FDA Adverse Event Summary report: N

GRABER FORK

MDR report key: 12513 · Received March 31, 1994

Report

Report Number
MW4000344
Date Received
March 31, 1994
Date of Event
October 12, 1993
Report Date
October 28, 1993
Manufacturer
SPACE MAINTAINERS LAB
Report Source
Voluntary report
Reporter Location
IL, US
Reporter Occupation
PATIENT FAMILY MEMBER OR FRIEND

Narratives

Description of Event or Problem · 1

ON 10/11/93 THE DENTIST PLACED AN ORTHODONTIC APPLIANCE INTO A 4-YR-OLD GIRL'S MOUTH. THIS DEVICE WAS INSERTED TO STOP THUMB SUCKING. THE DEVICE IS A METAL PLATE WHICH IS PERMANENTLY APPLIED TO THE ROOF OF THE MOUTH. THE DENTIST TOLD THE MOTHER THAT THE PLATE WAS MADE OF 100% STAINLESS STEEL AND WAS NON-TOXIC AND SAFE. ON 10/12/93, CHILD BEGAN VOMITING AND HER JOINTS BECAME STIFF AND SWOLLEN. THAT AFTERNOON MOTHER TOOK THE CHILD TO THE DR WHO ADMITTED THE CHILD INTO HOSP THE FOLLOWING MORNING. THE CHILD'S SYMPTOMS AT THIS TIME INCLUDED: FEVER (101), PURPLE/RED RASH, SWOLLEN AND STIFF JOINTS, AND SWOLLEN LYMPH NODES. THE CHILD WAS DIAGNOSED WITH KAWASAKI DISEASE, BUT LATER DRS DETERMINED THE SYMPTOMS TO BE DUE TO AN ALLERGIC REACTION TO THE ORTHODONTIC PLATE. ON 10/16/93, THE DENTIST REMOVED THE ORTHODONTIC PLATE FROM THE CHILD'S MOUTH DUE TO THE MOTHER'S REQUEST. SIX HRS LATER THE CHILD'S SYMPTOMS BEGAN TO DISAPPEAR. TWENTY-FOUR HRS LATER, THE CHILD WAS RELEASED FROM THE HOSP. SINCE THE ABOVE INCIDENT THE MOTHER HAS OBTAINED MSDS SHEETS FROM THE PLATE'S DISTRIBUTOR. THE MSDS SHEETS STATED THAT THE METAL (SILVER, TIN, COPPER, AND ZINC) WAS TOXIC AND SHOULD NOT BE USED TO MFR ITEMS THAT HAVE PHYSICAL CONTACT WITH HUMAN TISSUE. PT'S MOTHER HAS THE DEVICE IN HER POSSESSION.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 GRABER FORK Implant THUMB SUCKING FIXED ORTHODONTIC APPLIANCE SPACE MAINTAINERS LAB

Patients

Seq Age Sex Outcome Treatment
1 4 YR