MAUDE Adverse Event Report: KAVO DENTAL GMBH GENTLEPOWER LUX CONTRA ANGLE 25LPA; DENTAL HANDPIECE

Model Number 25 LPA

Device Problems Overheating of Device (1437); Dent in Material (2526); Physical Resistance/Sticking (4012)

Patient Problem Burn(s) (1757)

Event Date 08/14/2021

Event Type  malfunction  

Manufacturer Narrative

The visual and functional check of the handpiece prior to the repair showed that the product was running out of specification.It was found that the ball bearings have been worn out and hence it was running slow with a too high power consumption.The worn-out bearings caused higher friction and hence heat up of the head.The visual inspection showed also that the head was bent in around the push button.It is a sign that the product received a stronger external force, e.G.By dropping it.After disassembly it got visible that the push button had a groove worn into it from rubbing on chuck release.This is a sign that the push button either stuck in due to the bent head or that the head was used to retract tissue during the treatment.This causes contact between the spinning inner parts and the not moving push button.Due to the friction between the parts it causes heat up.To avoid such issues the user instruction contains already several notes, warnings and requests how to prepare the handpiece for each treatment and how to use it: warning: hazards for the care provider and the patient.In the case of damage, irregular running noise, excessive vibration, untypical warming or when the cutter or grinder cannot be held.-> do not use further and notify service.Caution: burning hazard from hot instrument head or hot instruments cover.If the instrument overheats, burns may arise in the oral area.->never contact soft tissue with the instrument head or instrument cover the following guidelines must be observed to ensure save use of the electrically driven contra-angle handpieces: >the service instructions for contra-angle handpieces must be precisely following when using kavo spray or quattrocare care systems.> before each use, the contra-angle handpiece must be checked for external damage.> before each use, perform a test run with the contra-angle handpiece, and watch for atypical heating and unusual noise and vibration.> immediately stop using contra-angle handpieces that act unusual.> never press the push button during operation.This also includes lifting the cheek or tongue! to ensure proper function, the medical device must be set up according to the reprocessing methods described in the kavo instructions for use, and the care products and care systems described therein must be used.Kavo recommends specifying a service interval at the dental office for a licensed shop to clean, service and check the functioning of the medical device.This service interval depends on the frequency of use and should be adjusted accordingly.

Event Description

During a crown preparation to tooth #30 the handpiece heated up and burned the patient on 3 spots, each approximately 1cm in size.2 times on tongue and a third spot on his right buccal mucosa.When dentist noticed the issue, he finished the treatment with another handpiece.He recommended the patient saline swishing and applying vitamin e oil.There was no medical care necessary for the burns.

• Brand Name: GENTLEPOWER LUX CONTRA ANGLE 25LPA
• Type of Device: DENTAL HANDPIECE
• Manufacturer (Section D): KAVO DENTAL GMBH; bismarckring 39; biberach / riss, 88400 ; GM 88400
• Manufacturer (Section G): KAVO DENTAL GMBH; bismarckring 39; biberach / riss, 88400 ; GM 88400
• Manufacturer Contact: klaus reisenauer ; bismarckring 39; biberach / riss, 88400 ; GM 88400
• MDR Report Key: 16749612
• MDR Text Key: 313397655
• Report Number: 3003637274-2023-00007
• Device Sequence Number: 1
• Product Code: EGS
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K073478
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,User Facility
• Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date: 04/17/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/17/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 25 LPA
• Device Catalogue Number: 1.002.1526
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/07/2023
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 03/23/2023
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 10/23/2003
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1
• Patient Outcome(s): Other