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The new marginal plaque index (MPI) may allow a more valid assessment of
gingival plaque level than the Turesky modification of the Quigley and Hein
Index (TQHI)

Article  in  Journal of Evidence Based Dental Practice · October 2017

DOI: 10.1016/j.jebdp.2017.10.008

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Hee-Eun Kim Baek-Il Kim

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 The Journal of EVIDENCE-BASED DENTAL PRACTICE

ARTICLE ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS

THE NEW MARGINAL PLAQUE INDEX MAY

ALLOW A MORE VALID ASSESSMENT OF
GINGIVAL PLAQUE LEVEL THAN THE
TURESKY MODIFICATION OF THE QUIGLEY
AND HEIN INDEX
REVIEWERS
HEE-EUN KIM, BAEK-IL KIM
Can the newly developed marginal plaque index (MPI) for efficient monitoring of oral hygiene maintenance replace the
existing Turesky modification of the Quigley and Hein Index (TQHI)?

SORT SCORE ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Establishment of a new marginal plaque index with high sensitivity for changes in
A B C NA
SORT, Strength of Recommendation Taxonomy
oral hygiene. Deinzer R, Jahns S, Harnacke D. J Periodontol 2014; 85(12):1730-8.

LEVEL OF EVIDENCE
1 2 3 SUMMARY
See page 9A for complete details regarding SORT and LEVEL OF
EVIDENCE grading system
Subjects
Study 1 was conducted from May 2013 to November 2013 on 64 participants (32
men and 32 women, age: 18-66 years; mean 6 standard deviation age:
SOURCE OF FUNDING
34.49 6 11.91 years). Study 2 was conducted from November 2009 to September
The study was supported by a
2010 on 67 participants (15 men and 52 women, age: 20-29 years; mean age:
sponsorship from GABA Interna-
23.3 years). The participants of study 2 were students who had not majored in
tional, Therwil, Switzerland.
dental medicine or medicine.

Key Exposure/Study Factor

TYPE OF STUDY/DESIGN
No oral hygiene instructions were provided to the subjects of study 1. The
Observational case–control study.
proximal sites of 2 opposite quadrants of the dentition were cleaned with dental
floss and/or interproximal brushes by a dental hygienist, whereas the other 2 were
left untreated. A blinded examiner assessed the areas using the Turesky Modi-
KEYWORDS fication of the Quigley and Hein Index (TQHI) and Marginal Plaque Index (MPI).
Marginal plaque index, Plaque The subjects of study 2 were randomly assigned either to a control group that
index, Autofluorescence-based received training on the basics of toothbrushing only or to 1 of the 2 intervention
plaque quantification, Quantitative groups that were provided with additional training using a modified Bass or
light-induced fluorescence, Fones technique, respectively. Data were assessed 2 weeks before the inter-
Reliability, Validity vention and 6, 12, and 28 weeks later by 4 trained and calibrated examiners.

J Evid Base Dent Pract 2017: [416-419] Main Outcome Measure

Gingivitis was assessed using a modified papillary bleeding index (PBI) with
1532-3382/$36.00
World Health Organization (WHO) probe. The bleeding responses were rated as
ª 2017 Elsevier Inc. All
follows: (1) 0 5 no bleeding; (2) 1 5 single bleeding point; (3) 2 5 bleeding from a
rights reserved.
doi: https://doi.org/10.1016/ narrow area; (4) 3 5 interdental triangle filled with blood; and (5) 4 5 profuse
j.jebdp.2017.10.008 bleeding. Dental plaque deposits revealed by a disclosing solution were assessed

