Citation Nr: 0003513 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 98-19 295 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a left shoulder disorder. 2. Entitlement to service connection for a left wrist disorder. 3. Entitlement to service connection for a Class II skeletal dental malocclusion, retrognathia, mandible hypoplasia and midline deviation (dental disorder). 4. Entitlement to an initial compensable evaluation for dislocation, left ring finger (minor). 5. Entitlement to an initial compensable evaluation for residuals of a left elbow injury. 6. Entitlement to an initial compensable evaluation for pseudo-folliculitis barbae. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION The veteran had active service from July 1977 to August 1997. This appeal to the Board of Veterans' Appeals (the Board) is from a rating action taken by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, in February 1998. The veteran requested and was scheduled for but did not appear for a hearing in February 1999 before a Member of the Board at the RO. Service connection is also in effect for duodenal ulcer, evaluated as 10 percent disabling. During the course of the current appeal, in a rating action in August 1998, the RO granted service connection for bilateral Achilles tendinitis, and assigned a 10 percent rating from the day following separation from service. A notice of disagreement has not been received with respect to this determination. FINDINGS OF FACT 1. The claim for service connection for a left shoulder disorder is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The claim for service connection for a left wrist disorder is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 3. The veteran's primary mouth/dental problem in service was due to preexisting malposing with no evidence of inservice dental trauma or other changes other than as a result of ameliorative therapy and surgery involving the teeth and both jaws. 4. Dental malposing and associated care is excluded from service connection, and there is no claim for any other dental disorder which is available by law. 5. Current residuals of inservice dislocation of the left ring finger are minimal and limited to no more than moderate at most swelling and slight tenderness of the proximal interphalangeal joint without significant functional impairment. 6. The veteran's left elbow injury residuals are limited to occasional discomfort without swelling or tenderness and normal range of motion; X-rays show a functionally unimportant small density in the elbow area. 7. The veteran wears a beard and uses a special razor and, on occasion, a topical medication on flare-ups of his pseudo- follicular barbae; he has no more than slight involvement on a limited area. CONCLUSION OF LAW 1. The claim for service connection for a left shoulder disorder is not well-grounded. 38 U.S.C.A. § 5107 (West 1991). 2. The claim for service connection for a left wrist disorder is not well-grounded. 38 U.S.C.A. § 5107. 3. The claim for service connection for a dental disorder is denied as a matter of law. 38 U.S.C.A. §§ 1110, 1131, 1712 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.371, 3.372, 3.381 (in effect before and since June 6, 1999). 4. The criteria for an initial compensable rating for a left ring finger dislocation are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.2, 4.7, 4.20, 4.31, 4.71a, Diagnostic Code 5227 (1999). 5. The criteria for an initial compensable rating for residuals of a left elbow injury are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.2, 4.7, 4.20, 4.31, 4.71a, Diagnostic Code 5208 (1999). 6. The criteria for an initial compensable rating for pseudo-folliculitis barbae are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.2, 4.7, 4.20, 4.71a, 4.118, Diagnostic Code 7814 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection General Criteria The threshold question to be answered in any case is whether the appellant has presented evidence of a well grounded claim; that is, a claim which is plausible and meritorious on its own or capable of substantiation. If he has not, his appeal must fail. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Case law provides that although a claim need not be conclusive to be well grounded, it must be accompanied by evidence. A claimant may submit some supporting evidence that justifies a belief by a fair and impartial individual that the claim is plausible. Dixon v. Derwinski, 3 Vet. App. 261, 262 (1992); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis), of an incurrence or aggravation of a disease or injury in service (lay or medical evidence), a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). Where the determinative issue involves the question of a medical diagnosis or causation, only individuals possessing specialized training and knowledge are competent to render a medical opinion. Espiritu v. Derwinski, 2 Vet. App. 192 (1992). The United States Court of Appeals for Veterans Claims (Court) has held that if an appellant fails to submit a well grounded claim, VA is under no duty to assist him/her in any further development of the claim. