This article reports the case of a patient suffering from Alzheimer's disease who underwent a dental procedure for the peri-implantitis of his dental implants placed some years earlier. Our aim was to describe a misinterpreted accidental foreign body aspiration and its management. Due to an involuntary movement, the patient accidentally ingested a screwdriver, so, although asymptomatic, he was taken to the hospital. Based on the radiographic interpretation, the radiologists diagnosed the presence of the object in the distal esophagus; an esophagogastroduodenoscopy was performed but the screwdriver was not found. Subsequently, a computed tomography (CT) scan was performed which placed the foreign body in the airways and it was successfully removed by bronchoscopy. Patients with dementia need additional care during dental procedures because of the increased risk of ingestion and/or aspiration. We demonstrated how important it is, even without any symptoms, the need to be vigilant in seeking out urgent care as soon as possible.
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