416 Volume 17, Number 4


by the TQHI and MPI. In study 1, all stained plaque was
assessed after proximal surfaces of the teeth were cleaned.
In study 2, old plaques having blue coloration stained with
Mira-2-Ton solution were assessed before toothbrushing as
an indicator of habitual oral hygiene. The subjects were
instructed to completely remove plaque using a toothbrush
and dental floss. All residual plaques staining pink and blue
were assessed immediately. TQHI assesses plaque in 6
grades (at oral and vestibular surfaces) according to the
distribution of the plaque. The MPI assesses the presence
(score 1) or absence (score 0) of plaque within 8 equal
sections of a tooth (4 at the oral and 4 at the vestibular
gingival margin, respectively) (Figure 1).
To prove whether the new MPI is a promising tool for evalu-
ating proximal and cervical plaque, convergent validity of MPI
with TQHI and criterion validity (ie, concurrent and predictive
validity) with PBI was assessed. The convergent validity of MPI
was assessed with TQHI in study 1 for quadrants without
dental flossing and in study 2 for baseline measures. To assess
the concurrent validity, the correlations of the plaque and
bleeding measures were computed for quadrants without
dental floss in study 1 and for baseline hygiene values in study
2. The predictive validity was assessed in the control group of
study 2 by evaluating the correlation of hygiene measures
(12 weeks after the treatment) and papillary bleeding
(28 weeks after the treatment). Moreover, the treatment
Figure 1. Scoring sample of the marginal plaque index
(MPI). Plaque was assessed at the proximal and cervical
sections of the gingival margin at the vestibular aspect
of a tooth (ie, percentage of all sections scoring 1: MPI
proximal values [ie, percentage of mesial plus distal
sections scoring 1] and MPI cervical values [ie,
percentage of cervico-distal plus cervico-mesial
sections scoring 1]). d 5 distal; cd 5 cervico-distal;
cm 5 cervico-mesial; m 5 mesial.
Adapted from Deinzer et al. J Periodontol 2014; 85:1730-8.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
sensitivity of MPI to TQHI was analyzed by a treatment with
proximal hygiene (study 1) or toothbrushing (study 2).
Main Results
First, convergent validity was analyzed to determine the accu-
racy of the new MPI in assessing plaque extension as compared
to the TxQHI, an international standard. The results showed that
there were moderate to excellent correlations (correlation co-
efficient [Pearson r or Spearman r] 5 0.5-0.9, P ,.05) between
MPI and TQHI, indicating a high convergent validity of MPI.
Second, concurrent validity was analyzed to determine the
degree of similarity between the new MPI and PBI while
assessing plaque accumulation. The results showed that in
study 1, MPI was not correlated with PBI at the proximal site (r or
r 5 0.080-0.275, P ..05), and there was only a fair correlation at
the cervical site (r 5 0.251; r 5 0.398, P ,.05). Third, predictive
validity was analyzed to determine the predictability of the new
MPI for gingivitis. There were moderate correlations (r or
r 5 0.549-0.742) between MPI at week 12 and PBI at week 28
after oral hygiene instruction (P ,.05), suggesting that MPI can
be used to assess gingivitis. Finally, the treatment sensitivity of
MPI significantly exceeded that of TQHI. In study 1, the largest
treatment sensitivity was observed for proximal MPI measures,
whereas study 2 showed the largest effects for cervical mea-
sures. This resulted in a reduction of more than 70% of the
sample size required to determine significant treatment effects.
Conclusions
The MPI allows a valid assessment of plaque at the gingival
margin. It shows good convergence with TQHI and has
similar concurrent and predictive validity for PBI. For oral
hygiene interventions, the treatment sensitivity of MPI
significantly exceeds that of TQHI.
COMMENTARY AND ANALYSIS
Various plaque indices have been developed since the 1960s.
These can be broadly classified into indices that quantita-
tively assess the area of plaque accumulation and those that
qualitatively assess the thickness and maturity of dental pla-
que.1,2 Most plaque indices have been used to assess the
plaque accumulation quantitatively based on various opera-
tional definitions. Of these indices, the Silness and Löe Index
(SLI) is virtually the only index that assesses the thickness and
maturity of plaque in relation to gingivitis.3 In this context, the
new marginal plaque index (MPI) suggested by Deinzer et al.4
is a promising attempt to develop a plaque index that focuses
on the assessment of gingivitis.
In the MPI, gingival margins of the buccal and lingual side are
divided into 4 areas to assess the presence of plaque on each
area dichotomously. The researchers used a sophisticated
study design to verify the accuracy of this tool in assessing
proximal and cervical plaques. Furthermore, on the basis of 3
types of validity analyses, they reported that the newly
December 2017 417
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 2. Visualization of old plaque by quantitative light-induced fluorescence–digital. White-light image (A) and
fluorescence image (B) were taken at the same time.
developed MPI is a significant tool for assessing plaque on
marginal sites, a cause of gingivitis. The authors proved that
MPI has a high convergent validity with the TQHI, a widely
accepted and already validated standard, by showing an
excellent correlation coefficient between the 2 indices.
Furthermore, the authors presented the clinical measurement
values of gingivitis through the PBI as well as determined the
criterion validity between this clinical reference value and the
MPI. When PBI and MPI were concurrently assessed or
assessed after a 16-week interval, the 2 indices had fair to
moderate correlation, with relatively lower criterion validity
than convergent validity. Nevertheless, the criterion validity of
MPI as reported by the authors validated the clinical use of MPI.
In particular, one of the strengths of MPI is that it can lower the
Figure 3. Red fluorescent dental plaque in a cat (A) and plaque detection algorithm of quantitative light-induced
fluorescence (B).
Adapted from Marshall–Jones et al. Res Vet Sci 2017; 111:99-107.
418 Volume 17, Number 4
number of required subjects for clinical trials by more than 30%
of that required conventionally. This may be attributed to a
considerably higher sensitivity of MPI for assessing proximal
and cervical plaques as compared to TQHI.
However, a few issues in terms of study methodology must be
addressed to confirm the clinical efficacy of MPI. First, reliability
should be preferentially proved prior to validity when verifying a
new technique. In particular, intraexaminer and interexaminer
reliabilities are very important factors that may affect the future
use of a new technique. The lack of reliability assessment was
mentioned as a limitation of this study, an important limitation
that precludes the clinical applicability of the results of the
study. Second, the establishment of the gold standard is very