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); 38 C.F.R. § 3.159(a) (1999). Service connection may be established for disability incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991). For a showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). Regulations also provide that service connection may 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) (1999). If not shown during service, service connection may be granted for certain given disabilities such as arthritis if manifested to a compensable degree during the first post service year. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). In this, and in other cases, only independent medical evidence may be considered to support Board findings. If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Moreover, it remains the duty of the Board as the fact finder to determine credibility of the testimony and other lay evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). Lay persons are not competent to render testimony concerning medical causation. See Grottveit v. Brown, op. cit. The credibility and weight to be attached to medical opinions are within the province of the Board as adjudicators. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). In LeShore v. Brown, 8 Vet. App. 406 (1995), the Court held that: Evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by the examiner, does not constitute "competent medical evidence" satisfying Grottveit v. Brown, 5 Vet. App. 91 (1993) requirement. Such evidence cannot enjoy the presumption of truthfulness accorded by Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995) (as to determination of well groundedness) and Justus v. Principi, 3 Vet. App. 510, 512 (1992)...because a medical professional is not competent to opine as to matters outside the scope of his or her expertise, and a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional." The Board is not bound to accept medical opinions which are based on history supplied by the veteran where that history is unsupported by the medical evidence. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Guimond v. Brown, 6 Vet. App. 69 (1993). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert v. Derwinski, op. cit. When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Left shoulder disorder Service medical records show that in April 1991, the veteran complained of left shoulder pain. He had been playing basketball at the base gym and fell on his left shoulder. He felt or heard a snap or pop of the left shoulder and then had pain on motion. Examination showed no swelling or ecchymosis, and range of motion was full. There was minimal discomfort on passive range of motion. He had mild tenderness of the acromioclavicular joint. Distal nerve examination was intact. X-ray was within normal limits. He was diagnosed as having mild acromioclavicular strain. A sling was prescribed, he was to take Tylox and was given a 4 day period of duty modification. Two days later, the veteran was seen for tenderness to palpation over the acromion at the acromioclavicular joint of the left shoulder. Range of motion was decreased to abduction down to less than 90 degrees. He was unable to bring his arm across his chest. Examination was negative for popping, crepitus, edema or discoloration. Neurological evaluation was intact. There was muscle spasm found in the trapezius and deltoids. Diagnosis was acromioclavicular joint strain with muscle spasm. Tolectin and Flexeril were prescribed and the Tylox was discontinued. He was to be given range of motion exercises and return in two weeks. He returned in two weeks and declined to remain for his appointment, stating that he had other things he had to do. He was to be rescheduled. A follow-up visit is not specifically noted, nor are further left shoulder complaints at that time. In January 1994, the veteran was seen for a 4 day history of neck strain. He said he had hurt his neck while at a field meet when he hit his head on a fellow Marine's hip. He also complained of left shoulder pain. He said that his left shoulder was also weak. Examination showed mild cervical tenderness. He seemed to have some weakness in the abductors of the left shoulder. Cervical strain was diagnosed. In July 1994, the veteran was taken by ambulance to an emergency room after hitting his head on someone's abdomen after an apparent tackle, at which time he felt a pop in his neck. He claimed that he had had weakness in his arms at the scene although not at the time of admission. Cervical spine X-rays were normal. Cervical strain was diagnosed and he was given a soft collar, prescribed Flexeril for pain and told to apply heat to his neck. In January 1997, the veteran was seen with complaints of left shoulder pain since the prior day during an obstacle course when he slipped from the bar and landed on the left shoulder. The examiner noted limitation of left shoulder motion but no swelling, discoloration or tenderness. Assessment was left shoulder strain. In April 1997, he was twice seen for complaints of left shoulder aching during push and pull activities using that shoulder. It was noted that he had had similar complaints in the past after a 1992 injury to that shoulder. He said that the problem had since been recurrent with weakness. Examination showed some tenderness