The aim of this study was to estimate prevalence of negative self-rated oral health and associated factors among adults in rural settlements. The probabilistic sample consisted of 557 adults 20 to 59 years of age in rural settlements in Pernambuco State, Brazil. The dependent variable was self-rated oral health, with the following independent variables: demographic characteristics, predisposition and availability of resources, oral health-related behavior, objective oral health conditions, and subjective oral health conditions. Crude and adjusted prevalence ratios were estimated using a Poisson regression model. Prevalence of negative self-rated oral health was 70.5%. Negative self-rated oral health was associated with younger age, lower schooling, female gender, and black or brown skin color. Predictors of negative self-rated oral health included skin color, self-defined need for dental care, and the impact of oral health problems on quality of life.