Recommended Ketorolac Dose for Post-Wisdom Tooth Extraction Pain
For adults aged 17-64 years undergoing wisdom tooth extraction, administer ketorolac 10 mg orally every 4-6 hours as needed (maximum 40 mg/day) following an initial IV/IM dose, with treatment duration not exceeding 5 days. 1
Dosing by Age and Patient Characteristics
Adults (17-64 years)
- Initial dose: 20 mg PO once (following IV/IM ketorolac administration) 1
- Maintenance: 10 mg every 4-6 hours as needed 1
- Maximum daily dose: 40 mg/day 1
- Duration: Combined IV/IM and oral therapy must not exceed 5 days 1
Elderly (≥65 years), Renally Impaired, or Weight <50 kg
- Initial dose: 10 mg PO once (following IV/IM ketorolac) 1
- Maintenance: 10 mg every 4-6 hours as needed 1
- Maximum daily dose: 40 mg/day 1, 2
- These patients face significantly elevated risk for NSAID-related renal, gastrointestinal, and cardiovascular toxicities 2
Pediatric Patients
- Intraoperative/perioperative: 0.5-1 mg/kg as a single dose 3
- Postoperative IV: 0.5 mg/kg bolus, followed by 1.0 mg/kg every 6 hours or continuous infusion of 0.17 mg/kg/h 4
- Maximum daily dose: 90 mg 4
- Maximum duration: 48 hours for IV use 4
- Not recommended for infants <1 year old 4
Evidence Supporting Ketorolac for Dental Pain
Ketorolac demonstrates superior analgesic efficacy compared to opioid alternatives in the dental surgery pain model. In a randomized controlled trial of 207 patients after third molar extraction, 10 mg oral ketorolac provided significantly greater pain relief at 3 and 6 hours compared to hydrocodone 10 mg plus acetaminophen 1000 mg (P ≤ 0.01), with fewer adverse events 5. A separate study of 30 mg IM ketorolac showed statistically significant improved pain relief at 2 hours post-extraction, with 72% of patients reporting satisfactory analgesia and minimal side effects 6.
Critical Safety Considerations
Absolute Contraindications
- Aspirin/NSAID-induced asthma 3, 2
- Active peptic ulcer disease or GI bleeding 2
- Cerebrovascular hemorrhage 3, 2
- Severe renal impairment 2
- Concurrent anticoagulant therapy 7, 2
- Pregnancy 3
NSAID Stacking Warning
Never combine ketorolac with other NSAIDs (including ibuprofen). The toxicities are additive without providing additional analgesic benefit, significantly increasing risks of gastrointestinal bleeding, renal toxicity, and cardiovascular complications 8. If a patient has taken ibuprofen, wait 6-8 hours for adequate drug clearance before administering ketorolac 8.
Monitoring Requirements
- Baseline assessment: Blood pressure, BUN, creatinine, liver function tests, CBC, fecal occult blood 2, 8
- Discontinue if: BUN/creatinine doubles, hypertension develops/worsens, LFTs >3x upper limit of normal, or GI bleeding occurs 8
Multimodal Analgesia Approach
Ketorolac should be part of an opioid-sparing multimodal regimen. Recent guidelines emphasize that opioid-free postoperative analgesia is feasible for many procedures, with nonopioid options recommended as first-line treatment 7. For wisdom tooth extraction specifically, evidence shows that perioperative opioid prescriptions are associated with 2.7 times higher odds of persistent opioid use in adolescents and young adults 7.
Recommended Adjuncts
- Acetaminophen: Can be safely combined with ketorolac for enhanced analgesia 8
- Dexamethasone: 0.15 mg/kg perioperatively reduces postoperative pain and opioid requirements 7
- Local anesthetics: Long-acting nerve blocks (bupivacaine 0.25%, ropivacaine 0.2%) provide extended pain control 7
Common Pitfalls to Avoid
Do not use oral ketorolac as initial therapy - FDA labeling explicitly states oral formulation should only be used as continuation therapy following IV/IM dosing 1
Do not exceed 5-day total duration - This includes combined IV/IM and oral administration 1
Do not shorten the 4-6 hour dosing interval - More frequent dosing increases toxicity risk without improving analgesia 1
Do not prescribe in elderly without dose adjustment - Patients ≥65 years require reduced maximum daily dose of 40 mg/day 2, 1
Avoid in patients with bleeding concerns - While ketorolac has reversible antiplatelet effects, there is conflicting evidence regarding increased bleeding after tonsillectomy, warranting caution in procedures with significant bleeding risk 4