Citation Nr: 0007398 Decision Date: 03/20/00 Archive Date: 03/23/00 DOCKET NO. 98-024 56 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a dental condition due to trauma. 2. Entitlement to a rating higher than 20 percent for a cervical spine disorder. 3. Entitlement to a rating higher than 10 percent for lichen planus. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. T. Jones, Counsel INTRODUCTION The veteran had active duty from July 1961 to June 1965, and from June 1971 to December 1996. This matter comes to the Board of Veterans' Appeals (Board) from a March 1997 RO decision that, among other actions, denied service connection for a dental condition (later claimed as due to service trauma), and granted service connection and a noncompensable rating for a cervical spine disorder (the veteran appealed for a higher rating). The appeal also comes to the Board from a February 1998 RO decision that granted service connection and a noncompensable rating for lichen planus (the veteran appealed for a higher rating). In that decision, the RO granted a higher 10 percent rating for the cervical spine disorder. In May 1998, the RO granted a higher 20 percent rating for the cervical spine disorder, and granted a higher 10 percent rating for lichen planus. However, the increased rating issues continue on appeal, as the veteran has not indicated he is satisfied with the ratings. AB v. Brown, 6 Vet.App. 35 (1993). FINDINGS OF FACT 1. The veteran does not have a dental condition due to service trauma. Any grinding of the teeth, or similar wear and tear, during service does not constitute dental trauma for purposes of service connection of residuals of dental trauma and eligibility for VA dental treatment based on dental trauma. 2. The veteran's service-connected cervical spine disorder, including arthritis, is manifested by no more than moderate limitation of motion. 3. His service-connected residuals of lichen planus of the tongue and buccal mucosa (rated by analogy to eczema) does not produce symptoms similar to constant exudation or itching, extensive lesions, or marked disfigurement. CONCLUSIONS OF LAW 1. Claimed residuals of dental trauma were not incurred in or aggravated by service. 38 U.S.C.A. § 1712 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.381, 17.161 (1999); 38 C.F.R. §§ 3.381, 4.149 (1998). 2. The criteria for a rating in excess of 20 percent for a cervical spine disorder have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5290 (1999). 3. The criteria for a rating in excess of 10 percent for lichen planus are not met. U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.20, 4.27, 4.118, Diagnostic Code 7899-7806 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The veteran served on active duty as a medical doctor from July 1961 to June 1965, and from June 1971 to December 1996. The service dental records show routine dental treatment without any traumatic dental conditions. In 1996 he was evaluated for mucosal lesions of the left lateral border of the tongue and buccal mucosa. The impression was that they were consistent with lichen planus; this was confirmed by biopsies. On his service retirement examination in 1996, the mouth and throat were normal, and it was reported that that he had mild multiple-level degenerative joint disease of the cervical spine. Dental clinic records in November and December 1996 noted that he had severely eroded occlusal and/or facial surfaces of a number of teeth. The dentist said it was not possible to complete needed dental care prior to his upcoming separation, and the veteran was advised to seek VA treatment after his separation. On a March 1997 VA orthopedic examination, the veteran had complaints of pain in the base of his neck. It was noted that he was a plastic surgeon and he reported he had accentuated neck pain when wearing a loop and light on his head while performing surgery. He related that pain was recently exacerbated when moving into a new home. He denied radicular symptoms. Examination showed tenderness and mild muscle spasm in the midline at the C6-C7 junction. Neck range of motion was normal except he had only 10 degrees of extension. The diagnoses included mechanical musculoskeletal cervicothoracic pain, and possible early arthritis at C6-C7. X-rays showed mild degenerative joint disease in the mid and lower cervical spine. In various written statements, the veteran related that he had occlusal and cervical erosion of teeth which he considered to be the result of trauma. He stated that his dental conditions were thought to occur as the result of bruxism or clenching his teeth due to stress. He related that some of the teeth had been restored by a VA dental clinic after service. He stated that his arthritis of the cervical spine caused pain and limited his ability to work with a light on his forehead. He stated that his lichen planus of the left tongue and buccal mucosa was painful and interfered with eating. He said that lichen planus predisposed him to oral carcinoma. With his statements, he submitted medical articles including one which identifies lichen planus as a pre-cancerous condition. At a VA outpatient clinic in February 1998, the veteran had complaints of intractable neck pain. Examination showed he had flexion of the head to 2inches from the sternum. His extension was 20 degrees, right turning was 50 degrees, left turning was 70 degrees, and right and left bending was to 20 degrees. There was tenderness over the C7 process. There were no related upper extremity symptoms. X-rays showed cervical spondylosis. At an RO hearing in May 1998, the veteran said his cervical arthritis bothered him in his work as a surgeon. He said he took Motrin for his neck pain and saw a doctor every 3 months. He said his lichen planus bothered him when eating, especially spicy foods. He said he ground his teeth in service because of stress. II. Analysis The veteran's claims are well grounded, meaning plausible; the RO has properly developed the evidence, and there is no further VA duty to assist him with his claims. 