FAQs (Frequently Asked Questions)
Below is a comprehensive list of questions regarding Merrell Clinic and the treatments we provide to our patients. Please click on the question to see an answer. If you have any further questions please do not hesitate to contact us directly.
Q - What kind of dentist can do this?
A – This is a complex medical field and you should seek professional advice. This is a dental treatment for a serious medical condition. Improper treatment or appliance selection could have significant health consequences. The dentist should be able to tell you the medical professionals that they work with in this area. In all cases, the medical care is managed with the Family Physician only after a medical diagnosis is obtained by a licensed and experience doctor with Sleep or Respirology training. In addition often a referral is needed with other medical specialties such as Ears, Nose and Throat or Cardiologist and Allergist.
Q - What are the appliances like?
A – Buyer beware! Several are very effective, researched and reputable. After only a few minutes on the internet, looking in many stores or pharmacies; you will see dozens of appliances advertised for snoring problems. Some even say they will treat mild sleep apnea! They cost anywhere from $29 - $199. These are not the appliances recognized to effectively treat Sleep Disordered Breathing (simple snoring, upper airway resistance and sleep apnea) by the leading authorities in medical research and teaching; and organizations such as the Canadian and American Thoracic Society and the American Academy of Sleep Medicine. In addition there are over 40 custom made dental sleep appliances marketed to the dental profession. The majority of these have little or no research published in peer reviewed medical/dental journals. Ask your dentist/provider what research has been done using the appliance(s) they use.
Q - Is wearing the appliance painful or uncomfortable?
A – The appliance is custom designed to your mouth. Research shows after 1-2 week adjustment period 1, 2, most patients find it is comfortable to wear. It is like a sports mouth guard.
Q - Will it adversely affect my dental health?
A – All patients are warned about minor tooth or bite shifting. Research confirms that recognized custom appliances have a low incidence of side effects 3, 4. We also give every patient instruction about cleaning the appliance, proper use and care. It is similar to grinding/TMJ appliances that are commonly worn at night by millions of people. If a filling were to fall out it or tooth break; it would be due to the tooth’s faulty nature not problems caused by the dental appliance.
Q - We’ve been hearing about the dangers of plastic bottles and the dangers of metals like mercury. Will any of the materials used in the appliance negatively affect my health?
A – No. All the materials are developed by specialists in this field and are used worldwide. The materials are carefully tested for optimum health and function. Appliances are commonly used in a number of dental applications an FDA approved.
Q - Do I have to do my sleep test away from my home?
A – No. Most patients usually start with an easy to administer, convenient and comfortable test conducted in your home. Some jurisdictions require a more comprehensive test done at a hospital or private lab. Check with the office nearest you. If you have a number of other health issues (hypertension, heart attack, diabetes, depression, lung disease, etc.) and you are not under the care of a Sleep Specialist or Respirologist, we may advise a referral to one.
Q – Is it difficult to adjust to sleeping with an appliance in your mouth?
A – Most patients find the appliances comfortable. Mild side effects are reported in the initial period 5. The discontinuance of appliance us is less than for CPAP. Often patients who can’t sleep using CPAP can easily adjust to a dental appliance 6.
Q - Does a dental appliance really work?
A – Yes. It is recognized by: leading medical research and teaching authorities and societies such as the Canadian and American Thoracic Society and the American Academy of Sleep Medicine. We follow the medical guidelines from these organizations. A dental appliance will not work in 100% of cases and some patients will do better with CPAP. We offer our patients many options.
Q - How soon does the appliance start to work?
A – The appliance will have an effect right away. It does need to be adjusted and titrated over a few weeks to reach its optimum effectiveness. This position and your sleep disordered breathing are checked by follow-up sleep studies.
Q - What are the appliances like?
A – Much like a grinding appliance or sports mouth guard except we use only cutom fitted appliances. They are designed to fit each individual patients teeth.
Q - What is a temporary appliance?
