FDA Adverse Event Injury Summary report: N

PREVIDENT 5% SODIUM FLUORIDE VARNISH

MDR report key: 2619044 · Received March 26, 2010

Report

Report Number
2218158-2010-00001
Event Type
Injury
Date Received
March 26, 2010
Date of Event
March 4, 2010
Report Date
March 18, 2010
Manufacturer
COLGATE-PALMOLIVE COMPANY
Product Code
LBH
PMA / PMN Number
K040098
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Location
WA, US
Reporter Occupation
DENTIST

Narratives

Description of Event or Problem · 1

THE INITIAL INFORMATION WAS RECEIVED ON (B)(6) 2010. THIS WAS REPORTED BY A DENTAL OFFICE FOR THE DENTIST. ON (B)(6) 2010, AT THE DENTAL OFFICE, PREVIDENT 5% SODIUM FLUORIDE VARNISH WAS APPLIED TO THE TEETH OF A (B)(6) FEMALE, WHO HAS ALLERGIES TO PALM OIL, COLOPHONY AND ROSIN. WHILE APPLYING THIS PRODUCT, THE PT EXPERIENCED TINGLING IN HER MOUTH AND LIP SWELLING. WHEN THE PT LEFT THE DENTAL OFFICE, SHE WAS STILL EXPERIENCING THE TINGLING MOUTH AND SWOLLEN LIPS. ON (B)(6) 2010, THE PT REPORTED WAKING UP IN THE MORNING WITH SWELLING TO HER FACE, LIPS AND TONGUE. SHE WAS TAKEN TO A LOCAL EMERGENCY ROOM (LENGTH OF STAY UNKNOWN) THAT SAME DAY WHERE AN EPI PEN WAS ADMINISTERED FOR THE ALLERGIC REACTION. THE PT WAS DISCHARGED FROM THE EMERGENCY ROOM (DATE UNKNOWN) WITH A PRESCRIPTION FOR ORAL PREDNISONE AND AN UNSPECIFIED MEDICATION (DOSAGE AND FREQUENCY UNKNOWN). AS OF THE DATE OF THE REPORT, THE PT WAS HOME, BUT THE STATUS OF HER SYMPTOMS WAS UNKNOWN. FOLLOW-UP INFORMATION OBTAINED (B)(6) 2010. THE REPORTER CONFIRMED THAT THE EVENTS EXPERIENCED BY THE PT WERE CONSIDERED TO BE MEDICALLY IMPORTANT AND THE EVENTS WERE LIKELY DUE TO THE PRODUCT. AT THE TIME OF THIS REPORT, THE PT WAS DOING FINE AND CONTINUES TO TAKE PREDNISONE.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 PREVIDENT 5% SODIUM FLUORIDE VARNISH CAVITY VARNISH LBH COLGATE-PALMOLIVE COMPANY

Patients

Seq Age Sex Outcome Treatment
1 49 YR Other