Dentofacial Disharmony Research Articles

Pediatrics, Craniofacial and Orthognathic Surgery Track: Impacts of Dentofacial Disharmony and its Surgical Correction on Speech

Pediatrics, Craniofacial and Orthognathic Surgery Track: Impacts of Dentofacial Disharmony and its Surgical Correction on Speech

Impact of orthognathic surgery on voice and speech: a systematic review and meta-analysis.

Orthognathic surgical procedures, whether in one or both jaws, can affect structures regarding the articulation and resonance of voice and speech. Evaluating the impact of orthognathic surgery on voice and speech performance in individuals with skeletal dentofacial disharmony. Word combinations and truncations were adapted for the following electronic databases: EMBASE, PubMed/Medline, Scopus, Web of Science, Cochrane Library, and Latin American and Caribbean Literature in Health Sciences (LILACS), and grey literature. The research included studies on nonsyndromic adults with skeletal dentofacial disharmony undergoing orthognathic surgery. These studies assessed patients before and after surgery or compared them with individuals with good facial harmony using voice and speech parameters through validated protocols. Two independent reviewers performed all stages of the review. The Joanna Briggs Institute tool was used to assess risk of bias in the cohort studies, and ROBINS-I was used for nonrandomized clinical trials. The authors also performed a meta-analysis of random effects. A total of 1163 articles were retrieved after the last search, of which 23 were read in full. Of these, four were excluded, totalling 19 articles for quantitative synthesis. When comparing the pre- and postoperative periods, both for fundamental frequency, formants, and jitter and shimmer perturbation measures, orthognathic surgery did not affect vowel production. According to the articles, the main articulatory errors associated with skeletal dentofacial disharmonies prior to surgery were distortions of fricative sounds, mainly/s/ and/z/. Orthognathic surgery may have little or no impact on vocal characteristics during vowel production. However, due to the confounding factors involved, estimates are inconclusive. The most prevalent articulatory disorders in the preoperative period were distortion of the fricative phonemes/s/ and/z/. However, further studies must be carried out to ensure greater robustness to these findings. PROSPERO (CRD42022291113).

Impacts of Development, Dentofacial Disharmony, and Its Surgical Correction on Speech: A Narrative Review for Dental Professionals.

Speech is a communication method found only in humans that relies on precisely articulated sounds to encode and express thoughts. Anatomical differences in the maxilla, mandible, tooth position, and vocal tract affect tongue placement and broadly influence the patterns of airflow and resonance during speech production. Alterations in these structures can create perceptual distortions in speech known as speech sound disorders (SSDs). As craniofacial development occurs, the vocal tract, jaws, and teeth change in parallel with stages of speech development, from babbling to adult phonation. Alterations from a normal Class 1 dental and skeletal relationship can impact speech. Dentofacial disharmony (DFD) patients have jaw disproportions, with a high prevalence of SSDs, where the severity of malocclusion correlates with the degree of speech distortion. DFD patients often seek orthodontic and orthognathic surgical treatment, but there is limited familiarity among dental providers on the impacts of malocclusion and its correction on speech. We sought to review the interplay between craniofacial and speech development and the impacts of orthodontic and surgical treatment on speech. Shared knowledge can facilitate collaborations between dental specialists and speech pathologists for the proper diagnosis, referral, and treatment of DFD patients with speech pathologies.

Impacts of anterior-posterior jaw disproportions on speech of dentofacial disharmony patients.

Articulation problems impact communication, development, and quality of life, and are diagnosed in 73-87% of patients with Class II Dentofacial Disharmony (DFD). We evaluated whether differences exist in stop (/t/ or/k/), fricative (/s/ or/ʃ/), and affricate (/tʃ/) consonant sounds of Class II DFD subjects, and whether extent of malocclusion correlates with severity of speech distortion. We hypothesized that Class II patients display milder distortions than Class III and anterior open bite (AOB), as Class II patients can posture into a Class I occlusion. Audio and orthodontic records were collected from DFD patients (N = 53-Class II, 102-Class III, 72-Controls) who were pursuing orthodontics and orthognathic surgery. A speech pathologist perceptually scored speech. Acoustic differences in recordings were measured using Spectral Moment Analysis. When Class II subjects were compared to controls, significant differences were found for the centroid frequency (M1) of the /s/ sound and the spectral spread (M2) of /t/, /tʃ/, and /s/ sounds, with pairwise significance for controls relative to Class II AOB and all Class II subjects. Class II AOB subjects had higher M1 and M2 values than patients with Class II closed bites and Class I controls for most sounds. When comparing across anterior-posterior (AP) groups, differences exist between controls, Class II and III DFD subjects for M1 of /t/, /tʃ/, and/ʃ/ and M2 for /t/, /tʃ/, /s/, and /ʃ/ sounds. Using linear regression, correlations between Class II and III severity and spectral measures were found for /t/ and /tʃ/ sounds. Class II and III patients have a higher prevalence of qualitative distortions and spectral changes in consonants compared to controls, but Class II spectral shifts are smaller and affect fewer sounds than in Class III and AOB cohorts. Linear correlations between AP discrepancy and spectral change suggest causation and that treatment may improve articulation problems.

