CPAP is the most prescribed treatment for sleep apnea — but for millions of people, it's also the treatment they can't actually use. If you're one of them, you're not out of options. You're just at the beginning of finding the right one.
The mask. The noise. The pressure. The hose. The way it makes travel feel like packing for a medical expedition. For a significant portion of people prescribed CPAP therapy, the treatment itself becomes a barrier to treatment — and poor CPAP adherence means sleep apnea goes uncontrolled, with all the cardiovascular, cognitive, and metabolic consequences that entails.
Custom oral appliance therapy is the most established and effective CPAP alternative for mild to moderate obstructive sleep apnea — and increasingly for severe cases where CPAP simply isn't tolerable. The challenge has always been accessing it. This post explains what oral appliance therapy involves, why the pathway to getting one has historically been complicated, and how telehealth is changing that entirely.
Before getting into alternatives, it's worth naming something directly: the framing of CPAP non-use as a "compliance problem" has done a lot of harm. For many people, CPAP is genuinely intolerable — not for lack of effort, but because of real physiological, anatomical, or psychological factors that make mask-based therapy unsustainable.
Common reasons people can't use CPAP long-term include claustrophobia triggered by mask contact, mouth breathing that undermines pressure delivery, positional discomfort, noise sensitivity, skin irritation, aerophagia from swallowed air, and the practical reality that CPAP is incompatible with certain sleeping positions and travel lifestyles.
When CPAP isn't being used, sleep apnea isn't being treated. And untreated sleep apnea is associated with serious downstream consequences: elevated cardiovascular risk, hypertension, cognitive impairment, metabolic disruption, and severely compromised quality of life. This is exactly why finding a CPAP alternative that you'll actually use isn't a lifestyle preference — it's a medical priority.
A custom oral appliance — sometimes called a mandibular advancement device (MAD) or mandibular repositioning device — is a precision-fitted device worn during sleep that works by gently repositioning the lower jaw forward. This forward position keeps the airway open, preventing the collapse and obstruction that causes obstructive sleep apnea.
The critical distinction is between custom-fit devices prescribed by a sleep physician and fabricated by a dental lab based on precise oral anatomy measurements — and over-the-counter or generic mandibular advancement devices purchased without professional involvement.
Generic devices are not the same thing. They're one-size-fits-all in a context where anatomy varies enormously. They can't be calibrated to the precise degree of jaw advancement required for your specific airway anatomy and apnea severity. They frequently cause temporomandibular joint (TMJ) discomfort because the advancement isn't optimized. And critically, their effectiveness is not monitored or verified — meaning you may be sleeping with a device that feels like it's doing something while your sleep apnea remains uncontrolled.
A properly prescribed, custom-fit oral appliance is fabricated from precise impressions of your teeth and jaw, calibrated by a trained clinician, and adjusted over time based on your treatment response. It's a medical device — not a consumer product.
For most people who've tried to pursue oral appliance therapy, the process has felt unnecessarily fragmented. Here's why that's been the case — and why it matters clinically:
Diagnosis and prescription are separate from fabrication. A physician must diagnose your sleep apnea and determine that oral appliance therapy is appropriate for your presentation. A dental professional with sleep medicine training fabricates and fits the device. Historically these have been disconnected pathways requiring multiple appointments across multiple providers.
Many telehealth platforms stop short of the full pathway. Some platforms offer home sleep testing but don't connect results to a physician who can issue an oral appliance prescription. Others offer general sleep consultations without diagnostic capability. The result is patients who have partial information and partial care — and no clear next step.
Without physician oversight, oral appliance therapy carries real risks. Prescribing an oral appliance without an accurate diagnosis of apnea type and severity, or without evaluating whether a patient is a good candidate, can result in undertreated sleep apnea, jaw problems, and a false sense of security. This is why physician involvement isn't a formality — it's a clinical requirement.
Insurance navigation has been complex. Oral appliance therapy is covered by many major insurance plans, but the documentation requirements — including a physician diagnosis, AHI scores from a sleep study, and a formal prescription — mean that getting coverage has required coordinating records across multiple providers. For most patients navigating this alone, it's been overwhelming.
An effective, medically sound pathway to a custom oral appliance involves several specific components — and a good telehealth sleep clinic handles all of them in one integrated process.
Everything starts with an accurate, physician-interpreted diagnosis. Home sleep testing — through an FDA-cleared device — establishes your apnea-hypopnea index (AHI), oxygen desaturation patterns, and sleep architecture in a way that supports both diagnosis and insurance documentation. It eliminates the inconvenience of in-lab sleep studies while providing clinically valid data that a board-certified physician can interpret meaningfully.
A home sleep test versus in-lab study is appropriate for the majority of patients with suspected obstructive sleep apnea — and for anyone whose primary complaint is CPAP intolerance and who needs a documented diagnosis to pursue alternatives.
Once your sleep test results are in, a board-certified sleep medicine physician reviews them in the context of your full medical history, symptoms, and CPAP experience. This is where candidacy for oral appliance therapy is determined — taking into account apnea severity, jaw anatomy, dental health, sleep position patterns, and your history with CPAP.
This step is non-negotiable and non-automatable. An algorithm cannot perform this clinical assessment. Real clinicians — not AI tools — are required to evaluate whether oral appliance therapy is appropriate for your specific presentation and to issue a prescription that a dental lab can act on.
With a physician prescription in hand, a dental professional with sleep medicine specialization takes precise impressions and fabricates a device calibrated to your jaw anatomy and the prescribed advancement setting. This is why custom fit matters: the degree of mandibular advancement must be precisely calibrated — too little fails to open the airway adequately; too much causes jaw pain and poor adherence.
Oral appliance therapy isn't a set-it-and-forget-it treatment. Effective therapy requires follow-up to assess whether your AHI has been adequately reduced, adjustment of the advancement setting if needed, and monitoring for any TMJ or dental side effects. An integrated care pathway ensures this follow-up is built in — not something you have to chase separately.
Who is a good candidate for oral appliance therapy?
Oral appliance therapy is most effective for mild to moderate obstructive sleep apnea and is increasingly used for severe OSA in patients who cannot tolerate CPAP. Patients with positional sleep apnea — where apnea worsens significantly in the supine position — tend to respond particularly well. A physician evaluation is required to determine candidacy for your specific presentation.
Are over-the-counter mandibular advancement devices effective?
Not comparably. Generic, non-custom devices don't provide the precise calibration required for therapeutic effectiveness, can't be adjusted based on your treatment response, and aren't monitored by a clinician. For anyone with diagnosed sleep apnea, an over-the-counter device is not a substitute for a physician-prescribed custom appliance.
Does insurance cover oral appliance therapy?
Many major insurance plans cover oral appliance therapy for obstructive sleep apnea with appropriate documentation — including a physician diagnosis and sleep study results. Navigating this coverage is one of the key reasons an integrated telehealth pathway is valuable: the documentation is generated and coordinated as part of the process. Insurance-eligible care is now available in many states through telehealth sleep clinics.
Can I get a home sleep test if I've never been formally diagnosed?
Yes. If you have symptoms of sleep apnea — snoring, gasping, witnessed apneas, unrefreshing sleep, morning headaches, or excessive daytime sleepiness — a home sleep test is the appropriate starting point. You don't need an existing diagnosis to initiate testing. Understanding your sleep apnea risk is the first step toward addressing it.
What if I have both sleep apnea and insomnia?
This is more common than most people realize. The combination — sometimes called COMISA (comorbid insomnia and sleep apnea) — requires an integrated treatment approach addressing both conditions. Sleep apnea can significantly worsen insomnia, and treating apnea alone often doesn't fully resolve sleep continuity problems. Platforms like Sleep Reset that offer both CBT-I-based insomnia treatment and sleep apnea diagnosis and treatment are particularly well-suited for this presentation.
How is oral appliance therapy different from BiPAP?
BiPAP is a pressure-based therapy like CPAP but delivers different pressures for inhalation and exhalation — often better tolerated by people who struggle with exhaling against CPAP pressure. Oral appliance therapy is entirely non-pressure-based — no machine, no mask, no tubing. For patients whose CPAP intolerance stems from mask discomfort or pressure sensitivity, oral appliance therapy represents a fundamentally different treatment category, not just a modified version of the same approach.
Sleep Reset provides the most complete, doctor-led telehealth pathway to custom oral appliance therapy currently available — addressing every point of fragmentation that has historically made this process unnecessarily difficult.
Here's what that integrated pathway looks like in practice:
FDA-cleared home sleep testing — accurate, convenient, and interpreted by board-certified sleep medicine physicians with a complete written report. No in-lab study required. No scheduling delays. Clinical-grade diagnostic data that supports both your treatment plan and your insurance documentation.
Board-certified sleep medicine physicians — including Dr. Michael Grandner, Dr. Daniel Jin Blum, Dr. Areti Vassilopoulos, Dr. Samantha Domingo, and Dr. Shiyan Yeo — conducting real telehealth consultations, evaluating oral appliance candidacy, and issuing medically sound prescriptions. Not automated questionnaires. Not algorithms. Actual physicians.
A direct prescription pathway for custom-fit oral appliances, tailored to your oral anatomy, apnea severity, and clinical history.
Integrated insomnia treatment — for patients with comorbid insomnia and sleep apnea, Sleep Reset's proprietary CBT-I program and dedicated sleep coaches address the behavioral and cognitive dimensions of sleep dysfunction that oral appliance therapy alone doesn't resolve.
Insurance-eligible care in 25 states — with streamlined documentation and support for navigating coverage. See pricing and coverage options or explore HSA/FSA eligibility.
Proven, published outcomes — Sleep Reset's program is clinically validated in a peer-reviewed study. Users gain an average of 85+ more minutes of deep sleep, and physicians actively refer patients to Sleep Reset for sleep apnea care.
Read verified user reviews, explore Sleep Reset's science and research, or see how Sleep Reset has been covered by press as a leading sleep health platform.
If CPAP isn't working for you, the answer isn't to keep trying harder at something that isn't tolerable — or to give up on treating your sleep apnea entirely. Custom oral appliance therapy is a clinically validated, physician-prescribed alternative that works for the majority of appropriate candidates. The key is getting there through a pathway that includes accurate diagnosis, real physician oversight, proper prescription, and follow-up care.
That pathway now exists entirely via telehealth. Start with a home sleep test to get an accurate diagnosis, or take Sleep Reset's sleep quiz to understand your sleep profile and see how an integrated treatment plan would approach your specific situation.
CPAP intolerance doesn't have to mean untreated sleep apnea. The right alternative — prescribed by a real physician, fitted precisely, and monitored over time — can be the difference between dreading sleep and finally getting the rest your body needs.
This article is for informational purposes only and does not constitute medical advice. Please review our editorial policy and terms of service for more information.
Dr. Areti Vassilopoulos | Psychologist | Sleep Medicine Expert
Dr. Vassilopoulos is the Clinical Content Lead for Sleep Reset and Assistant Professor at Yale School of Medicine. She has co-authored peer-reviewed research articles, provides expert consultation to national nonprofit organizations, and chairs clinical committees in pediatric health psychology for the American Psychological Association. She lives in New England with her partner and takes full advantage of the beautiful hiking trails.
Fax number: (984) 888-8385
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