A – A temporary appliance is fitted right away in the dental chair. Usually it is made from material that is warmed in hot water and moulded to fit the patient. They are GENERIC and a ONE SIZE FITS ALL approach. It is like a sports mouth guard and they are not very comfortable. Also, they only last a few months and are not as adjustable or effective as the permanent, custom fitted appliance. Temporary appliances are sometimes used as a trial appliance; in an emergency when an appliance is quickly needed; if an unexpected trip is planned or when a permanent appliance is lost or broken and a fast replacement is needed.
Q - What is a permanent appliance?
A – A permanent appliance is made from moulds of your teeth. It is fabricated away from the dental office in a specialized laboratory. It usually takes 2 – 3 weeks to be made. It is not softened by hot water. It is made from very durable material and CUSTOM FITTED to your mouth and teeth. They are comfortable, last 3 to 5 years, are adjustable and are highly effective compared to a temporary appliance 7.
Q - What if this therapy doesn’t work. Are there any guarantees?
A – No. Beware of guarantees in brain surgery, parachutes and dental appliances. We will do everything we can to attempt different appliances and collaborate with other medical specialists.
Q - How long do the appliances last?
A – Most of the appliances last about 3-5 years with proper care.
Q - What if it gets lost or damaged?
A – Sometimes the appliance can be repaired if it is damaged. In the first 6 months there is no charge. After this time the costs vary from $250 - $600 for repairs/replacement over the next 3 years. After 3 years you would be charged the usual fee for a new appliance. If it is damaged or broken beyond repair your home insurance may cover the cost of replacement. Please check with your insurance provider for details.
Q - What is the process for getting an appliance?
A – At the initial consultation you fill out a questionnaire about your sleep behaviors, medical history and concerns (1 hour). You are examined by the dentist who reviews the material and explains the different steps and costs. If you proceed, then at the next appointment (2 hours), there is a detailed examination with the doctor, impressions of the teeth, photos of the teeth, head and neck areas and x-rays of the head and neck. The Home Sleep Study is explained; you take the sleep recorder home and return it the next day (1 hour). The sleep study is reviewed with you in general terms and then the information is sent off to be evaluated by a Medical Sleep Specialist; who provides a Medical Diagnosis. This is important to understand. A dentist will provide a dental appliance if appropriate, but that is only after he has obtained a Medical Diagnosis from a licensed medical doctor.
At the next appointment (30 mins) the medical report on your sleep study is reviewed with you. Your treatment options are explained. Treatment can involve: life style changes, exercise, use of medications, Cognitive Behavioral Therapy, referral for further tests such as a Polysomnogram (advanced sleep test) referral to other medical specialists (through your Family Physician to specialists such as ENT, Allergist), possible trail of CPAP and discussion of possible dental appliances.
The Merrrell Clinic gives you options, which include:
CPAP and/or Dental Appliances
If appropriate for a dental appliance, the dentist will decide with you which is best and will then have it custom made. If appropriate a temporary appliance could be provided as an interim measure.
It takes about 3 weeks for a custom dental appliance to be made. At that appointment (1 hour) it is fitted, you receive instructions on its use, care and exercises to minimize possible side effects. You are then seen every few weeks for 2 months to ensure it is comfortable and working effectively.
After 2-3 months of use, a follow-up sleep study is performed to ensure your treatment is successful. Any adjustments or additional procedures are completed until a satisfactory result is obtained.
Treatment for Sleep Disordered Breathing is a serious, chronic, lifelong problem and you should be seen every 6 months for follow-up.
Q - What if I have problems with the appliance?
A – There are follow up visits by the dentist to ensure it works, fits properly and is comfortable. You can call us for an appointment at any time; if you have a concern before your next planned appointment.
Q - What if I move. Are there other locations to get support?
Q - Is there a payment plan?
A – Yes. We can break up the payments to coincide with your therapy schedule.
Q - What changes in my sleep, health or lifestyle should I expect?
A – The symptoms of sleep apnea are very broad and so are the benefits of sleep apnea therapy. Patients often see improvements in have severe snoring, heart and blood pressure problems, depression, lack of energy, moodiness, marital problems, sore throat, mental fogginess and many other symptoms. The medical literature has hundreds of research papers that have documented the success of dental appliance therapy for snoring and sleep disordered breathing (sleep apnea) over the last 20 years 8, 9.