TEMPORARY MALOCCLUSION TREATMENT AT MIX DENTITION PERIOD

The growth and development of primary teeth in children need attention from an early age because primary teeth have an important role in mastication, and speech development and provide a place for the eruption of their permanent teeth. Malocclusion is a condition of dentofacial disharmony that can interfere with mastication, swallowing, speech, and facial alignment. Case Report: A mother and her daughter, 9-year-old, came with the complaint that her daughter's teeth look crowding. The left mandibular canine looks more backward because previously, there were primary teeth that had accumulated and had been extracted, while the two maxillary canines looked crooked. The patient and parents were educated to push the teeth with the tongue daily as often as possible. After a 4-month evaluation, the tooth was in the proper dental arch. However, fixed orthodontic treatment was required when all of the patient's teeth fully erupted to correct the patient's maxillary malocclusion. Conclusion: The growth and development of primary teeth in children need attention from an early age. Malocclusions that are found early, can be treated early to prevent the severity of the malocclusion from increasing.

Validating Spectral Moment Analysis as a Quantitative Measure of Speech Distortions in Speakers With Class III Malocclusions.

This study examined the relationship between judged speech sound distortions and spectral moment metrics in speakers with Class III malocclusion. A quantitative online survey was distributed to 30 speech specialists (clinicians and/or students) and 100 lay listeners to judge the clarity of the sounds /s/, /ʃ/, /t/ and /k/ using a visual analog scale (VAS) from recordings of 11 Class III (underbite) Dentofacial Disharmony (DFD) patients and eight Class I controls. Patients and controls were grouped according to high, moderate, and low /s/-/ʃ/ first spectral moment differences. A linear mixed model was used to analyze the data. VAS scale ratings increased as a function of decreasing spectral contrast for both groups of listeners. VAS ratings of speech specialists were more homogenous than lay listeners, and speech specialists rated distortions as less severe than lay listeners. Recordings of Class III DFD patients with low /s/-/ʃ/ first spectral moment differences were scored by listeners as having increased VAS scale ratings, indicative of more significant perceived speech-sound distortions. Spectral moment analysis appears to be a promising approach for characterizing speech of DFD patients and other craniofacial disorders.

Ortho-surgical procedure involving mandible, maxilla, mento and associations: a systematic review

Introduction: Orthognathic surgery (OS) consists of the surgical procedure that aims to correct deformities of the bones of the maxilla and mandible. The records of the first surgeries for the correction of dentofacial deformities date from the mid-nineteenth century and were initially limited to mandibular surgeries. The malocclusion has as one of the primary etiological factors the facial growth pattern. Angle's statement already said that the only possibility of correcting true dentofacial deformities was the combination of orthodontics with surgery, and the importance of the combined effort of these two distinct areas in the approach to dentofacial disharmony in patients with problems was recognized skeletal. Objective: This study aimed to review the literature on OS involving mandible, maxilla, mento and associations. Methods: Clinical studies with qualitative and/or quantitative analysis were included, following the rules of the systematic review-PRISMA. Results: A total of 107 articles were found involving “orthognathic surgery". A total of 47 articles were evaluated in full, and 33 were included and discussed in this study. Individuals with class III dentofacial deformities are those that normally present greater aesthetic and functional impact, and for this reason, are the ones that more frequently seek treatment. However, some studies have shown a tendency for complications to occur in older patients submitted to orthognathic surgeries. Mandibular surgical procedures with maxillary segmentation and combining three types of osteotomies should be carefully planned and trained to reduce the occurrence of complications. The surgeon, orthodontist, and all staff involved should be focused on avoiding complications during all phases of treatment. Conclusion: It was concluded that there was an increase in the cases of OS in the last years, and with homogeneous samples between the masculine and feminine genres, and the advances in maxillary surgery corresponded to the greater number of surgical treatments.

