MAUDE MDR 2141063

MDR report key
2141063
Report number
1721729-2011-00001
Event key
0
Event type
3
Date of event
2011-04-28
Date received
2011-06-15
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
GARY LEFFLER, MANAGER
Address
416 SOUTH TAYLOR AVE. LOUISVILLE CO 80027 US
Phone
303-303-3036
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1HENRY SCHEIN SOFTLINE CHAIRSIDE RELINE KITDENTAL DENTURE RELINE MATERIALSEPTODONT CONFI-DENTAL DIVISIONEBC100-3029R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12011-06-1501. H

Event Narratives#

D

Patient 1

ACCORDING TO (B)(6), OFFICE MANAGER FOR (B)(6), A FEMALE PATIENT EXPERIENCED A SUDDEN RISE IN BLOOD PRESSURE WHILE THE RELINE MATERIAL WAS BEING USED AND WAS TRANSPORTED TO THE HOSPITAL BY AMBULANCE. THEY ADMINISTERED THE PRODUCT AND AFTER ABOUT A MINUTE, SHE COMPLAINED OF BEING DIZZY - THEY GAVE HER SOME WATER AND SHE FELT BETTER - THEY STARTED AGAIN AND AGAIN SHE WAS DIZZY - THE BLOOD PRESSURE READINGS TAKEN WERE 201/138; 217/121; AND 217/143. SHE GAVE THEM PERMISSION TO CALL AN AMBULANCE AND HAVE HER TRANSPORTED TO THE HOSPITAL WHERE SHE WAS ADMITTED. THEY SPOKE TO HER A FEW DAYS LATER AND ADVISED HER TO SEE AN ALLERGIST TO FIND OUT WHAT CAUSED THIS RISE IN BLOOD PRESSURE, BUT SHE REFUSED STATING "WHO IS GOING TO PAY FOR THIS? I CANNOT AFFORD TO GO TO ANOTHER DOCTOR." THEY REQUESTED THE TRANSCRIPTS FROM THE HOSPITAL, BUT SHE REFUSED TO SIGN THE RELEASE. THIS WAS THE FIRST TIME THIS PRODUCT WAS USED ON HER. THEY USE IT EVERY DAY ON OTHER PATIENTS AND HAVE HAD NO PROBLEM. THE BOX AND PRODUCT WAS GIVEN TO THE EMS SO THE LOT CODE IS NOT AVAILABLE. HE WILL RECORD LOT NUMBERS IN THE FUTURE.

N

Patient 1

THIS PRODUCT HAS BEEN USED IN DENTISTRY FOR MANY YEARS. TO DATE, WE HAVE NEVER HAD ANOTHER COMPLAINT OR REPORT OF BLOOD PRESSURE COMPLICATIONS ASSOCIATED WITH THIS PRODUCT. THE CUSTOMER, (B)(6), INDICATED THAT "NO PRODUCT IS BEING RETURNED FOR EVALUATION". AS OF THE DATE OF SUBMISSION OF THIS REPORT, NO SAMPLES OF THE SUSPECT PRODUCT HAD BEEN RECEIVED AND THE LOT NUMBER OF THE PRODUCT IN QUESTION COULD NOT BE DETERMINED. DR. (B)(6), WAS CONSULTED. HE WAS UNAWARE OF ANY SUCH HYPERTENSION RESPONSE FROM DENTAL APPLICATIONS OF THIS MATERIAL.