MAUDE MDR 7202588

MDR report key
7202588
Report number
1000582314-2018-00001
Event key
0
Event type
3
Date of event
2017-12-20
Date received
2018-01-17
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
0
Initial report to FDA
0
Event location
3

Manufacturer Contact#

Contact
MR. SANJAY PATEL
Address
1700 A SOUTH BAKER AVE ONTARIO CA 91761 US
Phone
909-909-9095
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1PHILIPS ZOOMZOOM CHAIRSIDE WHITENING KITDISCUS DENTAL, LLCEEGZM266616043036R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12018-01-1701. O

Event Narratives#

N

Patient 1

DISCUS DENTAL RECEIVED A COMPLAINT ON 12/21/2017 IN WHICH PATIENT'S UPPER AND LOWER LIPS WERE BURNED AFTER IN-OFFICE ZOOM TEETH WHITENING PROCEDURE. THE DENTIST STATED THAT THE PATIENT DID NOT HAVE THE FOUR (4) FRONT TEETH, AND THE RETRACTOR DID NOT FIT IN THE PATIENT'S MOUTH. DENTAL HYGIENIST USED GOGGLES TO COVER THE LIPS DURING THE WHITENING PROCEDURE. NO INFORMATION WAS PROVIDED IF MEDICAL TREATMENT WAS REQUIRED AFTER THE INCIDENT. INVESTIGATION: - THE RETAIN SAMPLE OF THE IN-OFFICE WHITENING GEL, SKU: (B)(4), LOT: 16035011 WAS TESTED ON 01/02/2018 AND RESULTS WERE WITHIN SPECIFICATIONS. - REVIEWED DEVICE HISTORY RECORDS OF ZOOM WHITENING KIT, SKU: (B)(4), LOT: 16043036, AND WHITENING GEL, SKU: (B)(4), LOT: 16035011 AND NO OUT OF SPECIFICATION OR DISCREPANCY WAS FOUND IN THE RECORDS. THE BILL OF MATERIAL SHOWS THAT 2 RETRACTORS WITH STANDARD AND SMALL SIZES WERE PROVIDED WITH THE KIT. - REVIEWED DIRECTION FOR USE PROVIDED WITH THE DEVICE. DFU DESCRIBES THE WARNINGS AND PRECAUTIONS AND STEPS FOR PROPER LIP ISOLATION - REVIEWED COMPLAINTS HISTORY, NO OTHER SIMILAR INCIDENTS WERE REPORTED WITH THE SAME LOT NUMBERS. - BASED ON THE INVESTIGATION RESULTS AND AVAILABLE INFORMATION, IT CAN BE CONCLUDED THAT THERE WAS NO FAILURE AND MALFUNCTION IN THE DEVICE. POTENTIAL CAUSES MAY BE IMPROPER LIPS ISOLATION PRIOR TO THE PROCEDURE AND NOT FOLLOWING THE INSTRUCTIONS PROVIDED IN THE DFU. BASED ON THE COMPLAINT DESCRIPTION AND INVESTIGATION RESULTS, NO PRODUCT FAILURE AND OUT OF SPECIFICATION WAS FOUND. DFU IS ADEQUATE AND NO CORRECTIVE ACTION IS NEEDED. PRODUCT WAS USED UP DURING THE PROCEDURE.

D

Patient 1

DISCUS DENTAL RECEIVED A COMPLAINT ON 12/21/2017 IN WHICH PATIENT'S UPPER AND LOWER LIPS WERE BURNED AFTER IN-OFFICE ZOOM TEETH WHITENING PROCEDURE. THE DENTIST STATED THAT THE PATIENT DID NOT HAVE THE FOUR (4) FRONT TEETH, THE RETRACTOR DID NOT FIT IN THE PATIENT'S MOUTH, AND THE DENTAL HYGIENIST USED GOGGLES TO COVER THE LIPS DURING THE WHITENING PROCEDURE. NO INFORMATION WAS PROVIDED IF MEDICAL TREATMENT WAS REQUIRED AFTER THE INCIDENT.