BVA9505843 DOCKET NO. 91-37 037 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES Entitlement to service connection for sinusitis and postoperative residuals of a deviated nasal septum. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. T. Jones, Counsel INTRODUCTION The veteran served on active duty from October 1976 to October 1979. This matter comes to the Board of Veterans' Appeals (Board) from a September 1990 rating determination by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied service connection for damage to the "skeletal structure of the face." After an April 1992 Board remand, the veteran's representative stated the disabilities for which the veteran was seeking service connection were all the upper teeth, loss of (maxillary) bone tissue, sinusitis, and a deviated nasal septum. In February 1993, the RO granted service connection for the loss of the substance of the body of the maxilla and all upper anterior teeth, rated as 10 percent disabling. Pursuant to a November 1993 Board remand, the RO made a dental rating decision in July 1994, identifying which maxillary teeth it deemed service connected, including on the basis of service trauma. The rating decision noted that the veteran had had trauma to the mouth during service and had resultant root canals to teeth numbers 8 and 9, and had subsequently lost all remaining teeth, except numbers 8, 9, and 11, as secondary to that trauma, and had apparently lost maxillary bone as well. In a July 1994 supplemental statement of the case, the RO indicated that, while the veteran still retained teeth numbers 8, 9, and 11, he had lost his maxillary bone tissue and could not bite with his upper teeth. The RO commented that it considered these upper anterior teeth were essentially lost. It appears that the RO has effectively granted service connection for all of the veteran's maxillary teeth as due to trauma. Service connection for replaceable missing teeth is to be granted only for the purpose of determining eligibility for VA dental treatment. 38 C.F.R. § 4.149 (1994). The RO has granted service connection for all maxillary teeth which are in fact missing, as well as for the remaining teeth affected by trauma in service. The veteran is eligible for VA dental treatment for maxillary dental conditions on the basis of service trauma, 38 C.F.R. § 17.123(c), and is also eligible for VA dental treatment of any dental condition by reason of having a compensable service-connected dental disability, 38 C.F.R. § 17.123(a). It appears that the RO has granted the veteran full relief on his claim for service connection for a dental condition of all maxillary teeth. Thus, that issue is no longer before the Board. The only issue remaining for appellate consideration is entitlement to service connection for sinusitis and postoperative residuals of a deviated nasal septum. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his sinusitis and deviated nasal septum are due to being hit in the face by a softball during service, at which time he also incurred his service-connected dental condition and a lip scar. He alternatively argues that his established service-connected conditions caused his sinusitis and deviated nasal septum. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file and attachments (including VA medical treatment and administrative records folders). Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for service connection for sinusitis and postoperative residuals of a deviated nasal septum. FINDING OF FACT Sinusitis and residuals of a deviated nasal septum were not present during service or until many years thereafter, and were not caused by any incident of service or by a service-connected disability. CONCLUSION OF LAW Sinusitis and residuals of a deviated nasal septum were not incurred in or aggravated by service and are not proximately due to or the result of a service-connected disability. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1994). REASONS AND BASES FOR FINDING AND CONCLUSION I. Factual Background The veteran served on active duty from October 1976 to October 1979. A service medical record from October 1977 shows the veteran was seen by a corpsman at a clinic, complaining of a cold and sore throat. The impression was that he had sinusitis and a post nasal drip. He was given medication and told to gargle with warm salt water. The service medical records contain no other references to sinusitis, and there is no mention of a deviated nasal septum. The service dental records show that the veteran was seen at a dental clinic in March 1978 after a softball hit him in the face. Tooth number 9 reportedly was placed back into its socket, and root canal therapy was started on that tooth. A cut on the lower lip was sutured. He had root canal therapy for tooth number 8 later in March 1978, and tooth number 10 was treated in April 1978. The dental records from March to July 1978 show numerous visits for dental treatment of these three upper anterior teeth. The veteran's service medical records show that he was seen in March and April 1978, and for the remainder of service, for unrelated conditions and no mention was made of a softball injury to the face or any problem with the nose or sinuses. The October 1979 service separation examination showed clinical evaluation of the nose and sinuses was normal. Dental evaluation showed he was missing two lower molars, and had a number of restorable teeth, including numbers 7 and 9. Applications for service connection for a dental condition due to trauma, dated in December 1979 and February 1986, were submitted by the veteran, for the purpose of obtaining VA dental treatment. No mention was made of a deviated nasal septum or sinusitis. The veteran was hospitalized at a VA medical center (VAMC) in September 1982 for treatment of substance abuse. The medical history noted that he had had blackouts and seizures related to drug abuse and had sutures above his left eye and shoulder tenderness from injuries while falling down while taking drugs. Physical examination noted a normal nose. Medical records from a VAMC show treatment in 1983, 1986 and 1987 for various ailments; no mention was made of sinusitis or a deviated nasal septum, until September 1987 when, at the VA dental clinic, he complained of pain in his right sinus in the area of tooth number 2; it was noted that he had had these symptoms for two weeks. The diagnosis was maxillary pain from the sinuses