Comparative efficacy and safety of bupivacaine versus articaine in third molar surgery: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION: This review systematically compares the efficacy and safety of bupivacaine and articaine in third molar surgery, with a focus on postoperative pain control, duration of analgesia, intraoperative outcomes, and hemodynamic stability. METHODS: PubMed, Scopus, Web of Science, and CENTRAL were searched through December 24th, 2024, for randomized controlled trials (RCTs) comparing bupivacaine and articaine in third molar surgery. Primary outcomes included postoperative pain intensity (visual analog scale [VAS]), duration of postoperative analgesia, and need for rescue analgesia. Secondary outcomes included anesthesia onset time, intraoperative bleeding, operative time, and hemodynamic parameters. Meta-analysis was performed using a random--effects model. RESULTS: A total of 11 RCTs involving 749 patients (bupivacaine: 367, articaine: 382) were included. Bupivacaine significantly reduced postoperative pain scores at multiple time points, with the greatest effect observed at 4 h postoperatively (mean difference [MD] = -2.59; 95% confidence interval [CI]: -3.41, -1.77; I2 = 0%). The duration of postoperative analgesia was comparable between groups (MD = 91.22 min; 95% CI: -5.13, 187.57; I2 = 99.68%), with sensitivity analysis confirming this effect. Articaine exhibited a significantly faster onset of anesthesia (MD = 0.74 min; 95% CI: 0.36, 1.12; I2 = 81.05%), while intraoperative pain scores, surgical difficulty, and operative time were comparable between groups. No significant differences were found in hemodynamic parameters, suggesting similar safety profiles. CONCLUSION: Bupivacaine provides superior postoperative pain control and prolonged analgesia, making it advantageous for extended pain relief in third molar surgery. However, articaine's faster onset may enhance surgical efficiency. Both anesthetics demonstrated comparable intraoperative efficacy and safety.