Problems your having with dental appliances

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DiligentDesertSandSeaLion1961 +0 points · 4 months ago

Hi Dr. Tony, I have moderate sleep apnea. I tried using a CPAP but found it quite uncomfortable, so decided to try an oral appliance (the Herbst device). At first, I had no problems, but after a week or so, I started getting jaw, ear and throat pain after taking the device out in the mornings. My sleep dentist has tried several things on the device so that it would not cause the pain, but the pain continued each morning and got progressively worse. I decided not to wear it until the pain subsides, as it still has lingered on for quite a while. I really would like to use the device, but the pain in my ear, jaw and throat make it unbearable. Any help you can offer would be much appreciative.

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DrTonySoileau +0 points · 4 months ago

Sounds like the appliance is set too far forward to begin with. A new bite needs to be taken and the appliance remade. You can try over counter anti inflammatory like Alleeve or Tylenol right before bed but that will not fix the problem and only offer mild relief. You could try massage or chiropractic therapy to loosen up the muscles which probably needs to be done regardless. But I would still want the initial position brought back if you ere my patient. Wish I had a better solution.

Dr Tony

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SleepDent +0 points · 3 months ago Sleep Commentator

The first question that comes to mind for me is whether or not you have a history of sleep clenching/bruxing and TMD(temporomandibular joint dysfunction). This is one of the conditions that I routinely screen for during the initial consultation with potential oral appliance patients. If so, those conditions need to be addressed PRIOR to oral appliance placement. Arthur B. Luisi, Jr., D.M.D.

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DiligentDesertSandSeaLion1961 -1 point · 3 months ago

I don't have a history of sleep crunching or TMD. I think my problem is due more to an improper bite impression. My dentist is working on the appliance to rectify the bite issue. The pain in my jaw and ear have subsided since he has 'tweaked' the device, but it hasn't totally gone away.

Thank you for your note!!! :)

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DiligentDesertSandSeaLion1961 +0 points · 3 months ago

Whatever the problem is, should I experience pain in the jaw and ear as now it's hurting on the other side. At first, it was the right ear and jaw; now it's the left ear and jaw. This is after tweaks on the device and an acrylic piece added to the upper front part. Am I not destined to wear the oral appliance? It's very disheartening.

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SociableRedWaterBuffalo0681 +0 points · 3 months ago

Dr Tony, I am thinking of ordering the TAP III Elite oral appliance to replace my 5 year old EMA. I am able to yawn multiple times before falling asleep with the EMA. also have a limited capability to talk with the EMA inserted. Will the TAP III allow me the same flexibility? Are there any drawbacks to the TAP III that I need to be aware of? I truly would appreciate getting a second opinion on these questions. Many thanks in advance for your input.

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SleepDent +0 points · 3 months ago Sleep Commentator

I am a dentist working in dental sleep medicine. You have posted the same question in a separate thread. I have answered it there. A.B.Luisi, D.M.D.

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DrTonySoileau +1 point · 3 months ago

Not sure what Dr Luisi reply was so if I am repeating it I am sorry about that.

The Tap III will allow you to move side to side and some open and close but not much. How big a deal is talking with it? There are other appliances on the market that you will like much better than an EMA. If you do not want you be locked together take a look at the Micro2 made by Prosomnus. Very nice appliance that also has a slim version that is very comfortable. If you want to be able to yawn and talk without restriction this would probably be your best choice.

Dr Tony

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SincereEmeraldHummingbird2858 +0 points · 3 months ago

I have mild sleep apnea, and last night I tried my micro2 appliance for the first time. After 1.5 hours I woke up gasping for air. Does this mean that it isn't going to work for me? Or do I just need to be patient and wait for it to be advanced to the right position? It was kind of discouraging.

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DrTonySoileau +0 points · 3 months ago

Be patient. did you have in the U0 and L0?

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SincereEmeraldHummingbird2858 +0 points · 3 months ago

Yes I did.

