MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,health report with the FDA on 2019-02-25 for THERMOFORM RETAINER NI manufactured by Prismatik Dentalcraft, Inc..
[137114632]
Patient's weight was asked but unknown. Multiple follow-ups were conducted to obtain additional information on the event; however, requested information has not been provided. Reported device was returned for evaluation. Once the evaluation is completed and new information is obtained, a supplemental report will be submitted.
Patient Sequence No: 1, Text Type: N, H10
[137114633]
It was reported that a patient experienced an allergic reaction to the thermoform retainer after the first use. The patient reported of bumps breaking out around her tongue. The patient has known nickel allergy.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 3011649314-2019-00016 |
| MDR Report Key | 8368658 |
| Report Source | COMPANY REPRESENTATIVE,HEALTH |
| Date Received | 2019-02-25 |
| Date of Report | 2019-05-29 |
| Date Mfgr Received | 2019-05-29 |
| Device Manufacturer Date | 2019-01-23 |
| Date Added to Maude | 2019-02-25 |
| 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 |
| Reporter Occupation | DENTIST |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | MR. TOAN HOANG |
| Manufacturer Street | 2212 DUPONT DRIVE SUITE P |
| Manufacturer City | IRVINE CA 92612 |
| Manufacturer Country | US |
| Manufacturer Postal | 92612 |
| Manufacturer Phone | 9492251235 |
| Manufacturer G1 | PRISMATIK DENTALCRAFT, INC. |
| Manufacturer Street | 2212 DUPONT DRIVE SUITE P |
| Manufacturer City | IRVINE CA 92612 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 92612 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | THERMOFORM RETAINER |
| Generic Name | THERMOFORM RETAINER |
| Product Code | DYJ |
| Date Received | 2019-02-25 |
| Returned To Mfg | 2019-02-06 |
| Model Number | NI |
| Catalog Number | NI |
| Lot Number | NI |
| Operator | LAY USER/PATIENT |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | PRISMATIK DENTALCRAFT, INC. |
| Manufacturer Address | 2212 DUPONT DRIVE SUITE P IRVINE CA 92612 US 92612 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other | 2019-02-25 |