Va Form 21-0960d-1 - Oral And Dental Conditions Including Mouth, Lips And Tongue (Other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire Page 2

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SECTION IV - DENTAL AND ORAL CONDITIONS

4. DOES THE VETERAN HAVE ANY OF THE FOLLOWING DENTAL OR ORAL CONDITIONS?

(If "No," proceed to Section V)

YES

(If "Yes," check all that apply)

(anatomical loss or bony injury) (If checked, complete Part A below.)

Mandible

(anatomical loss or bony injury) (If checked, complete Part B below.)

Maxilla

(anatomical loss or bony injury leading to loss of any teeth) (If checked, complete Part C below.)

Teeth

(anatomical loss or injury) (If checked, complete Part D below.)

Mouth, lips, tongue and disfiguring scars to the mouth or lips

(If checked, complete Part E below.)

Osteomyelitis/osteoradionecrosis/bisphposphonate-related osteonecrosis of the jaw

(If checked, complete Part F below.)

Tumors or neoplasms

(If checked, complete Part G below.)

Other dental or oral conditions, pertinent physical findings or scars due to dental or oral conditions

PART A - MANDIBLE, INCLUDING ANATOMICAL LOSS OR BONY INJURY (NOT DUE TO EDENTULOUS ATROPHY OR PERIODONTAL DISEASE)

(not due to edentulous atrophy or periodontal disease)

1. HAS THE VETERAN LOST ANY PART OF THE MANDIBLE OR MANDIBULAR RAMUS

(If "Yes," indicate severity (check all that apply))

YES

Loss of approximately 1/2 of the mandible, not involving the temporomandibular articulation

Loss of approximately 1/2 of the mandible, involving the temporomandibular articulation

Complete loss of the mandible between angles

(If checked, indicate side):

Loss of less than 1/2 the substance of mandibular ramus, not involving loss of continuity

Right

Left

Both

(If checked, indicate side):

Loss of whole or part of mandibular ramus, without loss of temporomandibular articulation

Right

Left

Both

(If checked, indicate side):

Loss of whole or part of mandibular ramus, involving loss of temporomandibular articulation

Right

Left

Both

(describe):

Other

(condyloid process)

2. HAS THE VETERAN LOST EITHER CONDYLOID

OF THE MANDIBLE?

(If "Yes," indicate side):

YES

Right

Left

Both

3. HAS THE VETERAN LOST EITHER CORONOID PROCESS OF THE MANDIBLE?

(If "Yes," indicate side):

YES

Right

Left

Both

4. HAS THE VETERAN HAD AN INJURY RESULTING IN MALUNION OR NONUNION OF THE MANDIBLE?

(If "Yes," indicate severity):

YES

Malunion with slight displacement

Malunion with moderate displacement

Malunion with severe displacement

Nonunion, moderate

Nonunion, severe

(describe):

Other

NOTE - The assessment of the severity of malunion or nonunion of the mandible is dependent upon degree of motion and relative loss of masticatory function.

PART B - MAXILLA, INCLUDING ANATOMICAL LOSS OR BONY INJURY (NOT DUE TO ENDENTULOUS ATROPHY OR PERIODONTAL DISEASE)

(Not due to endentulous atrophy or periodontal disease)

1. HAS THE VETERAN LOST ANY PART OF THE MAXILLA?

(If "Yes," indicate severity)

YES

Loss of less than 25%

Loss of 25 to 50%

Loss of more than 50%

2. IF THE VETERAN HAS LOST ANY PART OF THE MAXILLA, IS THE LOSS REPLACEABLE BY PROSTHESIS?

YES

NOT APPLICABLE

3. HAS THE VETERAN LOST ANY PART OF THE HARD PALATE?