CPAP vs. Oral Appliance: Which Is Best For You?

For decades, CPAP has been the automatic first choice for treating sleep apnea. In a conversation about this, Dr. Tom Gotsis argues for a different way of thinking about treatment. CPAP, oral appliance therapy, and hypoglossal nerve stimulation should be presented as three real options, not one first choice and two fallbacks.

Why CPAP Became the Default, and Why That Is Changing

Sleep physicians have long read the sleep studies and chosen the treatment, and CPAP has been the gold standard. Dr. Gotsis compares it to how medicine moves on from older drugs once something proven comes along. His view is that treatment should now be a choice, not a ranking.

He is honest about CPAP’s strengths. It is a very effective therapy that has helped millions of people, and he estimates it works for about 85% to 87% of patients. He puts oral appliances at about 78% to 83%. A CPAP can blow an airway open almost any time, while an oral appliance opens it mechanically and may leave some partial blockages behind.

Why So Many Patients Stop Using CPAP

Roughly half of CPAP users stop within six months. The reasons are practical. They don’t like feeling tied to the bed, the mask leaks, or the air pressure is set too high. A treatment only works if the patient keeps using it. Dr. Gotsis sees many people who failed CPAP, and he says that does not mean they will fail an oral appliance.

Why AHI Doesn’t Tell the Whole Story

The apnea-hypopnea index (AHI) counts how often breathing stops or is reduced each hour. Dr. Gotsis explains that it is only part of the picture. Other measures, like hypoxic burden, also matter. A patient who stops breathing 50 times an hour may say they aren’t tired. Another who stops only five or six times an hour may be exhausted. The difference often comes down to arousals, the brief wake-ups in the brain that fragment sleep. For many patients, the goal is to stop those arousals, not just to lower a number.

An Evaluation That Takes the Time

Dr. Gotsis’s new patient visit lasts about 90 minutes. It starts with a conversation of 30 to 45 minutes about why you think you have sleep apnea, how long it has been going on, and even how you slept as a teenager. He reviews medications, diet, and caffeine, because all of them affect sleep. He then examines your airway and uses a pharyngometer and rhinometer to check how well you breathe through your nose, which he considers essential in sleep medicine. Only then does he recommend a treatment plan.

Over the last 19 years, he has made an estimated 4,000 to 5,000 oral appliances.

Who This Conversation Is For

If you are a physician deciding where to send a patient who can’t tolerate CPAP, or a patient trying to understand your options, this conversation lays out the evidence and the reasoning behind oral appliance therapy as a legitimate first-line option.

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