38 U.S.C.A. § 5107(a). A. Service connection for a dental condition due to service trauma The veteran seeks service connection for residuals of dental trauma for the purpose of VA outpatient dental treatment. Service connection will be granted for a dental disease or injury of individual teeth and the investing tissue, shown by the evidence to have been incurred in or aggravated by service. 38 C.F.R. § 3.381(a) (1998). As to each noncompensable service-connected dental condition, a determination will be made as to whether it is due to a combat wound or other service trauma. 38 C.F.R. § 3.381(e) (1998). Periodontal disease and replaceable missing teeth, among certain other dental conditions, are not disabling, and may be considered service-connected solely for the purpose of determining entitlement to VA outpatient dental treatment. 38 C.F.R. § 4.149 (1998). [Effective June 8, 1999, the foregoing regulations were combined into a new version of 38 C.F.R. § 3.381, but there has been no substantive change in the legal provisions which would affect the present case. See 38 C.F.R. § 3.381 (1999); 64 Fed. Reg. 30393 (1999).] The significance of establishing service connection for a dental condition, on the basis of service trauma, is that a veteran will be eligible for perpetual VA dental care for the condition. 38 U.S.C.A. § 1712(a)(1)(C) (West 1991 & Supp. 1999); 38 C.F.R. § 17.161(c) (1999). The veteran claims that erosion of his teeth is the result of grinding or clenching his teeth in service, and he maintains that this constitutes dental trauma. However, the pertinent legal authority provides that the dental condition must result from combat wounds or other service trauma, and such contemplates an external injury such as a blow to the mouth. See VAOPGCPREC 5-97. In the cited precedent opinion, the General Counsel of the VA quoted Black's Law Dictionary which notes that "trauma" includes physical injury such as a blow or fall, and quoted Stedman's Medical Dictionary which notes that "trauma" involves a wound or an injury inflicted usually more or less suddenly by some physical agent. In the judgment of the Board, the dental trauma contemplated in the law, for the purpose of service connection of a dental condition for eligibility for VA dental treatment based on trauma, does not include grinding of the teeth or similar wear and tear over an extended period of time. Rather, for VA purposes, the dental trauma must be a sudden force external injury, which is not present in the instant case. The Board finds that the preponderance of the evidence is against the claim for service connection for residuals of dental trauma. Thus, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). B. Higher rating for a cervical spine disorder. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Moderate limitation of motion of the cervical spine is rated 20 percent. Severe limitation of motion is rated 30 percent. 38 C.F.R. § 4.71a, Code 5290. A VA examination in February 1997 revealed the veteran had tenderness and muscle spasm in the mid cervical spine but had painless and full range of motion except for only 10 degrees of extension. A February 1998 outpatient clinic visit showed the neck had a range of motion which included flexion to a point 2 inches from chin to chest, extension to 20 degrees, left rotation to 70 degrees, right rotation to 50 degrees, and lateral bending to 20 degrees on each side. These findings at most show that the veteran's cervical spine range of motion is slightly to moderately impaired, which would warrant no more than a 20 percent rating. Moreover, the evidence does not show severe limitation of motion due to pain on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Given all the evidence, a higher rating based on limitation of cervical spine motion is not warranted. The Board finds that the preponderance of the evidence is against the claim for a higher rating for the cervical spine disability. Thus, the benefit-of-the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. C. Higher rating for lichen planus. The veteran seeks a higher rating for lichen planus, and states that the condition is painful, interferes with his eating, and predisposes him to oral carcinoma. The RO granted a 10 percent rating for lichen planus of the left tongue and buccal mucosa, rating the condition analogous to eczema under the provision of 38 C.F.R. § 4.20, 4.27, 4.118, Code 7899-7806. The Board concurs that this is the most closely related diagnostic code. A 10 percent rating will be assigned for eczema with exfoliation, exudation, or itching, if involving an exposed surface or extensive area. Eczema is to be rated 30 percent when there is constant exudation or itching, extensive lesions, or marked disfigurement. 38 C.F.R. § 4.118, Code 7806. The evidence shows the veteran has small areas of lichen planus of the left tongue and buccal mucosa that he claims is painful and thus interferes with eating. It is not shown or alleged that the lichen planus involves constant exudation or itching, extensive lesions, or marked disfigurement, nor is it shown that the condition involves symptoms similar to these. The weight of the evidence shows that the lichen planus is no more than 10 percent disabling, rating by analogy to eczema. Even when the diagnostic codes pertaining to a tongue disorder (38 C.F.R. § 4.114, Code 7202) or to impairment of mastication (38 C.F.R. § 4.150, Codes 9903, 9904) are considered, it is clear that the veteran's lichen planus is no more than 10 percent disabling. The veteran does not now have oral carcinoma, so his contentions in this regard are premature; compensation is paid for current disability, not future disability which may or may not occur. The preponderance of the evidence is against a higher rating for the service-connected lichen planus. Thus, the benefit- of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Service connection for residuals of dental trauma is denied. A higher rating for a cervical spine disorder is denied. A higher rating for lichen planus is denied. L. W. TOBIN Member, Board of Veterans' Appeals