RESUMO
BACKGROUND: Periodontal disease remains one of the dog's most common health issues, even though it is largely preventable by tooth brushing. Implementation of daily tooth brushing would not only improve animal welfare, but also reduce veterinary costs for the owner. There is a paucity of studies investigating attitudes, opinions and practices of dog owners, veterinarians, and veterinary nurses regarding preventative dental home care in dogs. The objective of this study was to investigate these parameters in Sweden, thereby providing a basis for improved prophylactic strategies. METHODS: Validated questionnaire surveys were distributed to all Swedish dog owners (n = 209,263), veterinarians (n = 3657) and veterinary nurses (n = 1650) with e-mail addresses in the national registry. The response rates were 32% for dog owners and veterinarians, and 38% for veterinary nurses. The survey questions concerned attitudes, opinions and practices regarding dental home care, including whether dog owners received information concerning dental home care or not, and if this information resulted in implementation. RESULTS: Attitudes, opinions and practices regarding dental home care are presented for Swedish dog owners, veterinarians, and veterinary nurses. A fundamental finding was that the absolute majority of Swedish dog owners do not perform adequate prophylactic dental home care. Considerable discrepancies were identified in the opinions of veterinary health practitioners and dog owners regarding attitudes towards dental home care and conveying of information. Several areas for improvement in the communication between dog owners and veterinary health practitioners concerning dental home care were identified. CONCLUSION: Our results illustrates the need for validated methods to increase dog owner compliance with dental home care recommendations. We also see a need of further education, regarding canine dental home care, among veterinarians, veterinary nurses, and dog owners. The results from this unique study constitute an important foundation for future development of prophylactic strategies, with the ultimate goal to improve dental health, and thereby animal welfare, in dogs.
Assuntos
Técnicos em Manejo de Animais , Assistência Odontológica/veterinária , Doenças do Cão/prevenção & controle , Doenças Periodontais/veterinária , Médicos Veterinários , Animais , Coleta de Dados , Doenças do Cão/epidemiologia , Cães , Humanos , Propriedade , Doenças Periodontais/epidemiologia , Doenças Periodontais/prevenção & controle , Inquéritos e Questionários , Suécia/epidemiologiaRESUMO
Although rubber dams are widely used in endodontic treatment in humans with well-known advantages, their use in veterinary medicine is uncommon. The use of a dental rubber dam provides better control of cross-infection, prevents soft tissue contact of chemicals, and improves treatment efficiency. The purpose of this article is to describe a new line of clamps specifically designed for dogs and to review the procedure and materials used for isolating the operative field in endodontic patients. This new design of clamps, better adapted to canine tooth anatomy with different sizes and conformations, has been successfully used in dogs by the authors with good clinical results. The clamps allow for better adaptation to the tooth without injuring the gingiva or the furcation and provide increased retention of the dam for more effective isolation. Given the proven benefits in humans, the authors expect that the widespread use of a rubber dam with clamps specifically designed for canine dental anatomy will improve clinical outcomes in endodontics.
Assuntos
Cães , Endodontia/instrumentação , Doenças da Boca/terapia , Diques de Borracha/veterinária , AnimaisRESUMO
This review provides an in-depth comparison of advantages and disadvantages of different types of dental cements as they are used for cementing base metal alloy crowns in dogs.
Assuntos
Cimentação/veterinária , Coroas/veterinária , Cimentos Dentários/análise , Cães , AnimaisRESUMO
This step-by-step article describes the technique for cementation of a full metal prosthodontic crown on the maxillary fourth premolar tooth of a dog using a common resin-based cement.
Assuntos
Dente Pré-Molar/cirurgia , Cimentação/veterinária , Coroas/veterinária , Cães/cirurgia , Maxila/cirurgia , Cimentos de Resina/uso terapêutico , AnimaisRESUMO
This retrospective study documents the prevalence of various histopathological diagnoses within a practice specializing in veterinary dentistry and oral surgery. Histopathology results obtained from biopsies of oral lesions from 403 dogs and 73 cats were sorted and categorized. Lesions of inflammatory origin represented the most common histopathology result in cats (n = 37; 51%), followed by squamous cell carcinoma (n = 27; 37%). The most common histopathological diagnoses in dogs were malignant neoplasms (n = 151; 37%), followed by tumors of odontogenic origin (n = 138, 34%) and lesions of inflammatory origin (n = 114; 28%). The results of this study are representative of a private referral dentistry practice and are compared to other studies that assessed common oral neoplasia diagnoses in dogs and cats. Treatment options and prognoses of the most common canine and feline neoplasms are discussed.
