A living lab approach to understanding dairy farmers' needs of technologies and data to improve herd health: Focus groups from 6 European countries.

For successful development and adoption of technology on dairy farms, farmers need to be included in the innovation process. However, the design of agricultural technologies usually takes a top-down approach with little involvement of end-users at the early stages. Living Labs offer a methodology that involve end-users throughout the development process and emphasize the importance of understanding users' needs. Currently, exploration of dairy farmers' needs of technologies has been limited to specific types of technology (e.g., smartphone apps) and adult cattle. The aim of this study was to use a Living Lab approach to identify dairy farmers' needs of data and technologies to improve herd health and inform innovation development. Eighteen focus groups were conducted with, in total, 80 dairy farmers from Belgium, Ireland, the Netherlands, Norway, Sweden, and the UK. Data were analyzed using Template Analysis and 6 themes were generated which represented the fundamental needs of autonomy, comfort, competence, community and relatedness, purpose, and security. Farmers favored technologies that provided them with convenience, facilitated their knowledge and understanding of problems on farm, and allowed them to be self-reliant. Issues with data sharing and accessibility, and usability of software were barriers to technology use. Furthermore, farmers were facing problems around recruitment and management of labor and needed ways to reduce stress. Controlling aspects of the barn environment, such as air quality, hygiene, and stocking density, was a particular concern in relation to youngstock management. In conclusion, the findings suggest that developers of farm technologies may want to include farmers in the design process to ensure a positive user experience and improve accessibility. The needs identified in this study can be used as a framework when designing farm technologies to strengthen need satisfaction and reduce any potential harm toward needs.

Dutch dairy farmers' perspectives on culling reasons and strategies.

Since the abolishment of the milk quota system in Europe in 2014 and the introduction of environmental policies such as the phosphate rights system in the Netherlands, the reasons for culling dairy cows might have changed. The aim of this study was to determine the culling reasons for dairy cattle and to identify farmers' culling strategies and their intentions regarding the alteration of indicated culling strategies. To this end, an online questionnaire was distributed among dairy farmers nationally that resulted in 207 responses. Results showed that the most frequent culling reasons were related to problems with reproduction, udder, and hoof health. Primiparous cows were primarily culled for miscellaneous reasons such as injury, reproduction failure, and low milk yield. Multiparous cows were culled predominantly for reproduction failure, udder health and hoof health reasons. Most respondents indicated that they consider formulating a culling strategy, based on certain rules of thumb regarding the most common reasons for culling. Most farmers also reported that culling decisions on their farms were perceived to be unavoidable, though reproductive culling decisions are primarily voluntary. Most respondents stated that they intended to reduce the culling rate for better economic gain did not intend to alter the amount of replacement stock reared. The applied rules of thumb regarding culling strategies do not seem to have changed since the policy changes in dairy farming. The question remains whether farmers' rules of thumb might have made them unaware of the actual economic consequences of their culling strategies under the altered situation.

Corrigendum: Control and Eradication Programs for Six Cattle Diseases in the Netherlands.

[This corrects the article DOI: 10.3389/fvets.2021.670419.].

Control and Eradication Programs for Six Cattle Diseases in the Netherlands.

Within the European Union, infectious cattle diseases are categorized in the Animal Health Law. No strict EU regulations exist for control, evidence of disease freedom, and surveillance of diseases listed other than categories A and B. Consequently, EU member states follow their own varying strategies for disease control. The aim of this study was to provide an overview of the control and eradication programs (CPs) for six cattle diseases in the Netherlands between 2009 and 2019 and to highlight characteristics specific to the Dutch situation. All of these diseases were listed as C,D or E in the New Animal Health Law. In the Netherlands, CPs are in place for six endemic cattle diseases: bovine viral diarrhea, infectious bovine rhinotracheitis, salmonellosis, paratuberculosis, leptospirosis, and neosporosis. These CPs have been tailored to the specific situation in the Netherlands: a country with a high cattle density, a high rate of animal movements, a strong dependence on export of dairy products, and a high-quality data-infrastructure. The latter specifically applies to the dairy sector, which is the leading cattle sector in the Netherlands. When a herd enters a CP, generally the within-herd prevalence of infection is estimated in an initial assessment. The outcome creates awareness of the infection status of a herd and also provides an indication of the costs and time to achieve the preferred herd status. Subsequently, the herd enrolls in the control phase of the CP to, if present, eliminate the infection from a herd and a surveillance phase to substantiate the free or low prevalence status over time. The high-quality data infrastructure that results in complete and centrally registered census data on cattle movements provides the opportunity to design CPs while minimizing administrative efforts for the farmer. In the CPs, mostly routinely collected samples are used for surveillance. Where possible, requests for proof of the herd status are sent automatically. Automated detection of risk factors for introduction of new animals originating from a herd without the preferred herd status i.e., free or unsuspected, is in place using centrally registered data. The presented overview may inspire countries that want to develop cost-effective CPs for endemic diseases that are not (yet) regulated at EU level.

