MAUDE MDR 6528540

MDR report key
6528540
Report number
3005174370-2017-00038
Event key
0
Event type
3
Date of event
2017-04-06
Date received
2017-04-27
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
116
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
ANGIE DRAPER
Address
2510 CONWAY AVENUE ST. PAUL MN 55144 US
Phone
651-651-6517
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1RELYX LUTING PLUS CEMENTDENTAL CEMENT3M ESPE DENTAL PRODUCTSEMA3525R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12017-04-2701. R

Event Narratives#

N

Patient 1

ENGINEERING INVESTIGATION WAS LIMITED DUE TO LACK OF RETURNED PRODUCT AND LOT NUMBER INFORMATION. THE CAUSE OF THE PATIENT'S SYMPTOMS IS UNKNOWN; MULTIPLE PRODUCTS WERE USED DURING THE DENTAL APPOINTMENT. THIS PRODUCT CONTAINS POTASSIUM PERSULFATE, WHICH CAN TRIGGER AN ALLERGIC RESPIRATORY REACTION IN CERTAIN INDIVIDUALS. ALSO, IN THE UN-CURED STATE, THIS PRODUCT CONTAINS METHACRYLATE RESINS WHICH CAN TRIGGER AN ALLERGIC REACTION IN INDIVIDUALS WITH SENSITIVITIES TO ACRYLIC-BASED MATERIALS. INFORMATION ABOUT THESE POTENTIAL REACTIONS ARE ALREADY PROVIDED IN THE PRODUCT INSTRUCTIONS FOR USE.

D

Patient 1

ON (B)(6) 2017, A DENTIST REPORTED THAT A (B)(6) FEMALE PATIENT EXPERIENCED BREATHING DIFFICULTY UPON USE OF 3M ESPE RELYX LUTING PLUS CEMENT TO SEAT CROWN ON TOOTH #3. JUST PRIOR TO THE CROWN SEATING, THE PATIENT ALSO HAD A COMPOSITE RESTORATION PROCEDURE PERFORMED ON TOOTH #2. OTHER PRODUCTS USED INCLUDED AN ANESTHETIC, A PROPHY PASTE, AND A NON-3M BRAND COMPOSITE MATERIAL. THE DENTAL OFFICE ADMINISTERED OXYGEN AND CALLED FOR EMERGENCY MEDICAL ASSISTANCE. THE PARAMEDIC ADMINISTERED THE EPIPEN THAT THE PATIENT NORMALLY CARRIES. THE PATIENT WAS THEN TAKEN TO THE ER, WAS ADMITTED FOR OBSERVATION AND WAS DISCHARGED THE NEXT DAY.