Assuntos
Doenças do Gato/patologia , Doenças do Cão/patologia , Inflamação/veterinária , Doenças da Boca/veterinária , Neoplasias/veterinária , Animais , Arizona/epidemiologia , Biópsia/veterinária , Doenças do Gato/diagnóstico , Doenças do Gato/epidemiologia , Gatos , Doenças do Cão/diagnóstico , Doenças do Cão/epidemiologia , Cães , Inflamação/diagnóstico , Inflamação/epidemiologia , Inflamação/patologia , Doenças da Boca/diagnóstico , Doenças da Boca/epidemiologia , Doenças da Boca/patologia , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Neoplasias/patologia , Estudos RetrospectivosRESUMO
Performing oral surgery in dogs can present unique challenges. Among those challenges are the varying size and anatomical shape of the oral cavity in veterinary patients. Very small dogs and brachycephalic breeds provide limited exposure to the caudal maxilla. With the addition of an endotracheal tube and tie, the operating window can be quite limited and difficult to visualize and instrument. The following is a simple yet effective step-by-step procedure of tension-free closure of maxillary molar extractions in the dog.
Assuntos
Cães/cirurgia , Maxila/cirurgia , Dente Molar/cirurgia , Procedimentos Cirúrgicos Bucais/veterinária , Animais , Procedimentos Cirúrgicos Bucais/métodosRESUMO
Tooth transposition is a rare anomaly resulting in the interchanged position of 2 permanent teeth. Etiology of tooth transposition is unclear. In human dentistry, multiple influences are described, and there is strong evidence of a genetic basis. This is the first reported case of tooth transposition in a dog.
Assuntos
Doenças do Cão/cirurgia , Erupção Ectópica de Dente/veterinária , Animais , Doenças do Cão/diagnóstico , Doenças do Cão/etiologia , Cães , Masculino , Erupção Ectópica de Dente/diagnóstico , Erupção Ectópica de Dente/etiologia , Erupção Ectópica de Dente/cirurgiaRESUMO
The Iberian lynx is an endangered felid that has been subject to an intensive, ongoing conservation program to save it from extinction. Identification of dental pathologies could play an important role in the survival of this endangered species. The prevalence of periodontal bone loss, tooth resorption, and oral neoplasia was evaluated in this species. Skulls of 88 adult specimens of the Iberian lynx ( Lynx pardinus) from the Doñana Biological Station (EBD-CSIC), Seville, Spain, were examined macroscopically and full-mouth dental radiographs of all specimens were performed. Different stages of periodontal disease were identified in 81.3% of teeth. Approximately two-thirds (64.8%) of the specimens examined had at least 1 tooth affected by stage 3 or 4 periodontal disease. Maxillary and mandibular incisor teeth accounted for a majority (59.4%) of teeth affected by stage 3 or 4 periodontal disease. Tooth resorption affected 12 teeth (0.63% of evaluated teeth) in 6 skull specimens (6.8% of skulls evaluated). Five of the teeth with resorptive lesions were detected on 1 skull specimen. Six teeth (50%) of those affected by tooth resorption were incisor teeth. Only 1 (1.1%) adult specimen showed signs of oral neoplasia. Our study concluded that there is a high prevalence of periodontal disease that could lead to impaired hunting ability, as well as may represent a threat to overall health and subsequent survival of this endangered species. The extremely low prevalence of tooth resorption in L pardinus could open new pathways in the discovery on the pathogenesis of tooth resorption in felids.
