MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a health professional report with the FDA on 2019-12-10 for DREAM TAP manufactured by Prismatik Dentalcraft Inc..
[170251342]
The device has not yet been returned. An investigation will be conducted once the sample has been returned and a supplemental report will be submitted. Patient weight: asked, but unknown. Date of event: asked, but unknown. Model number: not applicable. Catalog number: not applicable. Lot number: not applicable. Udi: not available. Initial reporter: not available.
Patient Sequence No: 1, Text Type: N, H10
[170251343]
It was reported that a patient experienced an allergic reaction after using a dream tap appliance. According to the information provided by the doctor, the patient experienced redness and swelling of her lips and gum tissue, where they came in contact with the device. The patient didn't notice the reaction right away and is not sure if appliance is what is causing the reaction. It is unknown whether or not the patient has any known allergies. The patient has the sample with her and it is unknown if such a sample is being returned.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 3011649314-2019-00763 |
| MDR Report Key | 9444856 |
| Report Source | HEALTH PROFESSIONAL |
| Date Received | 2019-12-10 |
| Date of Report | 2020-03-18 |
| Date Mfgr Received | 2020-03-06 |
| Device Manufacturer Date | 2019-08-28 |
| Date Added to Maude | 2019-12-10 |
| 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. HERBERT SCHOENHOEFER |
| Manufacturer Street | 2212 DUPONT DRIVE SUITE P |
| Manufacturer City | IRVINE CA 92612 |
| Manufacturer Country | US |
| Manufacturer Postal | 92612 |
| Manufacturer Phone | 9494402632 |
| 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 | DREAM TAP |
| Generic Name | DREAM TAP |
| Product Code | LRK |
| Date Received | 2019-12-10 |
| Operator | LAY USER/PATIENT |
| Device Availability | N |
| Device Age | DA |
| Device Eval'ed by Mfgr | R |
| 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. Required No Informationntervention | 2019-12-10 |