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FatBear +0 points · 3 months ago

I have used TAP-II and TAP-III appliances since early 2005 along with my CPAP. TAP-II was definitely better, but apparently more expensive to manufacture or something. You were able to "un-hook" the top and bottom to talk or take a pill or something. TAP-III is still very good, but it locks together before you put it in your mouth and stays locked until you take it out. Both of these clamp to your teeth snugly if made correctly and don't wear out quickly like the mold-in-place ones. They do require a good fitting technician and a good lab or they can be painful. The techs at my dentist's office are excellent. The lab they use is a tiny little mom and pop place in a strip-mall nearby. (I visited them once: a very nice older married couple surrounded by a huge array of molding and plastic manufacturing equipment and clearly very proud of it all.) And the fits have always been excellent. I tried having a TAP-III made once at an orthodontist who specializes in sleep dentistry and ended up throwing away $2200 worth of useless plastic. Either the fit or the (in-house) labwork were terrible. They modded and even made an all-new second attempt and just couldn't do it.

One nice thing about the TAP appliances is that the fitting and the adjustment are separate things. My last one even came with two hooks so you have a huge range of adjustment. And you can start off easy and adjust your jaw out a little at a time so it gets used to the extension gradually. Of course other appliances can do this, too. I'm not necessarily recommending TAP over them, just relating my own very satisfactory experiences. If there's a better one out there, I'd be happy to hear of it!

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SleepDent +0 points · 3 months ago Sleep Commentator

I am a dentist working in dental sleep medicine. I agree that the Tap appliances are excellent. In my opinion, the best ones out there. In my twelve years of experience, the vast majority of appliances that I have placed have been Taps. However, the biggest drawback has been that they are extremely difficult to fit. You have to have supreme patience, experience, and real talent to do it. At this point, I know how to fit them reliably well, but it took time. Many dentists just don't want to bother, therefore, the Taps have been a bit less popular than they deserve to be. The new DreamTap is a real break through in that it is the first model that is HEAT ADJUSTABLE. I find that it is much easier to fit than the previous models. I think that when the dentists catch on to this, they will start to use them more. A.B. Luisi,D.M.D.

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FatBear +0 points · 3 months ago

My good dentist is retiring soon and my current TAP is about three years old. If they really are that hard to fit, maybe I should have a new one made before it's too late!

I have found that OTC heat adjustable appliances loosen up within just a few months. Are the DreamTaps better than that? If they were built like a TAP, but with a heat-softenable lining, I suppose you could get them molded and fitted to your teeth, but then heat them and let them "settle in" and relieve the various stresses that make them uncomfortable. Otherwise I'd want a money-back guarantee before I paid for one. It really hurt spending $2200 on an unusable TAP during the recession when I only made about $12,000 that whole year. There are no words that I could use publicly to describe my opinion of that dentist.

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SleepDent +0 points · about 2 months ago Sleep Commentator

Well, maybe what I said about the DreamTaps being heat adjustable was a bit misleading. I would not worry about the lining in the DreamTap being different from or inferior to that of the Tap3 because they are identical. Both are offered with the same choice of a TL or Thermacryl lining, The TL being the basic, common one. The real difference is that the hard outer layer of the DreamTap is made of a different plastic than the Tap3 and the DreamTap plastic is more heat resistant. You can place the DreamTap in boiling water briefly to soften the TL lining up just a bit so it inserts more easily and accurately and it works well. If you put the Tap3 into boiling water it would distort and be ruined. So I really see no down side for the DreamTAp. The lining is NOTHING like the boil and bite heat fit lining of OTC cheapie appliances and I would not worry about it. Arthur B. Luisi, Jr., D.M.D.