Assuntos
Lynx , Neoplasias Bucais/veterinária , Doenças Periodontais/veterinária , Reabsorção de Dente/veterinária , Animais , Feminino , Masculino , Neoplasias Bucais/patologia , Doenças Periodontais/patologia , Prevalência , Espanha/epidemiologia , Reabsorção de Dente/patologiaRESUMO
Dental disease is important in the population of pets seen by veterinarians. Knowledge and skills related to oral disease and dentistry are critical entry-level skills expected of graduating veterinarians. A descriptive survey on the state of veterinary dental education was sent to respondents from 35 veterinary schools in the United States, Canada, and the Caribbean. Using the online SurveyMonkey application, respondents answered up to 26 questions. Questions were primarily designed to determine the breadth and depth of veterinary dental education from didactic instruction in years 1-3 to the clinical year programs. There was an excellent response to the survey with 86% compliance. Learning opportunities for veterinary students in years 1-3 in both the lecture and laboratory environments were limited, as were the experiences in the clinical year 4, which were divided between community-type practices and veterinary dentistry and oral surgery services. The former provided more hands-on clinical experience, including tooth extraction, while the latter focused on dental charting and periodontal debridement. Data on degrees and certifications of faculty revealed only 12 programs with board-certified veterinary dentists. Of these, seven veterinary schools had residency programs in veterinary dentistry at the time of the survey. Data from this study demonstrate the lack of curricular time dedicated to dental content in the veterinary schools participating in the survey, thereby suggesting the need for veterinary schools to address the issue of veterinary dental education. By graduation, new veterinarians should have acquired the needed knowledge and skills to meet both societal demands and professional expectations.
Assuntos
Educação em Odontologia , Educação em Veterinária , Estudantes de Medicina , Animais , Canadá , Região do Caribe , Cálculos Dentários/terapia , Cálculos Dentários/veterinária , Humanos , Estados UnidosRESUMO
Rhinoliths are rare, intranasal, mineralized masses formed via the precipitation of mineral salts around an intranasal nidus. Clinical signs are typically consistent with inflammatory rhinitis and nasal obstruction, but asymptomatic cases are possible. Rhinoliths may be classified as exogenous or endogenous depending on the origin of the nidus, with endogenous rhinoliths reportedly being less common. This case report describes a suspected case of endogenous rhinolithiasis in a cat which was detected as an incidental finding during radiographic assessment of a maxillary canine tooth with endodontic disease. Treatment consisted of removal of the suspected rhinolith via a transalveolar approach after surgical extraction of the maxillary canine tooth.
Assuntos
Doenças do Gato/diagnóstico , Litíase/veterinária , Doenças Nasais/veterinária , Animais , Doenças do Gato/diagnóstico por imagem , Doenças do Gato/cirurgia , Gatos , Diagnóstico Diferencial , Feminino , Litíase/diagnóstico , Litíase/diagnóstico por imagem , Litíase/cirurgia , Doenças Nasais/diagnóstico , Doenças Nasais/diagnóstico por imagem , Doenças Nasais/cirurgiaRESUMO
A rare case of congenital supernumerary teeth, also known as hyperdontia, observed in a healthy 8-month-old female ewe is presented. The congenital defect consisted of the presence of 2 incisor teeth embedded in the lateral areas of the dental pad. The anomaly was found during a routine physical examination and no other congenital abnormalities were found in the patient. No prior congenital abnormalities had been seen in the herd and the study of possible associated teratogenic factors was inconclusive. To the authors' knowledge, this ovine odontogenic abnormality has not been described in the literature and appears to be an extraordinarily rare condition.
Assuntos
Incisivo/anormalidades , Carneiro Doméstico/anormalidades , Dente Supranumerário/veterinária , Animais , Feminino , Dente Supranumerário/diagnósticoRESUMO
The angulation of equine incisors is frequently used as a parameter for dental corrections. However, the term incisor angle is only vaguely defined, and no studies exist presenting a series of reliable measurements in individual incisors of multiple horses. The aim of this study was to establish an exact method to determine incisor angles and to test whether clinically accessible landmarks (facial crest and bars) are suitable to estimate incisor angles. Eighteen horses were used to create 3-dimensional (3D) reconstructions of the skulls from computed tomography (CT) data sets. Reference planes (median and transverse plane) were calculated using defined anatomical landmarks. Subsequently, occlusal planes for incisors and for incisor quadrants were calculated. Occlusal table angles were measured in relation to the reference planes. For each incisor, sagittal and transverse angles were measured. Mean values of individual incisor angles ranged from 3.5° to 6.8° (transverse angle) and from 32.6° to 44.9° (sagittal angle). No significant differences were detected in mean between the left and the right side when teeth in same Triadan positions were compared. However, in individual horses, marked differences between the left and the right side of the jaws occurred. Mandibular incisors showed significantly steeper sagittal angles than maxillary incisors. Furthermore, angles of opposing incisors were correlated with each other. The facial crest and the upper jaw bars featured a curved shape and were therefore of limited use to estimate the angulation of the upper incisors. In contrast, the lower jaw bars were suitable to determine the angulations of lower incisors.