Efficacy of a voluntary BVDV control programme: Experiences from the Netherlands.

The outcomes of a voluntary bovine viral diarrhoea virus (BVDV) control programme that has been in place in the Netherlands since 1997 were analysed. This 'BVDV-free' programme was studied in dairy herds in the period 1 August 2007 to 1 August 2013. The programme was based on a test and cull approach at the herd level, after which the BVDV status was monitored by testing young stock for antibodies against BVDV or by antigen testing of newborn calves. One of the challenges of the programme was that, without any legislation or subsidies, farmers had to be motivated to pay all costs involved, with eradication of BVDV from their farm as the only incentive. During the study period, the percentage of dairy farms with a 'BVDV-free' status in the Netherlands increased from 13% to 24%, while the prevalence of active BVDV infections in Dutch dairy herds decreased. This may be related to the increasing number of participants in the 'BVDV-free' programme.

Development of a Salmonella Typhimurium challenge model in weaned pigs to evaluate effects of water and feed interventions on fecal shedding and growth performance.

The aim of this study was to develop a Typhimurium (ST) challenge model in weaned pigs suitable to evaluate effects of water and feed interventions on fecal shedding and growth performance. Two studies were performed. In Exp. 1 weaned pigs were fed either a standard diet (CON) or a diet with a high buffer capacity (HB) and challenged for either 3 or 7 consecutive days in a Latin square design with 4 × 8 individually housed pigs. In Exp. 2, the CON 7-d challenge method was chosen for further model development and validation. Thirty-two individually housed weaned pigs were divided over 4 treatments: a nonchallenged control group (NCON), a challenged positive control group (PCON), a challenged intervention group with acidified water (WATER), and a challenged intervention group with acidified feed (FEED). Pigs were orally challenged once daily on d 7 to 9 or d 7 to 13 after weaning (d 0) with 1 ×10 cfu ST. From d 0 to 28, rectal temperature and occurrence of diarrhea were recorded daily, and BW and feed intake were measured weekly. Fecal samples were collected on d 0, 2, 7, 9, 13, 16, 20, 23, and 27 in Exp. 1 and d 0, 2, 7, 8, 9, 13, 15, and 27 in Exp. 2 for quantification. The results of both experiments showed quantifiable fecal shedding (average peak shedding of approximately 3.5 log and 5.5 log cfu/g, respectively), accompanied by a transient 0.5°C increase in rectal temperature and an increase in occurrence of diarrhea. In Exp. 2 during the week of challenge (i.e., d 7 to 14), a reduction in growth performance (ADG: -157 to 200 g/d and G:F: -0.22 to 0.25 g/d; < 0.01) in PCON and FEED was observed compared to NCON, with WATER showing an intermediate response. The WATER treatment also showed a numerically lower peak shedding (difference of -1.3 to 1.4 log cfu/g) compared to PCON and FEED. To conclude, we repeatedly infected weaned pigs successfully with 1 × 10 cfu of ST for 7 consecutive days, resulting in detectable and quantifiable fecal shedding. This ST challenge model may be suitable for evaluation of effects of water and feed interventions on peak fecal shedding and growth performance.

The effect of orthognathic surgery on the temporomandibular joint and oral function: a systematic review.