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HenryFromTheA +0 points · about 2 months ago

Thanks a lot for all the info Dr Tony. I was diagnosed with moderate OSA six years ago. I've given up on using a CPAP and about to get fitted for a MAD (one of the TAPs). However, my Dr informed me that I have enlarged turbinates as well as a host of different allergies. For the allergies, he prescribed daily allergy drops and recommended holding off on surgery for now. I'm wondering if my enlarged turbinates will make it harder for me to tolerate the MAD. I'm also wondering if my enlarged turbinates made it harder for me to tolerate the CPAP. Thanks.

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SleepDent +0 points · about 2 months ago Sleep Commentator

Well, I would say probably yes on both counts. The degree of nasal patency(how open your nasal passages are) does have an effect on how well your oral appliance will work. And if your nasal passages were pretty closed up before, it would have made it harder for the CPAP air to get into your nose and made the CPAP less comfortable. Your MAD may or may not work well enough and be comfortable enough with the enlarged turbinates. Only time will tell. Patients tell me, in general, that their turbinate reductions were not too tough a procedure as these things go, so I guess that you and your doctor could re-visit doing it if need be. Arthur B. Luisi, Jr., D.M.D.

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HenryFromTheA +0 points · about 1 month ago

Thanks so much for the reply. I was expecting to get email notifications from my post for some reason so I'm just seeing this.

I forgot to add that six years ago, I had UPPP surgery, where they fixed my deviated septum and reduced my turbinates. I then went for a follow up sleep study and was sleeping just as bad as in the first study. I think I was getting about 20% of the required REM sleep: explains why I rarely remember my dreams and haven't for some time.

As a side note, doctors always say that losing weight helps Sleep Apnea, but I started experiencing these symptoms when I was younger and my weight was normal.

Anyways, I went to see my ENT yesterday for a TAP fitting. I'm not sure which one, but I'm hoping it's the dreamtap. I asked him this same question in regards to the MAD. He said it advances the lower jaw enough to make breathing through the mouth possible. But I wonder if that's enough to sleep comfortably.

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SleepDent +0 points · about 1 month ago Sleep Commentator

Its highly likely that it will be enough. In my experience, everything that you do tends to help at least a little bit. Most likely, the surgeries got you closer to the finish line and the Tap will push you into the end zone. Good luck to you. Arthur B. Luisi, Jr., D.M.D.

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DrTonySoileau +0 points · 13 days ago

Yep, as Dr Luisi said every little thing help and gets you closer. I had turbinate reduction done two years ago. Best thing I ever did for my sleep after I made myself an appliance. Not saying its the best thing for you. But every little thing helps.

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BGailDemko140 +0 points · 30 days ago

I presume you have seen a good Ear Nose and Throat (ENT) doctor to evaluate your nose properly. As a dentist, I can see the front area of enlarged turbinates, but there are a host of things that can be involved in poor nasal breathing. Proper work-up is required, and see an ENT referred by your sleep physician. I worked with 8 different sleep centers in Boston and each had a preferred ENT. These ENT's worked with sleep apnea day in and day out and knew what was a problem for CPAP or oral appliances.

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SleepDent +0 points · 29 days ago Sleep Commentator

I absolutely agree. Ideally, an ENT who works with obstructive sleep apnea and understands oral appliances should evaluate each patient prior to doing the oral appliance and do what procedures are necessary in support of the appliance. The procedures should be finished and healed before placing the appliance. I said ideally because the area in which I work is in the stone age with respect to OAT and I am so far out in front of the sleep physicians and ENTs that it is a real struggle to get everyone to do the right thing, but I do the best that I can. Arthur B. Luisi, Jr., D.M.D.

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HenryFromTheA +0 points · 29 days ago

Yes I am. He was the one that prescribed the MAD. However, he's not the one that did the UPPP 7 years ago. He also did the fitting for the TAP 3. He knows his stuff.

He showed me my CAT scan and it seemed that the air reduced to a trickle after going through my turbinates. He also showed that my septum was still a little deviated. Since he has me on allergy drops and dymista, he suggested that I delay doing surgery on my turbinates. I get the sense that I'm going to have to prove that the MAD is not working before he'll recommend it.

