Mandibular Advancement Device Prescriptions Surge in France Sleep Apnea Study

Mandibular advancement device (MAD) prescriptions in France grew from 8,110 in 2014 to 29,546 in 2023 — a 17% average annual increase — according to a nationwide analysis of reimbursement data published in Sleep and Breathing. The same study found positive airway pressure (PAP) prescriptions more than tripled, signaling a major shift in how obstructive sleep apnea is treated across an entire country.

A Decade of Data: How France Treats Its Sleep Apnea

Researchers led by Dr. B. Ribeiro-Baptista at the CHRU de Nancy university hospital, working with colleagues from the Pitié-Salpêtrière sleep disorders unit in Paris, mined the French national health system’s open reimbursement database (Open LPP) covering 2014 through 2023. Because France reimburses both PAP machines and mandibular advancement devices through a single payer system, the dataset captured essentially every prescription in the country — a rare, near-complete picture of sleep apnea care.

The headline numbers are striking. PAP prescriptions climbed from 986,784 in 2014 to 3,362,040 in 2023. MAD prescriptions, while far smaller in absolute terms, followed the same trajectory: an average 17% growth per year. Private-sector specialists — largely pulmonologists working outside hospitals — drove most of the increase. The findings echo what smaller studies have shown about long-term MAD effectiveness; one related investigation found an oral appliance cut sleep apnea events by half over ten years of follow-up.

Why a Jaw Repositioning Splint Opens the Airway

A mandibular advancement device looks like a sports mouthguard, but its job is mechanical leverage. The appliance grips both dental arches and holds the lower jaw (mandible) a few millimeters forward during sleep. Because the tongue’s base attaches to the mandible’s inner surface, pulling the jaw forward drags the tongue root and soft palate tissues away from the back of the throat. This enlarges the retroglossal airway — the space behind the tongue where most nighttime collapse occurs in people with obstructive sleep apnea.

The mechanism differs fundamentally from PAP. A CPAP machine pushes pressurized air through the airway like a pneumatic splint, keeping it inflated regardless of jaw position. A MAD instead restructures the anatomy of the upper airway passively. That distinction matters clinically: patients who cannot tolerate the mask, the pressure sensation, or the machine noise of PAP often adhere better to a dental appliance — which may explain part of the steady prescription growth the French team documented.

Adherence Trouble Beneath the Growth Story

Beneath the growth curves sits a quieter problem. Adherence to PAP therapy declined over the study window: 67.6% of patients used their device more than 4 hours per day in 2018, falling to 63.6% in recent years (p = 0.03). Four hours daily is the conventional minimum for therapeutic benefit. Nearly one in three French PAP users falls below it.

This adherence gap is where MADs earn their place. Oral appliances require no machine, mask, or electricity, and side effects — typically jaw discomfort, tooth movement, or bite changes over years of use — are generally manageable with dental follow-up. Readers weighing this option should also understand the documented risks; our coverage of oral appliance side effects and posterior open bite explains what long-term wear can do to dental alignment. Adherence data for MADs was not separately reported in the French reimbursement dataset, which the authors acknowledge as a limitation — prescriptions were counted, not night-to-night usage.

Who Gets Treated — and What It Costs

The demographics shifted meaningfully. In 2014, 70% of sleep apnea device prescriptions went to men; by 2023, that figure had dropped to 64%. Rising obesity rates and growing recognition of sleep apnea in women — whose symptoms often present as fatigue rather than loud snoring — likely drive the change, though the study could not test these explanations directly.

Costs climbed even faster than prescriptions. French spending on PAP doubled to 934 million euros in 2023, despite the health system cutting reimbursement rates per device. More patients simply entered treatment. Whether that trajectory is sustainable is an open policy question the authors raise. For individuals, cost-effectiveness also depends on combining an appliance with behavioral levers — for example, avoiding back sleeping if apnea worsens in that position can amplify any device’s benefit.

Frequently Asked Questions

How much did mandibular advancement device use grow in France?

MAD prescriptions rose from 8,110 in 2014 to 29,546 in 2023 — roughly 17% average annual growth, slightly outpacing PAP’s 16% per year.

Can a mandibular advancement device replace a CPAP machine?

For many patients with mild-to-moderate obstructive sleep apnea, or those who cannot tolerate CPAP, a MAD is an accepted alternative — but the choice should be made with a sleep physician and a dentist experienced in dental sleep medicine.

Why is PAP adherence declining even as prescriptions rise?

The French data show adherence above 4 hours daily dropped from 67.6% to 63.6% of patients, likely reflecting mask discomfort and machine intolerance — one reason oral appliances are increasingly prescribed.

Are mandibular advancement devices safe for long-term use?

Most side effects involve jaw discomfort and gradual tooth movement, including posterior open bite in some users, so regular dental monitoring is recommended throughout treatment.

One decade of nationwide data makes the trend hard to ignore: oral appliances are moving from niche alternative to mainstream therapy. For patients and clinicians alike, the French experience suggests the future of sleep apnea care is plural — multiple devices matched to individual anatomy, tolerance, and preference rather than a single default.

Sources:
https://pubmed.ncbi.nlm.nih.gov/42714748/
https://pubmed.ncbi.nlm.nih.gov/42447761/
https://pubmed.ncbi.nlm.nih.gov/42369266/
https://pubmed.ncbi.nlm.nih.gov/42343369/
https://pubmed.ncbi.nlm.nih.gov/42331926/