MAUDE Adverse Event Report: TULSA DENTAL PRODUCTS LLC PROULTRA ENDO TIP #5 PACK; SCALER, ULTRASONIC

Catalog Number	PUENDO5
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Device Embedded In Tissue or Plaque (3165)
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 proultra endo tip #5 pack broke during first use.The broken part was not retrieved and was incorporated into the filling.No injury.
Additional Manufacturer Narrative
Customer returned 1x puendo5 lot 0000424576 in an autoclave bag.Using microscope visually checked tip.Instrument was broken as indicated in complaint.No manufacturing defects or markings were noted on instrument.Several factors may contribute to breakage of tips, such as number of uses, intensity, and pressure.All of these may affect the longevity of the tip.It is recommended that the tip be at treatment site before engaging power.Also, these tips should be used with water.No unopened product was returned for additional testing nothing unusual to report was found during dhr review.A query indicates no additional complaints have been received for this lot number.

• Brand Name: PROULTRA ENDO TIP #5 PACK
• Common Device Name: SCALER, ULTRASONIC
• 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: 21911307
• Report Number: 2320721-2025-00066
• Device Sequence Number: 20610312
• Product Code: ELC
• UDI-Device Identifier: D716PUENDO51
• UDI-Public: D716PUENDO51
• Combination Product (Y/N): N
• Initial Reporter State: NJ
• Initial Reporter Country: US
• PMA/510(K) Number: K960889
• 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): 06/16/2025

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: PUENDO5
• Device Lot Number: 0000424576
• Is the Reporter a Health Professional?: Yes
• Distributor Facility Aware Date: 04/24/2025
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 04/24/2025
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 04/25/2025
• Supplement Report FDA Received Date: 06/16/2025
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Usage of Device: A
• Patient Sequence Number: 1
• Patient Sex: Unknown