or tooth number 2. Later in September 1987, the veteran filed a claim for service connection for dental trauma and a sinus disability as the proximate result of trauma. He listed only dental treatment after service. The veteran returned to the VAMC in January 1988 when he reported a long history of facial trauma and dental problems. He reported that all his upper teeth had been aching for several years. Sinus X-rays showed air-fluid level in the left maxillary atrium consistent with acute sinusitis. The remainder of the paranasal sinuses were normal. On later occasions in 1988 the veteran again gave a long history of dental problems and sinusitis secondary to facial trauma. For example, in March 1988 he related that when hit by a softball nine years earlier, he had teeth knocked out and loosened and his "sinuses crushed." In May 1988, the veteran reported he had had sinus drainage for 3 to 4 years. He reported he had sustained trauma to the front teeth during service and his "crushed sinuses." The impression was severe deviated nasal septum, sinusitis and poor dental hygiene. There are a number of subsequent records from the VAMC noting a severe left deviated nasal septum and sinusitis. In February 1988 the veteran claimed service connection for a scar on the lower lip with a lump. In a statement dated in February 1988, Lee Palmer, D.D.S., reported treating the veteran in August 1987 for an abscessed tooth. It was reported the veteran complained of pain in several anterior upper teeth and congestion in his nose and throat, and pain in his ears and temples. It was reported the veteran had symptoms of myofascial pain dysfunction, cluster headaches, sinus headaches, and discomfort in the face and mouth. In a statement dated in February 1988, William J. Thompson, D.D.S., reported he first treated the veteran in the early 1980's for symptoms from a severe trauma at some earlier date. The veteran complained of pain in the upper anterior teeth and upper molars and premolars, for which dental treatment was given. The veteran also reportedly had complaints of sinusitis, congestion in his nose and throat, and severe headaches. Dr. Thompson reported that the veteran needed extended dental treatment, and it was opined that much of the problem was caused by some past trauma, rather than neglect. In a statement dated in February 1988, J. King, D.D.S., reported treating the veteran from October 1985 to March 1987 for dental problems. He added that the veteran also complained of headaches and sinus drainage. The veteran's pain was attributed to the sinus problems as well as trauma he received to the anterior teeth in an accident. On a VA examination in July 1988, the veteran reported that a softball hit his mouth in service in 1978, causing trauma to the upper front teeth and lacerating the lower lip. The veteran said that at the time of the accident one of his upper front teeth was knocked out and another one was very loose but was pushed back in. The veteran also gave a history of a sinus disorder. Current examination showed a deviated nasal septum, a healed laceration scar of the lower lip, and one artificial upper front tooth and a discolored upper front tooth (the veteran identified the two teeth as the ones involved in the service accident). The doctor noted a history of acute sinusitis in January 1988, with X-ray studies at that time. Current sinus X-rays showed a soft tissue density in the floor of the left maxillary sinus, most probably representing a retention cyst, and a deviated nasal septum. The diagnoses included a scar of the lower lip; and a history of acute sinusitis with a retention cyst in the left maxillary sinus, the sinusitis being most probably secondary to a deviated nasal septum. The examiner also diagnosed one artificial and one discolored upper front tooth, and it was noted these might be due to trauma to the mouth. In August 1988, the RO granted service connection for the lower lip scar. A number of subsequent VA medical records recite the veteran's history that his nose and sinuses were injured in the softball incident in service. For example, in February 1990 a marked nasal septal deviation was noted, and the veteran said he had nasal trauma with a septal fracture eight years earlier when struck by a softball. The veteran was hospitalized at a VAMC in March 1990, for surgical correction of the deviated nasal septum. He reported that he had been hit in the face with a softball eight years ago, sustaining dental and nasal trauma. He reported a long history of repeated left nasal obstruction and postnasal discharge and pain. It was reported the past medical history was consistent with the trauma described by the veteran. He underwent a septoplasty and bilateral inferior turbinate trimming. The veteran testified at an RO hearing in June 1991. He related that he was hit in the face with a softball during service, and his teeth were damaged and his lower lip cut, for which he received medical treatment. He said the softball hit him in the mouth but also bloodied his nose, although the nose was not broken. The veteran said he believed the deviated nasal septum, discovered years later, could have been due to the softball injury. He also stated he thought his sinus condition began after he entered service and was exposed to a different climate, and that the condition was worsened by the softball injury. Ongoing VA medical records, dated to 1992, note recurrent sinus problems and postoperative residuals of a deviated nasal septum. In 1992, dental treatment records were received from Drs. Thompson, King, and Palmer. The records from Dr. Thompson show the veteran underwent dental treatment (X-rays and extractions) from April 1982 to December 1985. The treatment records from Dr. King show that he saw the veteran for treatment of an upper molar in March 1987. The records from Dr. Palmer show that he began root canal therapy for the veteran in March 1992. On a July 1992 VA dental examination report, the examiner stated that the service records showed the veteran was hit in the face by a softball, had a root canal on tooth number 9, root canal on tooth number 8 two weeks later, and a crown on tooth number 10 several months later. The examiner also noted later loss of maxillary teeth, and it was felt such was due to residuals of the service trauma. The veteran's current complaints include aching sinuses. The diagnosis was loss of all maxillary teeth attributable to the