RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  Pd-2015-01406
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20071102

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Supply Specialist, medically separated for “bilateral temporomandibular joint [TMJ] arthralgia” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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:  

SERVICE PEB – 20070910	VARD - 20080509	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral TMJ Arthralgia	5099-5003	10%	Bilateral TMJ Arthralgia with Symptoms of Headaches	9905-5003	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral TMJ Arthralgia.  The PEB combined the right and left TMJ conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) and rated 10%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left TMJ conditions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured her right jaw on the obstacle course during basic training, approximately 3 years prior to referral for MEB.  At the 29 November 2005 dental encounter the CI complained of a history of right jaw (masseter) muscle pain with a closed locked jaw after wearing her Kevlar helmet.  At the time of examination she was able to open her mouth with no pain.  The diagnosis listed right closed TMJ and the plan was for splinting with a hard flat plain night guard (N/G).  At the 9 December 2005 oral and maxillofacial surgery (OMFS) consultation the CI complained of 2 years of right TMJ pain which was exacerbated by wearing the gas mask and Kevlar.  She reported a history of open and closed locked right TMJ.  The oral examination documented a pain-free opening of 27 mm, and a maximal inter-incisal opening (MIO) of 38 mm with right TMJ pain.  The assessment listed right TMJ pain secondary to anterior disc displacement.  The examiner recommended nonsteroidal anti-inflammatory drugs, a soft diet, and N/G therapy.  The 16 December 2005 TMJ MRI showed minimal arthritic disease and anteriorly dislocated menisci (left greater than right) which showed recapture upon mouth opening.  

During the 3 August 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI complained of right face pain and headaches which were exacerbated by wearing a helmet or stress.  The physical examination revealed no jaw clicking or subluxation (incomplete dislocation).  In the 10 August 2007 MEB NARSUM, 3 months before separation, the CI complained of "jaw pain which causes headaches and loss of sleep.  The jaw pain makes it unbearable to wear the gas mask and Kevlar."  The constant pain was controlled with medications.  At a dental comprehensive examination 19 October 2005 the examiner recounted the MRI findings.  The diagnosis listed TMJ arthralgia (joint pain).  The 28 August 2007 dental evaluation reported a history of right face trauma, TMJ, and jaw locking.  “Pt had a hard N/G fabricated but pt didn’t wear appliance and it was discarded by patient.”  The CI was asymptomatic and was not interested in having another N/G fabricated.  The 3 January 2008 VA primary care examination documented, “Unable to open mouth fully” but it did not quantify the range of motion (ROM).  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether each TMJ condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  While the profile listed TMJ dysfunction, the MEB listed arthralgia of TMJ, and the PEB listed bilateral TMJ joint arthralgia, the majority of complaints, pathology, and therapeutic interventions in the STR were related to the right TMJ.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing bilateral TMJ arthralgia, no obvious restriction of motion, and rated for pain (slight/constant).  The VA assigned a 10% rating under the 9905-5003 codes (temporomandibular articulation, limited motion of-arthritis, degenerative) based on the STR and noting the CI did not report for a scheduled VA dental and oral examination.  The VA cited TMJ and associated headaches, no obvious restriction of motion, slight/constant pain, and evidence of painful or limited motion of a major joint or group of minor joints.  The MIO of 38 mm documented in the OMFS evaluation, 23 months before separation, was consistent with a 10% rating (inter-incisal ROM limited to 31 to 40 mm).  The dental evaluation, 2 months before separation, reported the CI was “asymptomatic” and did not document inter-incisal ROM.  The VA primary care examination, 2 months after separation, documented, “Unable to open mouth fully” but did not quantify ROM.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral TMJ condition.  

BOARD FINDINGS:  In the matter of the bilateral TMJ condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170008472, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					       
						      					
Enclosure