The objective of this systematic review was to examine the effect of orthognathic surgery (OS) on the temporomandibular joint and oral function. Electronic databases were systematically searched for studies published until October 2015. Articles were assessed against predefined inclusion criteria. The included papers were divided into four groups based on the type of OS performed. The following items were recorded: quality of evidence using the Oxford Centre for Evidence-Based medicine (CEBM) criteria, number of patients, presence/absence of controls, mean age at treatment, follow-up time, clinical examination findings, bite force, use of the Helkimo Index and Research Diagnostic Criteria for Temporomandibular Disorders, imaging findings, and patient questionnaire results. A total of 4669 articles were identified; 76 relevant articles were included in the review. These studies assessed a total 3399 patients and 380 controls, with a mean age of 25.4 years. The great variety of OS techniques, examination techniques, diagnostic criteria, and imaging techniques used in the articles studied, as well as the quality of the study designs, made it difficult to compare studies and to draw conclusions. However, looking at the different aspects studied in general, it can be stated that OS seems to have little or no harmful effect on the TMJ and oral function (level of evidence: levels II, III, and IV).

Two Years After the Schmallenberg Virus Epidemic in the Netherlands: Does the Virus still Circulate?

Two years after the introduction of the Schmallenberg virus in north-western Europe, it is unknown whether the virus is still circulating in countries that were the first to be confronted with it. When the population-level immunity declines in Europe, reintroduction or the re-emergence of SBV in Europe might eventually result in an outbreak of similar magnitude of that seen in 2011-2012. The Netherlands was part of the primary outbreak region of SBV in 2011. The aim of this study was to determine whether SBV circulated amongst dairy herds in the Netherlands in 2013, and if so, to which extent. For this purpose, the presence of SBV-specific antibodies in naive cattle was investigated. A total of 394 dairy farms were sampled between October and December 2013 by collecting five serum samples per herd. Antibodies were detected in 1.1% [95% confidence interval (CI): 0.7-1.7)] of the animals. All seropositive animals were single reactors per herd and were at least 8 months old at sampling. As these results were inconclusive in demonstrating freedom of SBV circulation, a more in-depth investigation was initiated to provide more insight: an additional sample of 20 youngstock within the same age category (including the five initially sampled animals) was collected from 17 of the 21 positive herds and tested for SBV-specific antibodies. This resulted in 9 antibody-positive test results of 316 samples. Again, the positive samples were single reactors within the sample obtained from each farm, which is unlikely given the characteristics of SBV. Therefore, assuming the single reactors as false-positive, this survey showed with 95% confidence that the maximum possible prevalence of herds with SBV circulation in the Netherlands was <1% in 2013.

Effectiveness and Cost Efficiency of Different Surveillance Components for Proving Freedom and Early Detection of Disease: Bluetongue Serotype 8 in Cattle as Case Study for Belgium, France and the Netherlands.

Quick detection and recovery of country's freedom status remain a constant challenge in animal health surveillance. The efficacy and cost efficiency of different surveillance components in proving the absence of infection or (early) detection of bluetongue serotype 8 in cattle populations within different countries (the Netherlands, France, Belgium) using surveillance data from years 2006 and 2007 were investigated using an adapted scenario tree model approach. First, surveillance components (sentinel, yearly cross-sectional and passive clinical reporting) within each country were evaluated in terms of efficacy for substantiating freedom of infection. Yearly cross-sectional survey and passive clinical reporting performed well within each country with sensitivity of detection values ranging around 0.99. The sentinel component had a sensitivity of detection around 0.7. Secondly, how effective the components were for (early) detection of bluetongue serotype 8 and whether syndromic surveillance on reproductive performance, milk production and mortality data available from the Netherlands and Belgium could be of added value were evaluated. Epidemic curves were used to estimate the timeliness of detection. Sensitivity analysis revealed that expected within-herd prevalence and number of herds processed were the most influential parameters for proving freedom and early detection. Looking at the assumed direct costs, although total costs were low for sentinel and passive clinical surveillance components, passive clinical surveillance together with syndromic surveillance (based on reproductive performance data) turned out most cost-efficient for the detection of bluetongue serotype 8. To conclude, for emerging or re-emerging vectorborne disease that behaves such as bluetongue serotype 8, it is recommended to use passive clinical and syndromic surveillance as early detection systems for maximum cost efficiency and sensitivity. Once an infection is detected and eradicated, cross-sectional screening for substantiating freedom of infection and sentinel for monitoring the disease evolution are recommended.

Association between Dictyocaulus viviparus status and milk production parameters in Dutch dairy herds.

