BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    NITE GUARD

    MDR report key: 4113685 · Received May 1, 2014

    Report

    Report Number
    1825660-2014-00125
    Event Type
    Malfunction
    Date Received
    May 1, 2014
    Date of Event
    March 19, 2013
    Report Date
    April 29, 2014
    Manufacturer
    RANIR, LLC
    Product Code
    OBR
    PMA / PMN Number
    K120103
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MI, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THIS COMPLAINT HAS NOT BEEN CONFIRMED. DEVICE NOT RETURNED TO MANUFACTURER, AND NO LOT NUMBER INFORMATION WAS GIVEN, SO AN EVALUATION CANNOT BE PERFORMED AS TO THE ROOT CAUSE OR ACTUAL NATURE OF THE PROBLEM. NO INJURY WAS REPORTED, NO MEDICAL ATTENTION WAS REPORTED TO HAVE BEEN SOUGHT. THIS IS BEING REPORTED AS A POSSIBLE DELAMINATION, AS CHOKING IS POSSIBLE AS A RESULT OF DELAMINATION.

    Description of Event or Problem · 1

    ALL DIRECTIONS ON ONE SIDE OF PAGE OR INDICATION AFTER AND OF BITE SECTION TO TURN OVER FOR REST OF DIRECTIONS. WITHIN A FEW DAYS, THE LAYERS SEPARATED AND PINCHED MY GUMS MAKING IT IMPOSSIBLE TO USE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    262705 NITE GUARD MOUTHGUARD, OVER THE COUNTER OBR RANIR, LLC GEN III

    Patients

    Seq Age Sex Outcome Treatment
    1 Life Threatening