What is the recommended dosage of Ativan (lorazepam) for anxiolysis in an adult patient with no significant medical history prior to a tooth extraction or dental procedure?

Lorazepam Dosing for Pre-Dental Procedure Anxiolysis

For a healthy adult undergoing tooth extraction or dental procedures, administer 1-2 mg of lorazepam orally 90-120 minutes before the procedure. 1, 2

Recommended Dosing Protocol

Standard adult dose:

• 1-2 mg orally, taken 90-120 minutes prior to the dental appointment 1, 3, 2
• The 90-120 minute timing is critical because lorazepam has a latent period of 30-40 minutes before maximum sedative effect occurs, even when given intravenously 2, 4
• This single pre-procedure dose provides effective anxiolysis without requiring ongoing therapy 5

Elderly or debilitated patients:

• Reduce dose to 0.5-1 mg orally 1, 5
• Elderly patients have increased sensitivity to benzodiazepines with higher risk of falls, cognitive decline, and paradoxical agitation 5, 6

Important Clinical Considerations

Avoid intramuscular administration:

• While 4 mg IM lorazepam has been studied for preoperative use, this route causes high frequency of injection site pain and restlessness persisting 20-40 minutes 2
• Oral administration is preferred for dental procedures 3, 2

Duration of effects:

• Drowsiness persists for at least 4 hours after administration 2
• Patients must not drive or operate machinery for at least 24 hours 2
• The drug should not be used for outpatient procedures where rapid recovery is essential 7

Key advantage for dental procedures:

• Lorazepam reliably produces anterograde amnesia, which is particularly valuable for preventing recall of unpleasant dental experiences 7, 2, 4

Critical Safety Warnings

Absolute contraindications:

• Do not combine with other sedatives or opioids due to significantly increased respiratory depression risk 5
• Avoid in patients with severe pulmonary insufficiency, severe liver disease, or myasthenia gravis 5

Monitoring requirements:

• Patients should be observed for respiratory depression, particularly those with underlying respiratory disease 8
• Have respiratory support immediately available 8

Special populations requiring dose reduction:

• Hepatic impairment: reduce to 0.25 mg 5
• Elderly patients: maximum 2 mg/24 hours 5, 1
• Frail or debilitated patients: start at 0.5-1 mg 1

Common Pitfalls to Avoid

Timing errors:

• Do not administer lorazepam less than 90 minutes before the procedure, as peak effect will not be achieved 2
• Unlike diazepam which peaks in 2-3 minutes IV, lorazepam requires 30-40 minutes even intravenously 4

Inappropriate patient selection:

• Avoid routine use in elderly patients where benzodiazepines should be minimized due to cognitive impairment and fall risk 6
• Consider non-pharmacologic anxiolysis (patient education, quiet environment) as first-line approach 6

Paradoxical reactions:

• Approximately 10% of patients may experience paradoxical agitation rather than sedation 5
• This is more common in elderly populations 5