MAUDE Adverse Event Report: TULSA DENTAL PRODUCTS LLC PROTAPER GOLD ROTARY S1 25MM; FILE, PULP CANAL, ENDODONTIC

Catalog Number	PTGRS125
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Device Embedded In Tissue or Plaque (3165)
Date of Event	04/26/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
As a result of this malfunction, the potential for surgical intervention exists to preclude permanent damage to a body structure or permanent impairment of a body function as evidenced by previous reported events with similar files.This event, therefore, is reportable per 21cfr 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 a protaper gold rotary s1 25mm broke during use.Doctor was able to bypass and complete the procedure.No injury occurred.
Additional Manufacturer Narrative
Investigation results.Dhr.Nothing unusual to report was found during dhr review.A query indicates no additional complaints have been received for this lot number.Other.Unsuccessful attempts to retrieve suspect product for investigation/evaluation have been made and documented (see notes).Case can be re-opened if product is received.

• Brand Name: PROTAPER GOLD ROTARY S1 25MM
• Common Device Name: FILE, PULP CANAL, ENDODONTIC
• Manufacturer (Section D): TULSA DENTAL PRODUCTS LLC; 608 rolling hills drive; johnson city TN 37604
• Manufacturer (Section G): TULSA DENTAL PRODUCTS LLC; 608 rolling hills drive; johnson city TN 37604
• Manufacturer Contact: dan eagar ; 221 west philadelphia st.; york, PA 17401 ; 7178457511
• MDR Report Key: 19230914
• Report Number: 2320721-2024-00025
• Device Sequence Number: 20313357
• Product Code: EKS
• UDI-Device Identifier: D716PTGRS1251
• UDI-Public: D716PTGRS1251
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: EXEMPT
• 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): 06/10/2024

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: PTGRS125
• Device Lot Number: 0000375341
• Is the Reporter a Health Professional?: Yes
• Distributor Facility Aware Date: 04/26/2024
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 04/26/2024
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 05/02/2024
• Supplement Report FDA Received Date: 06/10/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Usage of Device: A
• Patient Sequence Number: 1
• Patient Sex: Unknown