RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00250
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Guard and Reserve (AGR) Program E-5 (Transportation Management Coordinator) medically separated for temporomandibular joint pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “temporomandibular joint (TMJ) arthralgia” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded 3 other conditions (see rating chart below) for PEB adjudication.  The Informal PEB the TMJ pain as unfitting, rated 20%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  Her conditions continue to worsen and negatively impact her life.  Additionally, she believes she was not compensated enough.  Her complete submission is at Exhibit A. 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  

IPEB – Dated 20070525	VA* - (~10 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Temporomandibular Joint Pain	5099-5003	20%	Temporomandibular Joint Syndrome	9905	10%	20080411	
Urinary Stress Incontinence	Not Unfitting	Urinary Incontinence	7599-7517	60%	20080225	
Gout	Not Unfitting	Irritable Bowel Syndrome; Gastroesophageal Reflux
Disease; Gastric Ulcer	7319-7346	10%	20080225	
Gastric Ulcer	Not Unfitting					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 15 	
RATING:  20%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20080918 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Temporomandibular Joint (TMJ) Condition.  The service treatment record (STR) documents that the CI underwent elective surgery to eliminate a non-esthetic skeletal overbite.  The CI underwent an orthognathic surgery (OGS) procedure (surgical manipulation of facial skeleton elements to restore the proper anatomic/functional relationships) by oral and maxillofacial surgery (OMFS).  At an OMFS follow-up the CI indicated her unit was preparing for long-term deployment.  Treatment options were discussed and pre-mature termination of the orthodontic treatment was agreed upon.  The transpalatal arch was removed.  At the OMFS follow-up a week later, the CI stated that the mission of her unit took priority over elective dental treatments.  The examiner documented that the CI understood that the orthodontic treatment was not finished and that the appliance might need to be replaced prior to the final prosthodontic procedure.  The examiner performed a total deband of the orthodontic appliance.  An OMFS encounter reported that the CI was air evacuated from Iraq through Germany for continued jaw and ear pain (mostly right side) since her OGS.  Pain had increased in intensity since deployment and extended Kevlar helmet wear.  The examiner documented that she had been ordered to active duty and an oral surgeon released her despite continued symptoms.  Symptoms included tenderness at the right posterior inferior border of the mandible and TMJ area.  There was no crepitus (grating sensation or sound), popping, or clicking and the maximal interincisor opening (MIO) was 40 mm.  The CI reported that she felt she didn’t have enough time to heal and her bite wasn’t fully corrected.  A Panorex (panoramic X-ray) showed stable fixation hardware, some “lipping” on the anterior surface of the right condyle, and a partially impacted tooth.  The assessment listed right sided facial and TMJ pain since OGS.  The OMFS follow-up impression listed myofascial pain dysfunction (MPD) with no apparent TMJ disc displacement.  The plan was for medical management through the orofacial pain center.  At the orofacial pain encounter the CI complained of 5/10 sharp, electric-like, aching, throbbing, jaw, right temple, and right ear pain.  She reported episodic jaw joint sounds.  The examiner recorded paresthesias (abnormal sensation, tingling, burning, prickling) and allodynias (pain from stimuli which are not normally painful) around the mouth secondary to the surgical procedure.  The right jaw (masseter muscle) pain was 4/10 (worst 10/10), constant, daily, and pressure-like.  The assessment listed neuropathic pain secondary to surgery, masticatory co-contraction/myalgia (muscle pain), episodic tension headaches, and periodic right TMJ sounds.  The following OMFS encounter recorded a comfortable interincisor opening of 32mm and a MIO of 51mm with a little discomfort.  The CI underwent a rhinoplasty (nasal surgery) by OMFS to correct a deficient nasal septum.  A dental evaluation documented the CI’s jaw had “a closed lock bilateral and unable to open more than 25mm ….”  The primary diagnosis was TMJ and the secondary diagnosis was myofascial pain.  The narrative summary (NARSUM), 2 months before separation, recounted the history and interventions.  The CI complained of continued headaches and jaw pains.  Pain was exacerbated by stress and tight neck and facial muscles.  Symptom relief was good with an NSAID (Naprosyn) and a muscle relaxant (Robaxin) and poor with an antidepressant (Nortriptyline).  The physical exam documented bilateral clicking felt at TMJs, with the right much more pronounced than the left.  No MIO was documented.  The diagnosis listed TMJ arthralgia, which began prior to service.  The examiner opined that surgery worsened the condition, most likely because she was not allowed to recover fully before being deployed.  

