Objective The role of elective neck dissection (END) in patients with stage I (T1N0) and II (T2N0) squamous cell carcinoma of the oral cavity remains a controversial topic. We investigate the need for END by establishing a true incidence of occult nodal disease as a function of T stage Data Sources MEDLINE, Google Scholar, Scopus. Review Methods Studies were selected using a set of inclusion and exclusion criteria. Meta‐analysis using a random‐effects model was employed to generate an odds ratio (OR) comparing the incidence of occult metastasis between T1 and T2 tumors, as well as regional recurrence rates between patients receiving END versus observation. Results Thirty‐nine publications comprising five randomized controlled trials and 34 retrospective studies were selected for inclusion, yielding over 4,300 patients for analysis. The overall incidence of occult nodal metastasis, weighted by study size, was found to be 23%. Patients with T2 tumors have a significantly higher odds of having occult nodal disease (OR: 2.6, 95% confidence interval [CI]: 2.0‐3.4) over patients with T1 tumors. We also demonstrate that for patients who are observed, the odds of recurrence are significantly higher (OR: 4.18, 95% CI: 2.78‐6.28) compared to those who undergo END, although statistically significant interstudy heterogeneity was observed. Conclusions END should be reserved for stage II tumors given the significantly higher rate of occult metastasis. Observation may be more appropriate for stage I cancers. Laryngoscope, 129:E284–E298, 2019