Surgically Facilitated Orthodontic Therapy (SFOT): Diagnosis and Indications in Interdisciplinary Dentofacial Therapy Involving Tooth Movement.

What are the key considerations for the interdisciplinary dentofacial therapy (IDT) team in the diagnostic process to evaluate a patient for surgically facilitated orthodontic therapy (SFOT)? SFOT creates a demineralized bone matrix and augments dentoalveolar deficiencies in the management of dentofacial disharmony malocclusion. Numerous indications and contraindications exist which are essential to the periodontal surgeon for proper case selection. A collaboratively focused workup by an IDT team is equally essential. Cone beam computed tomography (CBCT) and orthodontic simulation software which identifies changes in the dentoalveolar complex influenced by tooth movement are critical in providing transparency to the patient and IDT team during the treatment planning process. Such transparency can aid the team in assessing goals and outcomes that consider and respect foundational dentoalveolar parameters while contributing to sustainable outcomes. The SFOT IDT decision making process is complex, yet full of opportunities. Embracing SFOT IDT with innovative and novel 3D technology can optimize conditions leading to long-term outcomes that align with periodontal stability as well as patient goals and preferences which permeate beyond the achievement of "straightening teeth". Transparency of complex IDT through 3D CBCT and orthodontic simulation software engenders "collaborative accountability" and can improve patient communication which is critical to developing meaningful and essential treatment plans.

Manejo de pseudoaneurisma de la arteria esfenopalatina posterior a osteotomía LeFort I

La formación de pseudo-aneurismas en el complejo vascular de la región maxilofacial no son comunes, los reportes encontrados en la bibliografía indican que los mecanismos romos (iatrogenia) es la causa principal. Se describe caso de paciente masculino de 17 años de edad con desarmonía dentofacial, que presentó un pseudo-aneurisma de la arteria esfenopalatina derecha, como una rara y seria complicación a una ostetomía Lefort I, misma que se trató con embolización trans-arterial mediante la liberación de dos coils. Se revisó los conceptos de aneurismas, así como las modalidades para su tratamiento. Sugiriendo la intervención endovascular como primera línea de manejo, relegando a la intervención quirúrgica a situaciones de trauma penetrante, con instalaciones y habilidades adecuadas.

Orthodontic-surgical treatment of a class II division 1 patient. Case report

The objective of this case report was to show the correction of a class II division 1 malocclusion in an adult patient. A female patient of 20 years of age attended the Orthodontics Clinic of the Division of Postgraduate Studies and Research of the Odontology Faculty at the National Autonomous University of Mexico. Her main reason for consultation was: «When I removed the wisdom teeth I was told that I could have orthognathic surgery but fi rst I needed braces»; this in order to correct the dentofacial disharmony. Upon facial clinical examination, the patient presented a mesofacial biotype with competent lips; vertically she presented an increased lower third. Her profile was convex with deficient chin projection. Intraorally, the patient exhibited upper and lower crowding, molar and canine class II, considerably increased overbite and overjet as well as noncoincident dental midlines. The cephalometric diagnosis showed a skeletal class II due to maxillary protrusion. It was suggested an orthodontic-surgical treatment in three phases: presurgical, surgical and postsurgical. In the presurgical phase the patient was decompensated in order to prepare her for surgery. During the surgical phase, mandibular sagittal osteotomies were performed to advance the mandible in combination with an advancement genioplasty. During the post-surgical phase, ideal occlusal relationships were achieved in terms of canine classes, overbite, overjet, dental midlines and fi nal detailing of the case. Through the treatment, the occlusion and facial harmony of the patient were improved.

