## 4 Discussion  
An increase in implant rehabilitation has revealed an emerging number of peri-implant pathologies [22]. The prevalence of these conditions reach a range of 32-54% [23; 24], and a possible natural evolution of the mucositis condition may be peri-implantitis affection [25]. Currently, the strategies implemented for the management of peri-implantitis are derived from the knowledge and treatment standards used for periodontitis. Recent studies show that there is no consensus on the most suitable and effective treatment for the cure of peri-implantitis; however, the results are less encouraging than those obtained from periodontology through natural elements. Research has evaluated various therapeutic opportunities: the detachment of a full thickness flap and subsequent debridement seems more predictable than debridement procedures alone. On the other hand, the local use of antibiotic and antiseptic molecules also seem to lead to better clinical results compared to the non-surgical debridement procedure alone. Since mucositis represents the onset of peri-implant pathology, it therefore represents the crucial stage in which to intervene to avoid the manifestation of more serious signs and symptoms that could significantly compromise the success and survival of the implant [26; 27; 28]. Although mucositis definition is complex, bleeding during probing, depending on probing depth, is a predictable marker for health or pathological status [22; 23]. According to previous definitions, the modified bleeding index (mBI) was used as an evaluation parameter in the present randomized clinical study. Plaque presence is an adjunctive etiological factor for the beginning of mucositis and a risk factor for the permanence of this condition [29]; so, in addition to mBI index, the plaque index (PI) was utilized as a clinical evaluation parameter. Moreover, smoking, surface roughness, residual cement, the dimension of the keratinized tissue, the time of implant in function, and diabetes are adjunctive risk factors, but the significance is not already conclusive [22; 29] and no definitive treatment for the condition has been found [22]. Some RCTs reported the superior outcomes of clinical parameters in favor of rinsing with an essential oil [30], the use of irrigation with CHX [31], or use of a triclosan-containing toothpaste [32]. A multicenter randomized clinical trial by [PERSON] et al. evaluated the efficacy of an adjunctive treatment to debridement in patients affected by peri-implantitis using chlorhexidine chips (chlorhexidine gluconate 2.5 mg chips). Patients were on strict plaque control regimen for 24 weeks and gingival index was evaluated; results presented a significant reduction in implant pocket depths (IPD) compared to the control group [33]. On the other hand, other RCTs failed to report a superiority of different protocols, such as brushing with adjunctive CHX gel [34] and the adjunctive use of CHX rinsing or gel application. There is emerging evidence regarding patient control of the inflammation level, namely that the lack of annual supportive therapy in patients diagnosed with peri implant mucositis was associated with increased risk for the conversion of mucositis in peri-implantitis [22]. The literature provides a study evaluating the efficacy of patient-administered treatment with domiciliary oral hygiene procedures [35], and another focused on the efficacy of professionally administered measures [36] for plaque control in patients with peri-implant mucositis; these studies taken together show that a well administered home care program is a suitable solution for the maintenance of the implants affected by this pathology. According to the consensus report of the VIII European Workshop [37], three major groups of treatment were identified, i.e., mechanical plaque removal by means of manual or powered toothbrushes, chemical plaque control by means of adjunctive delivery of antimicrobials, and triclosan-containing toothpastes or gel.