At the VA dental and oral compensation and pension (C&P) exam the CI reported myofascial and TMJ discomfort and that she clenches and grinds.  It documented “…she opted for elective orthognathic surgery to eliminate nonesthetic skeletal overbite … the surgical consents…may have listed her present condition as a possible sequelae…was wired for 2 months and then ortho [dontics] was started…orthodontic brackets were removed so…could be deployed to Iraq…had swelling that never healed…prematurely sent back from her tour…”  The physical exam noted normal facial symmetry, lips, mucosa, tongue, palate, oropharynx, gingiva, occlusion, and tooth mobility.  Intraoral and extraoral palpation of musculature and joints provoked tenderness and discomfort responses at 4/10.  The vertical maximum opening was 37mm with 5mm right and 4mm left excursive movements.  No clicking, popping, or crepitus was noted.  The dentist concluded the CI appeared to have discomfort in the TMJ area and corresponding musculature.  There was no trauma or accident incurred to her because of the military.  The surgery was elective, done for esthetic reasons, and consents were signed.  The dentist opined that the condition could be a sequela of orthognathic surgery, but it did not appear that it could be positively service connected.

The Board directed attention to its rating recommendation based on the above evidence.  In accordance with DoDI 1332.38, E3.P4.5.6., “Treatment of Pre-Existing Conditions:  Generally recognized risks associated with treating preexisting conditions shall not be considered service aggravation.”  The PEB rated the TMJ condition 20% (coded 5099-5003).  The PEB cited pain following surgery to correct a pre-existing condition, worsening pain, and moderate/constant pain.  A 20% rating under 5003 requires joint limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations.  The VA, citing the C&P exam 10 months after separation, rated the TMJ condition 10% (coded 9905).  The VA cited TMJ area discomfort, maximum vertical opening of 37mm, excursive movement to right (5mm) and left (4mm).  The inter-incisal range-of-motion (ROM) (25mm) documented in the dental evaluation, 15 months before separation, was consistent with a 20% rating (inter-incisal ROM limited to 21 to 30mm).  No inter-incisal ROM was documented in the NARSUM.  The jaw ROM (MIO 37mm, right 5mm, and left 4 mm) documented in the C&P exam, 10 months after separation, was consistent with a 10% rating (inter-incisal ROM limited to 31 to 40 mm, or lateral excursion to 0 to 4 mm).  Other routes to a rating higher than the PEB’s 20% were considered, but there was no evidence of osteomyelitis, osteonecrosis, loss, nonunion, or malunion of the maxilla, mandible, ramus, condyloid process, coronoid process, or hard palate for consideration under the applicable codes.  After due deliberation, considering all of the evidence, and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the TMJ condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the urinary incontinence, gout, and gastric ulcer conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Contended Urinary Incontinence Condition.  The STR documents a history of mild urinary incontinence following childbirth.  The CI underwent urodynamic testing by urogynecology which revealed mixed urinary incontinence.  The examiner did not recommend surgical correction until cessation of child bearing.  The NARSUM documented the CI “… developed symptoms of mild urinary incontinence after childbirth in 1994.  However, in 2006 the symptoms became much worse, now requiring a box of pads approximately every three days.  The incontinence has not required absence from duty other than for medical appointments.”  The diagnosis listed urinary stress incontinence, meets retention standards.  While the incontinence was implicated in the commander’s statement, it was not profiled, met retention standards by the MEB, and was considered to be not unfitting by the PEB.

Contended Gout Condition.  The STR documented a single reference to “probable gout” in a podiatry encounter.  The impression listed probable gout with a symptomatic right hallux rigidus (big toe restricted mobility).  The NARSUM made a tangential reference to gout “… recently diagnosed with gout …” which met retention standards.  The gout, was not profiled, not implicated in the commander’s statement, met retention standards by the MEB, and was considered to be not unfitting by the PEB.

Contended Gastric Ulcer Condition.  The STR documented findings suggesting nonerosive reflux disease (NERD) and irritable bowel syndrome (IBS).  Gastroenterology performed an esophagogastroduodenoscopy.  The assessment documented “Essentially normal upper endoscopy.  The patient’s symptoms consistent with NERD (nonerosive reflux disease), probably as part of an irritable bowel syndrome with spastic stomach component.”  The same day gastroenterology encounter listed a primary assessment of chronic reflux and regurgitation with aerophagia [swallowing air], “… which is probably contributing to some of her symptoms that she describes as acid reflux.”  The secondary assessment listed chronic constipation, “… probably part of an irritable bowel syndrome … Some of the upper gastrointestinal tract symptoms may also be related to the irritable bowel syndrome.”  The NARSUM made a tangential reference to gastric ulcers “… recently diagnosed with … gastric ulcers …” which met retention standards.  The gastric ulcers were not profiled, not implicated in the commander’s statement, met retention standards by the MEB, and were considered to be not unfitting by the PEB.

All contended conditions were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  The Board determined that the preponderance of evidence indicated that these conditions were not unfitting for continued military service.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the urinary incontinence, gout, and gastric ulcer conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating the TMJ condition was operant in this case and the condition was adjudicated independently of that policy/ instruction by this Board.  In the matter of the TMJ condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended urinary incontinence, gout, and gastric ulcer conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140101, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX, AR20160002100 (PD201400250)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA