CPAP vs mandibular device vs surgery

Obstructive sleep apnoea has three well-established treatment modalities in the UK: continuous positive airway pressure (CPAP), mandibular advancement devices (MADs), and specific surgical interventions. Plus adjuncts: positional therapy, weight loss, and newer options like hypoglossal nerve stimulation. The right choice depends on severity, anatomy, patient preference, and tolerability. This article walks through each honestly.

CPAP - the gold standard

CPAP is a small bedside device that delivers a continuous stream of pressurised air through a mask to hold the upper airway open during sleep. It is the most effective single treatment for moderate-to-severe obstructive sleep apnoea.

Effectiveness. Reduces AHI to near zero in most patients when properly titrated. Improves daytime sleepiness, concentration, mood, and blood pressure. Reduces cardiovascular event risk over years of use. Evidence base is large and consistent.

Tolerability. This is where CPAP becomes controversial. Long-term adherence (defined as 4 or more hours nightly for at least 70 percent of nights) is roughly 50 to 70 percent in real-world populations. Patients who tolerate CPAP generally do very well; patients who cannot tolerate it stop using it, and the treatment effect disappears.

Common reasons for poor tolerance: mask leak, dry mouth, nasal congestion, claustrophobia, partner disruption, travel inconvenience. Most of these are manageable with proper titration, mask refitting, humidification, and patient education.

Cost and supply. NHS CPAP is free once you qualify. Private CPAP devices cost £300 to £900 depending on model (auto-adjusting machines are more expensive but usually better). Masks cost £80 to £150 with replacement every 6 to 12 months. Filters and tubing add another £30 to £80 per year.

Ongoing support. CPAP titration, mask fitting, and troubleshooting are essential for good outcomes. We refer to preferred suppliers (typically Intus or similar) for device and initial titration, and continue clinical support through our ongoing programme.

Best for. Moderate-to-severe apnoea (AHI over 15). Significant daytime sleepiness. Cardiovascular risk benefit is desired. Patient is motivated and able to tolerate mask use.

Mandibular advancement devices

A custom-fitted dental appliance that holds the lower jaw forward during sleep, opening the upper airway. Can be bought off-the-shelf (boil-and-bite), but custom-made-by-dentist devices are significantly more effective.

Effectiveness. Reduces AHI by 50 to 70 percent on average, less reliably than CPAP. More effective in mild-to-moderate apnoea (AHI under 30) than severe apnoea. Works best for positional apnoea and for patients with specific anatomy (retrognathic lower jaw, relatively large soft tissue in a forward-growable frame).

Tolerability. Most patients tolerate MAD better than CPAP. The main issues are jaw discomfort in the first few weeks (usually settles), tooth movement over years (worth discussing with a dentist before committing), excess salivation, and some reduction in bite symmetry. Real but usually minor.

Cost. Custom MAD from a specialist sleep dentist typically £600 to £1,200. Lifespan 3 to 5 years of nightly use before needing replacement. Not NHS-funded in most regions.

Monitoring. After fitting, we repeat the WatchPAT study on MAD use at 6 to 8 weeks to confirm effectiveness. If AHI is well controlled, the device is working. If not, we explore alternative options or a different device.

Best for. Mild-to-moderate apnoea. Positional apnoea. CPAP intolerance. Patients who travel frequently. Patients who want a discreet option.

Surgical options

A genuinely useful option for a specific subset of patients. Not for everyone.

Uvulopalatopharyngoplasty (UPPP). Removes tissue from the back of the throat. Outcomes are variable; long-term AHI reduction of 40 to 60 percent in selected patients. Recovery is significantly painful. Reserved for patients with specific anatomical features where soft-tissue excess is clearly the problem.

Maxillomandibular advancement (MMA). Bigger operation. The upper and lower jaws are repositioned forward, expanding the posterior airway. Highly effective in selected patients (AHI reductions comparable to CPAP). Major surgery with weeks of recovery. Usually reserved for younger patients with severe apnoea who cannot tolerate CPAP and have suitable anatomy.

Inspire hypoglossal nerve stimulation. Surgically-implanted device that stimulates the tongue muscle during sleep to prevent airway collapse. Effectiveness is good in selected patients (AHI reduction around 70 percent, often with durable tolerance). Expensive and technical. Available at specialist NHS centres and private. Suitable for moderate-to-severe apnoea with CPAP intolerance and specific anatomical criteria.

Nasal surgery (septoplasty, turbinate reduction). Does not fix apnoea alone but can dramatically improve CPAP tolerance by improving nasal airflow. Worth considering in patients with clear nasal obstruction who have failed CPAP due to mask issues.

Best for. Specific anatomical presentations where a surgical target is identified. CPAP failure despite good attempts. Patient preference for a one-time procedure rather than lifelong treatment.

Positional therapy

For patients with clearly supine-predominant apnoea (AHI high when on back, low when on side), positional therapy alone can be effective. Various devices: a tennis ball sewn into the back of a pyjama top (DIY), a vest with an inflatable back pouch, wearable vibrating devices that buzz when you turn supine.

Effectiveness. Reduces AHI to manageable levels in roughly 40 to 60 percent of appropriately selected patients. Usually augments rather than replaces other treatment.

Cost. £30 to £200 depending on device.

Best for. Clear supine-predominant apnoea. As an adjunct to other treatment. In patients who want to try something simple first.

Weight loss

Not a single-night treatment, but in patients with elevated BMI, weight loss produces meaningful improvement in apnoea. A 10 to 15 percent weight loss reduces AHI by roughly 50 percent on average. GLP-1 medications (Mounjaro, Wegovy) have dramatically changed what is achievable here; sustained weight loss of 15 to 25 percent is now regularly accomplished.

For a patient with mild-to-moderate apnoea and elevated BMI, weight loss plus a mandibular device is often a complete solution without CPAP. Our weight-management service integrates with sleep.

When we recommend each

Mild apnoea (AHI 5-15), no or minimal daytime symptoms. Positional therapy, weight loss, or MAD. CPAP is often unnecessary.

Mild-to-moderate apnoea, symptomatic. MAD is often the first choice. CPAP if MAD is ineffective or anatomy suggests low MAD success probability.

Moderate apnoea (AHI 15-30). CPAP is standard first-line. MAD in CPAP-intolerant patients. Positional therapy as adjunct if applicable.

Severe apnoea (AHI over 30). CPAP is clearly indicated. Surgery considered for CPAP failure. MAD is rarely sufficient alone.

REM-related apnoea. CPAP or MAD. Response often good.

What we do not do

We do not sell CPAP devices directly. We do not do surgery. We refer to appropriate specialists for both. This avoids the conflict of interest that dominates some UK sleep providers.

Follow-up after treatment starts

Regardless of modality, we repeat the WatchPAT study at 6 to 8 weeks to confirm the treatment is working. If AHI is controlled, we transition to lighter monitoring. If AHI is not controlled, we revisit the treatment plan.

Annual review covers adherence (with CPAP data download if appropriate), symptoms, weight, blood pressure, daytime function.

The honest bottom line

The right apnoea treatment is the one that reduces AHI meaningfully and that you will actually use long-term. For most patients that is CPAP. For a significant minority it is MAD, positional therapy, or weight loss. For a smaller group it is surgery. Our job is to find the right match rather than selling any particular modality.

Ready to start?

If this article has made you think our assessment might help, the next step is a short consultation with one of our sleep-medicine doctors.

Begin your consultation at this link. Online with a WatchPAT One home study, or in person at Westfield London.