important when assessing the validity of the new technique.
The authors presented TQHI as the standard to verify the val-
idity of MPI. Developed in 1970, TQHI is an index that reflects
the morphological differences in the extension of plaque
deposition; fundamentally, it is an index that only considers the
quantitative aspect of plaque.5 For this reason, TQHI has been
widely used as an index to assess the effectiveness of
toothbrushing. The newly developed MPI is an index to
assess plaque accumulation related to gingivitis. The fact that
the concurrent validity of MPI with PBI (a gold standard
reflecting gingivitis) as well as TQHI was weak (r or r 5 0.251-
0.398, P , .05) suggests that both these indices mostly assess
the area of plaque accumulation and are inadequate for
assessing the pathogenic maturity of plaque related to
gingivitis. Such a limitation is also evident from studies where
the correlation coefficients improved after staining old
plaques blue with the Mira-2-Ton solution. Therefore, the au-
thors would have been able to present better clinically relevant
outcomes if they had assessed the validity of MPI with reference
to SLI, which has a high association with the pathogenic
maturity of plaque.
The new MPI method introduced in this study has not
fundamentally deviated much from the paradigm of subjec-
tive visual assessment in the area of stained plaque, as with
the TQHI. The authors also mention subjective visual in-
spection as a limitation of MPI. Thus, any new plaque index
that is developed in the future should meet various conditions
that include the following: ensuring objectivity, reducing the
number of subjects by increasing the sensitivity of the tool,
and lowering the degree of discomfort for the subjects. Pla-
que assessment using image analysis may be such an alter-
native. The autofluorescence-based plaque quantification
(APQ) method by quantitative light-induced fluorescence
(QLF) technology may be a promising method that can assess
the accumulation area as well as the pathogenic maturity of
the plaque. A recent study reported the potential of the APQ
method as a new plaque index, due to the reason that it had
an excellent interexaminer reliability (intraclass correlation
coefficient 5 0.980, P , .0001), as well as a moderate cor-
relation with the traditional plaque indices TQHI and SLI (for
TQHI, r 5 0.479; for SLI, r 5 0.506, P , .05).6 In addition,
plaque emitting red fluorescence assessed by the QLF-
Digital (QLF-D; QLF-D Biluminator21; Inspektor Research
Systems BV, Amsterdam, the Netherlands) was highly corre-
lated with blue-stained plaque that represents the old plaque
(r 5 0.58-0.62, P , .05, Figure 2).7 Furthermore, red
fluorescence was useful for determining the pathogenicity,
as the cutoff point for the intensity of the red fluorescence
could be freely adjusted in the analysis software. The APQ
method also significantly reduced the discomfort of the
subjects and lowered the number of required subjects with
enhanced sensitivity. Recently, in veterinary medicine, the
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The Journal of EVIDENCE-BASED DENTAL PRACTICE
QLF technology was used in place of the modified Logan
and Boyce method—a traditional plaque assessment
method that requires general anesthesia and plaque
staining—to assess the plaque in cats. This eliminated the
need for general anesthesia, thereby promoting animal
welfare (Figure 3).8 Furthermore, the study reported that the
number of animal subjects was reduced to less than one-
third of that required by the traditional plaque assessment
method by substantially enhancing the sensitivity of the test.
Such previous findings imply that replacing the current use
of subjective visual inspection methods with image analysis
using QLF technology would lead to the beginning of an era
of automated plaque assessments. Moreover, these new
attempts would further improve the clinical significance of
plaque indices by improving sensitivity in assessment of old
plaques, a cause of periodontal diseases.
REFERENCES
1. Löe H. The gingival index, the plaque index and the retention
index systems. J Periodontol 1967;38:610-6.
2. Greene JC, Vermillion JR. The oral hygiene index: a method for
classifying oral hygiene status. J Am Dent Assoc 1960;1:172-9.
3. Silness J, Löe H. Periodontal disease in pregnancy II. Correlation
between oral hygiene and periodontal condition. Acta Odontol
Scand 1964;22:121-35.
4. Deinzer R, Jahns S, Harnacke D. Establishment of a new marginal
plaque index with high sensitivity for changes in oral hygiene.
J Periodontol 2014;85:1730-8.
5. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation
by the chloromethyl analogue of victamine C. J Periodontol
1970;41:41-3.
6. Han SY, Kim BR, Ko HY, et al. Validity and reliability of
autofluorescence-based quantification method of dental plaque.
Photodiagnosis Photodyn Ther 2015;12:587-91.
7. Han SY, Kim BR, Ko HY, et al. Assessing the use of Quantitative
Light-induced Fluorescence-Digital as a clinical plaque assess-
ment. Photodiagnosis Photodyn Ther 2016;13:34-9.
8. Marshall-Jones ZV, Wallis CV, Allsopp JM, et al. Assessment of dental
plaque coverage by Quantitative Light-induced Fluorescence (QLF)
in domestic short-haired cats. Res Vet Sci 2017;111:99-107.
REVIEWERS
Hee-Eun Kim, RDH, PhD
Department of Dental Hygiene, Gachon University College
of Health Science, Yeonsu-gu, Incheon, Republic of Korea
Baek-Il Kim, DDS, PhD
Department of Preventive Dentistry and Public Oral Health,
Yonsei University College of Dentistry, Seodaemun-gu,
Seoul, Republic of Korea, drkbi@yuhs.ac
December 2017 419