Psychological Evaluation of the Patient Treated for Skeletal Disharmony of the Jaws Corrected with Orthognathic Surgery: An Assessment Tool

The number of patients treated with orthognathic surgery is steadily increasing. It is estimated 1.2 million people in the US could benefit from orthognathic surgery. From a surgical standpoint the goal is to correct a functional handicap, whether it is an inability to correctly masticate, a presence of temporomandibular disease or airway abolition. Orthognathic surgery candidate patients normally are well aware of their dentofacial disharmony before seeking treatment. It is well documented that there is a high prevalence of psychological disturbances in patients seeking esthetic alteration through plastic surgery. Currently, the Oral Surgeon is limited in the management of the psychological aspect of patients undergoing orthognathic surgery since there is a lack of a validated tool for assessment. Our overall goal was to develop a survey focusing specifically on the patient’s perception regarding orthognathic surgery.

Optimizing Hybrid Occlusion in Face-Jaw-Teeth Transplantation: A Preliminary Assessment of Real-Time Cephalometry as Part of the Computer-Assisted Planning and Execution Workstation for Craniomaxillofacial Surgery.

The aesthetic and functional outcomes surrounding Le Fort-based, face-jaw-teeth transplantation have been suboptimal, often leading to posttransplant class II/III skeletal profiles, palatal defects, and "hybrid malocclusion." Therefore, a novel technology-real-time cephalometry-was developed to provide the surgical team instantaneous, intraoperative knowledge of three-dimensional dentoskeletal parameters. Mock face-jaw-teeth transplantation operations were performed on plastic and cadaveric human donor/recipient pairs (n = 2). Preoperatively, cephalometric landmarks were identified on donor/recipient skeletons using segmented computed tomographic scans. The computer-assisted planning and execution workstation tracked the position of the donor face-jaw-teeth segment in real time during the placement/inset onto recipient, reporting pertinent hybrid cephalometric parameters from any movement of donor tissue. The intraoperative data measured through real-time cephalometry were compared to posttransplant measurements for accuracy assessment. In addition, posttransplant cephalometric relationships were compared to planned outcomes to determine face-jaw-teeth transplantation success. Compared with postoperative data, the real-time cephalometry-calculated intraoperative measurement errors were 1.37 ± 1.11 mm and 0.45 ± 0.28 degrees for the plastic skull and 2.99 ± 2.24 mm and 2.63 ± 1.33 degrees for the human cadaver experiments. These results were comparable to the posttransplant relations to planned outcome (human cadaver experiment, 1.39 ± 1.81 mm and 2.18 ± 1.88 degrees; plastic skull experiment, 1.06 ± 0.63 mm and 0.53 ± 0.39 degrees). Based on this preliminary testing, real-time cephalometry may be a valuable adjunct for adjusting and measuring "hybrid occlusion" in face-jaw-teeth transplantation and other orthognathic surgical procedures.

Orientation of the occlusal plane in a Class I adult population

To primarily evaluate whether Delaire's ideal occlusal plane is present in Class I occlusal relationship adults. Pretreatment lateral cephalometric radiographs from 30 orthodontically untreated Caucasian Class I malocclusion adults were obtained. The occlusal, mandibular, and maxillary planes were traced and compared with the ideal occlusal, mandibular, and maxillary planes according to Delaire. The average occlusal plane was 3.5° below the ideal plane. This divergence was more pronounced in males, and in patients presenting with a hypodivergent skeletal pattern. The maxillary plane displayed on average less than 0.5° of divergence to the ideal. The average mandibular plane showed a divergence of 3.3° below the ideal. When aiming to obtain an ideal orientation of the occlusal plane postoperatively, one must keep in mind that in Class I occlusal relationship adults without any dentofacial disharmony, the occlusal plane is rarely coincident with the ideal plane.

Sensory retraining: burden in daily life related to altered sensation after orthognathic surgery, a randomized clinical trial

Assess the long-term effect of sensory retraining exercises, age, gender, type of surgery, and pre-surgical psychological distress on patients' perception of the interference related to altered sensation 2 years after orthognathic surgery. A total of 186 subjects with a developmental dentofacial disharmony were enrolled in a multicenter randomized clinical trial: one center was a community-based practice and the other a university-based center. Subjects were randomly allocated to two groups: standard of care mouth opening exercises after BSSO or a progressive series of sensory retraining facial exercises in addition to the opening exercises. At 1, 3, 6, 12, and 24 months after surgery, subjects scored unusual feelings on the face, numbness, and loss of lip sensitivity from 'no problem (1)' to 'serious problem (7)'. A marginal proportional odds model was fit for each of the ordinal outcomes. Up to 2 years after surgery, the opening exercise only group had a higher likelihood of reporting interference in daily activities related to numbness and loss of lip sensitivity than the sensory retraining exercise group. The difference between the two groups was relatively constant. Older subjects and those with elevated psychological distress before surgery reported higher burdens related to unusual facial feelings, numbness, and loss of lip sensitivity (p < 0.02). The positive effect of sensory retraining facial exercises observed after surgery is maintained over time. Clinicians should consider the patient's age and psychological well-being prior to providing pre-surgical counseling regarding the impact on daily life of persistent altered sensation following a mandibular osteotomy.

