M21-1 Manual / Part V, Subpart iii, Chapter 14

Dental and Oral Conditions

M21-1, Part V, Subpart iii, Chapter 14

Overview

In This Chapter

This chapter contains the following topics:

Topic	Topic Name
1	General Principles for Rating Dental and Oral Conditions for Compensation Purposes
2	Rating Specific Dental and Oral Conditions

1. General Principles for Rating Dental and Oral Conditions for Compensation Purposes

Introduction

This topic contains information on and general principles for rating dental and oral conditions for compensation purposes, including

interpreting claims raising dental issues
general information on service connection (SC) for dental and oral disabilities for compensation purposes
dental/oral contentions for which compensation-purpose SC may not be established
dental examinations in compensation claims for a dental disability
denying dental claims for SC compensation
schedule of ratings for dental and oral conditions, and
dental-oral rating schedule changes.

Change Date

October 10, 2019

V.iii.14.1.a. Interpreting Claims Raising Dental Issues

Service connection (SC) for dental/oral disabilities and conditions can be established for

compensation purposes, or
treatment purposes only.

Generally assume that a claim for a dental/oral disability or condition, filed on a prescribed form, seeks SC for compensation purposes unless the claim’s wording clearly communicates pursuit of dental treatment, in which case, follow procedures found in M21-1, Part XIII, Subpart i, 4.B.1.a. Important:
Under 38 CFR 3.381(a), the Veterans Benefits Administration will adjudicate a claim for SC of a dental condition for treatment purposes after the Veterans Health Administration (VHA) determines a Veteran meets the basic eligibility requirements of 38 CFR 17.161. Therefore, do not address as an actionable contention, or in the setting of a rating decision, the issue of SC for treatment purposes unless prompted to do so by a specific request from VHA.
The rating principles discussed in this section are specific to determinations of SC for compensation purposes. Rating for dental treatment purposes, conversely, is discussed in M21-1, Part XIII, Subpart i, 4.C.
References: For more information on
processing dental treatment requests, see M21-1, Part XIII, Subpart i, 4.B, and
clarifying claims, see M21-1, Part III, Subpart i, 2.D.1.c.

V.iii.14.1.b. General Information on SC for Dental and Oral Disabilities for Compensation Purposes

Claims for SC of dental and oral disabilities are developed and decided pursuant to the same policies and procedures that apply to SC for compensation purposes of conditions of other body systems. When notifying a Veteran of a decision to grant compensation-purpose SC for a dental or oral disability, include language to the following effect in the rating decision narrative: Although your dental condition or disability is service-connected, eligibility for treatment for that disability is limited by statute. You may not be eligible for VA dental care. Please contact the VHA facility that is nearest your home for a determination on whether you are eligible for treatment for your service-connected dental condition or disability.Reference: For more information on interpreting claims raising dental issues and the definition of a dental disability, see M21-1, Part V, Subpart iii, 14.1.a.

V.iii.14.1.c. Dental/Oral Contentions for Which Compensation-Purpose SC May Not Be Established

Generally, and unless otherwise contraindicated, any dental/oral condition that may be rated under, or by appropriate analogy to, the diagnostic code (DC) criteria of 38 CFR 4.150 is potentially subject to SC for compensation purposes. However, the following are prohibited from being deemed service-connected (SC) for compensation purposes:

treatable carious teeth
replaceable missing teeth
dental or alveolar abscesses
periodontal disease
dental calculi
third molars
impacted or malposed teeth (and other similar developmental defects), and
teeth extracted because of chronic periodontal disease.

Note: 38 CFR 4.150, DC 9913, does permit and provide for potential compensation-purpose SC for missing teeth; however, it also requires that such tooth loss be associated with underlying bone (maxilla/mandible) loss acquired as a result of

service trauma, as discussed in M21-1, Part XIII, Subpart i, 4.C.1, or
non-periodontal disease, such as osteomyelitis.

