MAUDE MDR 9591559

MDR report key
9591559
Report number
8010908-2020-00001
Event key
0
Event type
3
Date of event
2020-01-09
Date received
2020-01-15
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
MR MICHAEL CYLL
Address
ANTON-FLETTNER-STRASSE 1-3 CUXHAVEN, NIEDERSACHSEN 27472 GM
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1VOCO PROFLUORID VARNISHPROFLUORID VARNISHVOCO GMBHLBHREF 22311814071R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12020-01-1501. O

Event Narratives#

N

Patient 1

ON THE BASIS OF THE INFORMATION AVAILABLE,WE SHARE THE DENTIST OPINION THAT THE PATIENT'S SYMPTOMS WERE PROBABLY NOT CAUSED BY TREATMENT WITH PROFLUORID VARNISH. VPV CONTAINS COLOPHONY. ALLERGIC REACTIONS CANNOT BE EXCLUDED IN INDIVIDUAL CASES. HOWEVER, BECAUSE THE PATIENT NEEDED MEDICAL INTERVENTION AND IT CANNOT BE EXCLUDED THAT VPV CONTRIBUTED TO THE INCIDENT, WE PRECAUTIONARY REPORT THE INCIDENT TO THE FDA IN ACCORDANCE WITH 21 CFR 803. FURTHER ACTION ARE NOT REQUIRED.

D

Patient 1

MOTHER OF (B)(6)YO FEMALE PATIENT, WITH NO KNOWN ALLERGIES/ NO CURRENT MEDICAL CONDITIONS CALLED THE DENTISTS OFFICE ON 10-JAN-2020 REPORTING "AN ANAPHYLACTIC REACTION TO THE VARNISH" FROM THE CLEANING APPOINTMENT HER CHILD HAD ON THURSDAY ((B)(6) 2020). SHE SAID THE CHILD COMPLAINED OF A SORE/ BURNING THROAT ON THE WAY HOME. THE PATIENT HAD A TYPICAL EXAM, PROPHYLAXIS AND VPV WAS PLACED. THE PATIENT HAD BEEN TREATED ONCE PRIOR TO THIS APPOINTMENT IN THE OFFICE (PROPHYLAXIS) WITHOUT ISSUE. A PHOTO WE RECEIVED ON FRIDAY (10-JAN-2020) AFTERNOON SHOWS SWOLLEN LESIONS IN THE TONSIL/ THROAT AREA. NO PHOTO WAS TAKEN OF THE GINGIVA, LIPS, TONGUE OR BUCCAL MUCOSA. THE PATIENT NEVER COMPLAINED OF PAIN WHILE IN THE OFFICE OR AS THE VPV WAS PLACED. THERE WAS NO FEVER AND NO ISSUES BREATHING. THE HYGIENIST/ DOCTOR WAS UNAWARE OF ANY ISSUE UNTIL THE FOLLOWING DAY (FRIDAY 10-JAN-2020). THE MOTHER THEN REPORTED TO THE OFFICE THAT THE CHILD SAW AN ORAL SURGEON, WHO WAS A NEIGHBOR, AND HE SUGGEST IT WAS A REACTION TO THE VPV. THE MOTHER THEN TOOK THE PATIENT TO THE PAEDIATRICIAN WHO DIAGNOSED THE PATIENT WITH ALLERGIES. THE PATIENT WAS PRESCRIBED STEROIDS BY THE PAEDIATRICIAN. ON 14-01-2020 THERE WAS A REPORT TO THE PRACTICE STAFF THE BROTHER NOW PRESENTS WITH THE SAME LESIONS. THE DENTIST FEELS THIS IS A VIRAL/ BACTERIAL INFECTION AND NOT ASSOCIATED WITH THE VARNISH TREATMENT.