at the acromioclavicular joint, which was said to be prominent. However, the examiner noted that there was no swelling, ecchymosis or other findings, and range of motion was full without neurological deficits. Pertinent diagnosis was strain left shoulder, rotator cuff. Another impression was left acromioclavicular joint, chronic pain. X-rays of the left shoulder were negative. On separation examination in May 1997, the veteran reported that he had minimal pain and tenderness in the acromioclavicular joint. Historically, he reported aching in that shoulder after lifting, pushups, etc. He was told to continue his physical therapy for the left shoulder. Diagnosis was left shoulder rotator cuff, acromioclavicular separation. On VA examination in November 1997, the veteran reported that he had dislocated his left shoulder while playing basketball in service. He still could play occasional basketball, but had intermittent aching in the left shoulder joint particularly on cold weather. He had no abnormality on examination. X-rays were negative. Diagnosis was history of dislocation of left shoulder, presently asymptomatic. Analysis Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that a claim is well grounded; that is, that a claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit, 5 Vet. App. at 92. Because the veteran has failed to meet this burden, the Board finds that his claim for service connection for a left shoulder disorder is not well grounded and should be denied. Where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy, 1 Vet. App. at 81. The claimant does not meet this burden by merely presenting his lay opinion because such evidence does not constitute competent medical authority. Espiritu, op. cit. Consequently, lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well grounded claim, Tirpak, 2 Vet. App. at 611, the absence of cognizable evidence renders the veteran's claim not well grounded. Based upon the evidence of record, the Board finds that competent medical evidence has not been submitted which demonstrates that the veteran currently demonstrates chronic residuals of a left shoulder disorder of service origin. In the absence of medical evidence of a present disability due to service or any incident therein, there is no valid claim. In summary, the Board finds that the evidentiary record does not contain competent medical evidence of a left shoulder disorder which has been linked to the veteran's period of service on any basis. Although there were some recurrent episodes of left shoulder complaints in service, there has been no evidence of a chronic left shoulder disability since service, and/or more importantly, no competent medical authority to establish a reasonable nexus from one to the other. Thus, at least one and perhaps two of the three mandatory components of a well grounded claim have not been met in this case. Because the veteran has not submitted a well grounded claim of service connection for a left shoulder disorder, VA is under no obligation to assist him in the development of facts pertinent to the claim. 38 U.S.C.A. § 5107(a). The Board is cognizant, however, that the Court has held that VA may have an obligation under 38 U.S.C.A. § 5103(a) (West 1991) to advise the claimant of evidence needed to complete a claim. Beausoleil v. Brown, 8 Vet. App. 459 (1996). The Court has held that the section 5103(a) duty requires that, when a claimant identifies medical evidence that may complete an application but is not in the possession of VA, VA must advise the claimant to attempt to obtain that evidence. Brewer v. West, 11 Vet. App. 228 (1998). In this case, the record indicates that the veteran has identified no such evidence. The Board further finds that the RO advised the appellant of the evidence necessary to establish a well grounded claim, and the appellant has not indicated the existence of any post service medical evidence that has not already been requested and/or obtained that would well ground his claim. 38 U.S.C.A. § 5103(a) (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). As the appellant has not submitted a well grounded claim of entitlement to service connection for a left shoulder disorder, the doctrine of reasonable doubt has no application to his case. Left wrist disorder Service records show no complaints or findings of a left wrist disorder. In November 1996, the veteran complained that he had pain in the right wrist since he injured it when trying to break a fall several days before. Examination showed slight tenderness in the snuffbox areas. Diagnosis was right wrist strain. He was told to take Motrin and limit his activities for 10 days. In May 1997, the veteran reported, among other things, a history of right wrist problems and stated that he had filed a VA claim in that regard. On documents filed with his representative and thereafter associated with his claim for VA benefits in August 1997, the veteran reported having left wrist pain since 1997. On VA examination in November 1997, the veteran reported that he had jammed his left wrist (sprain) during physical therapy in service. This reportedly caused intermittent discomfort but had not caused any swelling. Absent clinical findings including limitation