Assuntos
Oclusão Dentária , Cavalos/anatomia & histologia , Incisivo/anatomia & histologia , Mandíbula/anatomia & histologia , Maxila/anatomia & histologia , Animais , Feminino , MasculinoRESUMO
BACKGROUND: Equine odontoclastic tooth resorption and hypercementosis (EOTRH) is a frequently diagnosed condition in adult horses. The underlying etiology is still unknown. Hematologic, biochemical, and endocrine values have not been reported in EOTRH-affected horses. OBJECTIVES: The main objective of the study was to describe the hematologic, biochemical, and endocrine parameters in horses with EOTRH. STUDY DESIGN: Descriptive cross-sectional study of client-owned animals with EOTRH. METHODS: A complete blood count, biochemistry panel, and endocrine profile were performed in horses diagnosed with EOTRH. Diagnosis was based on oral and radiographic examination findings and confirmed with histopathology. RESULTS: Eighteen horses with EOTRH aged 10 to 32 years from various regions of the United States were sampled. The only consistent abnormality on the complete blood cell count and chemistry panel was hypoalbuminemia (88%). Endocrine parameters demonstrated no major abnormalities in the functioning of the thyroid and pituitary pars intermedia. The parathyroid hormone concentration was increased in 7 (47%) of 15 horses with an elevated 25-hydroxy vitamin D in 3 (17%) of 17 horses. Main Limitations: The main limitations of this study are the small sample size and lack of age-matched and management-matched control horses. CONCLUSIONS: The relevance of elevated parathyroid hormone in this study cannot be determined due to the lack of age-based controls and large population studies. With the small population evaluated in this study, there are no obvious hematological, biochemical, and endocrine changes evident. Further evaluation with signalment-matched controls will be necessary to evaluate some trends noted in the laboratory values.
Assuntos
Doenças dos Cavalos/fisiopatologia , Hipercementose/veterinária , Reabsorção de Dente/veterinária , Animais , Estudos Transversais , Feminino , Doenças dos Cavalos/sangue , Doenças dos Cavalos/etiologia , Cavalos , Hipercementose/sangue , Hipercementose/etiologia , Hipercementose/fisiopatologia , Masculino , Estudos Prospectivos , Reabsorção de Dente/sangue , Reabsorção de Dente/etiologia , Reabsorção de Dente/fisiopatologiaRESUMO
During daily routine oral examinations in a research colony of nonhuman primates (NHPs, Macaca fascicularis), a variety of oral-dental lesions were identified. A dental care program was established based on these findings. Based on the presence of dental clinical signs and their severity, 31 animals were triaged to be examined and treated by a veterinarian. Clinical examination consisted of visual inspection using a periodontal probe/explorer and full or partial mouth dental radiographs. Treatment was performed during the same procedure. Some animals had a follow-up examination including radiographs months later. Four common dental diseases were diagnosed: periodontal disease, caries, tooth fracture, and tooth attrition. Less frequent were dental abscess, enamel hypomineralization, gingival hyperplasia, hypercementosis, tooth luxation, tooth dysplasia, root resorption, abrasion. Less severe periodontal disease was treated conservatively. If severely affected, teeth were extracted. Well-circumscribed caries without endodontic involvement were treated by composite restoration. Teeth with extensive caries and pulp involvement were extracted. Teeth with exposed pulp were treated via extraction or orthograde root canal treatment. In this case series, 27 (87%) of 31 NHPs exhibited at least 1 moderate to severe dental lesion that required treatment. The presumable improvement in welfare and weight of oral/dental lesions for the overall health status in research NHPs encourages us to continue this program prospectively.