Occlusal perceptions of children seeking orthodontic treatment: Impact of ethnicity and socioeconomic status

With the growth of orthodontic intervention at younger ages and increased interest in improving dentofacial appearance among the general public, it is important to assess whether demand for treatment is uniform across ethnic and socioeconomic groups. This study compared 3 groups of children who varied by location, payment source, and ethnicity. The sample consisted of 150 children in the Bronx, NY, and 100 in Seattle, Wash, who were undergoing or anticipating orthodontic treatment in publicly funded dental clinics. Ethnic minorities comprised 69% and 92%, respectively, of these groups. The third group consisted of 84 children in Seattle, Anchorage (Alaska), and Chicago who had sought treatment by private practitioners; ethnic minorities comprised 22% of this group. Data were collected from children and parents or guardians by questionnaires. Desire for treatment was higher among children in the publicly funded clinics and among black children than whites or Asian Americans. Children in publicly funded clinics rated themselves as having worse occlusions as determined by anterior crowding, overbite, overjet, diastema, and open bite. Children in the Bronx clinic accepted a wider range of occlusion as attractive. Stage of treatment affected judgments of attractiveness. Vicarious experience with orthodontics through parents or siblings made children more tolerant of dentofacial disharmony, with more favorable ratings of malocclusion in this group than among children who had no family experience with orthodontics. Hispanic and mixed-ethnicity children rated themselves more negatively on all dimensions. These results suggest that both socioeconomic status and ethnicity play roles in children's desire for treatment, self-assessed need, and judgments of esthetics. A clinician's sensitivity to such differences can improve patient cooperation with treatment.

Perceptions of recovery and satisfaction in the short term after orthognathic surgery

Purpose A 2-arm, parallel-group, stratified-block, randomized clinical trial was designed to assess whether patients’ perceptions of recovery and satisfaction 4 to 6 weeks after surgery were affected by 3 factors: preparation strategy (viewing a visual treatment simulation), attitudes (expectations about recovery), and psychologic distress (reported before surgery). Patients and methods One hundred eighty-four patients with a dentofacial disharmony scheduled for orthognathic surgery were randomly assigned to 1 of 2 preparation strategy groups: a standard presurgical consultation with or without a computerized treatment simulation presentation. Psychologic well-being and expectations regarding recovery were obtained before surgery and perceptions of recovery, and satisfaction were assessed for 126 patients at 4 to 6 weeks after surgery. Results Viewing a treatment simulation before surgery did not affect patients’ perceptions of postsurgical discomfort or satisfaction at 4 to 6 weeks after surgery. Patients who overestimated the discomfort or problems they would experience reported significantly lower average level of problems than those who did not overestimate. Patients who were psychologically distressed before surgery reported, on average, significantly more discomfort or difficulty with symptoms, social/self-concerns, general health, and overall recovery after surgery. Conclusion Viewing a treatment simulation before surgery does not, on average, negatively affect perception of symptoms or satisfaction 4 to 6 weeks after surgery. Orthognathic surgery patients who are psychologically distressed before surgery tend to report a higher recovery burden overall and, on average, experience more difficulty with symptoms, social/self-concerns, and general health in the first 1 or 2 months after surgery.