of motion of tenderness, the pertinent diagnosis was history of sprain, left wrist, presently asymptomatic. X-rays of the left wrist were negative. Analysis Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that a claim is well grounded; that is, that a claim is plausible. Grivois and Grottveit, op. cit. Because the veteran has failed to meet this burden, the Board finds that his claim for service connection for a left wrist disorder is not well grounded and should be denied. Where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy op. cit. The claimant does not meet this burden by merely presenting his lay opinion because such evidence does not constitute competent medical authority. Espiritu, op. cit. And consequently, lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well grounded claim, Tirpak, op. cit., the absence of cognizable evidence renders the veteran's claim not well grounded. Based upon the evidence of record, the Board finds that competent medical evidence has not been submitted which demonstrates that the veteran currently demonstrates chronic residuals of a left wrist disorder of service origin. In the absence of medical evidence of a present disability due to service or any incident therein, there is no valid claim. In summary, the Board finds that the evidentiary record does not contain competent medical evidence of a left wrist disorder which has been linked to the veteran's period of service on any basis. Absent a left wrist disorder in service, a chronic left wrist disability since service, and/or any competent medical authority to establish a reasonable nexus between a current left wrist disorder and service, none of the three components of a well grounded claim have been met in this case. Because the veteran has not submitted a well grounded claim of service connection for a left wrist disorder, VA is under no obligation to assist him in the development of facts pertinent to the claim. 38 U.S.C.A. § 5107(a). The Board is cognizant, however, that the Court has held that VA may have an obligation under 38 U.S.C.A. § 5103(a) (West 1991) to advise the claimant of evidence needed to complete a claim. Beausoleil v. Brown, 8 Vet. App. 459 (1996). The Court has held that the section 5103(a) duty requires that, when a claimant identifies medical evidence that may complete an application but is not in the possession of VA, VA must advise the claimant to attempt to obtain that evidence. Brewer v. West, 11 Vet. App. 228 (1998). In this case, the record indicates that the veteran has identified no such evidence. The Board further finds that the RO advised the appellant of the evidence necessary to establish a well grounded claim, and the appellant has not indicated the existence of any post service medical evidence that has not already been requested and/or obtained that would well ground his claim. 38 U.S.C.A. § 5103(a); McKnight and Epps cases, op. cit. As the appellant has not submitted a well grounded claim of entitlement to service connection for a left wrist disorder, the doctrine of reasonable doubt has no application to his case. Dental disorder Special Criteria On claims filed prior to 1994, service connection could be granted for certain dental disabilities. The laws changed again slightly in 1999. For instance, the presumption of soundness at entrance did not apply on dental claims filed before the 1999 changes (38 C.F.R. § 3.381). Furthermore, in that regard, malposed teeth were specifically excluded under the provisions of 38 C.F.R. § 3.382 in effect prior to 1999. Similarly, the law in effect since 1999 also precludes service connecting malposed teeth. As authorized by 38 U.S.C. § 1712, specifically, 38 C.F.R. § 3.381 (in effect since June 8, 1999, but comparable to 38 C.F.R. § 3.382 in effect prior thereto and since the veteran's separation from service and claim for benefits), sets out criteria for service connection of dental conditions for treatment purposes as (a) Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in Sec. 17.161 of this chapter. (b) The rating activity will consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in line of duty during active service. When applicable, the rating activity will determine whether the condition is due to combat or other in-service trauma, or whether the veteran was interned as a prisoner of war. (c) In determining service connection, the condition of teeth and periodontal tissues at the time of entry into active duty will be considered. Treatment during service, including filling or extraction of a tooth, or placement of a prosthesis, will not be considered evidence of aggravation of a condition that was noted at entry, unless additional pathology developed after 180 days or more of active service. Pursuant to 38 C.F.R. § 3.381(d), the following principles apply to dental conditions noted at entry and treated during service: (1) Teeth noted as normal at entry will be service- connected if they were filled or extracted after 180 days or more of active service. (2) Teeth noted as filled at entry will be service-connected if they were extracted, or if the existing filling was replaced, after 180 days or more of active service. (3) Teeth noted as carious but restorable at entry