References: For more information on conditions that may be considered SC for

treatment purposes only, see M21-1, Part XIII, Subpart i, 4.C.1, and
neither compensation nor treatment purposes, see M21-1, Part XIII, Subpart i, 4.C.1.

V.iii.14.1.d. Dental Examinations in Compensation Claims for a Dental Disability

Obtain a dental examination for purposes of SC or evaluation purposes when necessary. Dental examinations are considered specialist examinations. References: For more information on
when an examination is necessary under the duty to assist for a dental or other disability, see M21-1, Part IV, Subpart i, 1.A and B, and
specialist examinations, see
M21-1, Part IV, Subpart i, 2.A.1.g, and
M21-1, Part IV, Subpart i, 2.A.6.

V.iii.14.1.e. Denying Dental Claims for SC Compensation

Consider the issue of SC for compensation purposes for the conditions listed in 38 CFR 3.381(b) in a formal rating and deny the claim if

a Veteran claims compensation for one of these conditions, and
the record shows no complicating condition that is subject to SC.

In the Narrative of the rating decision, discuss that under 38 CFR 3.381(b) SC for such conditions can be established only for treatment purposes, and note if dental treatment in service was limited to conditions affecting only the teeth or gums.

V.iii.14.1.f. Schedule of Ratings for Dental and Oral Conditions

The schedule of ratings for dental and oral conditions are contained at 38 CFR 4.150. Important: When there is competent and credible medical evidence of impairment associated with conditions listed in 38 CFR 4.150 DCs that cannot be evaluated within the listed diagnostic criteria, that impairment must be evaluated separately. Examples of potentially-associated impairments include (but are not limited to)

loss of
- vocal articulation
- smell, or
- taste
- neurological impairment
- respiratory dysfunction, or
- other impairments (such as scars).
Important: The guidance on other impairment associated with dental and oral conditions was added as Note (2) to changes to 38 CFR 4.150 effective September 10, 2017. However, as currently provided in M21-1, Part V, Subpart ii, 3.A.2.c, when deciding expressly claimed issues, decision makers must consider entitlement to any complications that are within the scope of the claim including those identified by the rating criteria. Reference: For more information on the dental-oral rating schedule changes, see M21-1, Part V, Subpart iii, 14.1.g.

V.iii.14.1.g. Dental-Oral Rating Schedule Changes

A final rule made amendments to the rating schedule provisions for dental and oral conditions (38 CFR 4.150) effective September 10, 2017. The changes were not considered liberalizing. Reference: For more information on handing claims when there are regulatory changes, see M21-1, Part V, Subpart ii, 4.A.

2. Rating Specific Dental and Oral Conditions

Introduction

This topic contains information on rating specific dental and oral conditions, including

diagnostic imaging confirmation requirement for evaluations based on nonunion of the mandible or maxilla
special considerations in evaluations for temporomandibular disorder (TMD), and
definition and evaluation guidelines for bruxism.

Change Date

May 27, 2020

V.iii.14.2.a. Diagnostic Imaging Confirmation Requirement for Evaluations Based on Nonunion of the Mandible or Maxilla

Under 38 CFR 4.150, DC 9903, nonunion of the mandible requires confirmation by diagnostic imaging studies. Under 38 CFR 4.150, DC 9916, maxillary nonunion requires confirmation by diagnostic imaging studies. As defined in the note to 38 CFR 4.150, diagnostic imaging studies include but are not limited to
conventional radiography (x-ray)
computed tomography (CT)
magnetic resonance imaging (MRI)
positron emission tomography (PET)
radionuclide bone scanning, and
ultrasonography.
The term nonunion refers to incomplete healing after an adequate healing period with fibrous union and mobility of fracture segments. Important: An actual copy of the imaging study does not need to be present in the claims folder. However, the folder must reflect confirmation that the imaging was reviewed by the examiner. Note: Although this is a new regulatory requirement, added to 38 CFR 4.150 effective September 10, 2017, the September 2016 version of the Oral and Dental Conditions Including Mouth, Lips And Tongue (Other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire asks if x-rays or other studies, to include studies of the maxilla and mandible, have been conducted and instructs the examiner that if studies supporting the diagnosis are already of record they do not have to be repeated. For cases pending on the effective date of the change of law, September 10, 2017, if there is a diagnosis of nonunion unsupported by diagnostic studies, obtain clarification.

