Occult spread to regional lymphatics occurs in a significant percentage of patients with early-stage oral cavity cancer. While elective neck dissection continues to be the gold standard for assessing for the presence of occult regional disease, the optimal management strategy continues to evolve. Increasingly, sentinel lymph node biopsy is being recognized as a viable alternative to elective neck dissection for staging the neck in early-stage oral cavity cancer. In this article, we examine the evidence supporting sentinel lymph node biopsy for early-stage oral cancer and provide an update on some of the novel developments in this field.