will not be service-connected on the basis that they were filled during service. However, new caries that developed 180 days or more after such a tooth was filled will be service-connected. (4) Teeth noted as carious but restorable at entry, whether or not filled, will be service-connected if extraction was required after 180 days or more of active service. (5) Teeth noted at entry as non-restorable will not be service-connected, regardless of treatment during service. (6) Teeth noted as missing at entry will not be service connected, regardless of treatment during service. Under 38 C.F.R. § 3.381(e) the following will not be considered service-connected for treatment purposes: (1) Calculus; (2) Acute periodontal disease; (3) Third molars, unless disease or pathology of the tooth developed after 180 days or more of active service, or was due to combat or in- service trauma; and (4) Impacted or malposed teeth, and other developmental defects, unless disease or pathology of these teeth developed after 180 days or more of active service. (f) Teeth extracted because of chronic periodontal disease will be service-connected only if they were extracted after 180 days or more of active service. It is also noted that dental treatment, or lack thereof, does not constitute dental trauma for the purpose of obtaining VA outpatient dental treatment. Woodson v. Brown, 8 Vet. App. 352 (1995); see also VAOPGCPREC 5-97. [In that regard, it is important to determine if a dental condition is due to service trauma only in that this allows a veteran to become eligible for VA outpatient dental care without being subject to the usual restrictions of a timely application and one time treatment under 38 C.F.R. § 17.161(c).] The basic question to be addressed is whether or not the veteran has presented a legal claim for a VA benefit. If not, the appeal must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 425 (1994). Factual Background On examinations and evaluations concurrent with and shortly after the veteran's entrance into service, it was noted that he had several dental problems including overbite due to malocclusion and midline deviation, numerous deep caries, deep and heavy calculus, severe gingivitis, complaints of pain in some lingual tissue areas, and a Class II occlusion with anterior tooth splaying, and generally crowded teeth. Dental records show that on numerous occasions he had the carious teeth noted early in service filled or otherwise restored and treated. In July 1990, the veteran requested an orthodontics evaluation for his posterior open bite (bilaterally) and a general assessment of what might be able to be done to help his overall dental condition. This was undertaken, and he was fully informed as to the involved risks, his options. With a notation that he had given his informed consent, the ongoing therapy regimen selected was performed over a period of many months, as shown in ongoing dental reports which are in the file. The rigorous first portion of his elective orthodontics program was completed in July 1991. Thereafter, over a period of months the veteran was given continued treatment for the Class II, Div. 1, moderately severe crowding, double protrusion, skeleto-dental malocclusion superimposed on a mandibular dental retrognathia. As noted in August 1991, treatment included the extraction of all first bicuspids and inpactions in preparation for use of full orthodontic appliances. In November 1992, it was noted that the veteran had developed a small submandibular pustule on the right lip border which was tender and felt to be an infected hair follicle. The use of orthodontic wires caused some complaints of pain in his cheeks in the summer and fall of 1992. By April 1995, the veteran was described by the oral surgery department to have mild skeletal class II, dental Class II malocclusion. The left side was full step; the right end was Class II. It was noted that his presurgical orthodontic alignment for preparation for mandibular advancement was then near completion. The diagnosis was asymmetrical Class II and midline discrepancy. In October 1995, as noted in the complete hospital and surgical report packet, having completed his orthodontic portion of the treatment, the veteran was scheduled for the final surgical portions He underwent bilateral sagittal ramus osteotomies of the mandible; rigid internal fixation of the mandible; and a surgical splint. The postoperative diagnoses were Class II dental skeletal malocclusion mandibular retrognathia; mandibular hypoplasia; and midline deviation. The veteran was released for a recovery period. In December 1995, when recalled for periodontal evaluation, he was asymptomatic except for a slight gingival inflammation at the surgical site. He continued his orthodontic therapy, and his gingival and periodontal health was said to be excellent in March 1996. The following month he had a brief bout with drainage around one remaining screw. He healed rapidly after screw removal. Except for a small area of root sensitivity seemingly on the root surface area of one tooth, in June 1997 he was felt to be without symptomatic pathology. On VA examination in November 1997, the veteran reported that in service, he had had surgery for