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SleepDent +0 points · 29 days ago Sleep Commentator

Sounds reasonable enough. Things will get sorted out in due time. Arthur B. Luisi, Jr.,D.M.D.

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DiligentAmberMagpie1168 -1 point · 27 days ago

I am 59 female and weigh 140. I believe I’ve had apnea even as a child I remember waking up gasping for air but just thought I was having a bad dream. All my back teeth are crowns because I clench. About 5 years ago I had a sleep study which I happened to mention to my dentist who then suggested the silent nite guard. I was all for it since it seemed simpler. I think it did work but in the morning it took a couple hours for my jaw to go back. After 3 years my jaw stopped going back and my back teeth would not touch. My dentist took impressions and said he would adjust my teeth by grinding them down in certain spots. I did not have it done and stopped using the guard. I had another sleep study and got an APAP. I still feel like I am clenching which I thought would go away once I got the APAP. i am wearing a drug store guard until I figure out what to do. Now my jaw has changed and my back teeth feel too close they clank together when I eat. So if I had gotten my teeth “adjusted “ and now my jaw has changed then what? I don’t know who to go to. I do go to a chiropractor because I have tight shoulders which affects the rest of my back. He says my jaw is fine that it is not out of place So do I now need an orthodontist or what. I am really afraid who to trust because the dentist was so sure my jaw would be fine. I did ask him at the start “is this going to affect my jaw?” Hopefully there are some answers. Thank you.

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BGailDemko140 +0 points · 14 days ago

Any dentist who treats patients with oral appliances, even grinding, should know the science behind what is being done. All oral appliances, even those you can buy in the drugstore, can change how your teeth meet. This is mostly related to minute swelling in the joint area called edema. When using a Silent Night, or any device that moves the jaw forward as well as keeps the teeth from touching, can make this bit of edema worse. For most, the symptoms resolve quickly each morning. The expectation of permanent changes increasing with longer use of the oral appliance. Returning to positive airway pressure is the common result.

Grinding and clenching are a different sleep disorder and is not often corrected with correction of your apnea. It is correlated to everything from acid reflux and alcohol consumption to medication use. While they may not cause it, these triggers often occur simultaneously. Bite guards do not stop grinding, only give you a way to spread out the forces on your teeth or a material to grind through instead of breaking your teeth. Adjusting your bite, by reshaping the teeth is not supported by science but can be helpful if the teeth are only slightly out of alignment. If the teeth are seriously out of alignment and use of the APAP is not helping to reset your back teeth, I recommend you discuss this with an orthodontist.

B. Gail Demko, DMD Associate Editor of the Journal of Dental Sleep Medicine

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DiligentBurgundyCamel0439 -1 point · 14 days ago

As Dr. Demko said, oral sleep apnea appliances work by holding the mandible forward slightly, this pulls the condyle(ball) of the jaw joint forward, allowing the tissues behind the condyle to accumulate fluid and swell. This can throw your bite off in the morning, but is usually resolved with in a thirty to ninety minute period. If it does not resolve, it is incumbent upon the patient to cease use of the oral appliance quickly or the bite does have a significant chance of being thrown off permanently. Sleep dentists need to tell their patients from the outset to look out for this and to be sensitive to the urgency. One thing that I have tried in my patients who have shown this tendency, but struggle with PAP machines is to alternate treatment, using the OA as long as the bite stays stable and going back to CPAP for a while if it starts to shift. I agree that the typical flat plane bite guards really do not more than distribute the forces more evenly among the teeth. However, there is another type of appliance, called an anterior discluding device, that, in my opinion, does lessen the force and, perhaps, also the freqency of clenching and bruxing. It keeps the jaws somewhat open, thus stretching the fibers of the masticatory muscles, making it impossible for them to exert maximum biting force. The down side, is that they can also cause the bite to shift if not monitored closely. In all, fairness, dentist's opinions on these devices vary and they remain controversial. Arthur B. Luisi, Jr., D.M.D.

