Two Ways Around CPAP
If CPAP has not worked for you, two common next steps are an oral appliance and hypoglossal nerve stimulation. Both are used for obstructive sleep apnea (OSA), and both are chosen with a sleep physician. They work in very different ways and fit different people.
This page compares them neutrally. It is not a recommendation for either one, and "Inspire" is named only because it is the name of the FDA-reviewed hypoglossal nerve stimulation device that most people ask about. For details on the dental option, see dental treatment for sleep apnea. For other choices beyond CPAP, see our CPAP alternatives guide.
How Each One Works
Hypoglossal nerve stimulation
The hypoglossal nerve controls the muscles that move your tongue. In HGNS, a surgeon implants a small device that senses your breathing and sends mild pulses to that nerve. The pulses tighten the tongue muscles so the tongue is less likely to fall back and block your airway. In the main clinical trial, a device was surgically implanted in people with moderate to severe OSA who had trouble accepting or sticking with CPAP.[1]
This is a surgical procedure. It is done by a surgeon trained in it, such as an ear, nose, and throat surgeon. AAOMS also lists hypoglossal nerve stimulation among the options oral and maxillofacial surgeons discuss with OSA patients.[12]
Oral appliance therapy
A dentist makes a custom device that holds the lower jaw slightly forward while you sleep, which keeps the airway more open. It is made on a physician's prescription and adjusted over several visits.[5] The AASM and American Academy of Dental Sleep Medicine guideline suggests that qualified dentists provide oversight of the therapy and that physicians confirm results with a follow-up sleep test.[5]
Who Qualifies for HGNS: The Label and the Exam
HGNS has stricter entry criteria than an oral appliance. The details below reflect the device labeling as we could verify it. Labels change, so check the current version with your surgeon.
- Diagnosis and severity: Moderate to severe OSA in adults, with an AHI between 15 and 100, after positive airway pressure treatment was unsuccessful or not tolerated.[9] An FDA supplement decided on June 8, 2023 raised the upper AHI limit from 65 to 100.[8]
- Body mass index (BMI): The FDA record describes a BMI warning threshold of 40, raised from 32.[8] The manufacturer's safety information lists a BMI above 40 as a situation where safety and effectiveness are unknown.[9]
- Central and mixed apneas: The manufacturer's contraindications include central and mixed apneas making up 25 percent or more of the AHI.[9]
- Airway collapse pattern: The label lists complete concentric collapse at the level of the soft palate as a contraindication.[9]
- Age: The label covers adults, with separate indications for ages 18 to 21 and for some adolescents with Down syndrome.[9]
Drug-induced sleep endoscopy (DISE)
To see how your airway collapses, a physician looks at your throat with a small camera while you are lightly sedated. This is called drug-induced sleep endoscopy, or DISE. A 2026 systematic review describes DISE before implantation as mandatory for HGNS candidacy assessment, with complete concentric collapse at the soft palate as the only formally accepted contraindication.[3]
Other patterns, such as side-wall collapse in the throat, are still debated. Several studies found lower response rates with complete lateral wall collapse, but the link weakened in the largest study after adjusting for other factors, and the reviewers rated the studies as moderate to high risk of bias.[3] That means your DISE findings matter, and your team may use judgment in borderline cases.
Professional guidance
The American Academy of Otolaryngology-Head and Neck Surgery position statement describes HGNS as appropriate for moderate to severe OSA in adults who are intolerant of or unable to benefit from positive pressure therapy.[10]
Outcomes Compared
Studies of the two treatments use different patients, follow-up times, and success definitions, so the numbers below cannot be compared directly. No single study here compares HGNS with an oral appliance head to head.