The objective of this study was to estimate the association between Dictyocaulus viviparus bulk tank milk (BTM) test results and milk production and milk composition parameters in adult Dutch dairy cattle herds. Bulk tank milk samples were collected in August and November 2013, and ELISA tests were performed. Two hundred BTM positive (BTM+) and 200 BTM negative (BTM-) herds were selected based on their BTM test result of November 2013, obtained from a list of farms that participated in the Dutch GD Animal Health voluntary monitoring program for controlling nematode infections. The relationship between D. viviparus BTM status and 3 production parameters (milk production, milk fat %, and milk protein %) in summer (June to August 2013) and autumn (September and October 2013) was investigated using generalized linear mixed models. Production data were available for 126 BTM- herds and 109 BTM+ herds. Results showed that a positive D. viviparus status was associated with decreased milk production (June: -1.01, July: -1.19, August: -1.68, September and October: -1.33kg/cow per d). Milk fat percentage was 0.14% and 0.08% lower during summer and autumn, respectively, in BTM+ herds. No significant association was demonstrated between a positive BTM test result and milk protein percentage. Because a strong correlation was present between the BTM status for D. viviparus and that for Ostertagia ostertagi, these losses cannot be attributed to one of the two parasites. However, it is clear that these parasite infections have a considerable effect on production.

Schmallenberg virus epidemic: impact on milk production, reproductive performance and mortality in dairy cattle in the Netherlands and Kleve district, Germany.

Schmallenberg virus (SBV), a novel orthobunyavirus that rapidly spread throughout north-western Europe in 2011, caused congenital malformations in lambs and goat kids (Van den Brom et al., 2012) and newborn calves (Hoffmann et al., 2012). The impact of the SBV epidemic seemed limited however, in terms of the number of affected herds with malformed offspring (European Food Safety Authority, 2012b). Nevertheless, little is known with regard to the overall within-herd impact of SBV infection. The objective of the current study was to quantify the impact of the 2011 SBV epidemic on the productivity of dairy cattle in the Netherlands and the district of Kleve, Germany. For the Netherlands, several multilevel multivariable statistical models were applied on eight productivity parameters regarding milk production, reproductive performance and mortality. All four fertility parameters analysed were slightly but significantly reduced between August 1st and November 1st 2011 compared to the reference period in 2009-2010. Between August 15th and September 19th 2011, the average loss in milk production per cow was -0.26kg (95% CI: -0.30; -0.22) per day in dairy herds, compared to the reference period (p<0.001). The total loss per cow in a subgroup of dairy herds that notified malformations in newborn calves during the mandatory notification period in the Netherlands was -0.43kg (95% CI: -0.59; -0.28) per day (p<0.001). For Germany, a study was carried out in the district of Kleve, situated in the state of North Rhine-Westphalia near the Dutch border. Data on milk yield, two fertility parameters and the number of rendered calves in this specific region were analysed. There was a small but significant increase in the number of secondary and third inseminations between August 1st and November 1st 2011, indicating reduced fertility. No significant change in calf mortality was observed in the assumed SBV period. Milk production at district level did not seem to be affected by SBV in August and September 2011. SBV had no or limited impact on mortality rates, which was as expected given the relatively mild expression of SBV in adult cows and the low incidence of notified malformations in newborn calves. Our results indicate that SBV had a limited impact on productivity of dairy cattle. However, the total economic impact of SBV on the ruminant industry not only consists of productivity caused losses; it is expected that international trade restrictions formed a larger part of the total economic impact.

Schmallenberg virus in Dutch dairy herds: potential risk factors for high within-herd seroprevalence and malformations in calves, and its impact on productivity.

