MAUDE Adverse Event Report: DENTSPLY LLC 30K CAV.THINSERT-FG,PACKED; SCALER, ULTRASONIC

Catalog Number	82009
Medical Device Problem Codes	Overheating of Device (1437); No Flow (2991)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/18/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Since an overheating insert could necessitate medical/surgical intervention to preclude permanent damage to a body structure or permanent impairment of a body function, this malfunction would be likely to cause/contribute to a serious injury should it recur.As such, this event meets the criteria for reportability per 21 cfr part 803.The device is available for evaluation, though has not been returned as of this report.Evaluation results will be submitted as they become available.
Event or Problem Description
In this event it is reported that 30k cav.Thinsert-fg,packed overheats and has no water flow.No injury occurred.
Additional Manufacturer Narrative
Adding udi # (b)(4), this is a follow up report to report this information.Investigation results: returned qty.1 insert, 82009, 23017-00089922, 52, warranty test method / gp005-wi02 inductance: gauge id# 5349 due: (b)(6) 2024 result: 2.98.Tested on: g136 gage id# 9626-2 due date: (b)(6) 2023 set pressure: 35 psi.Water flow: output rate: 35 psi - meets spec.Other visual observation: insert tip is clogged, no water flow.

• Brand Name: 30K CAV.THINSERT-FG,PACKED
• Common Device Name: SCALER, ULTRASONIC
• Manufacturer (Section D): DENTSPLY LLC; 1301 smile way; york PA 17404
• Manufacturer (Section G): DENTSPLY LLC; 1301 smile way; york PA 17404
• Manufacturer Contact: hannah seevaratnam ; 221 west philadelphia st.; york, PA 17401 ; 7178457511
• MDR Report Key: 16973687
• Report Number: 2424472-2023-00377
• Device Sequence Number: 2543478
• Product Code: ELC
• UDI-Device Identifier: D003820091
• UDI-Public: D003820091
• Combination Product (Y/N): N
• Initial Reporter State: WI
• Initial Reporter Country: US
• PMA/510(K) Number: K052334
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup
• Report Date (Section B): 08/10/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Catalogue Number: 82009
• Device Lot Number: 23017
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Distributor Facility Aware Date: 05/19/2023
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 05/19/2023
• Supplement Date Received by Manufacturer: 05/19/2023
• Initial Report FDA Received Date: 05/22/2023
• Supplement Report FDA Received Date: 08/10/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Usage of Device: A
• Patient Sequence Number: 1
• Patient Sex: Unknown