HGNS
In the pivotal trial of 126 people, the median AHI fell 68 percent at 12 months, from 29.3 to 9.0 events per hour. When some responders had the therapy turned off in a randomized phase, their AHI rose to 25.8, which supports the idea that the device is doing the work. Serious procedure-related adverse events occurred in fewer than 2 percent of participants.[1]
A 2024 meta-analysis of 44 studies and 8,670 patients found that, at 12 months, about 47, 72, and 82 percent of patients reached an AHI under 5, 10, and 15. Clinical success by one common definition was about 80 percent within 12 months and 73 percent between 12 and 36 months.[2] These are average results in people who were selected for the procedure, so they do not apply to everyone with OSA.
Oral appliances
A systematic review found CPAP lowers the AHI more than an oral appliance, with no significant difference in sleepiness scores.[13] In a randomized trial of 126 people with moderate to severe OSA, average AHI was 4.5 on CPAP and 11.1 on the appliance, yet people used the appliance longer each night, and sleepiness and quality of life improved by similar amounts.[6] The AASM guideline suggests that oral appliances be considered for adults with OSA who cannot tolerate CPAP or prefer another treatment.[5]
Risks and Side Effects
HGNS carries the risks of any implant surgery, such as infection, along with device-specific issues. A systematic review of adverse events found reporting was inconsistent across studies, that infection and patient requests for removal were the most common reasons for device removal, and that stimulation discomfort and tongue abrasions were the most common treatment-related side effects. Several of the review's authors report financial ties to the manufacturer, so keep that in mind when reading it.[4] The label also lists limits on some medical procedures, such as diathermy, for people with the implant.[9]
Oral appliances have milder risks. They can cause jaw soreness, extra saliva, dry mouth, and slow changes in your bite over years of use, which is why the guideline suggests dentist oversight and regular visits.[5] They can also fail to lower the AHI enough, which is why a repeat sleep test is important.
Cost and Insurance
HGNS involves a surgical procedure, an implanted device, hospital or surgery-center fees, and follow-up visits to set and adjust the device. The total is much higher than a dental appliance in most cases, and it varies widely by location, facility, and your insurance. We do not give a price here, because published numbers vary too much to be a fair guide. Ask your surgeon's office for an itemized estimate.
Oral appliance costs vary widely by location, provider, and case. Medicare covers custom-made appliances that meet its criteria when a physician orders the device and a licensed dentist provides it.[11] For HGNS, coverage rules are set by each insurer or Medicare contractor. Insurers set their own criteria, so ask your plan for its written criteria before you schedule any procedure. Our guide on oral appliance cost and insurance explains the dental side in more detail.
Who Fits Which
Your sleep physician and surgeon or dentist decide this with you. These are general patterns, not rules.
- An oral appliance may fit if you have mild to moderate OSA, or you have severe OSA and cannot use CPAP, and you have healthy teeth and jaw joints that can support a device.[5]
- HGNS may fit if you have moderate to severe OSA, tried CPAP without success, fall within the label's AHI and BMI limits, have no complete concentric collapse on DISE, and are willing to have surgery.[9][10]
- Neither may fit if your airway anatomy points to another surgery, such as jaw surgery. Our page on maxillomandibular advancement explains that option.
- You can try the less invasive option first. Many people try an oral appliance first because it is removable, and later consider HGNS if it does not work. The AASM's review supports upper airway surgery as a rescue option for adults who cannot accept positive airway pressure. The decision belongs to you and your physician.[7]
Where an oral surgeon fits in
An oral and maxillofacial surgeon is a real dental specialist trained in surgery of the jaws, face, and mouth. Depending on your case, an oral and maxillofacial surgeon may discuss jaw surgery or other airway options with your sleep team.[12] The surgeon who places a hypoglossal nerve stimulator is chosen with your physician, so ask who does the procedure and how many they have done.
Next Steps and Finding a Provider
Start with a diagnosis from a physician, then discuss all of your options with your sleep physician. If an oral appliance sounds right, look for a dentist who provides oral appliance therapy or has training in dental sleep medicine through our provider directory. If HGNS interests you, ask your physician for a referral to a surgeon who performs the procedure and for a DISE exam. Wherever you land, plan for a repeat sleep test to check that the treatment is working. Browse our list of dentists who provide oral appliance therapy, grouped by state.
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