bilateral mandibular overbite (cosmetic surgery). He said that currently this caused no difficulty except in extremely cold weather, at which time he would have aching in his jaws bilaterally. On examination, the veteran was able to open his mouth normally and without any pain or tenderness in the jaws. The pertinent diagnosis was status post mandibular surgery, presently asymptomatic. Analysis With respect to the claim of entitlement to service connection for a dental disorder, the Board does not need to reach the question whether or not this claim is well grounded because the law concerning awards of service connection are dispositive. As such, regardless of the character or the quality of any evidence which the veteran could submit, such dental disabilities, cannot be recognized as a disability under the law. The veteran's claim was filed in 1997 at the time of his separation from service. However, irrespective of the criteria applied to the veteran's case, before 1994 or since, including the most recent 1999 revisions, the standard is the same. From a substantive standpoint, in this case, the veteran had a serious overbite [Class II skeletal dental malocclusion, retrognathia, mandible hypoplasia and midline deviation] at the time of entrance which he eventually elected to have corrected, presumably for functional as well as cosmetic purposes. In the interim from entrance until the time he sought dental therapies, there was no sign of dental trauma or other incident which precipitated any dental disorder other than that which clearly preexisted service entrance, namely the malposing; and the inservice elective treatment regimen, albeit of some extent and duration, was not, under pertinent regulations, an aggravation thereof. As noted above, he did indeed seek correction thereof, which was undertaken in segments, first orthodontically and then surgically, over a period of months by the service department. At the conclusion thereof, he had no untoward residuals. On the examination conducted shortly after separation from service by VA, his status post mandibular surgery was asymptomatic. The veteran's underlying and pivotal problem relates solely to his malposed teeth. As a result, dental examiners have noted the periodic development of other symptoms associated therewith, as described above such as gingival irritations, etc. [There were also some caries noted at about the time of entrance which were filled; given the time frame involved, i.e., a very brief period from entrance, these are also excluded]. However, the aggregate treatment in service, albeit extensive and over a lengthy period, was exclusively for the malposition problem. In this regard, the veteran had some periodic pain before, during and on rare occasions (on extreme cold) since his extensive inservice procedures which were of an ameliorative nature. Since this is clearly reflective of no new symptoms, these are not subject to service connection as subsequently acquired disability entities. It may be beneficial to relate again the regulations in this regard. Treatment during service, including filling or extraction of a tooth, or placement of a prosthesis, will not be considered evidence of aggravation of a condition that was noted at entry, unless additional pathology developed after 180 days or more of active service. In this case, there was no such additional pathology. Initial compensable evaluation General Criteria Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board has also considered all regulatory provisions which are potentially applicable through the assertions and issues raised in the evidence of record as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Conclusions reached on any given medical issue to include a determination with regard to such things as degree or extent of functional impairment of a disability, etc., the Court has repeatedly admonished that VA cannot substitute its own judgment or opinion for that of a medical expert. See, i.e., Colvin v. Derwinski, 1 Vet. App. 761 (1991). The Court has also held that a determination with regard to both entitlement to the assignment of specific ratings must be made upon a review of the entire evidentiary record including thorough and comprehensive examinations that are representative of the entire clinical picture. Brown v. Brown, 5 Vet. App. 413 (1993). The assignment of a particular diagnostic code is completely dependent upon the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in diagnostic codes by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). As will be discussed below in pertinent part, in this case, the Board has considered whether other rating codes might be more appropriate than the ones used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). When an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies are to be avoided, as are the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor are ratings assigned to organic diseases and injuries to be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (1999). However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (1999). The Court has held that a claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). In every instance where the schedule does