March 1978 in-service accident. The veteran had no maxillary teeth, except for numbers 8, 9, and 11, and the doctor commented that these were also in danger of being lost as a long-term consequence of the trauma. The examiner also noted the loss of significant anterior maxillary bone and teeth numbers 6, 7 and 10 due to the trauma. He stated that there was less than 50 percent of the normal function of mastication with the existing prosthesis. There were no findings relating to the sinuses or nose. On an October 1992 VA nose and sinus examination, the examiner noted the veteran reported a history of nasal trauma in 1978 when he was struck with a softball resulting in facial fractures and trauma to his upper teeth. The veteran reported he had facial pain since the 1990 septoplasty and inferior turbinectomy with maxillary antrostomies. The diagnosis was chronic facial pain. The examiner reported that a CAT scan revealed mild mucosal thickening in the left inferior maxillary sinus and no other evidence of either ethmoid or right sinusitis. II. Analysis The veteran's claims are well grounded; that is, they are not inherently implausible. 38 U.S.C.A. § 5107(a). The VA has fulfilled its duty to assist the veteran by obtaining all evidence pertinent to the claims. Id. In order to establish service connection for a disability, the facts, as shown by the evidence, must demonstrate that a particular disease or injury resulting in current disability was incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Secondary service connection may be granted for a disability which is proximately due to or the result of a service-connected disorder. 38 C.F.R. § 3.310(a). The veteran claims that he sustained trauma to the sinuses and nose (including a deviated nasal septum) at the time he sustained dental trauma to his upper teeth and a cut lower lip during service, when struck by a softball, or in the alternative, that his service-connected conditions eventually caused sinus and nasal septum problems. A review of the service medical records shows that the veteran was seen at a dental clinic in March 1978 for treatment limited to injuries to the upper front teeth and a laceration of the lower lip. Other service medical records, from March and April 1978, and later, show treatment for unrelated disorders and make no mention of any skeletal damage to the face or facial injuries, including trauma to the sinuses or a deviated nasal septum. The October 1979 service separation examination specifically noted the veteran had a normal nose and sinuses. The service medical records are persuasive evidence of the absence of chronic sinusitis or a deviated nasal septum during the time of active duty. Contrary to the veteran's assertions (which have varied) made years after service, the service records indicate the softball injury did not "crush" or otherwise damage his sinuses and did not "fracture" or otherwise damage his nose or deviate the nasal septum. Claims for VA compensation or treatment for years after service did not refer to sinusitis or a deviated nasal septum. This tends to show no sinusitis or a deviated nasal septum at that time, given that the veteran had the opportunity to claim service connection but did not do so. The initial indication of any sinus symptoms was when the veteran reported sinus pain at a VA dental clinic in September 1987, and the first report of facial injury (in addition to the lower lip and tooth injury) was when the veteran was seen at a VA clinic in January 1988, shortly after he filed a claim for service connection for a sinus disability. The 1988 statements of three private dentists, Drs. Thompson, King, and Palmer, intimate that the veteran complained of sinus symptoms earlier in the 1980's, but the actual treatment records of these dentists give no indication of this. On numerous occasions, in and after 1988, the veteran has reported that he had the onset of the facial pain and sinus pathology as the result of the softball injury in service in 1978. The initial notation of a nasoseptal deviation was on a VA outpatient clinic in 1988, and, on a VA examination in July 1988, the sinusitis was attributed to the deviated nasal septum. The evidence shows sinusitis or a deviated nasal septum no earlier than 1987, many years following service. It is significant that the veteran had a history of substance abuse- related seizures and blackouts during the interval since service, with at least one head injury (a cut above the eye, noted during VA treatment in 1982) as a result of substance abuse following service. A number of the medical records since 1988 implicate trauma with the claimed conditions, which may well be true, but any suggestion in these records that the causative trauma occurred in service is without probative value, such suggestion being based on an inaccurate history as related by the veteran. Reonal v. Brown, 5 Vet.App. 458 (1993). The reliable service and post-service records indicate that any causative trauma occurred long after service. The absence of medical treatment for chronic sinusitis or a deviated nasal septum, for many years following service, is persuasive evidence of an absence of continuity of symptoms since the time of active duty. 38 C.F.R. § 3.303(b); Mense v. Derwinski, 1 Vet.App. 354 (1991). As to the theory of secondary service connection, there is no medical evidence indicating that the veteran's service-connected dental condition and lip scar caused him to later develop deviation of the nasal septum and sinusitis. The veteran's assertions in this regard have no probative evidence, since as a layman he has no competence to offer a medical opinion on the etiology of a disorder. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). The weight of the evidence establishes that chronic sinusitis and a deviated nasal septum began years after service and were not caused by any incident of service or by a service-connected disability. The claimed disorders were not incurred in or aggravated by service, and they are not proximately due to or the result of a service-connected condition. Neither direct nor secondary service connection is warranted. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and service connection must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER Service connection for sinusitis and postoperative residuals of a deviated nasal septum is denied. L. W. TOBIN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.