CPAP is not the only treatment for sleep apnea. It’s the most commonly prescribed and widely studied option, but several alternatives exist, ranging from oral devices and positional therapy to implantable nerve stimulators and surgery. The right choice depends on how severe your apnea is, what’s causing the airway obstruction, and whether you can tolerate CPAP in the first place.
Oral Appliances
Oral appliances, often called mandibular advancement devices, are custom-fitted mouthpieces that hold your lower jaw slightly forward while you sleep. This keeps the tongue and soft tissues from collapsing into the airway. They’re best suited for mild to moderate sleep apnea, particularly in people with a lower body mass index and favorable jaw anatomy.
The results vary, but they consistently reduce the number of breathing interruptions per hour. Across multiple studies, patients starting with 16 to 40 events per hour saw reductions roughly in the range of 30% to 60%. Someone with 32 events per hour, for example, dropped to about 13 in one study. Someone starting at 22 dropped to 9. These aren’t as dramatic as CPAP reductions in severe cases, but for many people with mild to moderate apnea, they’re enough to bring breathing events into a normal or near-normal range.
One major advantage is that people actually use them. CPAP adherence (defined as at least four hours of use per night) ranges from just 17% to 60%, depending on the study. By contrast, 56% to 68% of oral appliance users are still wearing their device at 30 months. The American Dental Association notes that overall adherence with oral appliances is better than with CPAP, and serious side effects leading to discontinuation are less common. A treatment that works slightly less well on paper but gets worn every night can outperform one that sits on the nightstand.
Positional Therapy
Some people only stop breathing when they sleep on their back. This is called positional obstructive sleep apnea, and it’s surprisingly common. When you lie face-up, gravity pulls the tongue and soft palate backward, narrowing the airway. If your apnea mostly or entirely happens in this position, simply staying off your back can be an effective treatment on its own.
The simplest version is the old “tennis ball technique,” where a ball sewn into the back of a sleep shirt makes it uncomfortable to roll over. More modern options include wearable vibrating devices that gently nudge you onto your side without fully waking you. Both approaches reduce the time spent sleeping on your back and lower the number of breathing events per hour in people with mild to moderate positional apnea.
Positional therapy performs comparably to oral appliances for reducing breathing interruptions and oxygen dips in this group. It doesn’t seem to improve daytime sleepiness or quality of life on its own, though. Combining positional therapy with an oral appliance may be more effective than either one alone, making it a useful add-on rather than a standalone fix for some people.
Hypoglossal Nerve Stimulation
If you can’t tolerate CPAP or an oral appliance, an implantable device that stimulates the nerve controlling your tongue may be an option. A small generator is placed under the skin of the chest, with a wire running to the nerve beneath the tongue. It senses your breathing pattern and delivers mild stimulation to push the tongue forward each time you inhale, keeping the airway open. You turn it on with a remote before bed and off when you wake up.
The results can be striking. Cleveland Clinic reported that in one group of 27 patients, the average number of breathing events per hour dropped from 46 to 4.6, essentially from severe apnea to near-normal. The implant has also outperformed traditional throat surgery in head-to-head comparisons when patients were matched for severity, age, and weight.
Not everyone qualifies. Candidates must be at least 22 years old, have moderate to severe apnea (15 to 65 events per hour), a BMI of 35 or less, and have already failed or been unable to use CPAP or a dental device. Before implantation, a sleep endoscopy is performed under sedation to check how the palate collapses. If the airway closes in a circular pattern rather than front-to-back, the device is less likely to work, and the FDA has excluded those patients from eligibility.
Surgical Options
Surgery for sleep apnea aims to permanently widen the airway by removing or repositioning tissue. The two most studied procedures are throat tissue removal (uvulopalatopharyngoplasty, commonly called UPPP) and jaw advancement surgery (maxillomandibular advancement, or MMA).
The difference in effectiveness between the two is substantial. In a comparative study of 106 patients with moderate to severe apnea, jaw advancement reduced breathing events from an average of 56 per hour down to about 11. Throat tissue removal only reduced events from 42 to 30. After adjusting for differences in starting severity, jaw advancement produced roughly twice the improvement. Combining both procedures didn’t add meaningful benefit beyond jaw advancement alone.
Jaw advancement is a more involved operation, requiring the upper and lower jaw bones to be repositioned forward, with a recovery period of several weeks. But for patients with moderate to severe apnea who genuinely cannot use CPAP, it’s considered the stronger surgical option. Throat tissue removal is a less invasive procedure but has more variable and often disappointing long-term results, particularly for severe cases.
Weight Loss and Lifestyle Changes
Excess weight is the single biggest modifiable risk factor for obstructive sleep apnea. Fat deposits around the upper airway narrow the breathing passage, and abdominal fat reduces lung volume, making collapse more likely. Losing even 10% of body weight can meaningfully reduce the severity of apnea, and in some cases of mild apnea, weight loss alone can resolve it entirely.
Alcohol and sedatives relax the muscles that hold the airway open, so avoiding them in the hours before sleep can reduce the frequency of breathing events. Sleeping with your head elevated can also help by reducing the gravitational effect on airway tissues.
These changes work best as part of a broader treatment plan rather than a replacement for other therapies, especially in moderate or severe cases. But they’re worth pursuing regardless of what other treatment you use, because they address the underlying mechanics that cause the airway to collapse.
Choosing the Right Treatment
Severity matters most in narrowing your options. Mild apnea (5 to 15 events per hour) responds well to oral appliances, positional therapy, or weight loss. Moderate apnea (15 to 30 events per hour) may be managed with oral appliances or nerve stimulation, depending on your anatomy. Severe apnea (over 30 events per hour) is where CPAP remains the most reliably effective option, though nerve stimulation and jaw advancement surgery have shown strong results for patients who can’t use it.
Anatomy also plays a role. Some people have structural features, like a recessed jaw or enlarged tonsils, that make specific treatments more or less likely to succeed. A sleep specialist can evaluate not just how many times you stop breathing but why your airway is collapsing, which shapes the recommendation.
CPAP is the gold standard because it works for virtually all severity levels and anatomies when used consistently. The challenge is that “when used consistently” is a significant caveat. If you’ve tried CPAP and genuinely can’t tolerate it, you have real alternatives, and some of them produce outcomes that rival CPAP for the right candidates.