Ingestion of a RPE activation key: Why do these accidents still happen?

AIM: To draw attention and increase professional awareness about the potentially serious complications that may occur when these misfortunes happen and to what actions could be implemented to avoid such accidents.

METHODS: The present case report is of an accidental ingestion of a rapid maxillary expander (RPE) activation key in a cardiac patient and the subsequent diagnostic confirmation with radiographs and the management of this accident thereafter.

RESULTS: On the third day after the accidental ingestion of the RPE key, the patient's parents reported that the key was expelled in the stools without further complication.

CONCLUSIONS: Ingestion of foreign bodies is a potential complication during orthodontic treatment. These types of accidents may cause serious consequences to the patient, especially if there is a pre-existing systemic condition, such as heart disease or respiratory problems.