SUPER POLIGRIP ORIGINAL (ZINC FREE FORMULA)

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 04 report with the FDA on 2015-06-09 for SUPER POLIGRIP ORIGINAL (ZINC FREE FORMULA) manufactured by Glaxosmithkline Dungarvan Ltd.

Event Text Entries

[24589781] Possible stomach infection [gastric infection]; indigestion; uncomfortable feeling [discomfort]; gaseous [gas]; upset stomach; threw up [vomiting]; fever; headache; whistling in my ears [ear noises]. Case description: this case was reported by a consumer and described the occurrence of gastric infection in a (b)(6) female patient who received double salt dental adhesive cream (super poligrip original (zinc free formula)) cream (batch#: v69c, expiry date unk) for an unk indication. In (b)(6) 2014, the patient started super poligrip original (zinc free formula). In november 2014, immediately after starting super poligrip original (zinc free formula), the patient experienced indigestion, discomfort, gas and upset stomach. In (b)(6) 2015, the patient experienced gastric infection (serious criteria gsk medically significant). On an unk date, the patient experienced vomiting, fever, headache and ear noises. Super poligrip original (zinc free formula) was discontinued (dechallenge was negative). On an unk date, the outcome of the gastric infection, indigestion, discomfort, gas, upset stomach, headache and ear noises were not recovered/not resolved and the outcome of the vomiting and fever were recovered/resolved. The reporter considered the gastric infection, indigestion, discomfort, gas, upset stomach, vomiting, fever, headache and ear noises to be related to super poligrip original (zinc free formula). Additional details: ae info received 06/04/2015: a female consumer reported that she began using super poligrip original cream in (b)(6) of 2014. She said it immediately caused her to have indigestion, an uncomfortable feeling, made her gaseous, and gave her an upset stomach, which all continue to occur. The said about a week ago, she thinks the super poligrip gave her a gastric infection, further described as possible stomach infection. She said the super poligrip made her throw up, further described as throwing up pink slime, and gave her a fever, both of which have resolved. She said the super poligrip has since made her have headache and whistling in her ears. Both of these are still occurring. She has stopped using the super poligrip. See scanned page.
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report Number9681138-2015-00024
MDR Report Key4863417
Report Source04
Date Received2015-06-09
Date of Report2015-06-04
Date of Event2015-05-01
Date Mfgr Received2015-06-04
Date Added to Maude2015-06-30
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional0
Initial Report to FDA0
Report to FDA0
Event Location0
Manufacturer StreetPO BOX 13398
Manufacturer CityRESEARCH TRIANGLE PARK NC 27709
Manufacturer CountryUS
Manufacturer Postal27709
Manufacturer Phone8888255249
Manufacturer G1GSK
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NameSUPER POLIGRIP ORIGINAL (ZINC FREE FORMULA)
Generic NameDENTURE ADHESIVE
Product CodeKOL
Date Received2015-06-09
Lot NumberV69C
OperatorLAY USER/PATIENT
Device AgeDA
Device Eval'ed by MfgrR
Device Sequence No1
Device Event Key0
ManufacturerGLAXOSMITHKLINE DUNGARVAN LTD
Manufacturer AddressDUNGARVAN EI


Patients

Patient NumberTreatmentOutcomeDate
101. Other 2015-06-09

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