Assuntos
Macaca fascicularis , Doenças dos Macacos/patologia , Doenças dos Macacos/terapia , Doenças Dentárias/veterinária , Animais , Cárie Dentária/epidemiologia , Cárie Dentária/patologia , Cárie Dentária/terapia , Cárie Dentária/veterinária , Masculino , Doenças dos Macacos/classificação , Doenças dos Macacos/epidemiologia , Doenças Periodontais/epidemiologia , Doenças Periodontais/patologia , Doenças Periodontais/terapia , Doenças Periodontais/veterinária , Atrito Dentário/epidemiologia , Atrito Dentário/patologia , Atrito Dentário/terapia , Atrito Dentário/veterinária , Doenças Dentárias/epidemiologia , Doenças Dentárias/patologia , Doenças Dentárias/terapia , Fraturas dos Dentes/epidemiologia , Fraturas dos Dentes/patologia , Fraturas dos Dentes/terapia , Fraturas dos Dentes/veterináriaRESUMO
Dental implants have become an option for replacement of lost canine teeth in cats. Although cats appear to manage well after a canine extraction, complications such as lip entrapment can occur after maxillary canine tooth extraction. Even cats with a complicated crown fracture of the maxillary canine tooth that have had root canal therapy can develop lip entrapment. This can lead to painful lip ulcers and potential need for further dental treatment. Canine tooth replacement with a dental implant and prosthodontic crown is, in the authors' experience, a predictable option that can be offered to clients who would like to replace a lost canine tooth. This report will discuss 2 long-term cases of maxillary canines replaced by dental implants/crowns.
Assuntos
Doenças do Gato/cirurgia , Dente Canino/cirurgia , Implantes Dentários/veterinária , Maxila/cirurgia , Perda de Dente/veterinária , Animais , Gatos , Seguimentos , Masculino , Perda de Dente/cirurgia , Resultado do TratamentoRESUMO
A 7-year-old, 31.3 kg spayed female Golden Retriever dog was presented for the treatment of Miller Class I gingival recession at the right maxillary fourth premolar (108). A semilunar coronally advanced periodontal flap was performed at this tooth and created an increase of approximately 3 mm of soft tissue coverage of the tooth. This method may have benefits over traditional periodontal advancement flaps in that there is no need for suturing, can be done more quickly, maintains lateral blood supply to the flap, and likely has decreased risk of surgical site dehiscence. This case shows that the semilunar coronally advanced periodontal flap demonstrates an appropriate method to treat Miller Class I gingival recession in the maxilla.
Assuntos
Doenças do Cão/cirurgia , Retração Gengival/veterinária , Retalhos Cirúrgicos/veterinária , Animais , Dente Pré-Molar , Cães , Feminino , Retração Gengival/cirurgia , Maxila/patologia , Retalhos Cirúrgicos/cirurgiaRESUMO
An 18-month-old neutered male labradoodle was treated with surgical debridement for maxillary osteomyelitis and sequestrum formation. Histopathologic findings of the necrotic bone were consistent with Cryptococcus subspecies, confirmed with latex agglutination serum titer testing. The patient responded to a combination of fluconazole and surgical debridement and was titer negative after 8 months of medical therapy. The patient never exhibited signs of systemic illness which is commonly reported with cryptococcosis. Cryptococcus subspecies infection in dogs in the Pacific Northwest is part of an ongoing outbreak in the region, first reported in 2001, and is associated with specific risk factors. This is the first published case of oral cryptococcosis from primary inoculation.