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grinderfrank -1 point · 13 days ago

Dr Tony, I am a lifetime bruxer, new to wearing a TAP device by airway management. I had TAP device for 10 nights before developing very a very sore jaw. Hurts to open, close and chew. stopped wearing the TAP. was told by dispensing dentist when i recieved it, device was set to minimum. It was not, looking at it closer, it can be backed up quite a bit. it has been a torture device as far as i am concerned. not wearing it till i get the jaw pain calmed down. have made pt appointment to get it looked at. also not sure why i did not receive an am adjuster. wished i would have found this forum to learn about these appliances before getting one.

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SleepDent +0 points · 13 days ago Sleep Commentator

I am a dentist working in dental sleep medicine. Unfortunately, there is no way to adequately address your question without the benefit of having examined you and knowing your full history. All that I can do is suggest some possible avenues for discussion between you and your health care providers. Actually, the Tap is usually one of the better choices for people with a history of bruxing. Obviously, your dispensing dentist must have evaluated your tmj status prior to placing the device. This is often tricky, at best. You just have to make a determination if the joint is healthy enough at that present time to deal with the device and sometimes you guess wrong. We all do. If I am concerned, I will sometimes order a course of head and jaw muscle message therapy by a specially trained LMT prior to placing the device as well as using some special bite guards. I try to calm down the muscles enough so that they will accept the appliance without fighting back too much. Undoubtedly, your dentist has determined your total range of protrusive movement. He may need to adjust where you are in that range, either less, or ironically, sometimes more, so that you will get better treatment, have less apnea, and brux less. But hang in there, be patient, work with your dentist, and it will most likely work out. Your certainly have the right to request an A.M. Aligner. One comes with every Tap and your dentist certainly can get you one. Good luck to you! Arthur B. Luisi, Jr.,D.M.D.

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DrTonySoileau +0 points · 13 days ago

Grinderfrank, I hear you. You were hoping for a solution to your sleep issues and instead woke up to sleep plus jaw and muscle issues. Sucks. Only way to put. These things do happen. Even with the best of care. Can I ask if between night 1-8 did you wake up feeling better. If you did then we know that the position your jaw is in with the TAP is a good one and now we just have to get the muscles to let go so you can be in that position comfortably. Good news is muscles are not hard to treat. Bad news is it may not be your dentist that fixes them. I have a massage therapist specially trained to work on muscles both out side and inside the mouth. I am really good at relaxing muscles. But the honest truth is I can't begin to compare to my massage therapist. She is just better than me. Its why I have her full time in my office. You need to find some one like her. Her name is Candid. Maybe she would know someone where you live. Our office number is 3372343551 if you want to call. And it does not have to be a massage therapist. Could also be chiropractor, physical therapist, acupuncturist, or anyone that can help. Think about an athlete that needs to run a certain speed. The speed is his goal. He then gets coaches and trainers to help him achieve it. If you slept better with the appliance in its current position then that the speed you need to run. Now go find a coach/trainer to get you there!

Treating sleep apnea is a team sport. It just is. Its not "one stop shopping".

If you had you knee or elbow operated on you would still need physical therapy no matter how great the surgeon performed. Same situation here. Your on the right road. Hang in there.

Dr Tony

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grinderfrank +0 points · 12 days ago

Thank you both for the suggestions and support. Dr Tony, yes i did wake up feeling better for the time i did wear the device. Good to know that relief is likely possible. I have a pt appointment with a staff of talented providers that have helped me with the facial,neck and shoulder issues that have been chronic with me due to the bruxing. I am hopeful they can help with this and help me along towards feeling better . Thanks for the contact information as well. I have'not contacted the dentist that made the device yet. Should I ask her about the am aligner, bite guard? thanks frank

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DrTonySoileau +0 points · 12 days ago

You may very well benefit from Combo therapy. Apnea appliance at night and TMJ appliance during the day. I use the Natural Fit Orthotic from Arum Lab in Canada. Fits great and looks like teeth. My patients love them. Probably half my sleep patients also wear an appliance during the day. Usually just for a few months and then the apnea is under control and they stop clenching/bruxing.