not provide a noncompensable rating for a diagnostic code, a noncompensable rating will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Dislocation, left ring finger Special Criteria Under 38 C.F.R. § 4.71a, a dislocation such as in a ring finger is rated on the basis of residual impairment. For instance, if comparable to ankylosis, the only pertinent and applicable schedular criteria provides only for a noncompensable rating when involving any finger other than thumb, index or middle finger, and whether on the major or minor extremity, under Diagnostic Code 5227. Factual Background The veteran injured his left ring finger while playing ball in service; fracture was not shown by X-rays. On VA examination in November 1997, he stated that he had "broken" the finger while playing basketball in service and had had continued interphalangeal joint swelling thereof since. On examination, the examiner noted that there was moderate swelling and slight tenderness of the proximal interphalangeal joint of the left ring finger without loss of grip or other functional impairment. Analysis Initially, the Board finds that the veteran's claim of entitlement to an initial compensable evaluation for his left ring finger dislocation is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of his left ring finger dislocation disability (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an initial compensable evaluation for that disability is well grounded. King v. Brown, 5 Vet. App. 19 (1993). The Board is also satisfied that all relevant facts have been properly developed to their full extent and that VA has met its duty to assist. Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). The Board notes that this case involves an appeal as to the initial rating of a left ring finger dislocation disability, rather than an increased rating claim where entitlement to compensation had previously been established. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. In the case at hand, the Board finds that a staged rating is inappropriate. The 1997 VA examination showed minimal complaints, moderate swelling and slight tenderness of the proximal interphalangeal joint of the left ring finger without loss of grip or other functional impairment. Under cited schedular criteria, the ring finger is not provided a compensable rating, even if the disability impairment were so severe as to be characterized as ankylosed, which is far from the case herein. There are no other appropriate criteria under which to rate the disability. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial compensable evaluation for any left ring finger dislocation disability. Residuals of a left elbow injury Special Criteria Impairment of an elbow as a result of injury may be rated in various ways depending on the nature of the injury and the type of residuals. These ratings are found within 38 C.F.R. § 4.71a, and normal range of elbow motion is demonstrated in diagrammatic form under Plate I thereunder. For instance, when there is limitation of major or minor forearm flexion to 100 degrees and extension to 45 degrees, a 20 percent rating is assignable under Code 5208. When forearm flexion is limited to 110 degrees, a noncompensable rating is assignable for major or minor extremity; a 10 percent rating assignable when limited to 100 degrees; and there are assignable proportionately increased ratings for more severely limited motion, respectively, under Code 5206. Other Codes such as 5207, 5211, 5212 provide for rating based on forearm limitation of extension, or radius or ulna impairment, etc. Factual Background On VA examination in November 1997, the veteran reported having injured his left elbow in service for which he was given a sling and conservative care. He stated that this gave him some discomfort at times. There had been no recent left elbow swelling. On examination, there was no swelling or elbow tenderness, and motions were normal. X-rays of the left elbow showed an apparent bone density within the joint space with calcification within the triceps region. Analysis Initially, the Board finds that the veteran's claim of entitlement to an initial compensable evaluation for residuals of a left elbow injury is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, op. cit. In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, op. cit. The veteran's assertions concerning the severity of residuals of a left elbow injury (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an initial compensable evaluation for that disability is well grounded. King v. Brown, op. cit. The Board is also satisfied that all relevant facts have been properly developed to their full extent and that VA has met its duty to assist. Godwin and White cases, op. cit. The Board notes that this case involves an appeal as to the initial rating of residuals of a left elbow injury, rather than an increased rating claim where entitlement to compensation had previously been established. Fenderson v. West, op. cit. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. In the case at hand, the Board finds that a staged rating is inappropriate. In this case, 1997 VA examination showed no swelling or elbow tenderness, and motions were normal. Absent any identifiable functional impairment, there is no basis for assigning a compensable rating under any potentially applicable code including 5208. