claim, the appeal of the claim must fail. 38 U.S.C.A. § 5107(a); Murphy, 1 Vet. App. at 81. The governing law, 38 U.S.C.A. § 5107(a), [R]eflects a policy that implausible claims should not consume the limited resources of the VA and force into even greater backlog and delay those claims which -- as well grounded -- require adjudication. . . . Attentiveness to this threshold issue is, by law, not only for the Board but for the initial adjudicators, for it is their duty to avoid adjudicating the implausible claims at the expense of delaying well grounded ones. Grivois v. Brown, 6 Vet. App. 136, 139 (1994). Finally, the Board notes that the veteran has not reported that any competent evidence exists that if obtained would establish a well-grounded claim for a stomach disorder. Under the circumstances, the VA has no further duty to assist the veteran in developing a well-grounded claim for entitlement to service connection for that disability. Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). II. TMJ Syndrome Initially, the Board finds that the veteran's claim for entitlement to service connection for TMJ syndrome, to include service connection secondary to PTSD, is well- grounded within the meaning of 38 U.S.C.A. § 5107, that is, the claim is plausible, meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78 (1990). The evidence discussed below includes competent evidence of a diagnosis of TMJ syndrome and competent evidence that stress is the main etiology of TMJ syndrome and more than one medical opinion that PTSD could be related to the veteran's TMJ syndrome. In particular, a November 1998 letter from Dr. Portia D. Turner-Holt discusses X-ray and examination findings on which her opinions are based and the statement that the main etiology of TMJ syndrome is stress. See Mattern v. West, No 96-1508 (U.S. Vet. App. Feb. 23, 1999); Molloy v. Brown, 9 Vet. App. 513 (1996). The Board further finds that the VA has met its duty to assist in developing the facts pertinent to the veteran's claim. 38 U.S.C.A. § 5107. The veteran was afforded a VA dental examination at which the examiner addressed the etiology of the veteran's TMJ symptoms. In the November 1998 letter discussed above, Dr. Turner-Holt, a private dentist, related that the veteran presented with a complaint of temporal mandibular joint dysfunction and a history of pain which started 20 plus years ago after he spent time in Vietnam. While the veteran testified that he was contending that the TMJ syndrome was related to his PTSD and not that TMJ syndrome started in service, Dr. Turner-Holt felt that the veteran had TMJ syndrome possibly caused by his experience in the war because TMJ syndrome's main etiology was stress. The dentist also noted that she had not seen translatory X-rays of the mandible joint to make a full assessment of the veteran's case. However, she did refer to X-ray findings. Additionally, the claims file includes dental X-rays dated the same day as the VA dental examination in March 1998, discussed below. Thus, the March 1998 VA dentist, who also addressed the issue of whether the veteran's TMJ syndrome was related to his service-connected psychiatric disorder, was also able to review dental X-rays. Additionally, even without reviewing the X-rays, Dr. Turner-Holt diagnosed TMJ syndrome. Under the circumstances, another examination with dental X-rays is not warranted. In an undated letter, a VA psychiatrist, who was treating the veteran for PTSD, reported that the veteran had mentioned "his teeth causing depression and pain." The psychiatrist related that the veteran's complaints "can be" caused by gritting and grinding of the teeth during stressful dreams associated with his PTSD. It was that psychiatrist's belief that the veteran's temporomandibular joint condition could be "in direct relation of his P.T.S.D." The psychiatrist added that the veteran was being treated with Xanax and Prozac and that the side effects of those drugs caused dry mouth which could also lead to "TMJ." The veteran was afforded a VA dental examination in March 1998. According to the examination report, the veteran denied jaw pain, problems or trauma while in service. He related that he first began to notice jaw joint symptoms around 1975. The diagnoses included symptoms consistent with bruxism (grinding of teeth). The examiner related that the etiology of the bruxism could not be determined but that PTSD could be a factor in the bruxism. With regard to the TMJ symptoms, the examiner reported that the popping and open lock were consistent with anterior displacement of the right TMJ disc and that the pain was consistent with arthritic changes to the left condylar head and eminence. With regard to the displacement of the disc and arthritic changes, the examiner further related that the etiology could not be determined but that loss of posterior occlusion and chronic bruxism could be factors. As noted earlier, the veteran's representative submitted a copy of text from the Physician's Desk Reference at the RO hearing in December 1997. According to that text, 9.5 percent of those taking Prozac reported having mouth dryness compared to 6 percent of those taking the placebo. This evidence is competent evidence tending to show that some of those who have taken Prozac have reported having mouth dryness, and such evidence supports the opinion of the VA psychiatrist discussed previously regarding the side effects of Prozac. Thus, there is competent medical evidence which supports finding that stress is a factor in TMJ syndrome, that the side effects of medications used to treat the veteran's PTSD cause dry mouth which can lead to TMJ problems, that the veteran's PTSD could be related to his TMJ syndrome, and that his TMJ syndrome was possibly caused by events in service. As shown above, a VA dentist in March 1998 reported that PTSD could be a factor in the veteran's bruxism and indicated that his chronic bruxism could be a factor in his TMJ symptoms. In light of that evidence, the Board finds that the pertinent evidence is, at the minimum, in equipoise as to whether the veteran's TMJ syndrome is proximately due to his PTSD and treatment for that psychiatric disorder. Therefore, resolving doubt in the veteran's favor, the Board finds that service connection for TMJ syndrome secondary to PTSD is warranted. 38 U.S.C.A. § 5107(b). ORDER Service connection for a stomach disorder, to include service connection secondary to PTSD, is denied. Service connection for TMJ syndrome secondary to PTSD is granted. LAWRENCE M. SULLIVAN Member, Board of Veterans' Appeals