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.