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Bearhug +0 points · 6 days ago

Hi Dr. Tony, I have been using a Dream TAP for several months, gradually moving it out until I'm midway on the shortest "hook" (which I estimate to be about 12mm). I have had no ill effects, jaw soreness, etc and snoring has been eliminated. Also my sleep patterns and daytime wakefulness seem unchanged. In addition to an initial sleep study from the sleep doctor (AHI 13), I had a sleep study from the dentist, first night without the appliance (AHI 16), second night with the appliance (AHI 7). We adjusted the appliance to the current setting hoping to bring it below 5. However, a follow-up sleep study from the sleep doctor turned out to be 26! The home study devices from the doctor and the dentist seem to be pretty similar. What do you think is going on? Could it be too far out and possibly counterproductive? Thank you.

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BGailDemko140 +0 points · 6 days ago

Moving the jaw too far is a common problem since most dentists do not understand that more in not always better. Thin, young people with mild-moderate sleep apnea may need to move their jaw only 2-5 mm. Larger patients or those with severe sleep apnea have to move their jaw more. Because a person’s response varies so much from other’s, follow-up testing is always required. All studies have shown that using multiple overnight sleep tests to ‘zero in’ on the best jaw position for each person improves outcomes. Remember, the best position for you may be backwards from where you are.

Side-effects increase the further forward you go (long-term tooth movement) so finding that perfect balance is important.

Also, achieving an AHI < 5 is statistically an end point used in studies. All the research shows that if you are no longer sleepy and your symptoms are gone, an AHI < 10 is fine. Oxygen levels mean more than the number of breathing events.

B. Gail Demko, DMD Associate editor Journal of Dental Sleep Medicine

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Bearhug +0 points · 6 days ago

Thank you for your response. I concur that my biggest concern should be oxygen levels. Originally, unaided by any device, my Sp02 reached a low of 81 (Avg. 93). The latest home study using the dental device revealed a low of 87 (Avg. 94). Curiously, my heart rate would also drop to a low of 32 (high of 92, avg. 39). Could the low heart rate be responsible for the low oxygen level and the apnea events? Thanks again.

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SleepDent +0 points · 5 days ago Sleep Commentator

Well, since you are using a dental appliance, I must assume that you have obstructive sleep apnea and not central sleep apnea, because an oral appliance is not effective against central sleep apnea. Obstructive sleep apnea, as the name implies, is caused by blockages in various areas of you respiratory system. In order for the heart to be implicated, you would need to have central sleep apnea or mixed sleep apnea(obstructive and central apnea mixed). However, poor circulation can contribute to low oxygenation, so some medical consultation concerning your heart rate would seem like a sensible move. Theoretically, you never want your SpO2 below 90% at night. However, sleep physicians also assess how long you are below 90% at night. If it is very brief, they might call it trivial hypoxemia and not make an issue of it. You need to ask your doctor to assess where you fall in the spectrum. Arthur B. Luisi, Jr., D.M.D.

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Bearhug +0 points · 4 days ago

Thank you. My most recent test revealed the duration of maximum desaturation at 89 sec., duration of minimum Sp02 at 21 sec. Would this be anywhere close to your definition of "very brief"?

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SleepDent +0 points · 3 days ago Sleep Commentator

Well, if by this you mean that you were below 90% only 21 seconds all night, that would meet my definition of "very brief". This is a very important point, however, and I would suggest that you discuss it with your health care providers to make sure that you are reading the report correctly. Arthur B. Luisi, Jr., D.M.D.

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