CLEARWATER — Nine-year-old Sandra Cruz-Quezada has spent a lot of time in the dentist's chair the last few years, with seven cavities needing filling.
Her mother, Sofia, says she tries to instill good dental habits in Sandra and her youngest daughter, Estrella, 3. But as a single mother working at a frame-making factory, she isn't always home to remind the girls to brush their teeth after eating sweets.
"It's difficult," Cruz-Quezada said through a translator, as she waited for her daughters last week at the Pinellas County Health Department dental clinic in Clearwater.
Dentists say low-income families will be hurt the most when Pinellas stops adding fluoride to its water system around the end of the year, a move that will save the county about $205,000 a year.
Sandra's dentist, Dr. Haychell Saraydar of the Health Department, said the girl's problems were with her baby teeth, which came in prior to fluoridation of the water. The dentist said her adult teeth are in better shape.
Though opponents to water fluoridation rightly point out that fluoride is more available than ever — in toothpastes, dental rinses and supplements — dentists and public health officials maintain that having it in tap water is the best, cheapest and easiest way to protect against tooth decay.
"It reaches people of all socioeconomic groups," said Dr. William Bailey, chief dental officer of the U.S. Public Health Service and acting director of the division of oral health at the Centers for Disease Control and Prevention. He called the county's recent decision "disheartening."
Numerous studies and government data show a strong correlation between poverty and kids' oral health. Poor children go to the dentist less frequently and have higher rates of untreated cavities. Poor children in Florida have it particularly tough, with only about a quarter of those covered by Medicaid — such as the Cruz-Quezada family — actually receiving dental services.
A study released this year by the Pew Center on the States gave Florida an F grade for access to dental care for disadvantaged children. Florida ranked last among the 50 states for the percentage of low-income children receiving dental services. Only 25.7 percent do, compared to the national average of 43.8 percent.
Many Pinellas dentists say they're certain what's going to happen once the county closes the taps on fluoridated water.
"There will be higher rates of decay and infection," said Saraydar, who directs the county Health Department's dental program.
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Saraydar has seen the difference fluoridated water makes, having provided dental services to the county's poorest children since 1988, years before fluoride was added to the water.
A few years after it was added to the St. Petersburg/Gulfport area water supply around 1993, "we started to see a marked difference in tooth decay," she said. And after it was added to the rest of the county in 2004, "we started seeing the change in children in the other areas as well."
Dr. Edward Hopwood, a Clearwater dentist and chairman of the fluoridation committee for the Upper Pinellas County Dental Association, said one measure of fluoridated water's success in the county can be seen during an annual program called "Give Kids a Smile," in which area dentists spend one day in February providing free services to low-income children.
Hopwood said dentists have seen a decrease in tooth decay and other dental problems over the past several years among the 400 or so Pinellas children who are seen.
Dr. William Layman, an orthodontist and previous chairman of the "Give Kids a Smile" program, said it will be interesting to see what impact the county's decision will have on those numbers in the years ahead.
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Opponents have raised numerous arguments against fluoridating water. They say it tramples on individual freedoms, and some liken it to the government force-medicating the population. Fluoride, however, is naturally found in many sources of water.
Others say fluoride is a toxic substance that can cause a number of health conditions, including brittle bones and rheumatoid arthritis. One woman who spoke at last week's Pinellas County Commission meeting blamed fluoride in the water for her inability to lose weight.
Some say fluoride is only meant to be applied directly to the teeth, and not ingested, though dentists and others say doing so helps tooth formation.
Because of those reasons, many opponents don't believe low-income children are being especially shortchanged by the decision to remove fluoride.
But then there are others who agree that fluoride is beneficial but still don't think it should be in the water because it's so readily available from other sources, such as toothpaste and dental rinses.
Layman called that a well-constructed debate point. But he also pointed out that salad is sold in stores everywhere, and that doesn't necessarily mean that people are buying it and are healthier as a result.
"Sure, there are tablets, rinses and toothpaste, but there's a cost attached to all of that," Saraydar said. "There's a reason that the indigent have much higher levels of decay."
The odds are stacked against them. Federal data shows that children in families earning below 100 percent of the federal poverty level, or $22,350 a year for a family of four, were much less likely to have visited the dentist in the past year than those earning twice as much. They also had more untreated cavities.
The Times contacted several dentists and scientists who have been on the record opposing fluoridation, but none either responded to or agreed to requests for interviews.
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Cruz-Quezada's children are in that minority of Medicaid recipients who visit the dentist regularly. But she worries about what will happen once they no longer drink fluoridated water.
Saraydar and other dentists likely will prescribe fluoride supplements for children in areas without fluoridated water. But Cruz-Quezada isn't sure whether her $7.25-an-hour job can cover the expense.
"I don't think I can afford that," she said.
Richard Martin can be reached at firstname.lastname@example.org or (813) 226-3322.