The cloud vs. on-premise question looks different at a DSO than it does at a single practice. A single office is choosing between a local server and a cloud subscription. A DSO is choosing between an infrastructure model that will be replicated across every location it opens or acquires for years to come.
That decision has compounding consequences. Here is how the tradeoffs actually play out at scale.
On-Premise: New Location Cost
New server + local IT setup + ongoing hardware maintenance at that site
Cloud: New Location Cost
Internet connection + workstation readiness + network configuration
Every new location a DSO opens on an on-premise model requires a new server, local IT setup, and ongoing hardware maintenance at that site.
Every new location on a cloud model requires an internet connection, workstation readiness, and network configuration. The upfront costs differ. The ongoing management costs differ more.
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On-premise means each location has a local server running the practice management software. Data is stored at the location. Each server requires its own maintenance, patching, backup management, and eventual hardware replacement.
Advantage at Scale
Data ownership and performance independence: daily operations do not depend on internet connectivity
If the internet goes down, the server keeps running: clinical work is not interrupted by connectivity issues
Full control over data storage location: relevant for practices with strong data sovereignty preferences
Disadvantage at Scale
Overhead multiplies: every server is a maintenance responsibility at every location
Hardware refresh affects multiple locations on different replacement cycles simultaneously
Cross-location reporting requires additional infrastructure to connect the separate databases
How Cloud Works at DSO Scale
Cloud infrastructure changes the DSO’s IT model in three ways:
1
No Server per Location
Cloud platforms eliminate the per-location server requirement
New locations are stood up faster with less upfront hardware cost and no server maintenance responsibility. The IT work at each new location shifts from hardware procurement and server setup to internet speed confirmation, workstation configuration, and network optimization.
2
Internet Becomes Critical Infrastructure
Every location’s daily operations depend on internet connectivity
A backup internet connection at each site is not optional. It is a requirement. This is the most significant operational difference from on-premise: a single ISP outage that was previously inconvenient becomes a practice-stopping event. Planning for this is part of the cloud migration, not an afterthought.
3
Centralized by Default
Cloud platforms store all location data in a single environment
Cross-location reporting and access control are easier to manage from the start because the data is already in one place. The infrastructure complexity that on-premise DSOs build over time to connect separate databases is eliminated by the architecture. This is why most DSO groups standardize on cloud as they scale.
What Most DSOs Actually Do
1
Start
Acquire practices already running on-premise systems
2
Transition
Manage mixed environment while standardizing over time
3
Goal
Cloud standardization via planned migration schedule
The practical implication is that your IT provider needs to support both models simultaneously during the transition period. A provider that only knows cloud or only knows on-premise is a liability in a mixed environment. Most DSOs spend two to four years in the mixed state before full cloud standardization.
Is Your DSO Ready to Move to Cloud?
Check each condition that currently applies to your group. The result points toward where your DSO sits on the cloud readiness spectrum.
Cloud readiness factors confirmed0 / 5
Your DSO has the infrastructure and IT support for cloud migration.
All five readiness factors are in place. Proceeding with cloud standardization on a planned schedule is the right next step. Confirm your data migration plan and staff training timeline with the cloud platform’s onboarding team before setting the go-live date at each location.
Cloud migration is viable but infrastructure gaps need to be addressed first.
The unchecked factors are the most common causes of failed cloud go-lives in dental DSO environments. Each one must be resolved before migration is scheduled, not after. The IT work required to close these gaps should be part of the migration planning timeline.
Your DSO is not ready for cloud migration.
Multiple infrastructure prerequisites are not in place. Migrating to a cloud platform before resolving these will result in performance failures at go-live that disrupt patient care. The on-premise model may be the right choice for current operations while the infrastructure needed for a successful cloud transition is built.
Both models can be fully HIPAA-compliant. The compliance requirements are the same regardless of infrastructure model. Cloud platforms shift some technical safeguard responsibilities to the vendor. On-premise keeps those responsibilities with the practice. Either way, documentation of the safeguards in place is required.
Most cloud dental platforms recommend a minimum of 25 Mbps download and 10 Mbps upload per active workstation. A location with six active workstations needs significantly more than the minimums. A backup internet connection is also essential for any location running a cloud-dependent practice management platform.
Yes, and most do during transition periods. Mixed environments are manageable with the right IT provider but require more support complexity than a standardized model. Centralized reporting across a mixed environment requires third-party analytics tools that can pull from both infrastructure types.
Dentrix Ascend, Curve Dental, CareStack, and Denticon are the most commonly evaluated cloud platforms for DSO use. Each has different strengths in multi-location management, reporting depth, and pricing structure. The right choice depends on the DSO's size, growth pace, and existing software relationships.
Deciding between cloud and on-premise for your DSO? That choice gets replicated across every location you open from here on out.
Ekim IT Solutions works exclusively with dental practices. We serve New England and New York with on-site support and dental practices nationwide with remote support. We help DSOs evaluate cloud vs. on-premise infrastructure based on their software stack, growth trajectory, and compliance requirements so the model you choose actually scales.
The wrong infrastructure model at the DSO level compounds with every location you add. Get the decision right before it scales.
Ezra Angelo
