ObjectivesWhen managing deep carious lesions, dentists can maintain pulp vitality via (1) avoiding pulp exposure and complications by performing selective (SE) instead of non-selective (NS) carious tissue removal, and/or (2) treat exposed pulps by direct capping with mineral-trioxide-aggregate (MTA) instead of calcium hydroxide (CH). We assessed the cost-effectiveness of SE vs. NS combined with direct pulp capping using MTA vs. CH. MethodsA mixed public-private-payer perspective within German healthcare was applied. We modeled a permanent molar with a deep carious lesion and a vital asymptomatic pulp. The lesion was treated by SE/NS and, in case of exposure, direct pulp capping using MTA/CH. The tooth was followed over the lifetime of an initially 30-year-old patient using Markov-models, informed by pairwise and Bayesian network meta-analyses and further data sources. The primary health outcome was tooth-retention time. Costs were derived from German fee item catalogues, combined with micro-costing. Monte-Carlo micro-simulation was performed, and uncertainty introduced via probabilistic and univariate sensitivity analyses. Value-of-information-analysis (VOI) was performed to quantify the value of further research. ResultsSE and, in case of pulp exposure, MTA had a high chance (>95 %) of being cost-effective, with teeth being retained for 37.37 years at costs of 2140 Euro in mean. Alternative strategies were both more costly and less effective; this ranking was robust in sensitivity analyses. The VOI was 1.18 Euro per treated case and 12.86 million Euro on population-level. ConclusionSelective carious tissue removal and, in case of pulp exposure, direct capping with MTA was the most cost-effective strategy. Clinical significanceAvoiding pulp exposure was more relevant for cost-effectiveness than how the exposed pulp was managed. Overall differences remain limited, though, and dentists may want to tailor treatment strategies according to their expertise and patients’ expectations.