Why This Question Comes Up
CPAP (continuous positive airway pressure) is the standard first treatment for obstructive sleep apnea (OSA). It works well when it is used. The problem is that many people stop using it. If you are one of them, you are not alone, and you have options.
This guide walks through those options in plain language: fixing CPAP problems first, dental oral appliances, sleeping position, weight loss and new medicine, a nerve stimulator implant, and surgery. It also covers using more than one treatment together.
One point matters before anything else. Sleep apnea is diagnosed by a physician using a sleep test, and the choice of treatment should be made with your sleep physician. Do not stop CPAP on your own without a plan. Untreated sleep apnea carries real health risks, so the goal is to switch to something that works, not to go without treatment. This page is general education and is not a substitute for your doctor's advice.
Why People Stop Using CPAP
Trouble sticking with CPAP is well documented. A review in the Proceedings of the American Thoracic Society found that when "adherence" was defined as more than 4 hours of use per night, between 46% and 83% of patients with OSA were reported as nonadherent. [1] The same review noted that the decision to accept or reject CPAP tends to happen in the first few days of treatment. [1]
A later systematic review of 82 papers covering 20 years of data reported an overall CPAP non-adherence rate of about 34%. It found no meaningful improvement over that time, even with coaching and behavioral programs. [2]
Why do people stop? The National Heart, Lung, and Blood Institute lists side effects such as congestion, dry eyes or mouth, nosebleeds, and a runny nose. [4] People also commonly describe a mask that feels confining, air leaks, noise, trouble sleeping with a hose attached, and difficulty traveling with the machine. Many of these problems have fixes, which is why the next step is to go back to your CPAP provider before giving up.
Try Fixing CPAP Problems First
The American Academy of Sleep Medicine (AASM) guideline on positive airway pressure says people on CPAP should have follow-up that includes troubleshooting and a review of usage and effectiveness data. [3] In other words, trouble with CPAP is something your care team expects to hear about and is supposed to help with.
Bring the specific complaint to your sleep physician or CPAP supplier. Common areas to ask about include:
- Mask fit and style. Leaks, sore spots, and a feeling of being smothered are often linked to the wrong mask size or type. Nasal, nasal pillow, and full face masks fit differently.
- Humidification. Dry mouth, a dry nose, and nosebleeds may improve with a humidifier or changes to its setting. Your provider can adjust it.
- Pressure settings. Some people feel the pressure is too high to exhale against. Your physician can review your data and decide whether a setting or machine type change is appropriate. Never change pressure settings yourself.
- Nasal problems. Congestion or a blocked nose can make CPAP hard. Treating the nose may help.
- Getting used to it. Wearing the mask while awake for short periods during the day can help some people adjust. Behavioral coaching may also help.
What the Evidence Says About CPAP Fixes
Be realistic about what the evidence shows. The 2008 review found that many products marketed to improve CPAP use have little data behind them, and that no single factor reliably predicts who will stay on treatment. It did find that behavioral interventions may help. [1] The later 20-year review found that behavioral programs added about one hour of use per night on average. [2] So it is worth trying, but it does not solve the problem for everyone.
Oral Appliances (Dental Sleep Devices)
An oral appliance is a custom-made mouthpiece, usually a mandibular advancement device, that holds the lower jaw slightly forward during sleep. This helps keep the airway open. A dentist who provides oral appliance therapy makes and adjusts it on a physician's prescription. Dental sleep medicine is not a recognized dental specialty, so look for a dentist with training in it rather than a title.
The joint guideline from the AASM and the American Academy of Dental Sleep Medicine is the main reference. It recommends that sleep physicians consider prescribing oral appliances, rather than no treatment, for adults with OSA who cannot tolerate CPAP or prefer another option. [5] It suggests a custom, adjustable appliance over a non-custom device. [5] It also suggests dental follow-up to watch for bite changes, and follow-up sleep testing to confirm that the device works. [5]
Oral appliances usually do not lower the apnea-hypopnea index (AHI) as much as CPAP. In one randomized crossover trial of people with moderate to severe OSA, the average AHI was 4.5 events per hour on CPAP and 11.1 on an oral appliance. Reported use was higher with the appliance, 6.5 hours a night versus 5.2 for CPAP, and important health measures were similar after one month. [16] That is why the guideline frames appliances as a good option for people who will not use CPAP, and why a follow-up sleep test matters.
For more detail, see our guide to dental treatment for sleep apnea, our comparison of oral appliances and CPAP, and the cost and insurance guide.
Positional Therapy
For some people, sleep apnea is much worse when they sleep on their back. Positional therapy uses a device or habit to keep you on your side. Examples include a wearable trunk or backpack-style device, special pillows, a tennis ball sewn into the back of a shirt, and small sensors that vibrate when you roll onto your back. [6]
A Cochrane review pooled eight trials with 323 participants. CPAP lowered the AHI more than positional therapy, by an average of 6.4 events per hour. People used positional therapy about 2.5 hours more per night than CPAP, and there was no clear difference in sleepiness scores. Positional therapy did better than no treatment. The studies were short and small, so long-term results are not known. [6]
A review for family physicians reaches a similar view. It reports about 75% of participants still using positional therapy at two months, and about 10% reporting side effects such as back or chest pain. It also notes that CPAP is the stronger treatment overall. [7] A sleep test that measures sleep position can show whether this fits you.
