MAUDE MDR 908656

MDR report key
908656
Report number
2020467-2007-00003
Event key
0
Event type
3
Date of event
2007-08-27
Date received
2007-09-07
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
MARYLN SCHEFF
Address
2724 SOUTH PECK ROAD MONROVIA CA 91016 US
Phone
626-626-6265
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1TRANSBOND XT PRIMER,NONEDYHREF 712-0345CJNRN

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12007-09-0701. D

Event Narratives#

D

Patient 1

IN PREPARATION FOR ORTHODONTIC TREATMENT. A STOMATOLOGIST INJECTED A DENTAL ANESTHETIC INTRAORALLY INTO A PATIENT BEFORE MAKING AN INCISION IN THE GUM IN ORDER TO EXPOSE AN UNDERGUM CUSPID TOOTH. APPROXIMATELY FIVE MINUTES FOLLOWING THE ORAL SURGERY, THE ORTHODONTIST APPLIED ORTHODONTIC ETCHING GEL, ORTHODONTIC PRIMER, AND ORTHODONTIC ADHESIVE WITH ATTACHMENT TO THE PATIENT'S TOOTH. THE FIRST PREPARATION OF THE TOOTH WAS NOT ADEQUATE, SO THE ORTHODONTIST RE-PREPARED THE TOOTH. THE TREATMENT WAS INITIALLY UNEVENTFUL; HOWEVER, THE PATIENT STARTED TO EXPRESS DISTRESS AND SHORTLY THEREAFTER CARDIAC ARREST OCCURRED. SUBSEQUENT ATTEMPTS TO REVIVE THE PATIENT WERE UNSUCCESSFUL.

N

Patient 1

IT IS NOT CLEAR WHAT ORTHODONTIC DEVICES WERE USED IN THIS EVENT, SINCE THE ORTHODONTIST HAS NOT PROVIDED THIS INFORMATION TO 3M. HOWEVER, 3M UNITEK HAS DETERMINED THAT THE FOLLOWING DEVICES WERE SHIPPED TO THE ORTHODONTIST IN 2006 AND 2007. TRANSBOND XT PRIMER, LOT #S 5CJ, 6CX, 6EB; TRANSBOND XT ETCHING GEL, LOT # 6HE; TRANSBOND PLUS SELF ETCHING PRIMER, LOT # 266707; TRANSBOND XT ADHESIVE IN CAPSULES, LOT #S PH, RK, WN.