Assuntos
Criptococose/veterinária , Doenças do Cão/diagnóstico , Doenças Maxilares/veterinária , Osteomielite/veterinária , Osteonecrose/veterinária , Animais , Antifúngicos/administração & dosagem , Criptococose/diagnóstico , Criptococose/tratamento farmacológico , Criptococose/cirurgia , Cryptococcus/fisiologia , Desbridamento/veterinária , Doenças do Cão/tratamento farmacológico , Doenças do Cão/cirurgia , Cães , Fluconazol/administração & dosagem , Masculino , Doenças Maxilares/diagnóstico , Doenças Maxilares/tratamento farmacológico , Doenças Maxilares/cirurgia , Osteomielite/diagnóstico , Osteomielite/tratamento farmacológico , Osteomielite/cirurgia , Osteonecrose/diagnóstico , Osteonecrose/tratamento farmacológico , Osteonecrose/cirurgiaRESUMO
The present study compares a knotless, barbed, absorbable suture material against a conventional monofilament absorbable suture material in oral mucosal wound closure. The parameters measured include time of closure and differences in healing at 2 and 4 weeks postoperatively. A prospective study comparing a knotless, barbed suture system with conventional absorbable sutures was undertaken in 19 cats. Nineteen cats had full mouth extractions performed. Following the extraction procedures, the incisions in the arcades (maxillary and mandibular) were apposed with the barbed, knotless suture system in a continuous pattern on one side and with a conventional smooth suture in an interrupted pattern on the other. Suturing times for each arcade were recorded. The material used to close the first side of each cat varied. Healing, dehiscence, and other complications were assessed at 2 and 4 weeks postoperatively. The average closure time (± standard deviation) per quadrant with conventional monofilament suture was 8.7 (±1.3) minutes, while barbed suture required an average of 5.1 (±1.1) minutes per quadrant to complete the suture. This difference (95% confidence interval) of 3.6 (±3.2-4.1) minutes per quadrant was statistically significant ( P < .001). Dehiscence and ranula-like swelling formation were noted as uncommon postoperative complications, but the differences were not significant between the groups. Barbed, knotless sutures resulted in faster closure times than conventional, simple interrupted, monofilament sutures with similar healing and complication rates. To the author's knowledge, there is no current literature comparing conventional absorbable monofilament sutures to a knotless, barbed, absorbable suture system for closure of oral mucosal incisions in cats.
Assuntos
Boca/cirurgia , Complicações Pós-Operatórias/veterinária , Técnicas de Sutura/veterinária , Animais , Gatos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Estudos Prospectivos , Técnicas de Sutura/instrumentaçãoRESUMO
Dental diseases are among the most important reasons for presenting guinea pigs (Cavia porcellus) and other rodents to veterinary clinics, but the aetiopathology of this disease complex is unclear. Clinicians tend to believe that the ever-growing teeth of rabbits and rodents have a constant growth that needs to be worn down by the mastication of an appropriate diet. In this study, we tested the effect of four different pelleted diets of increasing abrasiveness [due to both internal (phytoliths) and external abrasives (sand)] or whole grass hay fed for 2 weeks each in random order to 16 guinea pigs on incisor growth and wear, and tooth length of incisors and cheek teeth. There was a positive correlation between wear and growth of incisors. Tooth lengths depended both on internal and external abrasives, but only upper incisors were additionally affected by the feeding of whole hay. Diet effects were most prominent in anterior cheek teeth, in particular M1 and m1. Cheek tooth angle did not become shallower with decreasing diet abrasiveness, suggesting that a lack of dietary abrasiveness does not cause the typical 'bridge formation' of anterior cheek teeth frequently observed in guinea pigs. The findings suggest that other factors than diet abrasiveness, such as mineral imbalances and in particular hereditary malocclusion, are more likely causes for dental problems observed in this species.
Assuntos
Ração Animal/análise , Dieta/veterinária , Cobaias/fisiologia , Desgaste dos Dentes/veterinária , Dente/crescimento & desenvolvimento , Animais , Estudos Cross-Over , Feminino , Mastigação , Animais de EstimaçãoRESUMO
Background and Aim: Understanding dental care in dogs has made remarkable progress in veterinary medicine. Therefore, this study aimed to analyze the academic literature published in veterinary dentistry from 1990 to 2023. Materials and Methods: A descriptive study was conducted using a scientometric approach and metadata from the Web of Science database. A search strategy adapted for this database was developed using MeSH and Emtree terms and the Boolean operators AND and OR. Using Bibliometrix, different metrics were evaluated to assess the scientific production of researchers and institutions and the impact of authors based on their publications. CiteSpace was also used for co-citation analysis and visualization of citation networks, trends, and patterns in this field of study over time. Results: The bibliometric study analyzed 211 documents from 50 different sources from 1990 to 2023, with an annual growth rate of 6.5%, covering the period 1990-2023. A total of 474 authors were identified, with an average of 2.82 coauthors per paper and 11.85% international coauthorships. The average age of the papers was 12.4 years and 4.55 citations per paper. The most common types of documents were articles (154 documents). Conclusion: Research in veterinary dentistry has shown steady growth from 1990 to 2023. Although there have been fluctuations in article production over the years, there has been a steady growth in article production in veterinary dentistry in general. The annual average number of citations per article has varied over the years, reaching 45 in 2015. However, the average number of citations per article has decreased significantly from 2021 to 2023.