MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 05 report with the FDA on 2012-12-26 for HERBST manufactured by Allesee Orthodontic Appliances.
[18525362]
A doctor alleged that a patient developed a sore in his mouth while wearing the herbst appliance on two (2) separate occasions.
Patient Sequence No: 1, Text Type: D, B5
[18761059]
The doctor had removed the appliance after the first occurrence of the sore; however, the appliance was placed again once the patient had healed. After the second occurrence of the sore, the appliance was removed and the patient was prescribed a chlorhexidine oral rinse for treatment. To date, the patient is doing fine and has fully recovered. A new appliance will be fabricated with consideration to patient comfort.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 2184045-2012-00013 |
| MDR Report Key | 2886442 |
| Report Source | 05 |
| Date Received | 2012-12-26 |
| Date of Report | 2012-12-04 |
| Date Mfgr Received | 2012-12-04 |
| Device Manufacturer Date | 2012-10-24 |
| Date Added to Maude | 2012-12-27 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 0 |
| Event Location | 0 |
| Manufacturer Contact | MRS. WENDY GARMAN |
| Manufacturer Street | 1717 WEST COLLINS AVENUE |
| Manufacturer City | ORANGE CA 92867 |
| Manufacturer Country | US |
| Manufacturer Postal | 92867 |
| Manufacturer Phone | 7145167602 |
| Manufacturer G1 | ALLESEE ORTHODONTIC APPLIANCES |
| Manufacturer Street | 13931 SPRING STREET |
| Manufacturer City | STURTEVANT WI 53177 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 53177 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | HERBST |
| Generic Name | BITE-JUMPING ORTHODONTIC APPLIANCE |
| Product Code | EJF |
| Date Received | 2012-12-26 |
| ID Number | WO# 7432140 |
| Operator | OTHER |
| Device Availability | N |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | ALLESEE ORTHODONTIC APPLIANCES |
| Manufacturer Address | 13931 SPRING STREET STURTEVANT WI 53177 US 53177 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other; 2. Required No Informationntervention | 2012-12-26 |