BEUDAMED
    FDA Adverse Event Injury Summary report: N

    AC-GM ESSIX ALIGNER CHEWIE GREEN MINT 20PK

    MDR report key: 19816018 · Received July 24, 2024

    Report

    Report Number
    1036212-2024-00001
    Event Type
    Injury
    Date Received
    July 24, 2024
    Report Date
    August 5, 2024
    Manufacturer
    DENTSPLY SIRONA ORTHODONTICS INC.
    Product Code
    ECS
    UDI-DI
    D746ACGM1
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    UK
    Reporter Occupation
    DENTIST
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    WHILE IT IS UNKNOWN IF THE DEVICE USED IN THIS CASE CAUSED OR CONTRIBUTED TO THE PATIENT¿S SYMPTOMS, IT IS POSSIBLE AS ALLERGIC REACTIONS TO DENTAL MATERIALS ARE KNOWN AND REPORTED, WITH MEDICAL CONSEQUENCES BEING DEPENDENT UPON THE SEVERITY OF THE INDIVIDUAL ALLERGIC RESPONSE AND SUBSEQUENT EXPOSURE TO THE SAME MATERIAL. THEREFORE, THIS EVENT MEETS THE CRITERIA FOR REPORTABILITY PER 21 CFR PART 803. THE DEVICE WAS NOT RETURNED FOR EVALUATION. HOWEVER, THE LOT NUMBER WAS PROVIDED AND RETAINED-PRODUCT TESTING AND/OR DHR REVIEW ARE PLANNED. THE RESULTS WILL BE SUBMITTED AS THEY BECOME AVAILABLE.

    Additional Manufacturer Narrative · 0

    2 DOCUMENTED ATTEMPTS(FOLLOW UPS) HAVE BEEN MADE TO RECEIVE PRODUCT FOR INVESTIGATION AND TRACKING #. THIS INFORMATION HAS NOT BEEN RECEIVED. DHR INVESTIGATION WILL BE CONDUCTED. 8-2-2024: DHR FOR ITEM# AC-GM ESSIX ALIGNER CHEWIE GREEN MINT 20PK BATCH# 07084909 HAS BEEN PULLED, REVIEWED, AND ATTACHED TO THIS CASE. DHR REVIEW ONLY IDENTIFIED ISSUES WITH PRINT QUALITY ISSUES THROUGHOUT THE AUTOBAGGING PORTION OF THE MANUFACTURING WORK ORDER. ALL OTHER INSPECTIONS WERE PERFORMED AND DEEMED ACCEPTABLE BY THE OPERATOR(S) AND QUALITY AS PER 0290-WI-7.5-50-16, 0290-IP-7.5-30-02, 0290-IP-7.5-50-07 AND 0290-WSS-7.5-50-07. THE NUMBER OF RAW MATERIALS AND AMOUNT PER PICKED AND CONSUMED TO THE WORK ORDER ARE EXACTLY AS THE BOM REQUIRED. RAW MATERIALS USED TO MAKE THE AC-GM CHEWIES AS PER 0290-SPEC-028 (MATERIAL SPECIFICATIONS FOR CHEWIES ALIGNER SEATERS) FOR THIS PRODUCTION ORDER ARE ITEM# GNLR (GLENROE NON LATEX RAW MATERIAL) BATCH# 04EAF1031 & ITEM# TB GREEN (MC-24243EV) BATCH# 7071727, ITEM# SPEARMINT 9295629 SPEARMINT SCENT) BATCH# 210506567. RECEIVING INSPECTIONS/DOCUMENTATION FOR ALL 3 RAW MATERIALS ALSO PULLED, REVIEWED, AND ATTACHED TO THIS DHR. EACH INSPECTION WAS COMPLETED BY QUALITY AND DOCUMENTED IN EACH RESPECTIVE RECEIVING INSPECTION HISTORY SHEETS. COA¿S FOR EACH MATERIAL WERE VERIFIED AGAINST 0290-SPEC-028 AND ARE CONFORMING. (NWV) 8-2-2024: RETAINS WERE NOT AVAILABLE FOR REVIEW AS PER 0290-WI-8.2-07 WHICH STATES RETENTION SAMPLES MUST BE MAINTAINED FOR A MINIMUM OF SIX MONTHS (PRODUCED 06-2023). (NWV) FAILURE MODE: ALLERGIC REACTION. ROOT CAUSE: NO DEFECT PROVEN. CONCLUSION CODE: NO FAILURE FOUND.

    Description of Event or Problem · 0

    IN THIS EVENT IT IS REPORTED THAT AC-GM ESSIX ALIGNER CHEWIE GREEN MINT 20PK THAT A PATIENT USED CAUSED AN ALLERGIC REACTION. THE PATIENT EXPERIENCED THROAT AND FACE SWELLING. THE PATIENT WAS HOSPITALIZED AND TREATED FOR ANAPHYLAXIS AND GIVEN STEROIDS OVERNIGHT. THEY WERE DISCHARGED THE FOLLOWING DAY, THE DOCTORS ADVISED THE PATIENT THEIR ANAPHYLAXIS WAS CAUSED BY THE CHEWIES AND TO CEASE USE. PATIENT HAD NO KNOWN ALLERGIES PRIOR TO THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2303254 AC-GM ESSIX ALIGNER CHEWIE GREEN MINT 20PK PUSHER, BAND, ORTHODONTIC ECS DENTSPLY SIRONA ORTHODONTICS INC. 07084909 D746ACGM1

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Unknown