A cost–utility analysis of patients undergoing orthognathic treatment for the management of dentofacial disharmony

Introduction: Management of dentofacial discrepancies using orthognathic treatment is now a common procedure in the United Kingdom. Although the benefits of orthognathic intervention are often considered, the cost implications have not been investigated to our knowledge. This study is a cost–utility analysis of orthognathic treatment. Patients and methods: Twenty-one patients were interviewed five times during treatment using the time trade-off (TTO) method to establish utility values. Quality adjusted life years (QALYs) gained as a result of treatment were calculated and discounted. The resource use was calculated for each of the 21 patients individually and the costs subjected to both a sensitivity analysis and discounting. The incremental mean cost per additional QALY was calculated (as compared with a ‘no treatment’ approach). Results: The incremental cost for each additional QALY was £561 for the groups combined, based on mean additional costs and QALYs (£546 for the bimaxillary group and £617 for the single jaw group). Discussion: Orthognathic treatment seems to provide good outcomes at relatively low cost. Even allowing for the uncertainty in mean costs and QALYs, there is a high probability of treatment being cost-effective. Cost–utility analysis is still a relatively new technique in dentistry and further studies should be encouraged.

Prevalence of adapted swallowing in a population of school children

Adapted swallowing (AS) and its effects on dentofacial balance are frequently observed in children with orofacial myofunctional alterations. The preliminary objective of this research was to identify the frequency of cases of adapted swallowing in a population of school children, and targeting early treatment to prevent morphofunctional alteration of the face and its consequences on dentofacial harmony. One hundred school children between seven and nine years old attending the Children and Adolescents' Supporting Program (PRODECAD) of the State University of Campinas (UNICAMP) Brazil were selected at random and examined. Orofacial myofunctional assessments were carried out through standardized protocol. Results indicated the prevalence of adapted swallowing associated with resting posture alterations of dentofacial structures and mastication with dentofacial disharmony was 57%. Adapted swallowing without alteration of dentofacial form was observed in 19% of cases, and 24% of cases had a swallowing pattern within normal limits. The high prevalence of alterations suggests the need for early professional intervention.

Issues in decision making: Should i have orthognathic surgery?

This article reviews theoretical issues related to self-perception and decision makingin patients with dentofacial disharmony. The decision-making process among patients seeking treatment for severe malocclusion is not well understood. Using phone interviews and chart audits, attitudes, behaviors, and demographics of 118 patients for whom orthognathic surgery was recommended within the past 2 years at 2 university-based dentofacial centers were examined. The mean age was similar (24.6 and 24.2 years) at both sites. Gender and ethnic distributions differed slightly. The northeast site (UMDNJ) had 50% females and 36% white, while the southeast site (UNC) had 77% females and 79% white. Treatment decisions were comparable across sites: approximately 60% of the patients chose orthognathic surgery, 30% chose orthodontics only, and 10% were undecided, waiting, or under observation. No perceptual differences across sites were observed. More than 50% of patients reported awareness of their condition since early adolescence: 11% indicated that someone else (eg, dentist) made them aware of their problem. Twenty percent said the timing for seeking care was related to financial security or schedule flexibility. Fifty percent reported aesthetics and function were their primary motives. Focus groups/interviews were held (orthognathic v orthodontics only; 2 groups per site). Emerging themes included the importance of patient-doctor communication and interpersonal skills (patient education, patience, and willingness to use “my words,” take time to explain), the importance of the patients' readiness to change, and availability of resources such as social support and finances/insurance. Knowing someone who had completed treatment at their facility was a significant facilitator expressed across sites. No insurance and fear were relevant barriers in the orthodontic group only. The decision-making process is multifaceted. Interpersonal communication skills (rapport, understanding), enabling resources (financial, social support), and psychosocial factors (stress, motivation) were primary factors in patients' decision making. Implications for clinicians are presented as well.

Social Desirability in Patients Seeking Surgical Treatment for Dentofacial Disharmony: Associations with Psychological Distress and Motivation for Treatment

The role of socially desirable responding in the report of treatment motivation and psychological distress by patients seeking surgical treatment for dentofacial disharmony was explored. Participants completed the Balanced Inventory of Desirable Responding (BIDR; Paulhus, 1988), which measures two components of socially desirable responding (SDR): impression management (IM), which is the purposeful tailoring of answers in order to create the most positive social image, and self-deceptive positivity (SDE), which is an honest, but overly positive self-presentation. When simple bivariate relationships were examined, statistically significant inverse associations were observed between socially desirable responding and specific motives for treatment and between SDR and psychological distress. However, the relationship between socially desirable responding and motives for treatment disappeared when the effect of psychological distress was controlled. The positive relationship between psychological distress and the report of social well-being, and self-image motives for treatment remained statistically significant even after the variance attributable to socially desirable responding was removed. Implications of the findings for the evaluation of psychological distress and treatment motivation in this population are discussed.