V.iii.14.2.b. Special Considerations in Evaluations for TMD

Temporomandibular disorder (TMD) (which may also be called temporomandibular joint dysfunction (“TMJD” or more colloquially TMJ”)) is evaluated under 38 CFR 4.150, DC 9905. Evaluation levels are based on

limitation of inter-incisal range of motion (with or without dietary restrictions), or
range of lateral excursion.

When assigning an evaluation there are a number of considerations. For Department of Veterans Affairs purposes, normal maximum unassisted range of inter-incisal motion is 35 to 50mm.

A 10-percent evaluation can be assigned for no more than 34 mm of inter-incisal motion.
Under the prior version of the DC (effective prior to September 10, 2017), a 10-percent evaluation was available for motion up to 40 mm.

For each range of maximum assisted inter-incisal motion, the appropriate evaluation to assign will depend on whether or not the condition necessitates dietary restriction to mechanically-altered foods.

The regulation provides in Note (3) that mechanically altered foods are foods altered by blending, chopping, grinding, or mashing to make them easier to chew and swallow. Mechanical alteration can be to one of four levels or gradations: full liquid, puree, soft, and semi-solid.
The note refers to dietary restrictions in which mechanically altered foods are required as texture modified diets.
Dietary restrictions involving any textured modified diet (any grade of mechanically altered food) must be recorded or verified by a physician.
- A contention or testimony by an individual that he or she is using a texture modified diet or requires one due to the SC condition is not sufficient to establish that the condition necessitates a texture modified diet with restriction to mechanically altered foods.
- Endorsement of the need for the dietary restriction to mechanically altered foods by a competent medical professional is required. An examination report may satisfactorily record or verify that the SC condition necessitates the dietary restriction to mechanically altered food.

With respect to inter-incisal range of motion, the DC requires ranges be “unassisted.” This means active range of motion. In assigning an evaluation for TMD or any other dental disability on the basis of limited motion of temporomandibular articulation under 38 CFR 4.150, DC 9905, do not assign separate evaluations for limited inter-incisal motion or painful motion involving each side of the jaw. Doing so is pyramiding. Only one evaluation may be assigned. If both sides of the jaw are affected, use the limitation of motion on the side that affords the highest evaluation. Example: Maximum unassisted inter-incisal motion is limited to 34 mm on the right and 25 mm on the left. There is no dietary restriction to mechanically altered foods. There is credible evidence of actually painful motion of both sides of the jaw. Assign a single 20-percent evaluation under 38 CFR 4.150, DC 9905. Do not assign separate 10-and 20-percent evaluations.Do not combine ratings for limited inter-incisal motion with a rating based on limitation of lateral excursion of the jaw. References: For more information on

entitlement to a single rating for limitation of inter-incisal motion to include as due to painful motion, see Vilfranc v. McDonald, 28 Vet.App. 357 (2017)
painful motion for joint conditions under 38 CFR 4.59, see M21-1, Part V, Subpart iii, 1.A.1
choice of law for cases pending at the time of a regulatory change, see M21-1, Part V, Subpart ii, 4.A.6, and
the prohibition against pyramiding, see
38 CFR 4.14, and
M21-1, Part V, Subpart ii, 3.D.2.b.

V.iii.14.2.c. Definition and Evaluation Guidelines for Bruxism

Bruxism is defined as excessive grinding of the teeth and/or excessive clenching of the jaw. It may not be evaluated as a stand-alone SC disability.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part V, Subpart iii, Chapter 14 (U.S. government work, reproduced for reference). Browse all sections →