VA Form 21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Ton

OMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes

ORAL AND DENTAL CONDITIONS INCLUDING MOUTH, LIPS AND TONGUE
(OTHER THAN TEMPOROMANDIBULAR JOINT CONDITIONS)
DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF
COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information
you provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSES

1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH AN ORAL OR DENTAL CONDITION? (This is the condition the veteran is claiming
or for which an exam has been requested)
YES

NO

(If "Yes," complete Item 1B)

1B. SELECT THE VETERAN'S CONDITION (check all that apply)
LOSS OF ANY PORTION OF MANDIBLE
(for reasons other than periodontal disease or edentulous atrophy)

ICD Code:___________

Date of diagnosis:______________

LOSS OF ANY PORTION OF MAXILLA
(for reasons other than periodontal disease or edentulous atrophy)

ICD Code:___________

Date of diagnosis:______________

MALUNION OR NONUNION OF MANDIBLE

ICD Code:___________

Date of diagnosis:______________

MALUNION OR NONUNION OF MAXILLA

ICD Code:___________

Date of diagnosis:______________

LOSS OF TEETH (for reasons other than periodontal disease,
or other routine dental maladies: this is intended for loss of teeth

ICD Code:___________

Date of diagnosis:______________

TEMPOROMANDIBULAR JOINT DISORDER (TMJD) (If checked,
complete the VA Form 21-0960M-15, Temporomandibular Joint
Conditions Disability Benefits Questionnaire in lieu of this questionnaire
if that is the veteran's only condition. If the veteran has a TMJD condition
AND additional oral or dental conditions, complete this questionnaire
and ALSO complete VA Form 21-0960M-15)

ICD Code:___________

Date of diagnosis:______________

LIMITATION OF MOTION OF THE TEMPOROMANDIBULAR JOINT
DUE TO CAUSES OTHER THAN TMJD
(If checked, complete this questionnaire and ALSO complete VAF Form
21-0960M-15, Temporomandibular Joint Conditions Disability Benefits
Questionnaire)
ANATOMICAL LOSS OR INJURY OF THE MOUTH, LIPS OR TONGUE

ICD Code:___________

Date of diagnosis:______________

ICD Code:__________

Date of diagnosis:______________

OSTEOMYELITIS, OSTEORADIONECROSIS OR BISPHOSPHONATERELATED OSTEONECROSIS OF THE JAW

ICD Code:__________

Date of diagnosis:______________

ORAL NEOPLASM (If checked, specify):__________________________

ICD Code:___________

Date of diagnosis:______________

PERIODONTAL DISEASE (if this is the ONLY diagnosis checked,
proceed to the signature section at the end of this form (for VA purposes
this disease is not considered disabling.))

ICD Code:___________

Date of diagnosis:______________

OTHER DIAGNOSIS #1:________________________________

ICD Code:___________

Date of diagnosis:______________

OTHER DIAGNOSIS #2:________________________________

ICD Code:___________

Date of diagnosis:______________

due to service-related trauma)

OTHER, specify:______________________________________

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO ORAL OR DENTAL CONDITIONS, LIST USING ABOVE FORMAT:

NOTE: This questionnaire is appropriate for bone loss due to trauma or disease such as osteomyelitis and not to the loss of the alveolar process as a
result of periodontal disease, edentulous atrophy since such loss is not considered disabling. This is intended for loss of teeth due to service-related trauma.

SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT
C-file (VA only)
Other, describe:_______________________________________
SECTION III - MEDICAL HISTORY
3. MEDICAL/DENTAL HISTORY (including onset and course) OF THE VETERAN'S ORAL AND/OR DENTAL CONDITION:

VA FORM
MAR 2011

21-0960D-1

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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 5)
YES
NO
(If "Yes," check all that apply)
Mandible (anatomical loss or bony injury) (If checked, complete Part A below.)
Maxilla (anatomical loss or bony injury) (If checked, complete Part B below.)
Teeth (anatomical loss or bony injury leading to loss of any teeth) (If checked, complete Part C below.)
Mouth, lips, tongue and disfiguring scars (anatomical loss or injury) (If checked, complete Part D below.)
Osteomyelitis/osteoradionecrosis/bisphposphonate-related osteonecrosis of the jaw (If checked, complete Part E below.)
Tumors or neoplasms (If checked, complete Part F below.)
Other dental or oral conditions, pertinent physical findings or scars due to dental or oral conditions (If checked, complete Part G below.)
PART A - MANDIBLE, INCLUDING ANATOMICAL LOSS OR BONY INJURY (NOT DUE TO EDENTULOUS ATROPHY OR PERIODONTAL DISEASE)
1. HAS THE VETERAN LOST ANY PART OF THE MANDIBLE OR MANDIBULAR RAMUS (not due to edentulous atrophy or peridontal disease)?
YES