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial compensable evaluation for residual left elbow disability regardless of the rating criteria applied. Pseudo-folliculitis barbae Special Criteria Under the general provisions of 38 C.F.R. § 4.118, various criteria are in effect for rating skin disorders. For instance, pseudo-folliculitis barbae is rated as for tinea barbae under Code 7814, rated as eczema [Code 7806)]. In such instances, a noncompensable rating is assignable with slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area. A 10 percent rating is assignable if there is exfoliation, exudation or itching, if involving an exposed surface or extensive area; a 20 percent rating is assignable with exudation or itching constant, extensive lesions, or marked disfigurement. A 50 percent rating is assignable with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. No other viable rating alternatives are available. Factual Background The veteran sought care on rare occasions in service for his facial skin lesions diagnosed as pseudo-folliculitis barbae. He had some other skin complaints from which he had no residuals and which are not service-connected. On VA examination in November 1997, he said he used a special razor on a daily basis and had problems when he shaved too closely. On occasion, he had to use Erythromycin to clear up the folliculitic lesions of the beard area. He reported another rash which involved the shoulders without associated itching. On examination, he had a fine growth in his beard region, with a slight amount of follicular lesions. The pertinent diagnosis was pseudo-folliculitis barbae. Analysis Initially, the Board finds that the veteran's claim of entitlement to an initial compensable evaluation for pseudo- folliculitis barbae is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, op. cit. In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, op. cit. The veteran's assertions concerning the severity of pseudo- folliculitis barbae (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an initial compensable evaluation for that disability is well grounded. King v. Brown, op. cit. In that regard, the Board is satisfied that all relevant facts have been properly developed to their full extent and that VA has met its duty to assist. Godwin and White cases, op. cit. The Board notes that this case involves an appeal as to the initial rating of pseudo-folliculitis barbae, rather than an increased rating claim where entitlement to compensation had previously been established. Fenderson v. West, op. cit. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. In the case at hand, the Board finds that a staged rating is inappropriate. In this instance, the veteran wears a beard. The follicular lesions, when present, are on a would-be exposed area were it not for the beard. On VA examination in 1997 the veteran was said to have some evidence of a slight folliculitis, but this is no more than slight and on only a small area. There is no evidence that there is such exfoliation, exudation or itching, or that there is involvement of such an extensive area as would support a rating to a compensable degree. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial compensable evaluation for pseudo-folliculitis barbae. Additional Matter Ratings shall be based as far as practicable. Upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The RO provided and addressed the criteria for assignment of an increased evaluation of the appellant's herein concerned disabilities on an extraschedular basis. The RO determined that an increased evaluation on an extraschedular basis was not supported by the evidentiary record. The Board agrees with the RO's determination. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the VA Undersecretary for Benefits or the Director of the VA Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). It is not claimed nor shown that the veteran's noncompensably evaluated disabilities have caused him to lose any time from work or to have required frequent, much less any inpatient care. There are no other factors which might suggest a disability picture which is any way unusual or exceptional in nature as to warrant referral of his case to the Director or Undersecretary for review for consideration of extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1). The current schedular criteria adequately compensate the veteran for the current nature and extent of his service- connected noncompensably evaluated disabilities at issue. Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. ORDER The veteran not having submitted well grounded claims of entitlement to service connection for a left shoulder disorder and for a left wrist disorder, the appeal is denied. The veteran's claim for service connection for a dental disorder is denied as a matter of law. The claims for entitlement to initial increased (compensable) ratings for dislocation, left ring finger, residuals of a left elbow disorder, and pseudo-folliculitis barbae, are denied. RONALD R. BOSCH Member, Board of Veterans' Appeals