MAUDE Adverse Event Report: DENTSPLY LLC 30K FSI-SLI-1000 INSERT,PKD; SCALER, ULTRASONIC

Catalog Number	81570
Medical Device Problem Code	No Flow (2991)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Event or Problem Description
In this event it is reported that 30k fsi-sli-1000 insert,pkd has no water flow and gets hot.No injury reported.
Additional Manufacturer Narrative
There has been a previous report received where lack of water flow has caused an overheating insert.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.
Additional Manufacturer Narrative
Additional information: udi # is being adding - udi # (b)(4).This is a follow up report to report this information.Investigation results: returned qty.1 insert, 81570, 19178-00031843, 80,bul.Test method / gp005-wi02.Inductance: gauge id# 5349, due: 11/30/2024 result: tested on: g136 gage id# 9626-2, due date: 09/30/2023, set pressure: 35 psi.Water flow: output rate: 35 psi.Water leak: hp sealing ring, proximal ring: distal ring.Other visual observation: insert is good, no fault found.Alleged event: confirmed - not confirmed.

• Brand Name: 30K FSI-SLI-1000 INSERT,PKD
• 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: 17059381
• Report Number: 2424472-2023-00380
• Device Sequence Number: 20124793
• Product Code: ELC
• UDI-Device Identifier: D003815701
• UDI-Public: D003815701
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K052334/K970
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup
• Report Date (Section B): 08/21/2023

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: 81570
• Device Lot Number: 19178
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Distributor Facility Aware Date: 05/31/2023
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 05/31/2023
• Supplement Date Received by Manufacturer: 05/31/2023
• Initial Report FDA Received Date: 06/05/2023
• Supplement Report FDA Received Date: 08/21/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Usage of Device: A
• Patient Sequence Number: 1
• Patient Sex: Unknown