MAUDE MDR 4308546

MDR report key
4308546
Report number
3005990499-2014-00001
Event key
0
Event type
3
Date of event
2014-08-28
Date received
2014-12-01
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
116
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
LIZ CACCIOLA
Address
144 MIDDLESEX TURNPIKE BURLINGTON MA 01803 US
Phone
781-781-7813
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1DYNABLAST PASTE 0.5CCKEYSTONE DENTAL INC.NUN10.210.1050140871R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12014-12-0101. H

Event Narratives#

D

Patient 1

THE CLINICIAN REPORTED THAT A MALE PATIENT, WHO HAS BEEN UNDER HIS CARE FOR 10 YEARS, UNDERWENT A TOOTH EXTRACTION PROCEDURE FOR DENTAL SITE 30. AFTER THE ATRAUMATIC EXTRACTION WAS COMPLETED ON SITE 30, THE SITE WAS GRAFTED WITH DYNABLAST FROM LOT # 140018 AND THE SITE WAS COVERED WITH GELFOAM AND SUTURED. THE PATIENT THEN BECAME FLUSH AND EXPERIENCED HEART PALPITATIONS, AT WHICH TIME HE WAS CLOSELY MONITORED. THE PATIENT WENT TO THE RESTROOM AND WHEN HE DID NOT RETURN IN A TIMELY MANNER, THE STAFF FOLLOWED UP TO FIND THE PATIENT UNCONSCIOUS ON THE FLOOR. THE STAFF INITIATED A 911 CALL AND THE PATIENT WAS TRANSPORTED TO THE EMERGENCY ROOM BY AMBULANCE. THE PATIENT WAS TREATED AND RELEASED AND THE GRAFT REMAINED IN PLACE. THE CLINICIAN FOLLOWED UP WITH THE PATIENT VIA TELEPHONE AND WAS TOLD BY THE PATIENT THAT HE HAD CONSULTED WITH HIS PRIMARY CARE PERSON AND THAT THEY SUSPECTED HE HAD A REACTION TO THE NOVOCAINE AND PRESCRIBED HIM AN EPIPEN. THE PRIMARY CARE OFFICE RECOMMENDED THAT THE PATIENT RETURN TO THE ORIGINAL CLINICIAN FOR A SMALL DOSE OF NOVOCAINE TO EITHER CONFIRM OR RULE IT OUT AS THE SOURCE OF THE INCIDENT. THE PATIENT RECEIVED A SMALL DOSE OF NOVOCAINE WITHOUT ANY SIDE EFFECTS.

N

Patient 1

(B)(4). THIS OCCURRENCE WAS COMMUNICATED TO THE CONTRACT MANUFACTURER (B)(4) AND A REVIEW OF THE MANUFACTURING RECORDS IS UNDERWAY, A FOLLOW-UP REPORT DETAILING THE MANUFACTURING FINDINGS WILL FOLLOW. NO ADDITIONAL COMPLAINTS FROM THIS LIST WERE IDENTIFIED DURING A REVIEW OF KEYSTONE COMPLAINTS DATABASE. THIS PATIENT HAS NO KNOWN ALLERGIES. POLYMYXIN SULFATE B, BACITRACIN, GENTIMYCIN AND IODINE ARE USED IN UPSTREAM PROCESSING AND TRACE AMOUNTS MAY REMAIN IN THE FINAL PRODUCT. CONSEQUENTLY THE DYNABLAST IFU LISTS CONTRAINDICATIONS FOR PATIENTS WITH KNOWN SENSITIVITIES TO THESE PROCESSING AGENTS. A COPY OF THE DYNABLAST IFU WAS FORWARDED TO THE CLINICIAN. THE ROOT CAUSE OF THIS OCCURRENCE REMAINS INCONCLUSIVE AT THIS TIME. (B)(4).