NO If "Yes, indicate severity (check all that apply)

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
Loss of less than 1/2 the substance of mandibular ramus, not involving loss of continuity (If checked, indicate side):

Right

Left

Both

Loss of whole than or part of mandibular ramus, without loss of temporomandibular articulation (If checked, indicate side):
Right

Left

Both

Loss of whole or part of mandibular ramus, involving loss of temporomandibular articulation (If checked, indicate side):

Right

Left

Both

Other, describe:______________________________________________________________
2. HAS THE VETERAN LOST EITHER CONDYLE (condyloid process) OF THE MANDIBLE?
NO If "Yes, indicate severity (check all that apply)

YES

Right

If "Yes, indicate side:

Left

Both

3. HAS THE VETERAN LOST EITHER CORONOID PROCESS OF THE MANDIBLE?
NO If "Yes, indicate severity (check all that apply)

YES

Right

If "Yes, indicate side:

Left

Both

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

NO If "Yes, indicate severity:

If "Yes, indicate severity:
Malunion with slight displacement
Malunion with moderate displacement
Malunion with sever displacement
Nonunion, moderate
Nonunion, severe
Other, describe:___________________
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 ATROPY OR PERIDONTAL DISEASE)
1. HAS THE VETERAN LOST ANY PART OF THE MAXILLA? (Not due to endentulous atrophy or peridontal disease)
YES

NO If "Yes, indicate severity:

Loss of less than 25%
Loss of 25 to 50%
Loss of 50% or more
2. IF THE VETERAN HAS LOST ANY PART OF THE MAXILLA, IS THE LOSS REPLACEABLE BY PROSTHESIS?
YES

NO

NOT APPLICABLE

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

NO If "Yes, indicate severity:

Loss of less than 50%
Loss of 50% or more
VA FORM 21-0960D-1, MAR 2011

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SECTION IV - DENTAL AND ORAL CONDITIONS (Continued)
PART B - MAXILLA, INCLUDING ANATOMICAL LOSS OR BONY INJURY (NOT DUE TO ENDENTULOUS ATROPHY OR PERIODONTAL DISEASE)

4. IF THE VETERAN HAS LOST ANY PART OF THE HARD PLALATE, IS THE LOSS REPLACEABLE BY PROSTHESIS?
YES

NO

NOT APPLICABLE

5. HAS THE VETERAN HAD AN INJURY RESULTING IN MALUNION OR NONUNION OF THE MAXILLA?
YES
NO If "Yes, indicate severity:
Malunion or nonunion with slight displacement
Malunion or nonunion with moderate displacement
Malunion or nonunion with severe displacement
PART C - TEETH, INCLUDING ANATOMICAL LOSS OR BONY INJURY LEADING TO LOSS OF ANY TEETH (OTHER THAN THAT DUE TO THE
LOSS OF THE ALVEOLAR PROCESS AS A RESULT OF PERIODONTAL DISEASE)
1. IS THE LOSS OF TEETH DUE TO LOSS OF SUBSTANCE OF BODY OF MAXILLA OR MANDIBLE WITHOUT LOSS OF CONTINUITY?
YES

NO

2. IS THE LOSS OF TEETH DUE TO TRAUMA OR DISEASE (SUCH AS OSTEOMYELITIS?)
YES

NO

If yes, describe:____________________________________________________________________
3. CAN THE MASTICATORY SURFACES BE RESTORED BY SUITABLE PROSTHESIS?
YES

NO

If yes, describe:____________________________________________________________________
4. INDICATE THE EXTENT OF LOSS OF TEETH (Check all that apply):
Upper Teeth
No missing teath

All right posterior missing

All posterior teeth missing bilaterally

All right anterior missing

All anterior teeth missing bilaterally

All left posterior missing

All upper teeth missing

All left anterior missing

Other, describe:________________________________

Lower Teeth
No missing teath

All right posterior missing

All posterior teeth missing bilaterally

All right anterior missing

All anterior teeth missing bilaterally

All left posterior missing

All lower teeth missing

All left anterior missing

Other, describe:________________________________

5. LIST MISSING TEETH BY NUMBER:_________________________________________________________
PART D - MOUTH, LIPS, TONGUE AND DISFIGURING SCARS (ANATOMICAL LOSS OR INJURY)
1. DOES THE VETERAN HAVE ANY DISFIGURING SCARS TO THE MOUTH OR LIPS?
YES

NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
2. DOES THE VETERAN HAVE A MOUTH INJURY THAT RESULTS IN IMPAIRMENT OF MASTICATION?
YES

NO

If yes, describe:____________________________________________________________________
3. DOES THE VETERAN HAVE PARTIAL OR COMPLETE LOSS OF THE TONGUE?
YES
NO If "Yes, indicate severity:
Loss of less than 1/2 of tongue
Loss of 1/2 or more of tongue
4. DOES THE VETERAN HAVE A SPEECH IMPAIRMENT CAUSED BY PARTIAL OR COMPLETE LOSS OF THE TONGUE, OR BY ANY
OTHER TONGUE CONDITION?
YES

NO If "Yes, indicate severity:

Marked speech impairment

If checked, describe:____________________________________________________________________

Inability to communicate by speech

If checked, describe:____________________________________________________________________

PART E - OSTEOMYELITIS/OSTEORADIONECROSIS/BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW
1. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH OSTEOMYELITIS OR OSTEORADIONECROSIS
OF THE MANDIBLE?
YES

NO

(If "Yes," ALSO complete VA Form 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire)
VA FORM 21-0960D-1, MAR 2011

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SECTION IV - DENTAL AND ORAL CONDITIONS (Continued)
PART E - OSTEOMYELITIS/OSTEORADIONECROSIS/BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW (Continued)
2. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH BISPHOSPHONATE-RELATED
OSTEONECROSIS OF THE JAW?
YES

NO

If yes, describe:____________________________________________________________________
PART F - TUMORS AND NEOPLASMS
1. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES CHECKED IN
SECTION I, DIAGNOSIS?
YES

NO

If yes, complete the following section:
A. IS THE NEOPLASM
Malignant

Benign

B. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR
MALIGNANT NEOPLASM SECTION?
YES

NO; Watchful Waiting

If yes, indicate type of treatment the veteran is currently undergoing or has completed (check all that apply):
Treatment completed; currently in watchful waiting status
Surgery
If checked, describe:___________________________________

Date(s) of surgery:_____________________________________

Radiation therapy
Date of most recent treatment:________________

Date of completion of treatment or anticipated date of completion:________________

Antineoplastic chemotherapy
Date of most recent treatment:________________

Date of completion of treatment or anticipated date of completion:________________

Other therapeutic procedure
If checked, describe procedure:_____________________________________________

Date of most recent procedure:______________

Other therapeutic treatment
If checked, describe treatment:_______________________________________________________________________________________
Date of completion of treatment or anticipated date of completion:________________
C. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases)
OR ITS TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
YES

NO

If yes, list residual conditions and complications (brief summary):

D. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN
SECTION I, DIAGNOSIS, DESCRIBE USING THE ABOVE FORMAT:
PART G - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
1. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATEDTO ANY CONDITIONS OR TO THE TREATMENT OF ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO

If yes, are any of the scars painful and/or unstable,or is the total area of all related scars greater than 39 square cm (6 square inches)?
YES

NO

If yes, ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire
2. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
RELATED TO ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES
NO If yes, describe (brief summary):

SECTION V - DIAGNOSTIC TESTING
NOTE: If diagnostic test results are in the medical record and reflect the veteran's current oral or dental condition, repeat testing is not required.
5A. HAVE IMAGING STUDIES OR PROCEDURES BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply):

Panographic/intraoral imaging to demonstrate loss of teeth, mandible or maxilla Date:________________ Result:______________________
Other:_______________________________________________________
VA FORM 21-0960D-1, MAR 2011

Date:________________ Result:______________________
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SECTION V - DIAGNOSTIC TESTING (Continued)
5B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO If yes, provide type of test or procedure, date and results (brief summary):

SECTION VI - FUNCTIONAL IMPACT
6. DOES THE VETERAN'S ORAL OR DENTAL CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If yes, describe impact of each of the veteran's oral or dental conditions, providing one or more examples):

7. REMARKS (If any)

SECTION VII - REMARKS

SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
8A. PHYSICIAN'S SIGNATURE
8B. PHYSICIAN'S PRINTED NAME

8C. DATE SIGNED

8D. PHYSICIAN'S PHONE AND FAX NUMBER 8E. PHYSICIAN'S MEDICAL LICENSE NUMBER 8F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations if necessary to complete VA's reveiw of the veteran's application.
IMPORTANT - Physician please fax the completed form to _________________________________________
(VA Regional Office FAX No.)
NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act
of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications,
epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest,
the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA
system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will
help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your
SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of
the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and
necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information
submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA
cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of
information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/
PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-0960D-1, MAR 2011

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