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An intermittent paste was injected inside the shaped root canal system. The paste of two different antibiotics (Augmentin and Metronidazole) was manu- ally mixed and injected with a paste filler. A hermetic tempo- rary filling was placed for a week. The wound was covered with a dressing of steroids and antibiotic paste to prevent further external infection. A week later, the pa- tient was already showing good progress. The wound had started to close and less inflammation and swelling were observed (Fig. 5). The root canal was reopened and cleaned, and no internal flu- ids were coming from the peri- apical region. RealSeal material was used as obturation material in a vertical condensation using RCPSL (Hu-Friedy) and an im- mediate build-up was performed. Thereafter, the patient was in- vited for regular control check- ups. A few weeks later, a post-op X-ray (Fig. 6) and photos were taken. The wound seemed to be in good condition and some skin and fibrous tissues were forming. While I was writing this arti- cle, the patient visited Beirut and decided to come in for a check- up. He complained of a muscle disturbance of his lower lip, but all the previous numbness had disappeared. He agreed to per- form an i-Cat scan in order to find out what was going on and to detect any pathology. I was amazed by the bone formation and complete healing (Figs. 7–9). The wound had also healed very well (Figs. 10a & b). I contacted a plastic surgeon and asked his opinion regarding the muscle disturbance. He posited that such symptoms may be caused by the tremendous loss of structure. Discussion An important diagnostic modal- ity is the determination of the nature of fluid draining (if any) from the cutaneous sinus. Dur- ing palpation, an attempt should be made to milk the sinus tract. Any discharge obtained should be scrutinised to determine its nature (saliva, pus or cystic fluid). Culture and sensitivity testing of the fluid should also be per- formed to rule out fungal and syphilitic infection. Laskin elaborates on the physiological and anatomical factors that influence the spread and ultimate localisation of den- tal infections. Stoll and Solomon also emphasise that the ultimate path of the sinus (irrespective of the source) depends on several factors: most importantly, the anatomy of the tooth involved, muscular attachments to the jaw, fascial planes of the neck, and involvement of permanent or de- ciduous teeth. Cutaneous rather than intra-oral lesions are likely to occur if the apices of the teeth are superior to the maxillary muscle attachments or inferior to the mandibular muscle attach- ments. A pustule is the most com- mon of all purulent draining le- sions and is readily recognised by its superficial location and short course. Actinomycosis exhibits multiple draining lesions and characteristic fine yellow gran- ules in the purulent discharge. The tooth is often not involved radiographically. If a sinus tract does not close after appropriate removal of the primary cause, the most common alternative cause is actinomycosis. (Fig. 5) The challenge in these kinds of cases is to assemble all the pieces of the puzzle and build up a full idea of the clinical situation. Assembling the pieces means that all the diagnostic materials, such as a history questionnaire, X-rays, CT scans, and sometimes biopsy and bacteria culturing, must be provided in order to es- tablish a correct diagnosis. Most of the time, the solution will only be a simple routine that must be performed in certain conditions. Turning to solutions that are more complicated—and that cer- tainly can be more profitable—is not always the right choice, nor the most ethical one. The author would like to thank Yulia Vorobyeva, PhD, in- terpreter and translator, for her help with this article. DT About the author Dr Philippe Sleiman received his DDS from the Lebanese University School of Dentistry in 1989. He conducted a DES in the endodontic programme at St Joseph University and a PhD at the Lebanese University Dental School. He has authored several international articles. He has his own line of instru- ments with the Hu-Friedy company and contributed to several project de- velopments, and he has lectured inter- nationally. Dr Sleiman is an instructor at the Lebanese University and an in- ternational trainer for the University of North Carolina. He is a fellow in the ICD and the AAE. Dr Sleiman main- tains a private practice in Beirut, Leba- non, and in Dubai, UAE. Dubai, UAE and can be reached at phil2sleiman@ hotmail.com. Figs. 10a & b_Post-op woundhealing. Figs. 7–9_i-Cat images showing good bone formation and complete healing. Fig. 6_Post-op X-ray a few weeks after treatment. Fig. 5_One week after steroids and antibiotic treatment. Fig. 2b_Sagittal slide showing the lesion around the distal root of tooth 47. Fig. 3_The mesial root of tooth 46 showing apical radiolucency, invading the tract of the lower mandibular nerve (014). Fig. 4_Axial slide under tooth 46 Fig. 2b Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 10 Fig. 9 Fig. 10b DENTALTRIBUNE Middle East & Africa Edition Media CME 7 Dental Tribune Middle East & Africa incollaborationwithCAPPintroduce to the market the new project mCME - Self Instruction Program. mCME gives you the opportunity to have a quick and easy way to meet your continuing education needs. mCME offers you the flexibility to work at your own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presents a regional outlook in terms of perspec- tive and subject matter. How can professionals enroll? Theycaneithersignupforaone-year (10 exercises) by subscription for the magazine for one year ($65) or pay ($20) per article. After the payment, participants will receive their mem- bershipnumberandwillbeabletoat- tend to the program. How to earn CME credits? Oncethereaderattendsthedistance- learning program, he/she can earn credits in three easy steps: 1. Read the articles. 2. Take the exercises 3. FillintheQuestionnaireandSub- mit the answers by Fax (+971 4 36868883) or Email :info@cappmea.com After submission of the answers, (name and membership number must be included for processing) they will receive the Certificate with unique ID Number within 48 to 72hours. Articles and Questionnaires will be availableinthewebsiteafterthepub- lication. www.cappmea.com MEDIA CME Self-Instruction Program