In November 2011, the new orthobunyavirus Schmallenberg virus (SBV) was identified in dairy cows that had induced fever, drop in milk production and diarrhoea in the Netherlands (Muskens et al., 2012. Tijdschrift voor Diergeneeskunde 137, 112-115) and a drop in milk production in cows in Northwestern Germany (Hoffmann et al., 2012. Emerging Infectious Diseases 18 (3), 469-472), in August/September 2011. This study aimed at quantifying risk factors for high within-herd prevalence of SBV and SBV-induced malformations in newborn calves in dairy herds in the Netherlands. Additionally, the within-herd impact of SBV infection on mortality rates and milk production was estimated. A case-control design was used, including 75 clinically affected case herds and 74 control herds. Control herds were selected based on absence of malformations in newborn calves and anomalies in reproductive performance. SBV-specific within-herd seroprevalences were estimated. Risk factors for high within-herd SBV seroprevalence (>50%) and the probability of malformed newborn calves in a herd were quantified. In addition, within-herd impact of SBV with regard to milk production and mortality was estimated. Animal-level seroprevalence was 84.4% (95% confidence interval (CI): 70.8-92.3) in case herds and 75.8% (95% CI: 67.5-82.5) in control herds. Control herds that were completely free from SBV were not present in the study. Herds that were grazed in 2011 had an increased odds (OR 9.9; 95% CI: 2.4-41.2)) of a high seroprevalence (>50%) compared to herds that were kept indoors. Also, when grazing was applied in 2011, the odds of malformations in newborn calves tended to be 2.6 times higher compared to herds in which cattle were kept indoors. Incidence of malformations in newborn calves at herd level was associated with both within-herd seroprevalence and clinical expression of the disease in adult cattle. The rate of vertical transmission of SBV to the fetus once a dam gets infected seemed low. A total of 146 stillborn or malformed calves were submitted by 65 farmers during the study period, of which 19 were diagnosed as SBV-positive based on pathological investigation and/or RT-qPCR testing of brain tissue. Based on these results combined with calving data from these herds we roughly estimated that at least 0.5% of the calves born between February and September 2012 have been infected by SBV. A drop in milk production was observed between the end of August 2011 and the first half of September (week 35-36), indicating the acute phase of the epidemic. During a 4-week period in which SBV infection was expected to have occurred, the total loss in milk production in affected dairy herds was around 30-51 kg per cow. SBV had no or limited impact on mortality rates which was as expected given the relatively mild expression of SBV in adult cows and the low incidence of malformations in newborn calves.

Schmallenberg virus epidemic in the Netherlands: spatiotemporal introduction in 2011 and seroprevalence in ruminants.

This study aimed at estimating the Schmallenberg virus (SBV) seroprevalence in dairy heifers, non-dairy adult cattle, sheep and goats in the Netherlands after cessation of SBV transmission at the end of 2011. Archived serum samples from ruminants submitted to the GD Animal Health Service for monitoring purposes between November 2011 and March 2012 were selected and tested for presence of SBV-specific antibodies using an in-house ELISA. Animal seroprevalences were estimated at 63.4% in dairy heifers, 98.5% in adult non-dairy cattle, 89.0% in sheep and 50.8% in goats. Multivariable analyses were carried out to describe the relationship between potential risk factors and the ELISA outcome S/P%. The overall SBV seroprevalence in ruminants and ruminant herds in the Netherlands at the end of 2011 was high, with considerable differences between species and farm types. No gradient spatial pattern in final seroprevalence could be detected and therefore no suggestions about the site of introduction and spread of SBV in the Netherlands in 2011 could be made. In dairy heifers, it was shown that S/P% increased with age. In sheep, S/P% was lower in animals located in the coastal area. Whether herds were located near the German border did not affect the S/P% in sheep nor in dairy heifers. An attempt was made to gain insight in the spatiotemporal introduction of SBV in the Netherlands in 2011, by testing sheep serum samples from 2011. A seroprevalence of about 2% was found in samples from April, June and July 2011, but the ELISA positive samples could not be confirmed in a virus neutralization test. A clear increase in seroprevalence started at August 2011. From mid-August 2011 onwards, seropositive samples were confirmed positive by virus neutralization testing. This indicated the start of the epidemic, but without a clear spatial pattern.

Disc displacement within the human temporomandibular joint: a systematic review of a 'noisy annoyance'.

To describe the scientific literature about the diagnosis, prevalence, aetiology, natural course and possible treatment modalities of disc displacements within the temporomandibular (TM) joint. PubMed was searched for specific indexing terms. The search yielded 1211 papers. After screening according to title and abstract, 695 papers were excluded, and after full-text reading, 107 papers remained. Hand-searching of the reference lists resulted in an extra 47 papers. Thirteen studies, published since the literature search was carried out, were also included, resulting in 167 papers for this review. A disc displacement is a highly prevalent derangement within the TM joint, with reported prevalence ranging from 18% to 35% in the general population. A disc displacement with reduction is mostly a stable, pain-free and lifelong condition of the joint. In only a small minority of patients, the disc loses its capacity to reduce on opening. Surprisingly, only in rare cases, the loss of disc reduction is accompanied by signs and symptoms of a closed lock (viz. a painful and limited mouth opening). These signs and symptoms have a tendency to reduce and in many cases to resolve within months. The favourable natural course of disc displacements only warrants active treatment for symptomatic disc displacements without reduction. The primary treatment option is a conservative, non-surgical treatment focusing at speeding up the natural process of alleviation of pain and of improvement in mouth opening. For most patients, a disc displacement is just a pain-free, lifelong lasting, 'noisy annoyance' from their TM joint.

