Introduction The demographic and epidemiological transitions are causing changes in the health profile worldwide. Among the various areas of healthcare, oral health is in a precarious situation. The objective was to examine the link between tooth loss and multilevel factors in a national sample of middle-aged adults in Brazil.

Methods Analyses were based on the 2003 cross-sectional national epidemiological survey of the oral health of the Brazilian population, which covered 13 431 individuals (age 35–44 years). Multistage cluster sampling was used. The dependent variable was tooth loss and the independent variables were classified according to the individual or contextual level. A multilevel negative binomial regression model was adopted.

Results The average tooth loss was 14 teeth. Half of the individuals had lost 12 teeth. The contextual variables showed independent effects on tooth loss. It was found that having 9 years or more of schooling was associated with protection against tooth loss (means ratio range 0.68–0.76). Not having visited the dentist and not having visited in the last 3 years accounted for increases of 33.5% and 21.3%, respectively, in the risk of tooth loss. The increase in tooth extraction ratio showed a strong contextual effect on increased risk, besides changing the effect of protective variables.

Conclusion Tooth loss in middle-aged adults has important associations with social determinants of health. This study points to the importance of the social context as the main cause of oral health injuries suffered by most middle-aged Brazilian adults.