Q - Do I need to be referred by a doctor?
A – No referral is needed. We will, of course, provide your family physician with all our findings and collaborate with them to ensure you receive the best management of your concerns and disease by licensed medical physicians.
Q - Should I try CPAP first?
A – That is an option. Keep in mind CPAP has a 30 - 50% success rate 10, 11. No therapy is started until a thorough examination and a diagnosis made by a licensed physician is obtained. All options are discussed and then the appropriate recommendation is made. In many cases of simple snoring, upper airway resistance and mild obstructive sleep apnea, treatment with a dental appliance is often the recommended treatment from Medical Authorities such as the American Academy of Sleep Medicine.
Q - Isn’t CPAP a more proven and effective therapy?
A – No. There is not one, single therapy, even CPAP that will work on all patients 100% of the time. This is a very specialized area of medicine with significant challenges, which in some cases has no effective treatment. Research tells us that in follow-up studies, after 1 year using CPAP, for a minimum of 6 hours, the success is only 30 – 50%. Similar studies using dental appliances show 60% - 80% success. It is interesting to note that for approximately 30% of CPAP users who continue to use CPAP after 1 year (for more than 6 hours a night) they still are symptomatic 12.
Q - Will it adversely affect the jaw joint or cause TMJ problems?
A - Less than 5% of patients develop significant long term problems. In some cases patients stopp using the appliance and their concerns resolve. Others have chosen to live with the changes, and continued using the appliance because their health, sleep and quality of life were greatly improved.
In the first few weeks about 20% of patients will encounter only temporary tooth or jaw soreness.
We acknowledge and inform all our patients that some studies have reported as high as 30% of patients develop significant bite or jaw issues.
1. Letteri JCSM 2011 Lettieri CJ, Paolino N, Holley AB. Adjustable & Fixed Oral Appliances for the Treatment of OSA. J Clin Sleep Med 2011;7(5):439
2. Hoekema Sleep Breath Hoekema A. Efficacy & comorbidity of oral appliances in the treatment of OSA Results of a randomized trial Sleep Breath (2006) 10: 102.
3. Phillips Am J Resp Crit Med Phillips C, Cistulli P. Health Outcomes of CPAP vs Oral Appliance Treatment for OSA Am J Respir Crit Care Med 2013 V187 (8) p 879
4. Doff Sleep 2013 Doff MH, Hoekema A, Wijkstra PJ, et al. Oral Appliance v CPAP in OSA 2-Year Follow-up. Sleep 2013 36(9):1289
5. Doff Clin Oral Invest 2013 Doff MH, Hoekema A, Stegenga B. Long-term OA therapy in OSA syndrome. A study on TMJ side effects. Clin Oral Investig. 2013 16(3):689
6. Ramar JCSM 2015 Ramar K, Dort LC, Katz SG, et al. Practice Guideline for Treatment of OSA & Snoring with Oral Appliance. J Clin Sleep Med 2015 11(7):773
7. Almeida Sleep 2013 Almeida FR, Bansback N. Effectiveness of Oral Appliance v CPAP & Understanding Patient Preferences. Sleep 2013 36(9):1271
8. CST Guidelines 2011 Sutherland K; Vanderveken OM, Cistulli PA. Oral appliance treatment for OSA. J Clin Sleep Med 2014 10(2):215
9. RAMARI J of Dental Sleep Med Ramar K, Dort LC, Katz SG, et al. Clinical Practice Guideline for Treatment of OSA & Snoring with Oral Appliance. JCSM 2015 11(7):773
10. Wohlgemuth Sleep Review Wohlgemuth WK, Wallace DM . Attempters, Adheres & Non-adherers CPAP Latent profile analysis. Sleep Medicine 2015 V16(3):336
11. Wallace JCSM 2013 Wallace DM, Wohlgemuth WK. Association of Age, Insomnia & Self-efficacy with CPAP Adherence. J Clin Sleep Med 9(9):885
12. McMillan Health Technology McMillan A, Bratton DJ, Morrell MJ. A RCT Trial & Economic Evaluation of CPAP for OSA. PREDICT. Health Technol Assess. 19(40):1