[Synovial chondromatosis of the temporomandibular joint. A systematic review of the literature on its characteristics]. / Synoviale chondromatose van het temporomandibulaire gewricht. Een systematisch literatuuronderzoek naar de kenmerken.

Synovial chondromatosis of the temporomandibular joint is a disease which occurs rarely. A systematic review of the literature was carried out to identify its demographical, etiological, radiological, and clinical characteristics. A total of 191 case presentations were discovered. The mean age of patients was 47. The disease has been identified more frequently in women than in men. A part from pre-auricular swelling, the most frequently reported clinical characteristics resembled those of temporomandibular disorders. Abnormalities on radiographs were often evident. Insufficient evidence was found that trauma or rheumatoid arthritis plays a role in the development of this disease. Given the similarities with temporomandibular disorders, synovial chondromatosis should be considered in the differential diagnosis of patients suffering from complaints of temporomandibular dysfunction.

[Adverse effect of local anaesthetics]. / Ongewenste neveneffecten van lokale anesthesie.

Local anaesthetics are frequently administered preceding oral treatment. Since little is known about the incidence of adverse effects after administration of local anaesthetics, a prospective study involving a group of 219 patients was performed. The most frequently observed complications were insufficient anaesthesia (17%) and positive blood aspiration (3%). Pain during administration, paralysis, blanching, haematoma, and vasovagal collapse occurred each in less than 1% of the patients. The results suggested that administration of local anaesthetics involves a limited risk of adverse events and that the adverse events are usually minor and transient.

Rendu-Osler-Weber disease: update of medical and dental considerations.

Rendu-Osler-Weber disease, also known as hereditary hemorrhagic telangiectasia (HHT), is an autosomal dominant inherited disorder characterized by an aberrant vascular development. The reported prevalence is approximately 1 per 5,000-10,000. The clinical manifestations consist of recurrent spontaneous nosebleeds, telangiectasias characteristically at the lips, oral cavity, fingers, and nose, and visceral arteriovenous malformations. Timely recognition of this syndrome makes screening for complications, preventive measurements, and genetic counselling possible. The important role of the dental profession in the recognition of this genetic disease is emphasized. In addition, a brief overview of the current literature is presented.

Five-year study of all-porcelain veneer fixed partial dentures.

Improvements in enamel-dentinal bonding systems combined with the introduction of new ceramics have encouraged replacement of missing anterior teeth in specific patients with porcelain veneer fixed partial dentures. Metal substructures are not needed, and more natural tooth structure can be preserved because the preparation of abutments is conservative. Twelve porcelain veneer fixed partial dentures were monitored for 5 years, and fractures attributed to degradation of the gingival margins occurred in the veneer surface of the fixed partial dentures. The success rate of 75% was dependent on rigid patient selection criteria, strength of the major connectors, and precise adjustment of occlusion to prevent overloading. The failing margins were attributed to the degeneration, attrition, and deterioration of the composite resin cements. Despite these limitations, patients were extremely satisfied with the esthetics. Improvement in the mechanical properties of composite resin cement will ameliorate the prognosis with this approach.

Eleven-year study of hydroxyapatite implants.

An 11-year clinical research study was conducted with both unloaded bulk hydroxyapatite implants and loaded hydroxyapatite-coated titanium implants. A total of 102 submerged bulk hydroxyapatite implants were placed after extraction of teeth to maintain the volume of the residual alveolar ridge by their physical presence. All 21 implants under fixed partial dentures and 51 of 81 implants under lower complete dentures remained submucosal. A total of 71 hydroxyapatite-coated titanium implants were connected with permucosal superstructures by use of a two-stage method. Modifications in design and in implantation technique were required. This long-term research indicates that cylindrical hydroxyapatite implants are reliable devices as natural tooth root substitutes that bond directly to bone instead of simply being osseointegrated.