Weight Loss and Medication
Extra weight can narrow the airway. NHLBI says healthy lifestyle changes can be very effective and lists a healthy weight, exercise, limiting alcohol and caffeine, and side sleeping among them. [4] Weight-loss surgery is also an option for some people, and the AASM guideline recommends that clinicians discuss referral to a bariatric surgeon with adults who have OSA, class II or III obesity (BMI 35 or higher), and who cannot or will not use PAP. [12]
There is now a medicine approved for this use. On December 20, 2024, the FDA approved tirzepatide (brand name Zepbound) for adults with moderate to severe OSA and obesity, to be used with a reduced-calorie diet and more physical activity. The FDA reported a statistically significant and clinically meaningful drop in apnea and hypopnea events compared with placebo after 52 weeks, and it also reported significant body weight reduction. [9]
The pivotal trials, published in the New England Journal of Medicine, enrolled adults with moderate to severe OSA and obesity. In the trial of people not using PAP, the AHI fell by 25.3 events per hour with tirzepatide versus 5.3 with placebo over 52 weeks. A second trial in people already using PAP also showed a greater drop with tirzepatide. [8] The trials did not compare tirzepatide directly with CPAP.
This treatment is for a specific group, it is a prescription medicine with its own side effects and costs, and it is managed by your physician. It is not a dental treatment.
Hypoglossal Nerve Stimulation
A hypoglossal nerve stimulator is a small device implanted in the chest that sends a signal to the nerve that moves your tongue. With each breath, it moves the tongue forward to keep the airway open. It is placed by a surgeon, usually an ear, nose, and throat (ENT) surgeon.
The landmark New England Journal of Medicine study followed 126 people with moderate to severe OSA who had trouble accepting or sticking with CPAP. After 12 months, the median AHI dropped 68%, from 29.3 to 9.0 events per hour. The average BMI in the study was 28.4, and 83% of participants were men. [10]
Not everyone qualifies. FDA labeling has expanded over time. The current approval covers an AHI up to 100 and carries a BMI warning at 40. [11] Candidacy also depends on the pattern of airway collapse, which is usually checked with an exam done under sedation, along with your overall health. [15] The AASM guideline recommends that clinicians discuss referral to a sleep surgeon with adults who have OSA and a BMI below 40 who cannot or will not use PAP. [12]
Nerve stimulation and oral appliances are sometimes compared head to head. See our comparison of nerve stimulation and oral appliances. The right choice depends on your anatomy and your physician's advice.
Surgery
Surgery changes the structure of the airway. The AASM surgical referral guideline recommends discussing referral to a sleep surgeon with adults with OSA and a BMI under 40 who cannot or will not use PAP, and suggests the same discussion for people whose CPAP use stays low because of pressure-related side effects. [12] For people with a major airway abnormality, the guideline suggests trying PAP first before upper airway surgery. [12]
Options range from procedures on the nose, tonsils, and soft palate to jaw surgery. One of the most studied jaw operations is maxillomandibular advancement (MMA), in which an oral and maxillofacial surgeon moves the upper and lower jaws forward. A meta-analysis of 45 studies and 518 patients found the average AHI fell from 57.2 to 9.5 events per hour, with a surgical success rate of 85.5% and a cure rate (AHI under 5) of 38.5%. [13] MMA is a major operation with a real recovery period, so it is usually reserved for people with more severe disease or specific anatomy. Read more in our guide to oral surgery for sleep apnea.
Results for soft tissue procedures vary widely from person to person. A surgeon should explain what to expect for your anatomy, including the chance that you will still need another treatment afterward.
Combining Treatments
You do not always have to choose just one option. A 2026 systematic review and meta-analysis of 47 studies found that combining treatments produced a bigger drop in AHI and sleepiness than single therapies, and that combined strategies increased CPAP use. [14] A recent review of alternatives to PAP also describes combination therapy as a central task for clinicians treating people who cannot use PAP alone. [15]
Examples might include an oral appliance plus positional therapy, weight-loss treatment plus another therapy, or a lower CPAP pressure made possible by another treatment. Which combinations make sense for you is a decision for your sleep physician.
How the Options Compare
The table-style list below gives a quick summary. It is a simplification. Individual results vary.
- CPAP: Most effective at lowering AHI when used, but many people stop.
- Oral appliance: Custom device from a dentist. Usually less effective at lowering AHI than CPAP, but often worn more hours. Needs dental follow-up. [5] [16]
- Positional therapy: Non-invasive, for people whose apnea depends on position. Less effective than CPAP. [6]
- Weight loss and tirzepatide: For adults with obesity. Prescription medicine approved in December 2024. [9]
- Nerve stimulation: Implanted device for selected people who cannot use CPAP. [10] [11]
- Surgery: Ranges from small procedures to jaw advancement. Highest reported success for MMA. [13]
How to Decide With Your Sleep Physician
Bring your sleep study results and a list of what you have tried. Ask what CPAP problems could still be fixed, what your sleep test says about your severity and sleep position, and which alternatives fit your anatomy and health. If an oral appliance is on the table, ask for a written prescription and a follow-up sleep test after the device is adjusted. [5]
If you have severe OSA, go into this conversation knowing that CPAP is usually the most effective option and that your physician may want to try to make CPAP work first. If you cannot, the alternatives above are real, evidence-based choices.
Find a Dentist Who Provides Oral Appliance Therapy
Get a diagnosis first. A physician must confirm sleep apnea with a sleep study before any treatment, including an oral appliance. If you already have a diagnosis and want to explore a dental option, search our provider directory for dentists in your area. A prosthodontist is one type of dental specialist who may offer oral appliance therapy, and some general dentists have training in dental sleep medicine as well. Ask each office about their training, how they coordinate with your physician, and how they handle follow-up testing. Browse our list of dentists who provide oral appliance therapy, grouped by state.
